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Central Venous Catheterization: Subclavian Approach

(Internal Medicine)
Editor(s): Todd W Thomsen, MD | Gary S Setnik, MD, FACEP
Contributor(s): Sean M. Burns, MD
Section Editor(s): David Feller-Kopman, MD
PRE-PROCEDURE
INTRODUCTION

See Figure 1.

Central venous lines are essential tools in the care of complicated patients, both
on inpatient wards and in the emergency department and intensive care unit.
They may provide access for blood draws, facilitate central administration of
fluids and medications, and allow direct measurement of cardiac filling pressure.

Unfortunately, central lines are associated with serious complications, including


nosocomial bloodstream infections. Recent data suggest that of the more than
200,000 such infections each year, 90% are due to central lines.1 One can
minimize patient risk by practicing proper sterile technique during line insertion,
maintaining adequate occlusive dressings, and removing all unnecessary lines as
soon as possible.

The three main approaches used to place central lines are the internal jugular,
subclavian, and femoral. This chapter reviews the subclavian approach; other
sites are detailed in separate chapters. See Central Venous Catheterization:
Internal Jugular Approach and Central Venous Catheterization: Femoral
Approach for further details.

INDICATIONS
Administration of agents into the central vasculature (see Figure 2)
o Central venous access is required to administer certain medications,
including most vasoactive and/or inotropic agents (i.e., vasopressors
such as dopamine and norepinephrine). In addition to expediting delivery of
these drugs to the heart and arterial system, central administration
decreases the risk of damaging peripheral tissue from the vasoconstrictive
effects of the medications.
o Patients needing total parenteral nutrition also require central access
because the osmolarity of the mixture exceeds what can safely be
administered into the peripheral circulation.
o Other hyperosmolar agents that are optimally infused through a central
line include concentrated potassium solutions, hypertonic saline solutions,
certain chemotherapeutic agents, and calcium chloride.
Central circulation and intracardiac access (see Figure 3)
o Measurement of central venous filling pressure within the right atrium
can be helpful in determining the volume status of a patient and can readily
be transduced via a central venous catheter in the internal jugular or
subclavian position.
o Specialized pulmonary artery (i.e., Swan-Ganz) catheters can be used
to measure pulmonary capillary wedge pressure, a means of approximating
left-sided filling pressure.
o Blood drawn from a central catheter can allow the measurement of mixed
venous (or central venous) oxygen saturation, often used to estimate
cardiac output.
o Temporary transvenous pacemakers can be inserted through central
venous catheters (more specifically, sheath introducer catheters) to provide
a more reliable and comfortable means of pacing than the transcutaneous
route. See Transvenous Pacing for further details.
Maintenance of venous access
o In acutely unstable patients, peripheral venous access may be inadequate.
o Patients requiring multiple medications in drip formulation can quickly run
out of access points.
o This problem is compounded in a chronically ill patient, who oftentimes has
insufficient peripheral access because of frequent blood drawing and
peripheral intravenous (IV) line placement.
o Central venous catheters provide reliable access for blood drawing and
administration of medication, until either peripheral access can be obtained
or less venous access is required.
Hemodialysis and plasmapheresis
o Emergency or short-term dialysis and plasmapheresis can be performed via
special central venous catheters (e.g. Quinton catheters).
Clinical Pearls: The subclavian vein approach is suitable for routine and
emergency central venous access. Advantages and disadvantages of the
subclavian approach include those listed in Table 1.
CONTRAINDICATIONS
Absolute contraindications
o Adequate peripheral IV access: Given the potential for serious morbidity
and the high rate of infection associated with central lines, they should be
used only when absolutely necessary. See Intravenous Cannulation for
further details. See Figure 4.
o Operator inexperience (unless supervised by an experienced
practitioner): Although placement of a central line is a relatively safe
procedure in experienced hands, those unfamiliar with the technique should
study the protocol beforehand to gain confidence and must be supervised at
all times during placement of a line.
o Uncooperative patient:
Placement of a central line requires that the patient remain still so that the
operator can define the anatomy accurately, concentrate on steps of the
procedure, and be vigilant for signs of complications.
Needles, scalpels, and sutures are necessary tools in this task.
Patients who are uncooperative have an unacceptably high risk of injury
and also expose the operator to increased risk.
Adequate steps must be taken to make the patient comfortable for the
length of the procedure before proceeding.
Relative contraindications
o Significant bleeding disorder: Coagulopathies and thrombocytopenia
increase a patient's risk for bleeding, but the hemorrhages are generally
mild and do not require transfusions.2
Clinical Pearls: Although traditional teachings recommend replacement
products (such as fresh frozen plasma or platelet concentrates) before central
catheterization, evidence from the literature suggests that this is not
necessary.2 The decision to use such products should be made on a case-by-
case basis.

