Is anyone doing subclavian central lines under ultrasound guidance?

[Outrigger]

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Is anyone doing subclavian central lines under ultrasound guidance? I'm sure there will be some people who doubt the need for one. However, I always feel safer sticking a needle tip where I can see the needle tip. Hence, I do virtually all my nerve blocks under ultrasound and I can count on one hand the number of internal jugular veins I've cannulated anatomically and that was only in residency when certain attendings forced me to. I would like to virtually eliminate the chance of a pneumothorax or subclavian artery stick. Another attending recently caused a pneumothorax doing the subclavian approach and I would like my patients to avoid that fate. If you do subclavian catheters under ultrasound guidance, what method do you use? Supraclavicular or infraclavicular? In plane or out of plane? Any tips or tricks? I've not before attempted it, and I've done very few subclavian lines overall.

 

[Bostonredsox]

Is anyone doing subclavian central lines under ultrasound guidance? I'm sure there will be some people who doubt the need for one. However, I always feel safer sticking a needle tip where I can see the needle tip. Hence, I do virtually all my nerve blocks under ultrasound and I can count on one hand the number of internal jugular veins I've cannulated anatomically and that was only in residency when certain attendings forced me to. I would like to virtually eliminate the chance of a pneumothorax or subclavian artery stick. Another attending recently caused a pneumothorax doing the subclavian approach and I would like my patients to avoid that fate. If you do subclavian catheters under ultrasound guidance, what method do you use? Supraclavicular or infraclavicular? In plane or out of plane? Any tips or tricks? I've not before attempted it, and I've done very few subclavian lines overall.

Yes.

Infraclavicular.

You need the combo of a good ultrasound and a non-obese patient. Bad machines mixed with fattys make it real hard for the probe to see deep enough.
I have done maybe 10-12 subclav with US. It does greatly minimize pneumo risk. However I would not call it an US guided line. Its tough to do this on the chest. IMO what I would call what I do in this case is 'US localized subclav, followed by blind stick'. Given the large number of obese patients and the general increased amount of tissue you are pushing through, If I have the US neaby and choose to use it, I stick it on the chest to localize the vessel, bounce my needle on the skin to see it above the vessel, then set the probe down and complete it as I would do blind. This is handy on really frail old ladys who for some reason have non favorable neck anatomy where you are worried the pleura will be really close to the chest wall or on hyperinflated COPD'rs.

That aside <1/4 of my subclavians are with US. If I am taking the time to setup the US I am generally sticking the neck, just a far easier line anyway. Although I am generally sticking the neck on all patients save particular cicumstances anyway. It is a good idea to get familiar with it. as someone pointed out in EM forum, medicare is no longer reimbursing iatrogenic Pneumos. So if you are sticking the chest, AND you have an US, might as well use it. Start trying it on your patients. Play around with the probe and get the feel of it and you'll find its not much different than any other US guided cannulation, save the aforementioned obese patients where you need alot of force to get under the clavicle. That force compresses the tissue and blurs out the image on the fattys.

 

[Mman]

Yes.

You need the combo of a good ultrasound and a non-obese patient. Bad machines mixed with fattys make it real hard for the probe to see deep enough.
I have done maybe 10-12 subclav with US. It does greatly minimize pneumo risk.

The incidence of pneumothorax on skinny easy patients with a subclavian is so low that you can't significantly change the risk by using ultrasound. And in the difficult ones where the risk is higher, the ultrasound is of less utility so it isn't helping that much.

IJs are perfect for U/S guidance. Easy visualization in far > 99% of patients. Subclavians are not ideal for U/S guidance.

 

[urge]

My residents are using ultrasound for everything nowadays: cental lines, a lines, iv's, blocks, epidurals, paravertebrals.....

I guess it is a good thing as long as they don't go to "help" in a 3rd world country without ultrasound machines.

PS: They also use the glidescope heavily.

 

[BobBarker]

Try to do a few and see if you like the angle of your needle diving directly at the pleura.

