Plate 152

The most common indication is for the short-term (7 to 10 days) administration of fluids, electrolytes, antibiotics, or other concentrated parenteral medications that are not well tolerated in peripheral veins. Absence of suitable peripheral veins and patient comfort are alternative indications, as is the inability to place a peripherally inserted central catheter (PICC).

The procedure may be performed at the bedside, in the operating room, or in an outpatient ambulatory setting. Electrolytes and clotting studies should be checked prior to the procedure. If the patient has had previous central catheters, a careful history should be obtained, as this will help with site selection. Transcutaneous ultrasound can assist with vein localization.

Moderate sedation and local anesthesia is preferred.

The patient is placed in the supine position, and the arms are tucked at each side. Fluoroscopy should be available.

The hair is removed with clippers. The chosen side of the neck and upper thorax are prepped and draped using the maximum sterile barrier technique.

Figures 1 and 2 show the relevant anatomy of the subclavian vein. It may be cannulated on the right or the left side. The plate shows cannulation on the right side. On the right, the subclavian vein courses behind the medial third of the clavicle and joins the internal jugular vein to drain into the superior vena cava. It lies anterior and inferior to the subclavian artery. The dome of the right lung lies behind the vessels. Ultrasound is used to confirm the patency of the vein and location. The same modified Seldinger technique is used as described in Plate 151. The patient is placed in a supine position. A rolled towel or sheet is placed in the interscapular area to allow the shoulder to drop to the side away from the infraclavicular site (Figure 1). The patient is placed in a 20-degree Trendelenburg position (head down) in order to minimize the risk of air embolism and increase the size of the vein. The head is turned slightly to the opposite side. After installation of local anesthetic to include the periosteum of the clavicle, the subclavian vein is cannulated with a small caliber needle (Figure 3). Ultrasound guidance may be used to provide assistance. A key landmark is the point one fingerbreadth lateral to the junction of the middle and medial thirds of the clavicle. The needle is inserted at this point and passed along a straight line toward the sternoclavicular joint on a plane parallel to the chest wall. A flexible guidewire is inserted into the needle (Figure 4), and if any arrhythmia is noted, the wire is withdrawn until the electrocardiogram returns to its usual pattern. The position of the wire is fluoroscopically verified. The triple lumen catheter is thread over the guidewire (Figure 5). Topical antiseptic and a dry sterile dressing are placed over the entrance site. The catheter hub and wings are secured to the chest skin with fine nonabsorbable sutures (Figure 6). A chest x-ray is obtained to verify the position of the catheter and exclude complications such as a pneumothorax.