Subclavian Central Lines

[Block-Buster]

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I did maybe 2 or 3 of them in residency b/c we did almost all of our central lines in the RIJ under real-time ultrasound guidance. Now I am at a place where the CT surgeon wants only subclavian lines and It's blatantly obvious that I suck at them. Any tips/tricks for me?

 

[deleted87051]

I did maybe 2 or 3 of them in residency b/c we did almost all of our central lines in the RIJ under real-time ultrasound guidance. Now I am at a place where the CT surgeon wants only subclavian lines and It's blatantly obvious that I suck at them. Any tips/tricks for me?

Use real time ultrasound and go lateral.

One of many on YouTube.

 

[caligas]

I did maybe 2 or 3 of them in residency b/c we did almost all of our central lines in the RIJ under real-time ultrasound guidance. Now I am at a place where the CT surgeon wants only subclavian lines and It's blatantly obvious that I suck at them. Any tips/tricks for me?

Weird. Tell us more. What is his reason? Do others in group do subclavians for him?

 

[T-burglar]

I’m curious as to the reason too, especially if it’s left SC. The sternotomy saw can rarely catch the innominate and saw your swan in half. I’m wondering if it’s because patients at your shop keep getting CLABSI?

The axillary vein crosses under the clavicle to become the subclavian somewhere in a less than perpendicular orientation to the clavicle. So if you can ride underneath the clavicle fairly close to PARALLEL to the clavicle bone starting from lateral and aiming at the manubrium, you should get in on the first pass.

 

[Orin]

Just do it like a supraclavicular block

Supraclavicular Subclavian Vein Catheterization: The Forgotten Central Line
Using the Supraclavicular Approach to Ultrasound-Guided Subclavian Vein Cannulation - ACEP Now

 

[deleted162650]

Or infraclavicular block.

 

[Ezekiel2517]

I placed 250-300 subclavian central lines in my fellowship year alone. Pretty pathetic of your program that you only did 2-3 of these. You should learn how to do them without ultrasound first. Such a simple line to place. If you have the choice and there's no contraindication, go with the left subclavian over the right. An easier line to place if you're right handed and less of a chance that the wire crosses over or up the neck. NEJM has a great video on technique you can find online. Middle third of clavicle, get the needle under it, keep it parallel and don't dive the needle down, aim toward the suprasternal notch. Push down on the tissue/fat to help you get the needle under while keeping it flat.

 

[Twiggidy]

Weird. Tell us more. What is his reason? Do others in group do subclavians for him?

I've heard this too. It's mostly post-op comfort for the patient. It's "theorectically 'cleaner'".

If they're doing a CABG then I say it's the best learning opportunity because they'll get into the chest anyway. Find the notch and got 1/3 distal to that point and aim for the notch. Our experienced CT surgeons even sometimes struggle with them. I tend to only do them if I'm struggle with an IJ, the surgeons asks, or if I happen to have extra time before surgical incision and want to give it a try (again, in CABGs)

It's a good skill for the arsenal although yes, most anesthesiologist are better and more comfortable with IJs.

 

[Twiggidy]

I placed 250-300 subclavian central lines in my fellowship year alone. Pretty pathetic of your program that you only did 2-3 of these. You should learn how to do them without ultrasound first. Such a simple line to place. If you have the choice and there's no contraindication, go with the left subclavian over the right. An easier line to place if you're right handed and less of a chance that the wire crosses over or up the neck. NEJM has a great video on technique you can find online. Middle third of clavicle, get the needle under it, keep it parallel and don't dive the needle down, aim toward the suprasternal notch. Push down on the tissue/fat to help you get the needle under while keeping it flat.

It's not unusual. I went to a pretty darn decent residency and fellowship program and the majority of our attendings did whatever they could to avoid doing subclavians. The best chance was at our city hospital where the traumas went and if someone was in a neck brace and needed a CVP that was your chance.

 

[Arch Guillotti]

It's not unusual. I went to a pretty darn decent residency and fellowship program and the majority of our attendings did whatever they could to avoid doing subclavians. The best chance was at our city hospital where the traumas went and if someone was in a neck brace and needed a CVP that was your chance.

Agree, most attendings avoided them like the plague.

 

[Block-Buster]

Weird. Tell us more. What is his reason? Do others in group do subclavians for him?

"patient comfort" is literally his only reason.

 

[deleted126335]

"patient comfort" is literally his only reason.

