Patient Education and Consent

Before the procedure, a discussion should be held with the patient to explain the procedure, in particular with regard to its benefits, risks, and complications. Signed informed consent must be obtained.

Equipment

Equipment required for central venous access via the subclavian (or infraclavicular or subclavicular) approach to the subclavian vein includes the following:

Central venous catheter tray (line kit; see the image below)
Sterile gloves
Antiseptic solution with skin swab
Sterile drapes or towels
Sterile gown
Sterile saline flush, approximately 30 mL
Lidocaine 1% (obtain additional vial of lidocaine 1% if needed)
Gauze
Dressing
Scalpel, No. 11

Central venous catheter equipment. Courtesy of Wikimedia Commons.

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Patient Preparation

Local anesthesia using 1% lidocaine is required. For more information, see Local Anesthetic Agents, Infiltrative Administration.

Place the patient in the supine position. If possible, the bed should be raised to a height that is comfortable for the operator, so that bending over will be unnecessary. Do not place towels between the shoulder blades or turn the head; these have been shown to decrease the size of the subclavian vein.^[5]

Place the patient in 15º of Trendelenburg position to reduce the risk of air embolism. Increasing this angle does not alleviate vessel distention, because the subclavian vein is fixed within surrounding tissue.

Technique

Merrer J, De Jonghe B, Golliot F, Lefrant JY, Raffy B, Barre E, et al. Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA. 2001 Aug 8. 286 (6):700-7. [QxMD MEDLINE Link].
Sznajder JI, Zveibil FR, Bitterman H, Weiner P, Bursztein S. Central vein catheterization. Failure and complication rates by three percutaneous approaches. Arch Intern Med. 1986 Feb. 146 (2):259-61. [QxMD MEDLINE Link].
Veenstra DL, Saint S, Saha S, Lumley T, Sullivan SD. Efficacy of antiseptic-impregnated central venous catheters in preventing catheter-related bloodstream infection: a meta-analysis. JAMA. 1999 Jan 20. 281 (3):261-7. [QxMD MEDLINE Link].
Mansfield PF, Hohn DC, Fornage BD, Gregurich MA, Ota DM. Complications and failures of subclavian-vein catheterization. N Engl J Med. 1994 Dec 29. 331 (26):1735-8. [QxMD MEDLINE Link].
Elliott TS, Faroqui MH, Armstrong RF, Hanson GC. Guidelines for good practice in central venous catheterization. Hospital Infection Society and the Research Unit of the Royal College of Physicians. J Hosp Infect. 1994 Nov. 28 (3):163-76. [QxMD MEDLINE Link].
McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med. 2003 Mar 20. 348 (12):1123-33. [QxMD MEDLINE Link].
Raad II, Hohn DC, Gilbreath BJ, Suleiman N, Hill LA, Bruso PA, et al. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infect Control Hosp Epidemiol. 1994 Apr. 15 (4 Pt 1):231-8. [QxMD MEDLINE Link].
Marik PE, Flemmer M, Harrison W. The risk of catheter-related bloodstream infection with femoral venous catheters as compared to subclavian and internal jugular venous catheters: a systematic review of the literature and meta-analysis. Crit Care Med. 2012 Aug. 40 (8):2479-85. [QxMD MEDLINE Link].
Lanspa MJ, Fair J, Hirshberg EL, Grissom CK, Brown SM. Ultrasound-guided subclavian vein cannulation using a micro-convex ultrasound probe. Ann Am Thorac Soc. 2014 May. 11 (4):583-6. [QxMD MEDLINE Link]. [Full Text].
Brass P, Hellmich M, Kolodziej L, Schick G, Smith AF. Ultrasound guidance versus anatomical landmarks for subclavian or femoral vein catheterization. Cochrane Database Syst Rev. 2015 Jan 9. 1:CD011447. [QxMD MEDLINE Link]. [Full Text].
Fragou M, Gravvanis A, Dimitriou V, Papalois A, Kouraklis G, Karabinis A, et al. Real-time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients: a prospective randomized study. Crit Care Med. 2011 Jul. 39 (7):1607-12. [QxMD MEDLINE Link]. [Full Text].
Wang Q, Cai J, Lu Z, Zhao Q, Yang Y, Sun L, et al. Static Ultrasound Guidance VS. Anatomical Landmarks for Subclavian Vein Puncture in the Intensive Care Unit: A Pilot Randomized Controlled Study. J Emerg Med. 2020 Dec. 59 (6):918-926. [QxMD MEDLINE Link].
Kilbourne MJ, Bochicchio GV, Scalea T, Xiao Y. Avoiding common technical errors in subclavian central venous catheter placement. J Am Coll Surg. 2009 Jan. 208 (1):104-9. [QxMD MEDLINE Link].
Braner DA, Lai S, Eman S, Tegtmeyer K. Videos in clinical medicine. Central venous catheterization--subclavian vein. N Engl J Med. 2007 Dec 13. 357 (24):e26. [QxMD MEDLINE Link].
Schulman PM, Gerstein NS, Merkel MJ, Braner DA, Tegtmeyer K. Ultrasound-Guided Cannulation of the Subclavian Vein. N Engl J Med. 2018 Jul 5. 379 (1):e1. [QxMD MEDLINE Link]. [Full Text].
Senussi MH, Kantamneni PC, Omranian A, Latifi M, Hanane T, Mireles-Cabodevila E, et al. Revisiting Ultrasound-Guided Subclavian/Axillary Vein Cannulations: Importance of Pleural Avoidance With Rib Trajectory. J Intensive Care Med. 2017 Jul. 32 (6):396-399. [QxMD MEDLINE Link].
Timsit JF, Farkas JC, Boyer JM, Martin JB, Misset B, Renaud B, et al. Central vein catheter-related thrombosis in intensive care patients: incidence, risks factors, and relationship with catheter-related sepsis. Chest. 1998 Jul. 114 (1):207-13. [QxMD MEDLINE Link].
Rath GP, Bithal PK, Toshniwal GR, Prabhakar H, Dash HH. Saline flush test for bedside detection of misplaced subclavian vein catheter into ipsilateral internal jugular vein. Br J Anaesth. 2009 Apr. 102 (4):499-502. [QxMD MEDLINE Link].

