Preventing complications of subclavian vein catheterization

Supraclavicular approach to subclavian catheterization: review of the literature and results of 178 attempts by the same operator

Over a period of 15 months, 178 consecutive attempts at supraclavicular catheterization of the subclavian veins were performed by the same operator. There were 42 additional central lines inserted during this period, which were placed via other methods as specified by the attending physicians. Results of the supraclavicular approach are presented and are believed to be the largest reported series of supraclavicular line insertions by one operator. Forty-five of the supraclavicular lines were placed after failed attempts by other emergency room and surgical physicians. Five were inserted in patients that were in hypovolemic shock, and three were placed in morbidly obese patients weighing 800, 400, and 335 pounds. Of the 178 attempts, there was only one significant complication: a left-sided pneumothorax on the 21st attempt in an emphysematous patient. The vein was successfully accessed in 177 cases with only two instances of inability to thread the catheter and one instance of malposition. Overall, there was satisfactory placement in 97.8% of attempts with a significant complication rate of 0.56%. This paper intends to describe the details of subclavian venipuncture by the supraclavicular technique, and, because of the high degree of reliability and safety of this technique in experienced hands, to recommend it as an excellent alternative for central venous access --especially in difficult cases.

A comparison of the supraclavicular approach and the infraclavicular approach for subclavian vein catheterization

Five hundred emergency department patients requiring subclavian vein catheterization were randomized prospectively into one of two groups, supraclavicular or infraclavicular. If catheterization was unsuccessful in a few attempts using the randomized approach, catheterization with the alternate approach was attempted. Two catheters were available for use, a short, 8-French introducer and a long, 16-gauge catheter. There were 38 failures (15.5%) among 245 patients in the supraclavicular group, with one malposition and five complications. There were 51 failures (20.0%) among 255 patients in the infraclavicular group, with 21 malpositions and 13 complications. No differences were significant except that of malpositions (P less than .01). The combination of infraclavicular approach and 16-gauge catheter accounted for 21 of 22 malpositions. When catheterization by the randomized approach failed, catheterization by the alternate approach was successful in all but seven cases, resulting in an overall success rate of 98.6%. Analysis of this series suggests that both the infraclavicular and supraclavicular approaches to subclavian vein catheterization are acceptable alternatives, with little difference in success rate or complications. Using an alternate approach if the initial approach was unsuccessful produced a high overall success rate and a low overall complication rate. A physician who is familiar with both approaches will be more successful at placing central venous catheters safely.

Major complications of percutaneous subclavian vein catheters

New and reportedly safet techniques for subclavian venipuncture with the passage of central venous catheters appear regularly in the surgical literature [55--59]; yet reports of major complications continue to appear as well. We have reported on eight patients with major complications of percutaneous subclavian vein catheters, two of whom died. In our own hospital an improved educational program for junior house staff and nurses has been instituted. Better supervision of junior house staff when performing this potentially lethal technique is necessary. Daily inspection of catheters, early removal of unnecessary catheters, and improved equipment should help to prevent these complications in the future.