Ultrasound-Guided Subclavian Central Lines: Part 2

by
|
Reading Time: 2 minutes
Picture of Harman Gill
Harman Gill
I am a proud Indian by ethnicity and Sikh by religion who lives in the lovely upper valley here in New Hampshire. I love to host, cook and engage in health conversations and loud debates where decibels can be raised but respect is never lost! Talk to you soon!
Picture of Matthew Tyler
Matthew Tyler

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

  1. 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.

Share:

More Posts

Related Posts

0
Would love your thoughts, please comment.x
()
x