Maybe lower infection rate. I really didn't like them in the Cardiac rooms. More than once the sternal retractor would kink them rendering them nearly useless. Maybe we had crappy CV surgeons.

 

[urge]

"patient comfort" is literally his only reason.

Patients complain a lot less. It is true.

 

[Cryc_to_the_point]

Ignorant student question:

Why does the surgeon get to dictate (or it appears, have strong influence) over which line you place?

 

[sethco]

I’m curious as to the reason too, especially if it’s left SC. The sternotomy saw can rarely catch the innominate and saw your swan in half. I’m wondering if it’s because patients at your shop keep getting CLABSI?
.

If the Sternotomy saw transects the Innominate, the Swan is the least of my concerns

 

[Twiggidy]

Ignorant student question:

Why does the surgeon get to dictate (or it appears, have strong influence) over which line you place?

Depends on the surgeon and depends on the situation. In private practice they bring the business and if they don't like the service you're providing to their "business" they may take their business somewhere else.

 

[sethco]

In my practice, all of our hearts are done with both a Introducer/PAC and a double lumen central line. We are a high volume Cardiac shop (>3K/year). The thought is to get the Cordis out sooner and still have the double lumen in place for vasoactive meds and definitive IV access. Most of my partners place their Introducer in the Right IJ and their double lumen in the Right Subclavian. A couple of us double stick the Left Subclavian, including myself. Couple of reasons behind this. Patient comfort, lower infection risk, predictable anatomy (aside from persistent Left SVCs), technically very easy are some of the reasons. Obviously, some situations preclude use of Left Subclavian like a Persistent Left SVC, Subclavian Stenosis, or AICD/PPM at site. My tips that I have are choose the Left SC as this has an easier path, place your left middle finger in the sternal notch and your thumb just inferior to about 1/3 of clavicle and then direct needle shallow enough to hit clavicle. Once there, withdraw needle and direct slightly more deeper with your left thumb with your needle advancing to the sternal notch until you get a flash. Trendelburg position is less necessary than for IJ placement, but it does help.

 

[vector2]

Ignorant student question:

Why does the surgeon get to dictate (or it appears, have strong influence) over which line you place?

It's the surgeon's pt, the surgeon is going to manage the lines once out of the OR, and ultimately the pt came to the hospital to get surgery, not anesthesia.

That being said, I'd tell the surgeon to F off with the SC line nonsense. The time savings from 10 flawless SC lines vs R IJ U/S is erased by the delay with the 1 SC where you're dickin' around for 25 min cause you can't get flash or thread the wire. Pt comfort isn't that big of a deal cause the cordis usually comes out day 1 or 1.5 for B&B hearts.

 

[sethco]

Maybe lower infection rate. I really didn't like them in the Cardiac rooms. More than once the sternal retractor would kink them rendering them nearly useless. Maybe we had crappy CV surgeons.

I have never had this happen on a Cardiac case, but had this happen once doing a Lobectomy

 

[T-burglar]

If the Sternotomy saw transects the Innominate, the Swan is the least of my concerns

Well yes it causes all kinds of problems but including immediate loss of maybe your only central venous access

Personally I think RIJ or RSC are the superior sites for sternotomies. Particularly redos. Rare occurrences still occur rarely.

 

[drmwvr]

If the Sternotomy saw transects the Innominate, the Swan is the least of my concerns

Precisely...your a-line on that side will be completely useless...

 

[Maverikk]

This is from the 2015 nejm article on cvc complications.

I did a fair share of SC in fellowship. The vein lies in the deltopectoral groove, easy to palpate even in the morbidly obese. Aim for the top of the sternal notch, walk off the bone. Its like any mechanical skill just need enough to get comfortable. Ive used ultrasound and it hasn't been to useful. The morbidly obese are a challenge, for the bmi>50 youre almost diving down at a 45 which can be uncomfortable. I think the super skinny are at more of a risk of pneumo, less space for error. Heres a trick: put them on 100%, when youre walking off the bone ask the circulator to turn the vent to spontaneous 🙂

 

[Ezekiel2517]

It's not unusual. I went to a pretty darn decent residency and fellowship program and the majority of our attendings did whatever they could to avoid doing subclavians. The best chance was at our city hospital where the traumas went and if someone was in a neck brace and needed a CVP that was your chance.

