Help with subclavian lines

[MAC Man]

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Question for you anesthesia veterans. I'm wondering where your sweet spot is for inserting the needle when placing a subclavian lines. Sadly I hit a patient's lung the other day and it has made me question my technique after I had gotten my first 5 in a row before it. I'm starting like a lot of manuals suggest where the lateral 1/3 of the clavicle meets the medial 2/3. I start about 1-2 cm inferior to that spot and advance toward the sternal notch. On all of them I try to slide my needle down the clavicle and bend under the posterior surface.

Any tricks or suggestions?

 

[thegasman]

I like to go to the spot you are talking about 1/3 2/3 on the clavicle, where the "bend" is, and go 1-2 cm inferior and 1-2 cm lateral to this point, hit the clavicle and walk it right under and the vein is almost always right there. I like to aim a little higher than the suprasternal notch, maybe like halfway between there and cricoid. This usually works pretty well, when you can't get it this way you go more medially and your chances of hitting lung go up. I've only done 30-40 of these last year in the icu, and now I'm very comfortable doing these, no pneumos yet. (they say if you do enough everybody gets some though so I know one of these days it is coming -- I'll be calling the surgeons for the chest tube.)

 

[Tenesma]

1) try to always keep the needle parallel to the ground

2) use ultrasound and puncture the subclavian as it becomes the axilary vein - almost impossible to cause a pneumothorax when you are that far lateral...

 

[Mike MacKinnon]

Hey there

I am not a physician (yet) but I do place subclavians on a semiregular basis. Ill attach a nice file here that i use when i teach the procedure.

I couldnt upload the files too big. Email me direct and i will send them to you they are awesome if i do say so myself 😛

Question for you anesthesia veterans. I'm wondering where your sweet spot is for inserting the needle when placing a subclavian lines. Sadly I hit a patient's lung the other day and it has made me question my technique after I had gotten my first 5 in a row before it. I'm starting like a lot of manuals suggest where the lateral 1/3 of the clavicle meets the medial 2/3. I start about 1-2 cm inferior to that spot and advance toward the sternal notch. On all of them I try to slide my needle down the clavicle and bend under the posterior surface.

Any tricks or suggestions?

 

[jetproppilot]

Question for you anesthesia veterans. I'm wondering where your sweet spot is for inserting the needle when placing a subclavian lines. Sadly I hit a patient's lung the other day and it has made me question my technique after I had gotten my first 5 in a row before it. I'm starting like a lot of manuals suggest where the lateral 1/3 of the clavicle meets the medial 2/3. I start about 1-2 cm inferior to that spot and advance toward the sternal notch. On all of them I try to slide my needle down the clavicle and bend under the posterior surface.

Any tricks or suggestions?

Internal jugulars were made for physicians who could not yield the Force. Bow down now, young warrior, and ask Military MD/UT/Jet for THE FORCE and ye shall never compromise pulmonary parenchyma again.

 

[southerndoc]

One of the surgical residents at my medical school taught me an interesting technique. He basically taught to forget the 1/2-2/3 rule. Find where the first rib meets the sternum, place your thumb in that groove, insert the needle 1-1.5 cm lateral to that. Aim for the sternal notch. Dive at a 5-10 degree angle hitting the clavicle, then once you hit it, back up, place pressure on the needle (pushing it down instead of tilting the needle for a steeper approach) and aim toward the sternal notch.

Following his approach, I haven't missed a subclavian yet. No pneumos either (knock on wood). However, you won't find this approach listed in any textbooks (and without someone physically showing you, it might be difficult to follow).

I think subclavians are probably the easiest central line of all. Nearly all patients have the same anatomy.

I wouldn't worry about the pneumo. As someone previously pointed out, if you do enough of them you'll cause a pneumo. The fact that I haven't just means I haven't done enough (maybe a total of 60). The literature supports a 1% pneumo rate. So who knows, you might do the next 200 without causing a pneumo.

Ultrasound-guided lines are nice, but cumbersome. We have to record our ultrasound-guided lines in real-time. That means an extra person at the bedside just to push the record button when you start and then stop it when you finish. It's either that or our ultrasound director gets to sit through a few minutes of "air time" while you finish dilating, suturing the line in, cleaning up the patient, etc.

 

[militarymd]

Sounds like you're doing the right thing...just need more practice. I tend to go just a little medial to the deltopectoral groove.

 

[cchoukal]

If it makes you feel any better, I caused a PTX yesterday during a thoracentesis... I felt like a jackass, but I'm thankful the patient remains asymptomatic (of course, by now he's probably got a hujass tube sticking out of him...).

 

[jetproppilot]

place pressure on the needle (pushing it down instead of tilting the needle for a steeper approach) and aim toward the sternal notch.

.

This is a very, very good trick.

 

[Noyac]

I saw an article in one of the journals last year that looked at the success rate of the subclavian line with regards to different positions of the shoulder. I think the highest success rate was with the arm at the pts side and some traction caudally which pulled the shoulder downward (not totally sure though). The other 2 positions were with the shoulder neutral and with the shoulder raised or pushed cephlad. Your technique is sound but may need some refining. The manuever mentioned above were you hit the clavicle and then put pressure downward with your thumb to push the needle under the clavicle is probably the best but you gotta be careful that you are not too close to the clavicle or it may be difficult to pass the flimsy double or triple lumen line over the wire due to the angle (not sure I explained that correctly) and the resistance of when sliding against the bone. Not a problem so much with the cordis because of the stiffness of the cordis.

 

[southerndoc]

Also, whatever you do, make sure you push the guidewire in and out while dilating. Nothing irritates me more than to see someone push the dilator down and not hold onto the wire and move it in and out a few times. What inevitably happens is the guidewire becomes bent when the dilator tip catches the wire and pins it against some soft tissue (fascia, muscle, etc.). By sliding the guidewire back and forth while dilating, you ensure that this does not happen.

 

[IceDoc]

Ultrasound-guided lines are nice, but cumbersome. We have to record our ultrasound-guided lines in real-time. That means an extra person at the bedside just to push the record button when you start and then stop it when you finish. It's either that or our ultrasound director gets to sit through a few minutes of "air time" while you finish dilating, suturing the line in, cleaning up the patient, etc.

Um....Exactly what is the radiologist going to tell you after he reviews the film?? Something like "No that wasn't a vein, but rather the kidney you catheterized." I think it sounds like a certain department wants to make a little extra cash reading some extra films....so let him fast forward through air time. Just tell him it's TIVO.

During internship (at community hosp) we had a surgeon who exclusively used US in non-emergent lines. He has had very good success with the axillary vein; and he's hasn't had a bleeding complication yet in a small series of line placements in patients with double digit INR's.

Also, Jet, I don't know how, but that blessed pulmonary parenchema has certainly met with a wayward needle during IJ Placements (obviously Ptx incidence is still less than SubClav, but higher than you'd expect)!