Please see the Annals of B Pod article on central line placement in order to review indications for this procedure and how to select an appropriate catheter.


Selecting an Insertion Site

Subclavian Insertion Site - by Jeffery Hill, MD MEd.  This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

 

 

Preparation

  • Assess the anatomy of the selected insertion site and evaluate it using ultrasound prior to starting procedure.
  • Identify necessary PPE- wash hands, wear cap, mask, sterile gown, and sterile gloves.  Use sterile probe cover for the ultrasound.
  • Clean the insertion site with chlorhexidine.
  • Place a full drape on the patient.
  • Maintain sterile field throughout the procedure.
  • Prepare equipment including flushing lines and placing caps on the ports.

Vessel Cannulation

  • Identify the needle insertion site that will allow cannulation of the desired vein.
  • Anesthetize the area over the insertion site.
  • Insert and advance the needle while continuously aspirating.
  • Follow the needle tip into the vessel using ultrasound guidance.  Needle visualization is a critical micro skill in the performance of any ultrasound-guided procedure.  Please watch this video from Dr. Stolz on how to improve your needle visualization.
  • Successfully cannulate the vessel and ensure free return of dark red, non-pulsatile blood.
  • Stabilize the needle while disconnecting the syringe.

Threading The Wire

  • Insert guidewire through the needle to a depth of 20 cm.
  • Remove needle while maintaining control of the guidewire.
  • Confirm guidewire is in the vessel using ultrasound.

Dilating the Vessel and Subcutaneous Tissues

  • Make small skin incision adjacent to the guidewire.
  • Advance dilator over the guidewire and into skin with a twisting motion while maintaining control of the guidewire.
  • Ensure the guidewire moves freely within the dilator, then remove dilator.

Advance the Catheter over the Guidewire

  • Advance catheter over the guidewire and into the vessel to the appropriate depth for the selected insertion site.
  • Remove guidewire and keep the brown port covered to prevent air entry until a cap can be placed on the brown port.
  • Aspirate and flush each lumen.

Securing the Line

  • Suture the line in place at the blue/white clips and the triangular holder.
  • Add biopatch and place a sterile dressing.
  • Obtain CXR following the procedure. 


References

  1. Kim, Won Young et al.  (2012) Optimal insertion depth of central venous catheters—Is a formula required? A prospective cohort study. Injury , Vol. 43(1), 38-41.

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