Ultrasound-Guided Subclavian Central Line Placements

The central line insertion location has an outsized impact on a number of quality metrics related to central line safety.

Sadly, the 20 y/o intern there to place the line, often late in the afternoon, rarely can connect their choice of location to the care and maintenance of that line by the nursing staff and subsequent increased risk of CLABSI due to dressing disruptions (1)

Knowing this limitation, design your systems of care such that the decisions of your least trained medical staff are not driving your quality outcomes.

Choosing an Insertion Site for Central Line Placement

The best central line for any patient is the one that your proceduralist safely performs, that the nursing staff can care for and that remains in place for the shortest period as possible.

If there is not a system in place to teach and evaluate trainees on their ability to safely insert central venous catheters you will have unwanted variability in your safety and quality metrics around central line insertion.

This study showed subclavian lines are typically better for infection and thrombosis, but worse for mechanical complications. (2)

Get past those mechanical complications and the subclavian site is a clear winner.

Ultrasound-Guided Subclavian Central Lines

This study showed no difference in infection between the three sites however while the findings were not statistically significant in this study they did resemble findings seen in other studies supporting the use of the subclavian site.

This study showed greater success, fewer complications, and less time for ultrasound-guided subclavian

This study showed arm abduction and external rotation can help to improve visualization of the subclavian vein in 70% of patients (however, 14% got worse)

The literature suggests that ultrasound-guided subclavian has a real benefit over landmark approach

Troubleshooting Arterial vs Venous Placement of Central Lines

This study showed that adding manometry to subclavian placement eliminated arterial cannulation

Can compare blood gas of known arterial source to central line blood (in sick patients arterial gas may look more like venous gas)

Look at pressure waveform to see if it is arterial or venous

References:

  1. Timsit JF, Bouadma L, Ruckly S, Schwebel C, Garrouste-Orgeas M, Bronchard R, Calvino-Gunther S, Laupland K, Adrie C, Thuong M, Herault MC, Pease S, Arrault X, Lucet JC. Dressing disruption is a major risk factor for catheter-related infections. Crit Care Med. 2012 Jun;40(6):1707-14. doi: 10.1097/CCM.0b013e31824e0d46. PMID: 22488003.
  2. 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. doi: 10.1056/NEJMoa1500964. PMID: 26398070.

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