 

[fakin' the funk]

Our institutional regional guru's technique is to find the view you'd normally use for an infraclavicular brachial plexus block, center the vein, then turn 90 degrees for a long-axis, in-plane approach. Technically you are only seeing the axillary vein at this point, not the subclavian since it's, y'know, under the clavicle.

He is emphatic that you must use the low-frequency, small curvilinear probe.

I have demonstrated these views on myself and on normal-habitus volunteers and patients but never attempted to do a line this way, mostly because the need for a subclavian line and a curvilinear probe have yet to cross paths in my career. Usually all that's around is that sh*tty linear probe that you can't see more than 3-4cm deep with.

 

[Oggg]

I think ultrasound is great for axillary-subclavian lines. It is not as easy as IJ or fem lines with us, true, but You can always see the vein if you have the linear and the curved probes. I've only done one in plane, and i can see its hard to keep the vein in view with a breathing patient. For out of plane, you really need to know the trajectory of the whole vein and you need to follow your tip in realtime by tilting your probe to follow the tip as it advances. So even though I do it out of plane, I'd call it an advanced skill. If your tip shoots past your probe view, you can easily hit lung. in plane is probably a little safer but only of you can hold the image. anyways the axillary-subclavian approach is nice because you hit the vein more laterally, a bit away from lung, and you don't have to worry about skyving under the clavicle. Also you can avoid the artery

 

[dotcb]

I do US guided subclavians and let our residents do them. They were the standard line in the SICU where I trained. Haven't caused a PTX yet.

Favorite study on this:
Real-time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients: A prospective randomized study

Conclusions: The present data suggested that ultrasound- guided cannulation of the subclavian vein in critical care patients is superior to the landmark method and should be the method of choice in these patients. (Crit Care Med 2011; 39:1607–1612)

see also:
http://ultrarounds.com/Ultrarounds/Subclavian_Ultrasound.html

 

[deleted126335]

Our institutional regional guru's technique is to find the view you'd normally use for an infraclavicular brachial plexus block, center the vein, then turn 90 degrees for a long-axis, in-plane approach. Technically you are only seeing the axillary vein at this point, not the subclavian since it's, y'know, under the clavicle.

He is emphatic that you must use the low-frequency, small curvilinear probe.

I have demonstrated these views on myself and on normal-habitus volunteers and patients but never attempted to do a line this way, mostly because the need for a subclavian line and a curvilinear probe have yet to cross paths in my career. Usually all that's around is that sh*tty linear probe that you can't see more than 3-4cm deep with.

Why will the big curvillinear probe not suffice?

 

[urge]

I do US guided subclavians and let our residents do them. They were the standard line in the SICU where I trained. Haven't caused a PTX yet.

I have done hundreds, if not more, without US and have not had a pneumo either.

 

[ProwlerturnGas]

Have been doing all US guided subclavian (actually more like axillary-subclavian as the line tends to enter more laterally) lines since 2009. I have gotten to be pretty fast with them.

 

[ProwlerturnGas]

to find the view you'd normally use for an infraclavicular brachial plexus block, center the vein, then turn 90 degrees for a long-axis, in-plane approach.

This is the way I do them as well. First out of plane view to see all the structures, then rotate 90 deg to in plane. Watch the needle go into the vein.

 

[somedumbDO]

Did sonosite sponsor the research... Honestly, I think it can be useful and have done it a time to two on difficult lines but are we creating a generation that can't do anything without some fancy gadget? There are a lot of places both in the states and abroad that don't have these luxuries. I sincerely hope residents are doing landmark tech (regional & lines) plus nerve stim blocks, using different drugs ie ketamine, brevital, ect. Or you may be in a very difficult situation later in your career.

I do US guided subclavians and let our residents do them. They were the standard line in the SICU where I trained. Haven't caused a PTX yet.

