Subclavian Vein
Unlike the IJ, and less commonly the femoral, which commonly collapse with probe or needle pressure, the subclavian vein is attached via its anterior wall and thus avoids these difficulties. Subclavian vein catheterization has classically been a landmark technique. More recently, ultrasound-guided techniques have been reported.
Supraclavicular Visualization, Infraclavicular approach
Positioning:
Mild Trendelenburg with the head in a neutral position
Infants may benefit from a shoulder roll for better extension
Pulling the ipsilateral arm towards the hip may help straighten the vein
The probe overlies the clavicle and first rib to optimize longitudinal SVC size
Technique:
The procedure is performed in-plane with direct visualization of the need advancing infraclavicularly through the anterior wall of the SVC and intraluminally
Some potential drawbacks are:
Shadowing from the clavicle may obscure some portion of the needle as it is advanced
Advancing the needle distant from the probe may make in-plane visualization challenging
Risks:
General risks: bleeding, infection, possibly arterial injury
Pneumothorax; Non-compressible bleeding; Hemothorax; DVT
“Pinch off” syndrome—cannula kinking traversing between the 1st rib and the clavicle.
Supraclavicular Visualization, Supraclavicular Approach
Positioning:
Similar to the above mentioned
Technique:
For those that feel comfortable doing supraclavicular brachial plexus blocks:
When the subclavian artery and the nerves are visualized, the probe is advanced medially until IJ is visualized transversely, then tilted to show a more anterior window (probe tail towards the bed, ultrasound beam more anteriorly into the thorax) until the SCV is identified
Performed in a supraclavicular approach with in-plane needle advancement with continuous visualization of the needle, the vessel, and the pleura
In neonates, one may have to place the probe across the midline to accommodate the ultrasound probe and to visualize all the relevant structures.
Risks:
General risks: bleeding, infection, possibly arterial injury
Pneumothorax; Non-compressible bleeding; Hemothorax; DVT
The infraclavicular approach was initially described by Pirotte et al. In their study, researchers found a first attempt success rate of 84%, with an ultimate success rate of 100% using the infraclavicular approach. Just a few years later, a ultrasound-guided supraclavicular approach to the subclavian vein was described. In their study, Rhondali et al had similar success rates (first attempt 81%, ultimate success 100%), while also better continuous visualization. Perhaps most importantly, by avoiding traversing between the first rib and the clavicle, the supraclavicular approach also avoids the potential for the catheter to kink over time as it courses under the clavicle. The supraclavicular approach has also been used in even the smallest of our patients. In a study of low birth weight infants, Lausten-Thomsen et al had an overall success rate of 97.3% in infants < 2500 g.
In a prospective, randomized trial comparing both techniques, Byon et al found the supraclavicular approach yielded a shorter puncture time (20 seconds faster) and decreased the incidence of guidewire misplacement (unintentionally advancing the guidewire cephalad into the ipsilateral IJ) when compared with the IC approach (0 vs 20.4%). The infraclavicular approach was also 4x more likely to require >3 attempts. So, while though they may have similar success rates and the supraclavicular approach may be quicker (though clinically irrelevant), the supraclavicular approach offers some relevant advantages. The supraclavicular approach allows for continuous visualization of the advancing needle, is associated with few overall attempts, and avoids the potential for “pinch-off syndrome,” or kinking of the catheter as it passes between the first rib and clavicle.
Unless there is a contraindication to perform this via a supraclavicular approach, I know which I will be performing.
Pirotte, T. and Veyckemans, F., 2007. Ultrasound-guided subclavian vein cannulation in infants and children: a novel approach. British Journal of Anaesthesia, 98(4), pp.509-514.
Rhondali, O., Attof, R., Combet, S., Chassard, D. and de Queiroz Siqueira, M., 2011. Ultrasound-guided subclavian vein cannulation in infants: supraclavicular approach. Pediatric Anesthesia, 21(11), pp.1136-1141.
Lausten-Thomsen, U., Merchaoui, Z., Dubois, C., Eleni Dit Trolli, S., Le Saché, N., Mokhtari, M. and Tissières, P., 2017. Ultrasound-guided subclavian vein cannulation in low birth weight neonates. Pediatric Critical Care Medicine, 18(2), pp.172-175.
Byon, H.J., Lee, G.W., Lee, J.H., Park, Y.H., Kim, H.S., Kim, C.S. and Kim, J.T., 2013. Comparison between ultrasound-guided supraclavicular and infraclavicular approaches for subclavian venous catheterization in children—a randomized trial. British Journal of Anaesthesia, 111(5), pp.788-792.