The Supraclavicular Subclavian Central Venous Cathetherization

• Central venous catheters (CVCs) are routinely placed in critically ill ED patients.
• The literature has clearly demonstrated that CVCs placed in the subclavian vein have lower risks of infection and thrombosis when compared to the femoral and internal jugular vein routes.
• Although we routinely teach the infraclavicular approach, don't forget the subclavian vein can also be cannulated via the supraclavicular approach.
• Some pearls on the supraclavicular approach:
  • Identify the clavisternomastoid angle: formed by the lateral head of the sternocleidomastoid muscle (SCM) and the clavicle
  • Insert the needle 1 cm lateral to the lateral head of the SCM and 1 cm posterior to the clavicle
  • Direct the needle at a 45-degree angle aimed at the contralateral nipple
  • The right side is preferred due to a more direct route to the SVC and a lower pleural dome (decreasing the incidence of pneumothorax)
  • Place the patient in Trendelenburg position and aim the bevel of the needle downward

References

Patrick SP, Tijunelis MA, Johnson S, Herbert ME. Supraclavicular subclavian vein catheterization: The forgotten central line. West J Emerg Med 2009;10(2):110-4.