Favorite study on this:
Real-time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients: A prospective randomized study

Conclusions: The present data suggested that ultrasound- guided cannulation of the subclavian vein in critical care patients is superior to the landmark method and should be the method of choice in these patients. (Crit Care Med 2011; 39:1607&#8211;1612)

see also:
http://ultrarounds.com/Ultrarounds/Subclavian_Ultrasound.html

 

[Oggg]

Even our cardiac surgeons who do pacemakers have trouble getting access occasionally. Lots of subclavian artery sticks. Getting a flash and not being able to wire. I bailed one surgeon out with the ultrasound. It's true, they don't hit the lung much (I don't remember ever seeing one).

 

[dotcb]

The article is from Athens, Greece. No industry sponsorship.

Did sonosite sponsor the research... Honestly, I think it can be useful and have done it a time to two on difficult lines but are we creating a generation that can't do anything without some fancy gadget? There are a lot of places both in the states and abroad that don't have these luxuries. I sincerely hope residents are doing landmark tech (regional & lines) plus nerve stim blocks, using different drugs ie ketamine, brevital, ect. Or you may be in a very difficult situation later in your career.

 

[OB1🤙]

I do a ton of subclavian lines for my hearts. Next week I'm gonna try to start doing them under u/s. I scanned my own subclavian/axillary area for orientation, seems fairly straightforward.

I'll let you all know how it goes.

 

[pseudoknot]

Try to do a few and see if you like the angle of your needle diving directly at the pleura.

Agreed. The angle for an infraclavicular subclavian with ultrasound is just much more dangerous and I am not convinced that this is a good idea.

The supraclavicular approach can be great if you can get a good view, but again this can be tough on fat people.

 

[nimbus]

Did sonosite sponsor the research... Honestly, I think it can be useful and have done it a time to two on difficult lines but are we creating a generation that can't do anything without some fancy gadget?.

In the 1980s they were saying this about capnography and pulse oximetry. US is a game changer as is video laryngoscopy.

 

[urge]

In the 1980s they were saying this about capnography and pulse oximetry.

True

US is a game changer

Maybe

as is video laryngoscopy.

Not sure on that one.

 

[Mman]

In the 1980s they were saying this about capnography and pulse oximetry. US is a game changer as is video laryngoscopy.

While ultrasound is amazing technology and I believe it will be considered standard for some things, but subclavian lines will not be one of them. Just because you can use U/S for something doesn't mean it is always better to do it.

IJ under ultrasound? Yes, great stuff. Supraclavicular nerve blocks? Please.

Subclavian line? No thanks. Classic sciatic? No thanks. Popliteal sciatic? Definitely!

 

[TrustMe]

I have done some with U/S and feel comfortable doing them with U/S guidance. I generally reserve it for patients that I specifically want a subclavian line but they have some sort of contraindication (usually full anticoagulation). Although, I feel like doing subclavians under landmark only is becoming a lost art (especially amongst anesthesia residents/staff). Unless contraindicated, I only do subclavian lines and I suggest (read "insist") that residents working with me place subclavians as well. I am trying to introduce residents in the ICU to U/S guided subclavians, but we currently only have a POS U/S for the unit I am in so it generally doesn't work-out too well. All of the residents I currently work with in the ICU are surgery residents and they do mostly subclavians anyway, so only adding the U/S approach to their knowledge base.

 

[BLADEMDA]

Anyone doing out of plane axillary/subclavian central lines? For those of us doing infraclavicular blocks under u/s on a routine basis how hard is it to stick the vein out of plane? It would seem fairly easy and the needle would be easily seen as it enters the vein. Finally, is it easier to stick the vein slightly more medial than our traditional infraclavicular block location? Is the vein larger a few cm more medial?

 

[glorfindel]

I've changed to doing US-guided subclavians with a supraclavicular approach. I've found it a lot easier in fat people than the infraclavicular approach. Using the color doppler makes things easier.

http://www.youtube.com/watch?v=I3Jqbxa1_Ts (this is the standard sonosite youtube video of this approach)

Even real fat people in C-collars can be imaged for this if your US machine has a few different probes. If the US machine is broken, the landmark approach for this is also really straightforward so long as you slide the needle just deep to the clavicle and don't stick too deep.

