Central Venous Access via Supraclavicular Approach to Subclavian Vein Periprocedural Care

Updated: Apr 20, 2017
  • Author: E Jedd Roe, lll, MD, MBA, FACEP, FAAEM, MSF, CPE; Chief Editor: Rick Kulkarni, MD  more...
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Periprocedural Care

Preprocedural Planning

Needle insertion site options include the following:

  • Insertion 1 cm lateral to the lateral border of the clavicular head of the sternocleidomastoid and 1 cm superior to the clavicle; the needle approach should bisect the angle of the muscle border and the clavicle
  • Insertion 1 cm medial and 1 cm superior to the midpoint of the clavicle; the introducer needle should be directed to the ipsilateral sternoclavicular joint [17]
  • Insertion just posterior to the clavicle at the middle/medial third junction of the clavicle; the needle should be directed toward the ipsilateral sternoclavicular joint, oriented parallel to the coronal plain [18]

Options for directing the needle include the following:

  • Contralateral nipple - The contralateral nipple may be used as a target for directing the introducer needle
  • Sternal notch - A point just superior and posterior to the sternal notch may be used as a target for directing the introducer needle

In the technique first described by Yoffa in 1965, the needle is directed at an angle of 45º from the sagittal plane and 15º anteriorly from the coronal plane. Studies using three-dimensional computed tomography (CT) have obtained higher success rates by placing the needle at the clavisternomastoid angle and directing the needle 10º from the sagittal plane and 35º posteriorly from the coronal plane. This change yields the shortest distance to the target vessel and allows the first rib to act as a physical barrier to reduce the risk of pneumothorax. [19]

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Equipment

Equipment used in obtaining central venous access via the supraclavicular approach to the subclavian vein includes the following (see the image below):

  • Central venous catheter tray (line kit)
  • Sterile gloves
  • Antiseptic solution with skin swabs
  • Sterile drapes or towels
  • Sterile gown
  • Sterile saline flush, approximately 30 mL
  • Lidocaine 1% (obtain additional vial of lidocaine 1%, if needed) - Because the amount of lidocaine provided in most line kits is often inadequate, the authors recommend supplementing the kit with a 10-mL syringe and a bottle of 1% lidocaine without epinephrine
  • Gauze
  • Dressing
  • Scalpel, No. 11
Central venous catheter equipment. Image courtesy Central venous catheter equipment. Image courtesy of Wikimedia Commons.

Some clinicians find it useful to remove the contents of the line kit and lay them out in the order and configuration that they will be used. Equipment should never be placed on a patient.

Antibiotic ointments are contraindicated. Transparent dressings are not necessary.

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Patient Preparation

Anesthesia

Local anesthesia using 1% lidocaine is required. For more information, see Local Anesthetic Agents, Infiltrative Administration. Anesthetize the suture site as well as the insertion site.

Positioning

Place the patient in the supine position. If possible, the bed should be raised to a comfortable height for the operator so that bending over is unnecessary.

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