Critical Care and Emergency doc in Chicagoland. Minimalist Intensivist. Advanced echo ultrasonographer. Proceduralist. ChoosingWisely advocate. Health policy wonk. I make a damn good pasta. Urban gardener
Long axis vs. short axis
-Short access allows constant visualization of the nearby artery, but requires ultrasound probe manipulation while advancing the needle
-Long access allows constant visualization of the vessel and needle, but can be challenging in deeper vessels if the needle slips out of plane during advancement
-Try both and develop your own preference
Pleural Avoidance with Rib Trajectory (PART) technique
-Align one of the ribs behind the subclavian/axillary vein as a ‘backboard’ to protect the pleura from accidental needle puncture. Utilized in the long access approach
-Adds an extra layer of safety, but not necessary for line placement
Skinny vs. obese patients
-Each has its advantages: The vessels are close to the skin in thin patients creating an easier target to access. The pleural line in obese patients will be a comfortable distance from the vessels
-Each has its pitfalls. The pleural line in skinny patients will be closer to the vessels with higher risk for a pneumothorax complication, especially in the blind placement approach. The vessels will be deeper and more challenging to access in obese patients
-Always look with ultrasound first to identify the path of the subclavian/axillary vein, even if planning on placing line by the anatomic approach. Be cautious using blind technique in very skinny, cachectic patients
Micropuncture catheter
-Be careful using this catheter in the subclavian vein, as the vessel is generally deeper and the micropuncture catheter may not be long enough to access the vessel
Ergonomics
-Trendelenburg position
-If prominent humeral head, consider bringing arm above head
-Take advantage of the wires natural curvature to ensure it’s directed downward toward the right atrium
-Less risk of pneumothorax if line placed in right subclavian/axillary vein as pleura is 2.5 cm shorter on right than left
-Likely will need a 20 cm CVC to ensure catheter is seated at SVC/RA junction
-The procedure isn’t done until the dressing is well secured
Practice ultrasound guided IVs!! If you can place an ultrasound guided IV, a central line should be easy
The Debrief
- Check out the video for a more in-depth analysis of ultrasound-guided subclavian central lines
- Long axis vs short axis views have their pros and cons; find the one that works best for you.
- Consider using the PART technique
- The micropuncture needle may not be the best tool for this procedure.
- Preparation is key; position the patient in the best way for first pass success.
References
Senussi MH, Kantamneni PC, Omranian A, Latifi M, Hanane T, Mireles-Cabodevila E, Chaisson NF, Duggal A, Moghekar A. Revisiting ultrasound-guided subclavian/axillary vein cannulations: importance of pleural avoidance with rib trajectory. Journal of intensive care medicine. 2017 Jul;32(6):396-9.
