05. Subclavian Vein Cannulation

Site Selection

SUBCLAVIAN LINES

ADVANTAGES

DISADVANTAGES

Direct path to right atrium favorable for cardiac access

Trendelenburg positioning (often not tolerated in respiratory distress)

Hemodynamic monitoring with CVP, CvO2, and PA catheter placement

Risk of pneumothorax (L>R)

Improved patient comfort and can be ambulatory

Risk of hemothorax with subclavian artery puncture

Reproducible anatomy regardless of patient BMI

Not compressible, higher risk of bleeding with coagulopathy

When to consider a different site:

  1. If lung disease, performing on site ipsilateral to lung pathology.
  2. Generally avoid in a patient with coagulopathy.
  3. Prior condition that alters local anatomy: clavicular fracture, indwelling pacemaker or defibrillator.

Catheter length: 15cm

Anatomy:

Technique

Positioning:

  1. Supine & Trendelenburg (10°) with towel roll between scapulae: reduces risk of air embolus and minimally engorges of subclavian vein. Accentuates anatomical landmarks.
  2. External rotation of ipsilateral arm & gentle traction: increases the size of the deltopectoral groove.
  3. Experienced operators may perform this procedure in upright positions if patient unable to tolerate Trendelenburg.
     

Locating access point: (infraclavicular access)

NOTE: this procedure is often done at UCSF using anatomic guidance instead of ultrasound guidance.

  1. Identify the middle third of the clavicle & follow it laterally until it deviates from the ribs. Subclavian vein and artery are medial and inferior to this point.
  2. Be aware of any pacemakers or defibrillators, in general do not place a subclavian on a side with a device.

Preparation:

NOTE: the finder needle may not be long enough to reach the vein. Infuse local anesthetic along the clavicular periosteum as this is richly innervated.

Entry: (infraclavicular access)

  1. Ensure entry site is 2cm lateral and 2cm caudal to the middle third of the clavicle.
  2. Direct needle tip infraclavicular aiming toward the sternal notch at a 30° angle to the skin.
  3. Keep the needle parallel to the floor (deltopectoral groove) and aim for the clavicle. Once you have hit bone, march down until just below the clavicle.
  4. Once under the clavicle, advance needle approximately 4-5cm while continuously aspirating.
  5. If unsuccessful, withdraw needle and redirect more cephalad.

Pearls:

  • Externally rotate the ipsilateral arm with gentle traction to increase depth of the deltopectoral groove.
  • Once the vein is found, rotate the needle 90˚ so that the bevel is facing caudally. This ensures ease of wire advancement to SVC.
  • Rotate head contralateral to compress ipsilateral IJ & improve wire advancement to SVC.
  • Access to the vein occurs just beneath the clavicle, but it may be several centimeters below skin.