Keywords

Preference Card

  • Three lumen central kit

  • Lidocaine 1% with or without epinephrine

Patient Positioning

  • The patient is placed supine with arms toward the side and head turned away from the implanting clinician.

  • Roll between shoulders can aid with exposure.

  • ChloraPrep is used as skin preparation.

  • Maximum sterile barrier is used.

  • The patient is placed in Trendelenburg position.

  • The sternal notch and acromion are palpated.

  • The site for needle insertion is chosen midway between the sternal notch and acromion below the curve of the clavicle (Fig. 27.1).

  • Equipment is checked and central line is flushed.

Fig. 27.1
figure 1

The 18-gauge needle is then inserted and advanced horizontally toward the clavicle, again directing it 1 fingerbreadth above the clavicle

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Nodal Points

Prep, Drape, and Checking Kit

  • The neck and upper chest should be prepped with ChloraPrep solution over the area until a suitably sized sterile field is obtained (about 5–6″ in diameter).

  • The catheter kit is opened sterilely.

  • Sterile gowns and gloves should be used by those in the room.

  • A sterile surgical drape should be placed over the upper chest centered on the clavicle.

  • The central venous catheter should be checked to ensure that the ports are open and not capped. All ports should be flushed.

Preparing the Insertion Site

  • Using a 22-gauge needle, 1% lidocaine is injected at the needle entrance site.

  • The needle is then advanced toward the clavicle and directed a fingerbreadth above the sternal notch, keeping the needle and the barrel of the syringe in the horizontal plane.

  • As the needle touches the clavicle, additional local anesthesia is injected.

Canalization of the Subclavian Vein

  • The 18-gauge needle is then inserted and advanced horizontally toward the clavicle, again directing it 1 fingerbreadth above the clavicle (Fig. 27.1).

  • The needle is then marched down under the clavicle and again advanced along toward a point 1 fingerbreadth above the sternal notch.

  • The entrance of the needle into the subclavian vein is confirmed by blood return (Fig. 27.2).

Fig. 27.2
figure 2

The entrance of the needle into the subclavian vein is confirmed by blood return

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Canalizing Vein with Guide Wire and Dilatation of Vein

  • The J-wire is threaded through the needle (Fig. 27.3).

  • Remove the needle over the J-wire, having control of the wire at all times.

  • Watch monitor as guide wire is advanced. Ventricular ectopy indicates placement in RV, and guide wire should be pulled back a few cm.

  • Skin is stabbed using an 11-blade, which will allow the catheter to pass freely.

  • A vein dilator is passed over the J-wire (Fig. 27.4).

Fig. 27.3
figure 3

J-wire is advanced through the needle

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Fig. 27.4
figure 4

A vein dilator is passed over the J-wire always having control of the wire

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Thread of Central Line Through Wire and Fixation of Line

  • The catheter is then threaded over the J-wire; assure wire control (Fig. 27.5).

  • Once catheter in place, the J-wire is removed.

  • The catheter is flushed with saline.

  • Immediately following placement, each of the ports is aspirated and flushed to verify patency. If any resistance is encountered, then obstruction of the catheter in the vein insertion site, the tunnel, or at the junction of the catheter with the reservoir should be suspected. These sites should be inspected.

Fig. 27.5
figure 5

The catheter is then threaded over the J-wire

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Confirmation of Line Position and Assessment of Pneumothorax

  • Obtain a chest x-ray.

  • The catheter is secured with 3-0 silk sutures.

  • Apply an antibiotic disk over the skin where catheter enters.

  • Use an occlusive dressing over this (Fig. 27.6).

  • The position of the catheter with its tip in the right atrium should be verified.

Fig. 27.6
figure 6

Central line is stitched in placed; antibiotic disc and occlusive dressing are placed

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Pitfalls and Pearls

  • Ultrasound guidance improves initial cannulation success.

  • Subclavian artery puncture is not uncommon. Management involves withdrawal of the needle and applying pressure over the site for 5–10 minutes. Elevation the arm will also help vein compression. Ipsilateral access can be later re-attempted.

  • Dilatation and cannulation of the subclavian artery, however, may be associated with more complications such as bleeding, thrombosis, or creation of pseudoaneuryms. In that case, the catheter should not be manipulated and the vascular surgeons be involved.

  • If anatomy is amenable bilaterally, left subclavian access is preferable as it has lower rates of malposition and vessel trauma.

  • Subclavian artery puncture during vein localization is not uncommon and can be managed by withdrawing the needle and applying pressure over the site for 5–10 minutes. Elevation of the ipsilateral arm overhead may help to compress the vein. If arterial catheterization is confirmed, the catheter should be left in place and a vascular consult obtained.