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Monday, February 15, 2010

CENTRAL VENOUS CANNULATION. WHICH ROUTE?

Central venous cannulation is an indispensable monitoring tool in intensive care.Central lines  are used for fluid resuscitation  and cvp monitoring, trans venous pacing, administration of irritant drugs, parenteral nutrition,venovenous hemodialysis, and as vascular access when peripheral cannulation is impossible.Veins used for cannulation are  internal jugular, subclavian, and femoral. The advantages of subclavian cannulation over internal jugular are : absence of valves, larger vein,and low rate of catheter related infection (2). Also the patency can be maintained as chance of kinking the catheter is less.Care of the catheter by the staff also is easy as the location is more convenient.

Subclavian cannulation is attempted by supraclavicular or infraclavicular approach, the second approach is more common and often described as classic. To our observation the supraclavicular route offers and excellent alternate way of subclavian cannulation and is associated with fewer side effects compared to infraclavicular approach, and is also relatively easy. The advantages of  this approach are,
  • There is a well defined anatomical landmark, the angle formed by the clavicular head of sternomastoid with the clavicle,
  • A straighter course to the IJV
  • Away from apex of lung
  • Less chance of arterial puncture
  • Can be inserted during cpcr, without interruption.
  • And is useful in obese patients and pregnant ladies, where land mark is obscure
TECHNIQUE:  The needle is inserted 1 cm lateral to the lateral head of the sternocleidomastoid muscle and 1 cm posterior to the clavicle and directed at a 45-degree angle to the sagittal and transverse planes. Aim towards the contralateral nipple. The needle  is advanced in an avascular plane, away from the subclavian artery and the dome of the pleura, entering the junction of the subclavian and internal jugular veins.a trendlenberg position is advised to avoid the risk of air embolism and distend the vein.  ref :(1)



CXR showing central line placed through Rt.subclavian by supraclavicular route

According to published literature  the overall complication rate  of supraclavicular route is around 0.56%.The author recommends supraclavicular route as the first choice of approach for central venous cannulation.
 
1.West J Emerg Med. 2009 May; 10(2):110–114.PMCID:PMC2691520,Supraclavicular Subclavian Vein Catheterization: The Forgotten Central Line
2. McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med. 2003;348:1123–33. [PubMed]

3 comments:

DR.RAMESH GUPTA,DELHI said...

Thanks for your information on forgotten central line.this seems to be an easy route.pual marino describes the chance of pneumothorax is the same for either subclavian lines or IJV lines,even though it is thought that internal jugular cannulation is associated with less chance of pneumothorax.The chance of arterial puncture is also more with IJV cannulation

Anonymous said...

one disadvantage i find in acute trauma is, it is not possible to optimise the postion of the neck in case of c spine trauma

Aditya said...

dr.aditya lamba
Definitely supraclavicular approach is better for subclavian venous cannulation compared to infraclavicular approach. well defined landmark , lesser complications as well.