 

[Oggg]

Ooooooo I like this video on supraclavicular subclavian lines. I gotta try this. Do you think a right supra-subclavian PA catheter would be hard I float?

 

[VentdependenT]

i am doing U/S guided infraclavicular SC lines with more regularity now. less scary on intubated pts. I had an ultrasonographer walk me through the vascular anatomy w/wo doppler then I just went for it. Now I love using U/S for these lines.

I havent done supraclaviculars but supposedly its an old tried and true line. decent articles on them. If Im going that high/close on/close to the neck I do IJ.

All this being said landmark guided lines are still my favorite. nearly NO ONE at my hospital does them.

 

[Bostonredsox]

i am doing U/S guided infraclavicular SC lines with more regularity now. less scary on intubated pts. I had an ultrasonographer walk me through the vascular anatomy w/wo doppler then I just went for it. Now I love using U/S for these lines.

I havent done supraclaviculars but supposedly its an old tried and true line. decent articles on them. If Im going that high/close on/close to the neck I do IJ.

All this being said landmark guided lines are still my favorite. nearly NO ONE at my hospital does them.

I have only been using US for my sublavs if I attempted an IJ which failed because of clot or anatomical problem and already have the US out. >2/3 of my subclavs are still landmark based only. Just feels right to do it that way, same as fem. I can do IJ via landmarks, cardio made me do it that way in cath lab for a pacer we put it in 'becasue he wanted me to know how to do it blind if ever needed'. But I find it scary. Do not ever plan on not using US for IJ again (though it went fine). Subclav just feels natural to do by landmarks and 'the feel of the clavicle". Although I am sure the surgeons and gas guys said the same thing about IJs 15 years ago.

 

[lushmd]

Although I am sure the surgeons and gas guys said the same thing about IJs 15 years ago.

Some even say it now...

 

[Bostonredsox]

Some even say it now...

haha yeah that is why I had to that pacer line without US. Old time cardiologist wanted me to know the anatomy. I said ok if your gonna take the blame if I hit the carotid, would take 6 min with an US...went fine but still. Lot of oppostion from old timers who cant use US, but far less opposition to IJ than subclav.

 

[BobBarker]

Blind IJ shouldn't be "scary". Put the fingers of your left hand on the carotid, press, pull it medically, and stick the needle where your fingers were.

 

[OB1🤙]

That supraclavicular stuff is cool and all, but jeez, I'm just gonna do the IJ if I'm up there.

Maybe I'll try it for poops and giggles, but I'm imagining the looks the ICU nurses would give me. On second thought, maybe I'll do it just to mess with them.

I can hear the conversation now-

"What the hell is that?"
"A subclavian line."
"But.... but....."
"I know. It's a supraclavicular subclavian line."
"But.... but...."
"OK, it's just an IJ."
"Oh OK good."

 

[Oggg]

Maybe supraclav subclavian lines are cleaner than internal jugular lines?

Looks like the in plane supraclav would be easier than an in plane int jugular in someone with a short neck.

 

[lushmd]

Blind IJ shouldn't be "scary". Put the fingers of your left hand on the carotid, press, pull it medically, and stick the needle where your fingers were.

Agreed, it shouldn't be scary. Alternatively, try a so called "no touch" technique (without palpating the carotid) using a 21G finder needle before the 18G angiocath/thin wall metal needle.

 

[Bostonredsox]

Agreed, it shouldn't be scary. Alternatively, try a so called "no touch" technique (without palpating the carotid) using a 21G finder needle before the 18G angiocath/thin wall metal needle.

I have seen many videos on this. palpating, pulling, sticking a finder needle then a larger 18 behind it, etc etc...it takes me 90 seconds to sleeve the US and just slam it in. No reason to ever do it blind. I suppose there are places that have no US at all and thus you have to do it blind, but if thats the case, I am more comfortable sticking the chest blind with a risk of pneumo, which I can fix, than sticking the neck blind, with a chance of dissecting a carotid, which I cannot fix. And yes I realise the finder needle leaves a small hole that you can compress but still. Id rather just stick the chest blind than the neck. Just me.