If there is concern about the possibility of a bleeding complication, the line


should be placed in a location that allows straightforward compression (e.g.,
internal jugular or femoral vein). The subclavian approach should be avoided
because hemorrhage in this location may require surgical intervention.
Injury or thrombosis in the target vessel or superior vena cava (SVC):
o Depending on the extent of injury or thrombosis, alternative locations may
be required for line placement.
o In particular, obstruction of the SVC (e.g., SVC syndrome) from either
external compression or internal thrombosis should prompt the operator to
use the femoral approach.
Inability to tolerate pneumothorax: (see Figure 5)
o Patients who have undergone pneumonectomy or who would otherwise not
be able to tolerate pneumothorax may not be appropriate candidates for a
subclavian or internal jugular venous line.
o If the line is absolutely necessary, consider using the femoral vein.
o Although the risk for infection is increased by using the femoral location,
there is no risk of entering the pleural space and potentially causing a fatal
pneumothorax.
Clinical Pearls: In the case of a patient who has undergone pneumonectomy or
has severe unilateral lung disease, an ipsilateral subclavian line may actually be
the site of choice.
Assisted ventilation with high end-expiratory pressure: In the event of
pneumothorax occurring in a ventilated patient, high end-expiratory pressure
puts the patient at risk for a persistent air leak or alveolar-pleural fistula.
Contraindications unique to the subclavian approach3,4
o Bleeding disorders: Because the subclavian site is noncompressible, either
the femoral (preferred) or the internal jugular site should be chosen for
patients with substantial bleeding disorders.
o Surgery or trauma to the clavicle, first rib, or subclavian vessels:
Anatomy may be distorted in these situations and make successful
catheterization difficult.
o Administration of thrombolytic medication: If fibrinolytic agents are
being used, central venous catheterization should be avoided if at all
possible because of the risk of hemorrhage. If a central line must be placed,
the femoral approach should be used.
EQUIPMENT
Clinical Pearls: A variety of prepackaged central venous catheterization kits
are commercially available. Although the contents of various kits are for the
most part quite similar, you should be familiar with the devices available at your
institution.
Equipment checklist

See Figure 6.