Well, every anesthesia resident has rotations in the ICU. As a fellow, I was teaching interns and CA-1's to place subclavians nearly every day. There were just so many lines to go around. Many were decently proficient by the end of the month.

 

[Ezekiel2517]

This is from the 2015 nejm article on cvc complications.

I did a fair share of SC in fellowship. The vein lies in the deltopectoral groove, easy to palpate even in the morbidly obese. Aim for the top of the sternal notch, walk off the bone. Its like any mechanical skill just need enough to get comfortable. Ive used ultrasound and it hasn't been to useful. The morbidly obese are a challenge, for the bmi>50 youre almost diving down at a 45 which can be uncomfortable. I think the super skinny are at more of a risk of pneumo, less space for error. Heres a trick: put them on 100%, when youre walking off the bone ask the circulator to turn the vent to spontaneous 🙂

Agree, probably better off avoiding a subclavian in the morbidly obese. Not bc of the pneumo risk but it's just technically more of a pain in the ass. The problem is that you have to compress all that fat tissue to access the vein but eventually you're gonna have to let go and once you do, you often lose your blood return. While doing these with U/S in morbidly obese patients, I have discovered that often times, without significant compression, the needle in the kit isn't even long enough to reach the vein.

 

[sethco]

Precisely...your a-line on that side will be completely useless...

Good possibility that an arterial line anywhere would be completely useless 😉

 

[anbuitachi]

Well, every anesthesia resident has rotations in the ICU. As a fellow, I was teaching interns and CA-1's to place subclavians nearly every day. There were just so many lines to go around. Many were decently proficient by the end of the month.

institution specific. our ICUs pretty much only do IJs. If no IJs then go subclavian. Most people got one usable IJ so rarely do subclavians

 

[Twiggidy]

institution specific. our ICUs pretty much only do IJs. If no IJs then go subclavian. Most people got one usable IJ so rarely do subclavians

It’s risk v benefit. Surgeons have no problem risking a subclavian because if they drop a lung they can just put in a chest tube themselves. For an anesthesiologist an IJ is just a flat out less risky line.

I had an attending who said, “In the CV room do IJ or subclavians with or without an U/S because if you screw up your surgical colleague is there to bail you out, but in the gyn room go IJ with the U/S sound because that surgeon will be useless.”

 

[Ronin786]

It’s risk v benefit. Surgeons have no problem risking a subclavian because if they drop a lung they can just put in a chest tube themselves. For an anesthesiologist an IJ is just a flat out less risky line.

I had an attending who said, “In the CV room do IJ or subclavians with or without an U/S because if you screw up your surgical colleague is there to bail you out, but in the gyn room go IJ with the U/S sound because that surgeon will be useless.”

Personal bias, I think every anesthesiologist should learn to place a CT or pigtail. Subclavian is one specific reason, but really easy to get a PTX in the OR and don't always want to have to rely on a general surgeon to bail you out. Indispensable skill in the ICU as well.

 

[caligas]

Personal bias, I think every anesthesiologist should learn to place a CT or pigtail. Subclavian is one specific reason, but really easy to get a PTX in the OR and don't always want to have to rely on a general surgeon to bail you out. Indispensable skill in the ICU as well.

Probably not realistic for every anesthesiologist to be able to keep this skill up. Angiocath, 2nd intercostal space.

 

[dhb]

SC is a very nice line that every anesthesiologist worth his grain of salt should master.
Chest tubes are easy and fun to place, every resident ought to get tought how to do them.

 

[Ezekiel2517]

institution specific. our ICUs pretty much only do IJs. If no IJs then go subclavian. Most people got one usable IJ so rarely do subclavians

That's ridiculous and it's not institution specific. Your institution's ICU's are not following the current guidelines, which are based on the large amount of evidence/literature supporting subclavians as the first option. It is a US Dept of Health AHRQ quality indicator and is a metric that is followed nationwide in every hospital. In fact, where I trained, it was mandatory to specifically document the reason if we did not place a subclavian.

 

[Ezekiel2517]

Personal bias, I think every anesthesiologist should learn to place a CT or pigtail. Subclavian is one specific reason, but really easy to get a PTX in the OR and don't always want to have to rely on a general surgeon to bail you out. Indispensable skill in the ICU as well.

I agree but it's not realistic. Surgery is always the first ones called when a chest tube is needed. Even during my icu fellowship, I only was able to place a handful of these. That's not nearly enough to be proficient at them. It's not as easy a procedure as it looks. The reason the surgeon makes it looks so slick is bc he's done a thousand of em.