 

[Arch Guillotti]

I have seen many videos on this. palpating, pulling, sticking a finder needle then a larger 18 behind it, etc etc...it takes me 90 seconds to sleeve the US and just slam it in. No reason to ever do it blind. I suppose there are places that have no US at all and thus you have to do it blind, but if thats the case, I am more comfortable sticking the chest blind with a risk of pneumo, which I can fix, than sticking the neck blind, with a chance of dissecting a carotid, which I cannot fix. And yes I realise the finder needle leaves a small hole that you can compress but still. Id rather just stick the chest blind than the neck. Just me.

This isn't always an option for anesthesiologists. If a crashing patient needs a central line under the drapes, a subclavian really isn't an option. Also, the u/s may not be readily available.

 

[Bostonredsox]

This isn't always an option for anesthesiologists. If a crashing patient needs a central line under the drapes, a subclavian really isn't an option. Also, the u/s may not be readily available.

to me this is synonomous with 'they get a fem line'. There is no substitute in a crashing pt. Nothing is faster then an emergent fem. Although I suppose in the OR with patients draped the groin isnt as easy for you to access as the neck so I see your point.

 

[VentdependenT]

Sticking the neck w/o US for the first time IS scary.

I taught the OBGYN intern covering for the MICU how to do IJ without US and yes, he was justifiably nervous.

Palpate carotid at level of cricoid. Go lateral to that with 22g finder. Leave that needle in then follow its trajectory with the 18g. He nailed it first shot and he had a big fat grin under that mask.

 

[glorfindel]

I can hear the conversation now-

"What the hell is that?"
"A subclavian line."
"But.... but....."
"I know. It's a supraclavicular subclavian line."
"But.... but...."
"OK, it's just an IJ."
"Oh OK good."

I have had that exact conversation.

 

[Bostonredsox]

Maybe supraclav subclavian lines are cleaner than internal jugular lines?

Looks like the in plane supraclav would be easier than an in plane int jugular in someone with a short neck.

My IJs are pretty close to supracliv subclavs. I stick as close to the clavicle as I can be while still being in the IJ. It is purely preference no data behind it, but I have noticed that awake patients and vented patients once they are extubated, find the more caudad line to be less obtrusive than the more cephalad stick point. I stick more near where the IR guys put in the IJ permcaths and then I curve the 3-4 extra cm of line off to the side and put two sutures in that so it forms a straight line somewhat running laterally along the superior edge of the clavicle. Seems to bother them alot less when they turn their heads and such. This is also why when a floor pt needs a line for whatever reason and they are completely awake and mobile, I generally give them a left suclav and make a nice "C-curl" with the extra wire. Seems more comfortable under their gown on their chest than in their neck.

 

[Oggg]

What is a C curl?

 

[VentdependenT]

Its like a donkey punch with a slap-shot twist

 

[glorfindel]

I call it "scrunching up the excess and taping it to the patient."

Bostonredsox just does it more elegantly.

 

[Bostonredsox]

I call it "scrunching up the excess and taping it to the patient."

Bostonredsox just does it more elegantly.

Lol essentially. Though I like the donkey punch analagy better. Basically most subclavs are shorter than IJs especially if on the right. I do left if possible, its just easier right handed, or feels more natural I should say, and leave the line at about 16cm. The line is coming out of the chest sort of parallel to the clavicle. I curve the extra 6cm or so in a sort of backwards C and put two sutures in the end. The other two are through the blue/white caps at the 16cm insertion site. I always use 4 sutures as you can still yank a line out from the blue and white caps if the actual end-triangle pieces isnt sewn. (I watched a 17 y/p brand new nurses aid/transporter yank one of my fresh swans out getting a pt on an elevator even with all 4 sutures in place..) This nice little C on the right, backwards C on the left, is compact and entirely on the chest and seems to be less obtrusive.