Central venous catheterization kit. Typical kits contain the following


equipment, all of which is sterile:
o Clear fenestrated plastic drape
o Paper drape
o Chlorhexidine antiseptic with applicators
o 1% lidocaine
o Small anesthetizing needle (25 gauge 1 inch)
o Large anesthetizing/finder needle (22 gauge 1.5 inch)
o Introducer needle (18 gauge 2.5 inch)
o Several syringes, 5 mL each
o J-tipped guidewire with housing and a straightener sleeve
o Scalpel with a No. 11 blade
o Skin dilator
o Catheter (e.g., triple lumen or sheath introducer)
o Gauze pads
o Suture with curved needle
o Disposable needle holder
Sterile gloves, sterile gown, cap, and mask with a fluid shield for each member
of the insertion team **STERILE TECHNIQUE****UNIVERSAL
PRECAUTIONS**
Large sterile drape (half-sheet)
Lidocaine 1% (often provided in the kit, although extra may be required) See
Local Anesthesia for further details.
Sterile saline suitable for injection
Sterile dressing (e.g., Tegaderm, 3M Corporation, Huntingdon Valley, PA)
Catheter selection
o A variety of catheters can be used for central venous catheterization;
the triple-lumen catheter and the sheath introducer are the most
commonly used and are detailed in this chapter.
o Triple-lumen catheters are used when central venous monitoring and/or the
administration of fluids or medications is clinically indicated.
o Sheath introducers are used when transvenous pacemakers or pulmonary
artery catheters must be introduced into the patient. They may also be
used when massive amounts of volume must be infused rapidly.
Clinical Pearls: Triple-lumen catheters should not be used if rapid volume
resuscitation is required. Peripheral IV lines with 14-gauge catheters can infuse
volume twice as fast as a triple-lumen catheter can.4 If peripheral access is not
available and volume infusion is urgent, consider placing a sheath introducer.
Triple-lumen catheter components: (see Figure 7)
o Flexible catheter of various sizes (7 French, 16 cm is typical). The catheter is
typically inscribed with depth markers along its shaft.
o Distal, middle, and proximal infusion channels:
The openings of these channels are visible at the distal (internal) tip of the
catheter, and each has a labeled port at the proximal (external) end.
In most situations, the middle external port corresponds to the distal
channel.
Each channel is usually 16 to 18 gauge in diameter.
o Each external port is supplied with a removable end cap.
The middle cap should be removed before insertion of the line to allow
passage of the guidewire.
Clinical Pearls: If necessary, replace the supplied end caps with the specific
needleless adapters that are used at your institution.
Sheath introducer components: (see Figure 8)
o Single, large sheath catheter (8.5 French, 10 cm is typical). The sheath is
designed to accept transvenous pacemakers and pulmonary artery
catheters.
o A one-way valve assembly on the proximal (external) end of the catheter
through which the pacing or pulmonary artery catheter is inserted. On some
sheath introducers, this valve can be rotated clockwise to tighten it around
the inserted catheter so that it does not move once properly positioned.
o Many sheath introducers have a side-arm port that allows infusion of fluids
through the introducer, even if a catheter is inserted through the main port.
This side-arm may have several ports and an integrated stopcock.
o A sterile sleeve is often included in sheath introducer kits. The sterile sleeve
device connects to the valve assembly and is designed to encase the
inserted device (pacing or pulmonary artery catheter) in a sterile
environment.
The guidewire (see Figure 9)
o The guidewire is used to perform the Seldinger technique, which is described
in detail in the Procedure section. Briefly, the main steps of the Seldinger
technique include
Insertion of an introducer needle into the vessel
Insertion of the guidewire through the introducer needle and into the
vessel
Removal of the needle, with the guidewire left in the vessel
Insertion of a dilator over the guidewire to create a clear passageway for
the catheter
Removal of the dilator

Advancement of the catheter over the guidewire and into the vessel

Removal of the guidewire

o Guidewires are often demarcated with lines every 10 cm to allow estimation
of the depth of insertion.
o Many guidewires have a spring-loaded mechanism on one end that produces
a 180-degree bend at the tip of the wire; they are referred to as J-wires.
The rounded leading edge of the J-wire allows it to bounce off vessel
walls, thereby reducing the risk for vessel perforation.4
A straightener sleeve is included with J-wires. The sleeve facilitates
insertion of the wire into the needle hub.
Clinical Pearls: Some wires may have a soft-tipped straight end on the opposite end of the
wire. They are engineered to be flexible (to avoid vessel injury) and may be used if there is
difficulty passing the J end.4 This type of wire should be used only if you are intimately
familiar with your equipment and the procedure.
ANATOMY

See Figure 10.

Subclavian vein
oAs the subclavian vein crosses the first rib, it lies posterior to the junction
between the medial third and lateral two thirds of the clavicle.
o The vein has a diameter of 1 to 2 cm.
o Connective tissue fixes the subclavian to the first rib and clavicle, and thus
the vein does not collapse in cases of hypovolemia or cardiac arrest.3
o The subclavian arteries are located posterior to the veins and are separated
from them by the scalene muscles.
o The domes of the pleurae of the lungs may extend above the first rib on the
left but rarely extend this far on the right, and thus the right side is often
preferred for line insertion.
o Insertion on the right also avoids the risk of damage to the thoracic duct,
which is located near the junction of the left subclavian and left internal
jugular.
Clinical Pearls: If you are anticipating the use of a transvenous pacemaker or
pulmonary artery catheter, you should use either the left subclavian vein or the
right internal jugular vein. These approaches align the catheter trajectory with
the SVC and right atrium. See Transvenous Pacing for further details.
Two approaches can be used for the subclavian vein, as shown in Table 2 (see
Figure 11).