Media Gallery

Central venous catheter equipment. Courtesy of Wikimedia Commons.
Anatomy for subclavian approach.

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Author

E Jedd Roe, lll, MD, MBA, MSF, FAAEM, FACEP Professor and Assistant Chair, Program Development and Community Relations, Department of Emergency Medicine, University of Florida at Jacksonville College of Medicine; Medical Director, UF Health Jacksonville-North

E Jedd Roe, lll, MD, MBA, MSF, FAAEM, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American Association for Physician Leadership, American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Danielle Turner-Lawrence, MD Associate Program Director, Simulation Director, Department of Emergency Medicine, William Beaumont Hospital; Associate Professor, Oakland University William Beaumont School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Vincent Lopez Rowe, MD, FACS Professor and Chief, Division of Vascular and Endovascular Surgery, Gonda (Goldschmied) Vascular Center, University of California, Los Angeles, David Geffen School of Medicine

Vincent Lopez Rowe, MD, FACS is a member of the following medical societies: American College of Surgeons, American Heart Association, American Surgical Association, Association of Program Directors in Vascular Surgery, Los Angeles Surgical Society, Pacific Coast Surgical Association, Society for Clinical Vascular Surgery, Society for Vascular Surgery, Society of Black Academic Surgeons, Society of Black Vascular Surgeons, Southern California Vascular Surgical Society, Western Vascular Society

Disclosure: Nothing to disclose.

Additional Contributors

Gil Z Shlamovitz, MD, FACEP Associate Professor of Clinical Emergency Medicine, Keck School of Medicine of the University of Southern California; Chief Medical Information Officer, Keck Medicine of USC

Gil Z Shlamovitz, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Drugs & Diseases gratefully acknowledge the contributions of previous author John P Gullett, MD, to the development and writing of this article.

Sections Central Venous Access via Infraclavicular (Subclavian/Subclavicular) Approach to Subclavian Vein
Overview
Periprocedural Care
Technique
Questions & Answers
Media Gallery
Tables
References

Error	Percent of Failures (N = 277)
Inadequate landmark identification	14.7
Improper insertion position	32.3
Insertion of needle through periosteum	21.9
Taking too shallow a trajectory with needle	16.1
Aiming the needle too cephalad	7.5
Failure to keep needle in place for wire passage	7.5

Complication	Internal Jugular Approach (%)	Subclavian Approach (%)	Femoral Approach (%)
Arterial puncture	6.3-9.1	3.1-4.9	9.0-15.0
Hematoma	< 0.1-2.2	1.2-2.1	3.8-4.4
Hemothorax	N/A	0.1-0.6	N/A
Pneumothorax	< 0.1-0.2	1.5-3.1	N/A
Thrombosis	7.6	1.9	21.5
Total	6.3-11.8	6.2-10.7	12.8-19.4

Central Venous Access via Infraclavicular (Subclavian/Subclavicular) Approach to Subclavian Vein Periprocedural Care

Patient Education and Consent

Equipment

Patient Preparation

References

Tables

Contributor Information and Disclosures

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