Central Line Insertion

Subclavian Vein

• Line related infections appear to be lower with the subclavian approach

Contraindications

• Infection of area overlying the target vein
• Thrombosis of the target vein
• Fracture of the clavicle or proximal ribs
• Coagulopathy - applying direct pressure at the subclavian artery or vein is difficult

Method

1. Place the patient in a 10-15 trendelenburg position
2. Turn the head so the chin points away from the vein and place a small role under the scapula to make the calvicle more prominent
3. Identify the posterior deviation (middle third) of the clavicle
4. Clean and drape the site
5. Flush the lines of the central line with heparin or saline
6. Ensure the guidewire threads easily through the needle
7. Remove the port through which the guidewire will be threaded (commonly the longer lumen)
8. Use local anaesthetic to anaesthetise the area
9. Approach the site at a 30 degree angle to the skin with the long axis of the needle aimed towards the sternal notch
10. Track the needle just below the clavicle
11. Feed the wire through the needle
12. Have an assistant watch the monitor watching for signs of arrhythmia; if they occur, withdraw the needle until the cease
13. Withdraw the needle leaving the guidewire in place
14. Make a small superficial incision at the insertion site to facilitate entry of the dilator
15. Place the dilator over the wire ensuring to have control over the wire at all times
16. Advance the dilator 1-2cm with a rotating motion, being careful not to cause a bend or kink in the wire
17. Remove the guidewire and maintain a grip on the wire
18. Feed the catheter over the guidewire making sure the end of the guidewire can be seen outside the catheter hub
19. Grasp the external end of the guidewire, advance the catheter over the guidewire using a rotating motion
20. If the catheter does not advance smoothly, the track may not have been adequately dilated; remove the catheter and insert the dilator
21. If it is suspected that the catheter might be in the artery check by connecting to a pressure transducing system
22. Remove the guidewire and check for blood return in all ports
23. Flush all ports, place caps on the hub and secure the port before removing the drape
24. Obtain a chest X-ray to assess for proper placement and ensure no haemothorax nor pneumothorax

Aftercare

• Minimise the number of times the lines is accessed
• Access the line under sterile or clean conditions
• Prepare access site with alcohol based solution
• Reassess need for central line daily

Sources

• Braner, D.A.V., Lai, S., Eman, S., Tegtmeyer, K., 2007. Central Venous Catheterization — Subclavian Vein. New England Journal of Medicine 357, e26. https://doi.org/10.1056/NEJMvcm074357