Percutaneous Cannulation of the Subclavian Vein

Chlorhexidine swab is used to do a sterile prep of the right anterior chest wall. We’re using the swab in a back and forth motion to prep a large area of the anterior chest wall and the right shoulder.

Now we’re applying a sterile drape over the area. This sterile drape covers the entire bed.

Now we are using sterile saline flush to flush all three ports of a triple lumen catheter. We can switch the normal caps on the triple lumen catheter to needleless caps. We’re applying the needleless caps on the white port and the blue port of the triple lumen catheter. We’re not going to apply the needleless cap on the brown port, which is the distal port of the triple lumen catheter, as that is the port that the wire will eventually come out of.

When we flush the brown port, as is shown here, we have to clip the line before we take off the syringe.

We’re now going to get all of our equipment that we need, including an introducer needle, the sterile wire, the scalpel, and the dilator in a position where we can easily grasp them. The J-curve of the wire will be directed towards the heart, which in a subclavian line is directed towards the feet, as is shown here for the right side and the left side.

Now we’re going to draw up some 1% lidocaine, which will be used for local anesthesia of the skin and the periosteum of the clavicle.

All of these syringes that contain sterile fluid have to be labeled on your sterile field. The sterile saline flushes are pre-labeled as sodium chloride, but the 1% lidocaine syringe is not labeled and, therefore, these sterile labels can be used to label the 1% lidocaine syringe, as is shown here.

Now we’re using our two hands to identify the curve of the clavicle, which is the primary landmark that you have to identify when you’re performing an infraclavicular subclavian line placement. Once you identify the curve of the clavicle, you will make the insertion site one centimeter towards the deltopectoral groove from the curve of the clavicle. At that insertion site, we’ll use 1% lidocaine for local anesthesia, as is shown here. We also insert deeply until we can anesthetize the periosteum of the clavicle along the track.

Now we’re inserting the introducer needle underneath the clavicle with the needle as parallel to the floor as possible. We put our index finger in the sternal notch and used the thumb of the nonsyringe hand to help guide that needle underneath the clavicle inserting towards the top of the index finger and the sternal notch until we see this flash of venous blood. We then advance that introducer needle about two millimeters and then take off the syringe when we see nonpulsatile blood, we can now advance the wire through the needle until you reach the 20 centimeter mark of the wire.

Now the needle is removed over the wire with a careful control of the wire. We’re using a scalpel to nick the skin. And now we are advancing a dilator over the wire to dilate a tract through the skin, subcutaneous tissue and into the subclavian vein. We’re advancing the dilator with a twisting motion until it is at the hub of the dilator for an infraclavicular subclavian line placement.

Now we’re removing the dilator and keeping control of the wire. We are introducing the catheter over the wire now, and the wire will come out the brown port of the catheter. The wire is grasped at the distal end beyond the brown port and then the catheter is advanced to the appropriate depth of insertion, which in a right subclavian line is approximately 15 centimeters at the skin. For a left subclavian line, you would advance the catheter until about 17 centimeters at the skin.

Now we are withdrawing the wire from the catheter, directly into the wire sheath. As you do this, you have control of the catheter to make sure that the catheter is not pulled out as you’re pulling the wire out.

Now we’re going to insert the last needleless cap onto the brown port. We withdraw blood into that brown port until you can see it in the syringe that contains sterile saline. Then the port is flushed with saline.

Now the blue port and the white port will be flushed and you just have to withdraw the saline until you see a little bit of blood in the line of both the blue port and the white port. Then flush the saline to clear out that blood.

Now we’re applying a white and blue central line clip, approximately two centimeters from the insertion site so that we can secure the central line to the skin in four places. We’re using 1% lidocaine to numb up the skin in these four places.

Now we’re applying a Biopatch, which is a chlorhexidine impregnated patch, with the blue side of the patch up towards the ceiling over the insertion site. This decreases the risk of central line-associated blood stream infections.

We’re using a needle driver with a curved needle to suture the central line in place in these four locations. Here an instrument tie is being used to secure the suture.

Once all four of those sites have been sutured into place, we can apply a sterile occlusive dressing with the window that has the insertion site, including the Biopatch, in view. Then the notch of the sterile occlusive dressing, will have the three ports of the central line, come through that notch.

Then the second part of the sterile occlusive dressing has these wings that will go underneath the three ports of the central line to fully secure the central line in place. A sterile pen can then be used to place your initials, the date and time of the central line.