Ultrasound Guided Subclavian Line Pearls

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A 50 year old male presents after a significant motor vehicle accident. The reports indicate a prolonged extrication and concern for multiple traumatic injuries. He arrives with cervical spine immobilization and a pelvic binder in place with concerns for pelvic fractures. His initial set of vital signs include: HR 120 bpm, BP 80/50, RR 30, T: 98.5F. On exam in addition to what is noted above, multiple extremities are splinted and there is one 20-guage IV for access. 

As the patient is hypotensive and in need of significant resuscitation, you and your trauma team agree on the need for central access. The internal jugular veins bilaterally are blocked by the cervical collar. The femoral vein sites are not favored when there is concern for pelvic fracture. You decide to proceed with placement of a Cordis in the subclavian vein.

Why choose a subclavian site?

The CDC prefers a subclavian site as opposed to jugular vs femoral in adult patients to minimize infection risk. Also, the clinical scenario may preclude you from using the typical IJ or femoral sites (think trauma situations with c-spine immobilization, pelvic fractures, etc). 

Can I use ultrasound guidance for this line? Should I? Isn't it landmark guided?

ABSOLUTELY you should use ultrasound guidance. There is evidence that there are less complications with ultrasound-guided subclavian as opposed to landmark guided (Fragou et. al). There is especially evidence that ultrasound guidance increases success for those who have less experience with subclavian lines, reduces complications, success at first attempt, etc. 

How do I tell whether I am in the axillary vein or the subclavian vein?

The axillary vein becomes the subclavian when it traverses the lateral margin of the 1st rib.  There is a theoretical increased risk of catheter related thrombosis if the axillary vein is canulated rather than the subclavian, with higher risk the more distal you go.  In reality, it is ok if the central line is placed into the proximal axillary vein.  

What are the complications of subclavian central lines?

Due to the proximity of the great vessels and the pleura, vascular injury and pneumothorax are the most common complications. Brachial plexus injury, hemothorax and hematoma are additional complications.  You can minimize the risk of puncturing the pleura by finding a plane in which the direction of your needle will hit a rib as opposed to the pleura and always visualizing the tip of your needle. You can use power doppler to help differentiate between the subclavian vein and artery as the vein is not going to be compressible at this site. 

Is there a video I can watch that describes how to do this ultrasound-guided?

Yes, there is a great NEJM article and video about ultrasound guided subclavian lines.

Any additional tips and tricks?

Yes, this PulmCrit post does a great job highlighting several ultrasound-related clinical pearls for subclavian lines. It describes the "shrug" technique where shrugging the shoulder pulls the clavicle superiorly and better optimizes the window for subclavian vein access in addition to many other useful pearls.  Consider a towel roll placed under the patient's back to help with subclavian visualization in patient's unable to perform or maintain a shrug.  This PulmCrit article also discusses the use of long axis vs. short axis technique for US guidance, as there are pros and cons to each method. Additionally, a micropuncture kit should be used when available as it can help prevent a number of complications.  

References

  1. Buzançais, G., Roger, C., Bastide, S., Jeannes, P., Lefrant, J. Y., & Muller, L. (2016). Comparison of two ultrasound guided approaches for axillary vein catheterization: A randomized controlled non-inferiority trial. British Journal of Anaesthesia, 116(2), 215–222. https://doi.org/10.1093/bja/aev458

  2. Fragou, M., Gravvanis, A., Dimitriou, V., Papalois, A., Kouraklis, G., Karabinis, A., Saranteas, T., Poularas, J., Papanikolaou, J., Davlouros, P., Labropoulos, N., & Karakitsos, D. (2011). Real-time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients: A prospective randomized study. Critical Care Medicine, 39(7), 1607–1612. https://doi.org/10.1097/CCM.0b013e318218a1ae

  3. “Prevention Strategies.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 5 Nov. 2015, www.cdc.gov/infectioncontrol/guidelines/bsi/background/prevention-strategies.html.

  4. PulmCrit- Shrug Technique for US-guided subclavian lines. (n.d.). Retrieved May 3, 2021, from https://emcrit.org/pulmcrit/shrug-subclavian/

  5. Schulman, P. M., Gerstein, N. S., Merkel, M. J., Braner, D. A., & Tegtmeyer, K. (2018). Ultrasound-Guided Cannulation of the Subclavian Vein. New England Journal of Medicine, 379(1), e1. https://doi.org/10.1056/nejmvcm1406114

Authorship

Written by: Benjamin Duncan, MD, Ultrasound Fellow, University of Cincinnati Department of Emergency Medicine

Peer Review and Posting: Jeffery Hill, MD MEd