PROCEDURE
Explain the procedure to the patient. **OBTAIN CONSENT**
Use lay terms to describe why you need to insert a central venous line.
o
Inform the patient/decision maker of the proposed benefits of the
o
procedure, its major risks, and the potential management of any
complications (including insertion of a chest tube, surgery, and
cardioversion).
o If time allows, obtain written informed consent from the patient/decision
maker.
Prepare the patient.
o Place the patient on oxygen, a pulse oximeter, and a cardiac monitor.
o Place the patient in the 15- to 30-degree Trendelenburg position to
prevent air embolism and to distend the vein. See Figure 12.
o Raise the bed to the appropriate height so that you are comfortable reaching
the patient's neck without bending over or stretching. You will be standing at
the head of the bed during the procedure.
Clinical Pearls: Traditional teaching recommends that a towel be placed
between the scapulae to make the scapula more prominent. However, this
practice may compress the vein between the clavicle and first rib and make
catheterization difficult.4

Arm abduction is also commonly recommended; however, this is most likely


unnecessary.4
Gather the equipment.
o Gather all needed materials before starting to avoid breaking the sterile field
in the middle of the procedure.
o It is often helpful to have an assistant present to gather any forgotten items
so that the primary operator can remain sterile.
o Before starting, be sure that all your materials are within reach and arrange
the room for patient and operator comfort.
Sterilize the field. **STERILE TECHNIQUE** **UNIVERSAL PRECAUTIONS**
o After each member of the procedure team has put on a cap and mask with a
face shield, wash your hands thoroughly with antimicrobial soap. See Figure
13.
o Each person should then put on a sterile gown and, last of all, sterile gloves.
o Cleanse the skin in a rectangular area from the suprasternal notch to the
lateral aspect of the clavicle and from the ipsilateral ear to the ipsilateral
nipple with chlorhexidine solution and applicators.
o Chlorhexidine is applied as a surgical scrub, as opposed to serial concentric
circles as typically done with povidone-iodine.
Clinical Pearls: Concurrent preparation of the internal jugular insertion site
during preparation for subclavian insertion allows a timely second attempt if
subclavian catheterization is unsuccessful.
Place the fenestrated drape over the procedure area, with the hole in the
drape centered on the intended insertion site. See Figure 14.
Use the large sterile drape to extend the sterile field down over the rest of the
patient's body.
Prepare your equipment.
o Review all equipment included in the kit.
o It is helpful to lay the equipment out in the order in which it will be used.
See Figure 15.
o Flush all ports of the catheter with sterile saline suitable for injection.
o If using a triple-lumen catheter, attach an end cap to the proximal and
middle port injection ports while leaving the distal port open (the guidewire
is fed through this port).
o Draw up the lidocaine into one of the 5-mL syringes with the larger 22-
gauge needle and then switch to the 25-gauge needle.
o Attach the 18-gauge introducer needle to one of the 5-mL syringes while
keeping the bevel of the needle aligned with the numbers on the syringe.
o The needle should be well attached to the syringe, though not too firmly, or
they will be difficult to separate.
Identify landmarks.
o Palpate where the clavicle bends in an anterior-posterior direction, at the
junction of the medial third and lateral two thirds of the clavicle.
o Select an insertion point:
Infraclavicular: 1 cm inferior to midportion of the clavicle, at the junction
of the proximal and middle thirds of the clavicle
Supraclavicular: 1 cm lateral to the clavicular head of the
sternocleidomastoid (SCM), 1 cm superior and posterior to the clavicle
Anesthetize the insertion site. See Local Anesthesia for further details.
oPlace a wheal of local anesthetic (1% lidocaine) over the insertion site with
the 25-gauge needle and 5-mL syringe. See Figure 16.
o Switch to the 22-gauge finder needle to anesthetize the subcutaneous tissue
and periosteum of the inferior border of the clavicle (the expected route of
insertion).
Locate the vein with the introducer needle (infraclavicular approach).
o With your nondominant hand, place your thumb over the bend in the clavicle
and your index finger in the suprasternal notch. See Figure 17.
o Insert the 18-gauge introducer needle 1 cm inferior to the junction of
the middle and proximal third of the clavicle while aiming slightly
cephalad toward your index finger in the suprasternal notch.
o Maintain a 5- to 10-degree angle relative to the chest wall.
o Insert the needle with the bevel directed inferiorly.
This bevel orientation facilitates proper advancement of the guidewire into
the SVC instead of up the internal jugular vein.
o Slowly advance the needle until it contacts the clavicle.
o Using the thumb on your nondominant hand, slowly push posteriorly on the
needle to help guide it toward the inferior surface of the clavicle.
o Do not change the angle of the needle relative to the chest wall, and keep
the angle of the needle parallel to the floor.
o With the needle still almost parallel to the floor, carefully advance it under
the clavicle while pulling back on the plunger and aiming for your index
finger in the suprasternal notch.
o Advance the needle until a flash of freely flowing dark venous blood (usually
approximately 3 to 4 cm deep) is seen. See Figure 18.
Clinical Pearls: If air is aspirated, the pleura has been violated and the patient
should be evaluated for pneumothorax. Any subsequent attempts at central
access should occur on the same side to avoid bilateral pneumothorax.

