Dr.

Sadu Aung Mag Consultant Intensivist

SUBCLAVIAN VEIN CATHETERISATION TECHNIQUES AND COMPLICATONS

Catheterization Kits

Advantage of S.C cannulaion

Consistent identifiable landmarks Low infection rate Relatively high patient comfort Easier long term catheter maintenance Ideal site in hypovolaemic shock patients as

the vein does not collapse due to fibrous attachments

anatomy

Indications
CVP, PA pressure, wedge pressure

measurement Emergency pacemaker insertion Volume resuscitation in shock patients Administering TPN, KCL, Ionotropes, soda bicarb etc SvO2 measurement in sepsis

contraindications

No absolute contraindications Ipsilateral AV fistula Infection of the site Venous thrombosis at or near the site of insertion Presence of venous filters(guidewire should not be inserted more than 20 cm) Severe coagulopathy and thrombocytopenia. (femoral route is preferred) combative patients

Technique
Seldinger technique

Use introducing needle to locate vein Wire is threaded through the needle Needle is removed Skin and vessel are dilated Catheter is placed over the wire Wire is removed Catheter is secured in place

The procedure
Consent Positioning vertical shoulder roll between the

shoulder, this opens up the deltopectoral groove and makes more parallel access to the vein , tredelenberg, arm adducted +/_ pulled towards foot, head turned to oppsite side Maximal barrier protection gown, cap, mask, gloves Stand on the shoulder side of the patient Sterile skin preparation with 2% chlorhexideine Large drape with a central opening

Approach
Infraclavicular or supraclavicular Open (usually by a surgeon) or percutaneous Local anaesthesia 1% solution at the puncture

site Infraclavicular approach - Needle inserted 2 cm below the mid point of clavicle directing towards suprasternal notch, angle should be parallel to the floor Threading of the guidewire not > 20 cm

 Dilatation of skin and s.c tissues Threading the catheter Aim to insert the catheter upto atrio caval junction All port aspirated and flushed with heparinised

saline Suturing to the skin with nylon suture Sterile, transparent dressing Chest x ray for checking position Writing a note

Tips
After 3-4 tries, let someone else try Get chest x-ray after unsuccessful attempt If attempt at one site fails, try new site on same side to

avoid bilateral complications Halt positive pressure ventilation as the needle penetrates the chest wall in subclavian approach If you meet resistance while inserting the guide wire, withdraw slightly and rotate the wire and re-advance Align the bevel with the syringe markings Use the vein on the same side as the pneumothorax Withdraw slowly, you will often hit the vein on the way out

Ultrasound-Guided Central Venous Access

Becoming standard of care
Vein is compressible Vein is not always larger

Vein is accessed under direct visualization

Helpful in patients with

difficult anatomy

complications
Atrial arrhythmia Arterial puncture, haemorrhage ( extrapleural hematoma or

haemothorax) Pnumothorax Venous thrombosis, embolism of air / thrombus/ catheter part Malposition of catheter into opposite sv, ijv or ipsilateral ijv or ivc Misposition subcutaneous tissue, thorax, heart Guidewire related - trauma to artery, vein, ,RA puncture l/t haemopericardium or tamponade, kinking of guidewire, arrhthmia, Infection local or blood stream Catheter shearing

complications

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