Subclavian Venous Cannulation Made Easy (Step by Step)

Indication

1. Measurement of CVP

2. Drug administration

3. IV access for fluid therapy or TPN)

Complication

1. Hemorrhage (Arterial puncture/ cannulation, AV Fistula formation)

2. Air embolism

3. Pneumothorax, hemothorax, Chylothorax

4. Phlebitis, thrombus formation

5. Bacterial colonization.

Contraindication

1. Absolute

- Infection at infected site

- Significant tricuspid regurgitation

- Renal cell cancer involving right atrium

2. Relative

- Coagulopathy

- Ipsilateral carotid endarterectomy

- Newly inserted cardiac pacemaker leads.

Steps

1) If possible, get the written consent, check the coagulation profile and platelet

2) Position the patient; supine with one pillow. Head down tilt if there is volume depleted

3) This is sterile procedure, therefore when all stuff you need is ready, wash your hand, wear gown and sterile gloves (Other material needed; lidocaine 1-2% 5-10 ml). Assemble the catheter and flush all lumina with saline

4) Clean the area with poviderm and spirit or chlorhexidane

5) Put the surgical tower and identify the insertion point. I cm below the point of medial 1/3^rd and lateral 2/3^rd. nick the point with scalpel.

6) Give local anesthesia with 5-10 ml of 1-2% lidocaine under the skin and subcutaneous tissue, down the clavicle.

7) Puncture the skin with introducer needle connected to syringe filled with hep-saline (You may modify the technique if want to take blood sample. You may flush it later after obtaining blood sample). Advance your needle to the clavicle by aiming at the direction of sternoclavicular joint. Once you hit it, draw it and hit again lower than your first spot until you enter the vein. This method will reduce the risk of puncturing the pleura.

8) Remove the syringe but keep the needle still. Secure the needle with your hand and close it opening to avoid leaking of blood.

9) Advance the guide wire and at the same time keeping the needle

10) Break the yellow cap to remove the introducing needle

11) flush it with Hep-saline and make sure that the line is functioning

12) Remove the trochar carefully. make sure the line is not moving

13) Now remove the guide wire and measure it from right atrium to the IV site. adjust the line accordingly

14) secure the line by suturing it.

15) You are nearly ready now.

16) Cover it with Opsin.

17) Connect it to the fluid and lower the tube to see whether it is funtioning and to confirm that you enter the vein. if there is backflow of blood with dark colored blood, it means that you're in. if it is backflow with bright red blood and spurting in nature, then it is in artery, therefore you need to reinsert again.


18) Order a cxr to confirm that the canulla is in position.

reference; Oxford Handbook of Clinical Medicine 7th edition.

Special thanks to Dr Izzani, MMED Surgery Dept.