 

[deleted50478]

It's the surgeon's pt, the surgeon is going to manage the lines once out of the OR, and ultimately the pt came to the hospital to get surgery, not anesthesia.

That being said, I'd tell the surgeon to F off with the SC line nonsense. The time savings from 10 flawless SC lines vs R IJ U/S is erased by the delay with the 1 SC where you're dickin' around for 25 min cause you can't get flash or thread the wire. Pt comfort isn't that big of a deal cause the cordis usually comes out day 1 or 1.5 for B&B hearts.

Just prep both, go for the subclavian, if it’s tough do the IJ. If you rarely need to do the IJ I’m sure it’s okay.

 

[anbuitachi]

That's ridiculous and it's not institution specific. Your institution's ICU's are not following the current guidelines, which are based on the large amount of evidence/literature supporting subclavians as the first option. It is a US Dept of Health AHRQ quality indicator and is a metric that is followed nationwide in every hospital. In fact, where I trained, it was mandatory to specifically document the reason if we did not place a subclavian.

I dont work in the ICU. link to the guideline saying first line is subclavian? I couldnt find it with a google search. All i know is here, IJ is first in all the ICUs, as well as the ORs.

SC is a very nice line that every anesthesiologist worth his grain of salt should master.
Chest tubes are easy and fun to place, every resident ought to get tought how to do them.

i would love to do chest tubes. except im not sure where to get the chance to do them. pretty sure none of our graduating class did a chest tube in anesthesiology residency

 

[abolt18]

During our intern year, we do a pulmonology consult rotation in the hospital. I got to do a few bronchoscopies and place a handful of pigtail chest tubes with the 'safetycentesis' kit. It's extremely easy. Watch one and you'll be ready to do it yourself. (I don't think any of my co-interns did any procedures in that month. I just asked to do as much as possible)

I have 'helped' place a couple surgical chest tubes in our CTICU. While I feel like I could probably do one, I definitely wouldn't be very proficient. I hope it's a skill I'll get to learn during residency.

I've placed a good amount of IJs but no SC Central lines. I know that there were a lot of graduating residents from my program who expressed that they had never done a subclavian line. Those that had done them, got the opportunity because they asked attendings to teach them. Those who didn't learn, hadn't pursued it. I intend to pursue it.

 

[Twiggidy]

I agree but it's not realistic. Surgery is always the first ones called when a chest tube is needed. Even during my icu fellowship, I only was able to place a handful of these. That's not nearly enough to be proficient at them. It's not as easy a procedure as it looks. The reason the surgeon makes it looks so slick is bc he's done a thousand of em.

And that’s the reason most anesthesiologist go to line is an IJ because we’ve done literally 1000s of them. As a matter of fact, our surgeons who are slick with subclavians are very vocal about not being great at IJs, even with an ultrasound.

 

[deleted87051]

They are both easy 99% of the time. Nothing that an average anesthesiologist cannot master after a few repetitions.

 

[dhb]

i would love to do chest tubes. except im not sure where to get the chance to do them.

Just start putting more SC lines and you'll have to opportunity to follow with a CT

 

[MirrorTodd]

I've done more subclavians as a med student/resident than IJs. Personally, I feel like I suck with ultrasound so the ease of landmark method with subclavian is appealing to me.

 

[The Shredder]

How are you guys confirming the wire is venous on SCs? I'm a little surprised by the amount of experience with SCs people have here. At major hospitals on both coasts they were definitely the exception vs IJ. Maybe my view is a little shaded by seeing a fellow put a TLC in big red on one of the first SC I ever witnessed

 

[chocomorsel]

I placed 250-300 subclavian central lines in my fellowship year alone. Pretty pathetic of your program that you only did 2-3 of these. You should learn how to do them without ultrasound first. Such a simple line to place. If you have the choice and there's no contraindication, go with the left subclavian over the right. An easier line to place if you're right handed and less of a chance that the wire crosses over or up the neck. NEJM has a great video on technique you can find online. Middle third of clavicle, get the needle under it, keep it parallel and don't dive the needle down, aim toward the suprasternal notch. Push down on the tissue/fat to help you get the needle under while keeping it flat.

This is not uncommon in many residencies as most focus on the UG IJ lines. So no it's not "pretty pathetic" as most residents I bet would be in the same boat. And also we are talking of residency versus fellowship. Come on.

