CARCINOVA CANCER HOSPITAL PVT. LTD.

NUAPATNA, NEAR CDA, CUTTACK

(ODISHA)
Centra-line Manual

STANDARD OPERATING PROCEDURE

Indications for Subclavian vein Catheterisation

• Secure or long-term venous access that is not available using

other sites
• Inability to obtain peripheral venous access or intraosseous
infusion
• IV infusion of fluids and drugs for patients in cardiac arrest
• IV infusion of concentrated or irritating fluids
• IV infusion of high flows or large fluid volumes beyond what is
possible using peripheral venous catheters
• Monitoring of central venous pressure (CVP)
• Hemodialysis or plasmapheresis

*For transvenous cardiac pacing or pulmonary arterial monitoring, a

right internal jugular or a left subclavian cannulation typically is
preferred.

Contraindications to Subclavian vein Catheterisation

• Absolute contraindications
• Unsuitable subclavian jugular vein, thrombosed
(uncompressible) or inaccessible as seen by ultrasound
• Local infection at the insertion site
• Antibiotic-impregnated catheter in allergic patient
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• Relative contraindications
• Coagulopathy, including therapeutic anticoagulation*
• Local anatomic distortion, traumatic or congenital, or gross
obesity
• Malignant superior vena cava syndrome
• Severe cardio respiratory insufficiency or increased intracranial
or intraocular pressure (patients will be compromised by
Trendelenburg [head down] positioning)
• History of prior catheterization of the intended central vein

Complications of Subclavian vein Catheterisation

Complications include

• Arterial puncture
• Hematoma
• Pneumothorax
• Damage to the vein
• Hemothorax
• Air embolism
• Catheter misplacement*
• Arrhythmias or atrial perforation, typically caused by guidewire
or catheter
• Nerve damage
• Infection
• Thrombosis
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*Rare complications due to catheter misplacement include arterial

catheterization, hydrothorax, hydromediastinum, and damage to the
tricuspid valve.

• To reduce the risk of venous thrombosis and catheter sepsis,

CVCs should be removed as soon as they are no longer needed.

Equipment for Subclavian vein Catheterisation

• Sterile procedure, barrier protection
• Antiseptic solution (eg, chlorhexidine-alcohol, chlorhexidine,
povidone iodine, alcohol)
• Large sterile drapes, towels
• Sterile head caps, masks, gowns, gloves
• Face shields

Seldinger (catheter-over-guidewire) technique

• Cardiac monitor
• Local anesthetic (eg, 1% lidocaine without epinephrine, about 5
mL)
• Small anesthetic needle (eg, 25 to 27 gauge, about 1 inch [3
cm] long)
• Large anesthetic/finder* needle (22 gauge, about 1.5 inches [4
cm] long)
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• Introducer needle (eg, thin-walled, 18 or 16 gauge, with

internally beveled hub, about 2.5 inches [6 cm] long)
• 3- and 5-mL syringes (use slip-tip syringes for the finder and
introducer needles)
• Guidewire, J-tipped
• Scalpel (#11 blade)
• Dilator
• Central venous catheter (adult: 8 French or larger, minimum
length for subclavian catheter is 15 cm for right side, 20 cm for
left side)
• Sterile gauze (eg, 4 × 4 inch [10 × 10 cm] squares)
• Sterile saline for flushing catheter port or ports
• Nonabsorbable nylon or silk suture (eg, 3-0 or 4-0)
• Chlorhexidine patch, transparent occlusive dressing
o A finder needle is a thinner needle used for locating the vein
before inserting the introducer needle. It is usually not
needed for ultrasound-guided cannulations.
• The external diameter of the CVC should be less than or equal
to one third of the internal diameter of the vein (as measured
by ultrasound) to reduce the risk of thrombosis.
• Having an assistant or two is helpful.
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Additional Consideration
• Cannulation attempts sometimes fail. Do not exceed 2 or 3
attempts (which increases the risk of complications), and use
new equipment with each attempt (ie, do not re-use needles,
catheters, or other equipment because they may have become
blocked with tissue or blood).
• During cardiopulmonary arrest, or even low blood pressure and
hypoxia, arterial blood may be dark and not pulsatile and may
be mistaken for venous blood.
• If the subclavian artery is errantly cannulated by either the
tissue dilator or the CVC, leave the dilator or catheter in place
and obtain surgical consultation for possible surgical removal.

Relevant Anantomy
• The anterior cervical triangle is bordered by the clavicle
inferiorly and by the sternal and clavicular heads of the
sternocleidomastoid muscle medially and laterally.
• Most commonly, the central approach to the subclavian vein is
used. An introducer needle is inserted into the skin inside the
apex (superior angle) of the triangle and is advanced proximally
(caudally) at about a 45° angle to the skin to intersect the vein.
• The right subclavian vein is usually preferred over the left for
cannulation because it has a larger diameter and affords a
straighter path to the superior vena cava.
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Positioning for Subclavian vein Catheterisation

• Raise the bed to a comfortable height for you (ie, so you may
stand straight while doing the procedure).
• Place the patient supine and in Trendelenburg position (bed
tilted with the head down 15 to 20°) to distend the subclavian
vein and prevent air embolism.
• Turn the patient's head slightly to the contralateral side to
preliminarily expose the subclavian vein but not cause overlap
with the carotid artery (during the procedure, you will use
ultrasound to optimally expose the vein).
• Stand at the head of the bed

Step-by-Step Description of Procedure

• Prepare the equipment
• Place sterile equipment on sterilely covered equipment trays.
• Dress in sterile garb and use barrier protection.
• Draw the local anesthetic into a syringe.
• Attach the introducer needle to a 5-mL syringe with 1 to 2 mL
of sterile saline in it. Align the bevel of the needle with the
volume markings on the syringe.
• Pre-flush all lines of the CVC with 3 to 5 mL of sterile saline and
then close the ports with caps or syringes.
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• When flushing a central line, use a 10-mL syringe (or one of

equal or greater diameter) and do not push too hard to avoid
rupturing the line.