If no blood is encountered while inserting the introducer needle, slowly withdraw


the needle while continuing to aspirate (occasionally, you will enter the vein as
you withdraw). If there is no blood return, withdraw the needle to just posterior
to the clavicle, aim more cephalad, and try again. If access is not achieved,
completely remove the needle and flush it before redirecting it slightly more
cephalad.
Locate the vein with the introducer needle (supraclavicular approach).
o Identify the junction of the clavicular head of the SCM and the clavicle.
o Insert the 18-gauge introducer needle 1 cm lateral to the SCM and 1 cm
superior and posterior to the clavicle. See Figure 19.
o Aim toward the contralateral nipple, bisecting the angle of the SCM and
the clavicle.
o Insert the needle with the bevel directed medially.
o Carefully advance the needle while pulling back on the plunger until a flash
of freely flowing dark venous blood (usually approximately2 to 3 cm deep)
is seen.
Advance the guidewire.
o When you are certain that the introducer needle is in the lumen of the vein,
grasp the needle hub with your nondominant hand and detach the syringe
with your dominant hand while taking care to not advance or withdraw the
needle.
o Occlude the hub of the needle with your nondominant index finger to
prevent air embolism. See Figure 20.
o While holding the needle in place with your nondominant hand, use the
other hand to feed the guidewire into the introducer needle hub.
Clinical Pearls: The guidewire assembly has a tapered, plastic sleeve that
straightens out the J at the end of the wire. Make sure that this sleeve is fully
extended over the J to facilitate insertion of the wire into the needle hub.
Use your dominant hand thumb to gently advance the wire into the vessel.
See Figure 21.
Always keep enough wire outside the patient so that the introducer needle can
be removed without losing grasp of the wire.
In general, no more than 15 cm of wire should be inserted because the
right atrium is on average 10 to 15 cm from the subclavian vein.
If the guidewire does not pass with relative ease, stop and recheck for blood
flow with the syringenever force the guidewire.
Clinical Pearls: If you are having trouble advancing the guidewire, withdraw it
slightly, rotate it a bit, and try to readvance it.3

Sometimes, resistance to insertion of the guidewire is met a third of the way in,
at the junction of the subclavian and internal jugular veins. If this occurs, try
increasing the degree of Trendelenburg positioning or turning the head to the
ipsilateral side with the intent of compressing the internal jugular vein.
Never let go of the guidewire once it is placed in the central venous
system; it can migrate into the venous system and require surgical
retrieval.
Prepare for catheter insertion.
o While holding the guidewire in place at all times to prevent migration,
remove the introducer needle.
o Nick the skin with the scalpel to enlarge the puncture site. See Figure 22.
Make sure that your incision is congruous with the hole in the skin that the
needle goes through.
Avoid cutting the guidewire with the scalpel.
Clinical Pearls: Failure to create a large enough nick with the scalpel will result
in difficult (or impossible) catheter insertion. This is especially the case with
sheath introducers.
To insert a triple-lumen catheter:
o Advance the dilator over the guidewire, through the skin and subcutaneous
tissue, and into the vessel. See Figure 23.
o You may encounter some resistance during this step; a slight rotating
motion may be helpful.
o Remove the dilator.
o You may notice more bleeding from the insertion site at this point; this is
normal.
Clinical Pearls: Remember, never let go of the wire during central venous
catheterization!
Advance the catheter over the wire and into the vessel. See Figure 24.
The external portion of the guidewire will protrude from the distal port as the
catheter is advanced.
During this process it is essential to always maintain control of the
wire.
If there is not enough wire external to the patient to protrude through the
distal port, withdraw the wire as needed before further catheter advancement.
Clinical Pearls: The catheter tip should be positioned in the SVC and not the
right atrium. In most adults, the right atrium is 10 to 15 cm from the subclavian
vein. Be sure that the catheter is not inserted deeper than this. Post-procedure
chest radiography will assist with proper depth of placement.
Hold the hub of the catheter with your nondominant hand and remove the
guidewire with your dominant hand.
Attach a syringe and withdraw blood from the port from which the guidewire
exited to confirm location within the lumen of a vein.
Flush the line with sterile normal saline, and place an end cap onto the port.
Flush the middle and proximal ports with saline to ensure patency.
To insert a sheath introducer:
o First, fully insert the dilator into the sheath introducer.
o Unlike the triple-lumen catheter, the sheath introducer and dilator are
inserted in the same step. See Figure 25.
o Advance the dilator and sheath introducer as a unit over the wire and into
the vessel.
o The external portion of the guidewire will protrude from the one-way valve
on the back of the sheath introducer.
o During this process it is essential to always maintain control of the
wire.
o If there is not enough wire external to the patient to protrude through the
valve, withdraw the wire as needed before further catheter advancement.
Clinical Pearls: The sheath introducer is a large catheter, and a considerable
amount of resistance may be encountered during advancement. A slight twisting
motion may be helpful.

