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Subclavian Central Lines – Step by Step
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INDICATIONS
Volume resuscitation
Emergent access
Caustic Medications
CVP monitoring
Nutritional support
Transvenous pacing
Hemodialysis
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CONTRAINDICATIONS
 Distorted local anatomy (vascular
injury, prior surgery, radiation
history)
 Infection at insertion site
 Thrombosis
 Coagulopathy
 Trauma to vessel
 Contralateral PTX or hemothorax
 Obesity, cachexia, severe COPD?
Position the patient – supine, 10-15 degree Trendelenburg, towel roll if needed.
Identify landmarks – middle third of clavicle, sternal notch.
Open kit, include Leur locks, flushes
Clean the insertion site with the chlorhexidine in a wide swath.
Mask, gown, and gloves. Remember, you are sterile.
Drape the patient in a sterile fashion, with the insertion site exposed.
Prepare your kit, flushing lines, attaching leur locks.
1% lidocaine  skin, subcutaneous tissue, and clavicular periosteum.
Insert needle ~ 1cm lateral and inferior to the middle third clavicular bend.
Gently withdraw the plunger of the syringe. Advance the needle under and along
the inferior border of the clavicle, “walking the clavicle” if needed, keep needle to
the chest wall, using pressure from non-dominant hand. Advance toward the
suprasternal notch until the vein is entered.
Aspirate venous blood (non-pulsatile), disconnect the syringe.
Insert the guide wire. Do not force if resistance is met. ALWAYS maintain control
of your guide wire.
Advance the wire until it is mostly in the vein or until ectopy is seen on the cardiac
monitor. Hold your wire, withdraw the needle.
Make a small skin nick with scalpel
Thread the dilator over the wire with a firm and gentle twisting motion while
maintaining constant control of the wire. Remove the dilator.
Thread the catheter over the wire until it exits the distal (brown) lumen and grasp
the wire as it exist the catheter. One hand ALWAYS on wire. Thread to desired
length(approximately 15cm L, 20cm R).
Remove the wire.
Attach a syringe with saline aspirate blood in each port, then flush the line clear.
Suture the catheter in place.
Apply a clean dressing.
Throw your sharps away.
CXR. Tip of the line should end in the vena cava, right above the right atrium.
Check for placement, pneumothorax, hemothorax.
GOOD RESOURCES FOR FURTHER LEARNING:
NEJM:
http://www.nejm.org/doi/full/10.1056/NEJMvcm074357
Ultrasound:
http://ultrarounds.com/Ultrarounds/Subclavian_Ultrasound.html
Subclavian Central Lines – Step by Step
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Pat yourself on the back, you’re a hero.
GOOD RESOURCES FOR FURTHER LEARNING:
NEJM:
http://www.nejm.org/doi/full/10.1056/NEJMvcm074357
Ultrasound:
http://ultrarounds.com/Ultrarounds/Subclavian_Ultrasound.html