Prepare the sterile field

• Swab a broad area of skin with antiseptic solution,
encompassing the side of the neck, clavicle, and anterior chest
to below the ipsilateral nipple. Creating this broad sterile area
permits immediately switching to subclavian vein cannulation
or unassisted (“blind”) subclavian cannulation should the
ultrasound-guided subclavian cannulation attempt fail.
• Allow the antiseptic solution to dry for at least 1 minute.
• Place sterile towels around the site.
• Place large sterile drapes (eg, a full-body drape) to establish a
large sterile field.
• Place a wheal of anesthetic at the needle entry point and then inject
anesthetic into the skin and soft tissues along the 45° path leading
toward the vein.
• Slightly tilt the probe fore and aft as you advance the anesthetic needle
to continually identify the needle tip and keep it safely distant from the
vein and artery
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Insert the introducer needle

• As the needle tip approaches the vein, temper your speed and
angle of insertion so the needle enters with as much control as
possible. The superficial wall of the vein will indent when the
needle tip encounters it. The needle then pops through the
wall to enter the lumen, accompanied by a flash of dark red
blood in the barrel of the syringe.
• Hold the syringe motionless in this spot and visualize the tip of
the needle at all times. Displacement is common, and even a
slight movement may displace the needle tip from the vein.

Assess the blood return

• Continue to hold the syringe motionless.
• Securely grasp the needle hub and also hold it motionless.
• Remove the syringe from the needle hub and briefly let blood
flow out to confirm that the blood is venous (ie, dark red and
flowing, but not pulsatile). Then immediately cover the hub
with your thumb to stop the blood flow and prevent air
embolism.

However, if the blood is bright red and pulsatile (arterial), terminate the
procedure. Remove the needle and use 4 × 4 squares for 10 minutes to
hold external pressure on the area and to help prevent bleeding and
hematoma.
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Inside the guidewire

 Subclavian vein catherization is done by advancing a 18G needle.
0.5cm below the angle of clavicle and advanced just underneath
the clavicle towards the suprasternal hatcha and vein is
confirmed by aspiration of venous blood.
 If you feel any resistance as you advance the guidewire, stop
advancing it. Try to gently withdraw the wire slightly, rotate it
slightly, and then readvance it, or try to gently withdraw the wire
entirely, reestablish the needle tip within the vein (confirmed by
venous blood return), and then reinsert the wire.

However, if you feel any resistance as you withdraw the wire,

terminate the procedure and withdraw the needle and guidewire
together as a unit (to prevent the needle tip from shearing through the
guidewire within the patient). Then use 4 × 4 gauze squares for 10
minutes to hold external pressure on the area and to help prevent
bleeding and hematoma.

Once the guidewire has been inserted, continue to hold it securely in

place with one hand and maintain control of it throughout the
remainder of the procedure.
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Remove the introducer needle (after successful guidewire insertion)

• First, securely hold the guidewire distal to the needle and pull
the needle from the skin.
• Then, securely hold the guidewire at the skin surface and slide the
needle down the remaining length of the guidewire to remove the
needle.

Widen the insertion tract

 Extend the skin insertion site: Using the scalpel, make a small stab incision
(about 4 mm) into the skin insertion site, avoiding contact with the
guidewire, to enlarge the site and allow it to accommodate the larger
diameters of the tissue dilator and the catheter.
 Advance the tissue dilator over the guidewire: First, grasp the guidewire at
the skin and slide the dilator down the length of the wire to the skin. Then
grasp the wire just distal to the dilator, hold the dilator near the skin
surface, and use a corkscrew motion as needed to stepwise insert the
entire length of the dilator. Maintain your grasp on the wire at all times
during the insertion.
 Remove the dilator: First, securely hold the guidewire distal to the dilator
and pull the dilator from the skin. When the guidewire is visible at the skin
surface, completely remove the dilator by sliding it down the remaining
length of the guidewire.Maintain your grasp on the guidewire at the skin
surface.
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Place the catheter

 Advance the catheter over the guidewire to the skin surface: Hold the
guidewire fixed at the skin surface, thread the catheter tip over the distal
end of the guidewire, and slide the catheter down to the skin surface. The
distal end of the guidewire should now be protruding from the port hub.
 Maintain your grasp on both the guidewire and the catheter.
 Remove the guidewire: Withdraw the guidewire while holding the
catheter securely in place at the skin surface.
 Flush each catheter port with saline: First, draw any air from the line and
confirm venous blood flow into the hub. Then, using a 10-mL syringe (or
one of equal or greater diameter) and nonexcessive force, push 20 mL of
saline into the line to clear it.

Dress the site

 If the patient is awake or minimally sedated, use 1% lidocaine to numb the

skin at the planned suture locations.
 Place a chlorhexidine-impregnated disk on the skin at the catheter
insertion point
 Suture the skin to the mounting clip on the catheter.
 To prevent pulling on the insertion site, suture the catheter at a second
site so that a curved or looped segment of catheter lies between the two
sites.
 Apply a sterile occlusive dressing. Transparent membrane dressings are
commonly used.
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Aftercare for Subclavian vein Catheterisation

• Do a chest x-ray to confirm that the tip of a jugular (or subclavian)
venous catheter lies in the superior vena cava near its junction with
the right atrium (the catheter can be advanced or retracted if not in
the appropriate position) and to confirm that pneumothorax has
not occurred.

X-Ray of a Central Venous Catheter

The red arrow points to the tip of a left subclavian venous port
catheter (placed appropriately in the lower superior vena cava).