The Subclavian Line: The Resuscitation Line of Champions

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Which central venous catheter (CVC) is best for our patients? Is it the internal jugular (IJ), subclavian, or femoral?

We all have our go-to, which I would argue for most, is the ultrasound (US) guided IJ. But is that what is best? Is it recommended by our medical societies?

To answer this question let’s dive into the literature . . . I think you’ll be surprised by what we find. (Hint: it’s the Subclavian!!)

WHAT IS RECOMMENDED?

As mentioned, we have a few options for our CVCs. Which of these options is the best overall for our patients and which is recommended?

The Center for Disease Control and Prevention (CDC) makes the following recommendation:

“Use a subclavian site, rather than a jugular or a femoral site, in adult patients to minimize infection risk for non-tunneled CVC placement. [Category IB]

Where does this recommendation come from? They base it on three studies outlined below [Merrer 2001, Goetz 1998, Robinson 1995].

Other value data on the topic comes from the 3 SITES Study by Parienti in the New England Journal of Medicine (2015). They compared the IJ to subclavian to femoral in a 1:1:1 randomization fashion. When looking at complications, they found the following:

Parienti et al. 2015

Parienti et al. 2015

The subclavian line had the lowest overall complication rate at just above 3%. As you can see, the majority of these were mechanical.

 

ENTER ULTRASOUND GUIDANCE

Possible effect of Ultrasound on mechanical complications of subclavian site

Possible effect of Ultrasound on mechanical complications of subclavian site

Wouldn’t it be great if there were a way to decrease the mechanical complication rate to make the graph look like this?

The use of ultrasound can achieve this in the right setting and with the correct skill set. This is supported by the literature.

A Cochrane Review in 2015 reviewed 9 articles on the use of US for subclavian lines, 5 of which involved 2 dimensional US (4 using doppler only). In their review they concluded:

“US offers small gains in safety and quality when compared to landmark technique.”

 

HOW TO PERFORM AN US GUIDED SUBCLAVIAN CVC

The secret to the US-guided subclavian CVC is to look much more laterally than a landmark technique. In the landmark approach we are finding the junction of the middle and medial thirds of the clavicle, then sneaking our needle in under the bone to hit the subclavian vein.

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In our US-guided approach, we start laterally to identify the axillary vein and find our ideal venipuncture site from there, sometimes even cannulating the axillary vein itself (remember the vessel changes names as it crosses over the 1st rib).

The axillary cannulation has the advantage of often being separated from the pleura more than the subclavian. It also has not yet begun to dive under the clavicle (as shown in the following diagrams and accompanying ultrasounds).

 
Reproduced w permission from:American Thoracic Society, Arun Kannappan.

Reproduced w permission from:American Thoracic Society, Arun Kannappan.

 

Now much of the literature on completing an US guided subclavian line talks about doing it in the longitudinal plane. This is the recommended plane given your ability to see the needle through the single visualized window. This decreases your risk of passing the target and possibly hitting the pleura. If you are more facile with the cross sectional plane by all means go that route. Consider working on your longitudinal plane approach on your peripheral IVs, then transition that approach back to the US guided subclavian CVC if and when you feel ready.

Here is a video of a subclavian CVC placed under US guidance in the longitudinal plane:

Longitudinal Ultrasound Subclavian courtesy of American Thoracic Society: Arun Kannappan, Lydia Chang https://www.youtube.com/watch?v=_VYHj4sRlkc

 

And to show you this is not just a handful of people who have this anatomy, here is my own axillary vein becoming the subclavian. It is pretty easy to spot where to cannulate the vein just before the clavicle comes into view.

 

Supporting Literature:

Here is a 10,000 foot view of some of the studies that comment on US guidance for CVC insertion. See the reference list below for all studies.

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REFERENCES

1. Mansfield PF1, Hohn DC, Fornage BD, Gregurich MA, Ota DM. Complications and failures of subclavian-vein catheterization.N Engl J Med. 1994 Dec 29;331(26):1735-8. [pubmed]

2. Gualtieri E, Deppe SA, Sipperly ME, Thompson DR. Subclavian venous catheterization: greater success rate for less experienced operators using ultrasound guidance. Crit Care Med. 1995 Apr;23(4):692-7. [pubmed]

3. Lefrant JY, Cuvillon P, Bénézet JF, Dauzat M, Peray P, Saïssi G, de La Coussaye JE, Eledjam JJ. Pulsed Doppler ultrasonography guidance for catheterization of the subclavian vein: a randomized study. Anesthesiology. 1998 May;88(5):1195-201. [pubmed]

4. Palepu GB, Deven J, Subrahmanyam M, Mohan S. Impact of ultrasonography on central venous catheter insertion in intensive care. Indian J Radiol Imaging. 2009 Jul-Sep;19(3):191-8. [pubmed]

5. Fragou M1, Gravvanis A, Dimitriou V, Papalois A, Kouraklis G, Karabinis A, Saranteas T, Poularas J, Papanikolaou J, Davlouros P, Labropoulos N, Karakitsos D. Real-time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients: a prospective randomized study. Crit Care Med. 2011 Jul;39(7):1607-12. [pubmed]

6. Merrer J1, De Jonghe B, Golliot F, Lefrant JY, Raffy B, Barre E, Rigaud JP, Casciani D, Misset B, Bosquet C, Outin H, Brun-Buisson C, Nitenberg G; French Catheter Study Group in Intensive Care. Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial. JAMA. 2001 Aug 8;286(6):700-7. [pubmed]

7. Shah A, Smith A, Panchatsharam S. Ultrasound-guided subclavian venous catheterisation - is this the way forward? A narrative review. Int J Clin Pract. 2013 Aug;67(8):726-32. [pubmed]

8. Parienti JJ, Mongardon N, Mégarbane B, Mira JP, Kalfon P, Gros A, Marqué S, Thuong M, Pottier V, Ramakers M, Savary B, Seguin A, Valette X, Terzi N, Sauneuf B, Cattoir V, Mermel LA, du Cheyron D; 3SITES Study Group. Intravascular Complications of Central Venous Catheterization by Insertion Site. N Engl J Med. 2015 Sep 24;373(13):1220-9. [pubmed]

9. Brass P, Hellmich M, Kolodziej L, Schick G, Smith AF. Ultrasound guidance versus anatomical landmarks for subclavian or femoral vein catheterization. Cochrane Database Syst Rev. 2015 Jan 9;1:CD011447. [pubmed]

10. Goetz AM1, Wagener MM, Miller JM, Muder RR. Risk of infection due to central venous catheters: effect of site of placement and catheter type. Infect Control Hosp Epidemiol. 1998 Nov;19(11):842-5. [pubmed]

11. Robinson JF, Robinson WA, Cohn A, Garg K, Armstrong JD, 2nd. Perforation of the great vessels during central venous line placement. Arch Intern Med 1995; 155:1225–8. [pubmed]