Be sure to advance the dilator and the sheath as a unit. If the sheath gets
advanced ahead of the dilator, the leading edge of the sheath may kink, and
proper insertion into the vessel will be unsuccessful.
Once the sheath is fully advanced, remove both the dilator and the guidewire
as a unit.
Turn the one-way valve on the end of the sheath clockwise to close it.
Attach a syringe and withdraw blood from the side-arm port to confirm
intravenous placement, and then flush it with saline.
Final steps
o Take the patient out of the Trendelenburg position.
o Secure the catheter at the insertion site with suture. See Figure 26.
o Cover the site with a sterile transparent occlusive dressing (gauze should
not be used).
o Remove gown, gloves, hat, and mask with face shield. Clean your hands
with antimicrobial soap.
o Order a chest radiograph to check for line placement (the tip of the line
should be in the SVC) and to rule out pneumothorax.

POST-PROCEDURE
CARE
Confirmation of line placement
o Before use, a central venous line must have its placement confirmed with a
radiograph. See Figure 27.
o The tip of the catheter should lie within the SVC and not the right atrium.
Clinical Pearls: The tip of the catheter should be positioned no lower than the
carina to ensure proper placement in the SVC.

The chest radiograph is also critical in evaluating for pneumothorax.


Correct line placement can be further confirmed by return of venous blood
during aspiration of the ports.
Clinical Pearls: Pulsatile blood rising in the tubing suggests intra-arterial
placement. If there is a question about whether the line is in the artery, it may be
transduced.
Dressing changes
o To minimize the risk for nosocomial bloodstream infection from central lines,
the dressing on each line must be changed every 72 hours, or sooner, if it
appears to no longer provide an adequate barrier to entry of organisms.
o The old dressing should be removed, the site cleaned with chlorhexidine, and
the new sterile dressing placed and dated.
o Chlorhexidine has been shown to be superior to ethanol and povidone-iodine
solutions in preventing line infections.5
o Interestingly, changing a line over a wire or starting a line in a new position
has been shown not to decrease line infections.6
o Sterile technique should be practiced throughout the dressing
change. **STERILE TECHNIQUE**
COMPLICATIONS
Infection
o Catheter-related bloodstream infection is the most frequent complication of
central lines; it occurs in approximately 5% of patients with a catheter.7
o The risk for development of an infection can be minimized in several
ways,8 including
Removing the line as soon as it is no longer required for patient care
Practicing sterile technique with barrier protection (e.g., full gown)9
Preferentially using the subclavian vein rather than the internal jugular vein
and either of these veins rather than the femoral vein
Assessing the entry site at least every other day and removing the line at
the first sign of infection
o A catheter-associated infection should be suspected in any patient in whom
bacteremia or sepsis develops after line placement.
Resolution of the infection requires that the central line be removed in most
cases.
The choice of antibiotic should be geared toward the organisms cultured
from blood and the catheter tip.
Bleeding
o Injury to an artery from either the finder needle or the introducer needle can
lead to significant bleeding, hematoma, or hemathorax.
o Accidental entry into an artery occurs most commonly during attempts at
cannulating the femoral vein (9.0% to 15.0%), followed by the internal
jugular vein (approximately 6.3% to 9.4% of attempts) and then by the
subclavian vein (3.1% to 4.9%).10-12
o You can minimize risk by establishing landmarks clearly and keeping your
nondominant hand on the artery during both internal jugular and femoral vein
cannulation.
o Accidental arterial entry is characterized by pulsatile and bright red flashback
in the syringe. If this occurs,
Withdraw the needle and apply firm pressure for 10 minutes over the
puncture site, although this is not as effective in patients undergoing
subclavian cannulation as it is with the internal jugular or femoral approach.
Take the patient out of the Trendelenburg position, if applicable.
Obtain a chest radiograph to rule out hemothorax. Repeat the chest
