CVP - Subclavian

Indications

1. Haemodynamic monitoring

2. Delivery of drugs (eg Norepinephrine) and nutrition

3. Poor peripheral venous access

4. Pacemaker

5. Hemodialysis

6. Pulmonary artery catheter

Advantage of Supraclavicular over Infraclavicular (paper)

1. shorter distance from skin to vein

2. a larger target area

3. a straighter path to the superior vena cava

4. less proximity to the lung

5. fewer complications of pleural or arterial puncture

6. CPR or chest tube insertion is not interrupted

C/I

- Infection over site

- Thrombosis

- Trauma (clavicle/proximal rib)

- Coagulopathy!

Steps

1. Indication, Informed Consent, Time out

2. Equipment

- 7-French 15cm or 20cm triple lumen

- smaller adults/children (5 french 8cm triple lumen or 4 french 8cm double lumen)

3. Positioning

- 15 degrees trendelenburg (to dilate vein and to decrease likelihood of air embolism)

- head neutral (unlike IJ), arm adducted, small roll on posterior shoulder to make the clavicle prominent

4. Prep x 60 seconds

5. Draped

6. All lumens flushed with saline/heparin

- ensure guidewire threads easily, then all hubs capped

7. Remove the cap of brown port/lumen

8. skin local anesthesia

9. Puncture the skin

a. infraclavicular subclavian: just lateral to midpoint of clavicle

- aim towards sternal notch, tracking just beneath clavicle

b. Identify SCM-clavicular angle (or clavisternomastoid angle)

Yoffa approach:

identify the attachment of SCM to clavicle

- 1cm superior and posterior to it, insert the needle towards contralateral nipple

45 deg off horizontal and sagittal plane and 15 degrees forwards off the coronal plane, needle heading to contralateral nipple

Conroy approach: bony landmark: identify the midpoint of clavicle, enter 1cm medial and superior, aim the needle at contralateral

- great for morbidly obese

confirm, non-pulsatile return flow

may also send blood for abg

10. insert the guidewire, watch the monitor if there's arrhythmia

optionally, Ambesh maneuver: constant pressure over ipsilateral supraclavicular fossa by one finger to prevent guidewire from migrating proximally to IJ

11. withraw the needle leaving the guidewire

12. small skin cut by blade 11

13. advance the dilator, rotating, and once satisfied with depth, remove it leaving behind just the guidewire

14. once dilator is removed, anticipate bleeding, press the site with finger and gauze

15. feed the catheter over the guidewire, make sure the tip of the guidewire is visible out of the longest lumen, grasp the wire and rotate/advance

- if resistance is met, may not adequately dilated, re-dilate with dilator

16. proper positioning is the tip at the junction of the SVC and RA

17. remove the guidewire

18. blood return confirmed on all ports, all ports flushed with saline, caps placed on the hubs

19. secured the line in place

20. sterile dressing

21. CXR to check placement and exclude hemo/pneumothorax or subcutaneous emphysema

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Procedure Notes:

Central catheter insertion on subclavian vein (Supraclavicular)

Indication _____

Informed Consent

Time out

Full asepsis

- Sterile grown, gloves, cap, mask, and face shield

Positioned, prepped and draped

All lumens primed with saline, all ports capped

Skin anaesthesized, punctured with introducer needle

Yoffa or Conroy _______ approach

Return blood flow, guidewire inserted

Skin nicked, track dilated

catheter fed over guidewire, then guidewire removed

all 3 ports = blood return, flushed with saline, capped

line secured, sterile dressing

CXR

On the chart/documentation:

central catheter inserted on supraclavicular vein, supraclavicular approach

Indication _____

Consent, full asepsis (sterile gown, gloves, cap, mask, face shield)

uneventful procedure (see procedure notes)

CXR

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