But as the Elf lord said, you can just scrunch up the extra 6 cm and stick gauze and a dressing over it. I just like when they look neat and clean and it only takes me 30 extra sec to do this.

 

[TrustMe]

The neatest way is to get a catheter that is the appropriate length and put it all the way in (I.e. 16cm on right and 20cm on left, whether IJ or SC). My new hospital only stocks 20cm catheters and I HATE it. Use the appropriate length catheter and you don't have to worry about using the blue/white snaps or making a "C". Just hub it and suture it in place. Another reason I do almost all left SC now. Hub it, suture it, dress it. Looks nice and neat.

 

[Bostonredsox]

The neatest way is to get a catheter that is the appropriate length and put it all the way in (I.e. 16cm on right and 20cm on left, whether IJ or SC). My new hospital only stocks 20cm catheters and I HATE it. Use the appropriate length catheter and you don't have to worry about using the blue/white snaps or making a "C". Just hub it and suture it in place. Another reason I do almost all left SC now. Hub it, suture it, dress it. Looks nice and neat.

We only have 20cm catheters. And a 20cm in the left subclav in a 5'2 old lady is almost always in the RV. So In those pts I am usually around 16-17. 5'10 male...I bury it.

 

[Oggg]

My axillary subclavian lines don't make it to the RA. (all 16cm)

 

[OB1🤙]

Earlier this week had a pretty good sized guy, I scanned for the axillary vein but it was deeeep, so I didn't go for it. Did my usual blind subclavian with echo wire confirmation.

Today had a tiny little ol' lady, and it worked well. The vein was easily identifiable. But jeesh, the needle direction you have to take is pretty hair-raising.

I'll try a few more before I decide which technique I like better. Early money is on blind.

 

[Bostonredsox]

Earlier this week had a pretty good sized guy, I scanned for the axillary vein but it was deeeep, so I didn't go for it. Did my usual blind subclavian with echo wire confirmation.

Today had a tiny little ol' lady, and it worked well. The vein was easily identifiable. But jeesh, the needle direction you have to take is pretty hair-raising.

I'll try a few more before I decide which technique I like better. Early money is on blind.

I also prefer blind. It just feels natural. I think of it as turning on a light in a dark room, getting a look, then turning it off and walking in. I don't do Us guided subclav like IJ, I do more of a US localized subclav, get a quick pick of where the vessel is, then proceed without the US. That's how a surgeon first described it to me, you are less likely to walk into a dresser if you flip a light on in a dark room, look quick, then flip it off and walk in then jus walking blind. Don't need to necessarily have it on while you walk in. So I have taken to calling it US localized subclav vs US guided IJ where I directly see cannulation and wire placement.

 

[Idiopathic]

Our institutional regional guru's technique is to find the view you'd normally use for an infraclavicular brachial plexus block, center the vein, then turn 90 degrees for a long-axis, in-plane approach. Technically you are only seeing the axillary vein at this point, not the subclavian since it's, y'know, under the clavicle.

He is emphatic that you must use the low-frequency, small curvilinear probe.

i didnt read the rest of the thread, but i treat it like a brachial plexus block in this region, although i do it out of plane, but I dont think you MUST do it that way, as long as you are reasonably good at approximating depth. barring that, you probably should do it in plane, as you will see your needle the whole way (ideally).

absolutely on the probe. i refuse to use the vascular probe for IC blocks and i would refuse to use it for SC CVL as well.

i dont routinely do US guided SC lines though, only when patient habitus is an issue. Sometimes Ill just scan for the vein and make sure it has an appropriate anatomical position relative the corresponding artery.

 

[Oggg]

In a thin or slim patient, a linear probe will find your target vessel and deeper pleura just fine. If you are going out of plane, the linear probe is great. In plane is tougher because the artery goes from shallow to deep, and the needle angle is steep. But it's still doable. The only time I break out the curved probe is when I need more than 6cm depth (HFL38 max depth).