radiograph in 4 to 6 hours (or sooner if clinically indicated) to ensure that a
hemothorax is not developing.
Check vital signs and radial pulses frequently.
Check a hematocrit immediately and then again in 1 hour.
Attempt insertion on the opposite side or at another location only after the
chest radiograph reveals no pneumothorax.
Clinical Pearls: In a hypotensive/hypoxemic patient, intra-arterial placement
may be difficult to appreciate. If the catheter has been placed and you suspect
arterial placement, you can transduce the pressure or send the blood for arterial
blood gas analysis.
Pneumothorax
o Though uncommon, pneumothorax can be a life-threatening complication of
line placement into the subclavian or internal jugular veins.
o The risk is somewhat higher with cannulation of the subclavian vein (1.5% to
3.1%) versus the internal jugular vein (<0.2%).12
This risk can be diminished by maintaining a shallow angle during insertion
of the needle and by not inserting the needle too deep in a search for the
vein.
o If the patient becomes acutely dyspneic with hyperresonance on the same
side as the recently placed line, needle decompression (or chest tube
placement) should be performed, and an emergency chest radiograph should
be ordered. See Needle Thoracostomy for further details.
A chest tube will then need to be placed once the patient is more stable if
needle decompression was performed previously.
Clinical Pearls: If pneumothorax occurs and central access remains a priority,
subsequent attempts should be made on the same side of the thorax as the
pneumothorax to prevent the development of bilateral pneumothorax.
Thrombosis
o The risk for catheter-related clots varies according to the site of insertion,
with subclavian lines providing the lowest risk (2%), followed by internal
jugular lines (8%) and then by femoral lines (21%).10
o In patients with hematologic and oncologic pathologies, heparin infusion
through the central line decreases the risk for associated clot
formation,13 although this technique has not been demonstrated to be
successful in all patients.
o Any unexplained or asymmetric edema should be investigated with Doppler
ultrasound, and if a clot is found, appropriate anticoagulation should be
initiated.
Air embolization
o Rarely, during insertion of either a subclavian or internal jugular venous line,
air can enter the catheter during a patient's inspiration and travel to the
heart.
o To reduce this risk, you should keep the patient in the Trendelenburg position
during line insertion and occlude the catheter ports at all times.
o If the patient takes a deep breath and sucks air into the catheter or suddenly
decompensates, you should consider an air embolism.
o Quickly occlude the catheter lumen, attempt to aspirate air through it, and
turn the patient to the left lateral decubitus, 30-degree Trendelenburg
position to prevent movement of air into the right ventricular outflow tract.
o Provide 100% oxygen to facilitate resorption of the embolism and consult
cardiac surgery.
Arrhythmia
o Placing a guidewire or catheter into the heart can lead to irritation of the
myocardium and cardiac arrhythmias.
o Patients should be monitored via telemetry during central line placement.
o If an arrhythmia develops, the guidewire or catheter may be in the right
atrium rather than in the SVC.
o Retracting the guidewire or catheter will frequently resolve the arrhythmia.
Myocardial perforation
o Though exceptionally rare, perforation of the myocardium can occur if the
catheter or guidewire is advanced too far into the right atrium.
o Studies have demonstrated that the catheter tip should never be inserted
more than 20 cm into the patient.14
o The development of signs of cardiac tamponade shortly after insertion of a
central line should prompt an emergency echocardiogram.
o If confirmed, tamponade will need to be relieved by emergency
pericardiocentesis in conjunction with cardiothoracic surgery to repair the
perforation.
Nerve injury
o Injury to neighboring nerves (e.g., phrenic, recurrent laryngeal) can occur in
rare circumstances.
o Paralysis of the ipsilateral hemidiaphragm should prompt evaluation of the
phrenic nerve, whereas acute hoarseness should prompt evaluation of the
recurrent laryngeal nerve.
o Neurosurgical consultation may be required.