 

[chocomorsel]

That's ridiculous and it's not institution specific. Your institution's ICU's are not following the current guidelines, which are based on the large amount of evidence/literature supporting subclavians as the first option. It is a US Dept of Health AHRQ quality indicator and is a metric that is followed nationwide in every hospital. In fact, where I trained, it was mandatory to specifically document the reason if we did not place a subclavian.

You seem like a know it all. And yes, IT IS institution specific.

 

[Southpaw]

That's ridiculous and it's not institution specific. Your institution's ICU's are not following the current guidelines, which are based on the large amount of evidence/literature supporting subclavians as the first option. It is a US Dept of Health AHRQ quality indicator and is a metric that is followed nationwide in every hospital. In fact, where I trained, it was mandatory to specifically document the reason if we did not place a subclavian.

Your training was very different than mine. I was taught that for reasons of safety an USG IJ was the premier central line, with subclavian being a considerably less ideal option. I did < 5 subclavian lines in residency. However, I watched a surgical fellow do a subclavian once in the OR (after we’d botched the IJ....) and it was a thing of beauty. However, IJ was the go to line in my program.

Were I to start subclavians now I’d do it with US guidance.

 

[sethco]

How are you guys confirming the wire is venous on SCs? I'm a little surprised by the amount of experience with SCs people have here. At major hospitals on both coasts they were definitely the exception vs IJ. Maybe my view is a little shaded by seeing a fellow put a TLC in big red on one of the first SC I ever witnessed

So, I know I am going to get crucified for this, but like all of my partners, I don't use Ultrasound and I don't transduce any of my central lines and I still have never dilated an arterial stick. I have an arterial stick probably 2-3 times per year (still <1%) and you can usually tell when you stick it because it's pumping out in a pulsatile fashion and autofills the syringe without drawing back, assuming that your not severely hypotensive

 

[pgg]

It's absolutely institution dependent.

I'm pretty sure I did exactly zero subclavian lines during my cardiac fellowship. I did a bunch during internship, and a few during residency, and approximately none in practice. They only place I've seen them done routinely was in major trauma, and that was mainly because the surgeon could get one in while we handled the airway.

 

[Southpaw]

So, I know I am going to get crucified for this, but like all of my partners, I don't use Ultrasound and I don't transduce any of my central lines and I still have never dilated an arterial stick. I have an arterial stick probably 2-3 times per year (still <1%) and you can usually tell when you stick it because it's pumping out in a pulsatile fashion and autofills the syringe without drawing back, assuming that your not severely hypotensive

Is there a reason other than culture (i.e. this is what the surgeon expects, what we’ve always done...) that dictates why you do a blind subclavian?

I’m not claiming superiority by any stretch but I’ve never stuck the carotid w USG IJ. After training w US I find carotid sticks to almost be inexcusable.

 

[Psai]

Is there a reason other than culture (i.e. this is what the surgeon expects, what we’ve always done...) that dictates why you do a blind subclavian?

I’m not claiming superiority by any stretch but I’ve never stuck the carotid w USG IJ. After training w US I find carotid sticks to almost be inexcusable.

I dunno, it seems very doable to stick the carotid by accident even with US

 

[sethco]

Is there a reason other than culture (i.e. this is what the surgeon expects, what we’ve always done...) that dictates why you do a blind subclavian?

I’m not claiming superiority by any stretch but I’ve never stuck the carotid w USG IJ. After training w US I find carotid sticks to almost be inexcusable.

Allow me to answer your question with another question. If Ultrasound was not available for whatever reason, would you feel comfortable doing a Central Line? This is the case at multiple places that I do Cardiac. I never used U/S during residency, then when I got to fellowship at a different institution, it was used for all lines. I think it is an important skill to learn for all trainees. Kind of like how Video Laryngoscopy had replaced the need for the vast majority of Awake techniques, but it remains a very important skill to learn

 

[sethco]

I dunno, it seems very doable to stick the carotid by accident even with US

I would also argue that I am less likely to have an arterial stick in the Subclavian position than IJ

 

[MirrorTodd]

How are you guys confirming the wire is venous on SCs? I'm a little surprised by the amount of experience with SCs people have here. At major hospitals on both coasts they were definitely the exception vs IJ. Maybe my view is a little shaded by seeing a fellow put a TLC in big red on one of the first SC I ever witnessed

Transduction is the way I’ve done it.