![]() 9 conducted a randomized prospective comparison of the supraclavicular and infraclavicular techniques in 76 patients undergoing CPR. Only a few well designed, randomized prospective trials comparing the infraclavicular and supraclavicular methods have been described in the literature.ĭronen et al. Most clinical studies on the supraclavicular approach are in the form of prospective case series. 5 To further minimize complications the needle bevel should be facing down prior to insertion, attempts should cease after 2–3 unsuccessful tries, and most importantly, the clavisternomastoid angle must be clearly identified prior to insertion. The Trendelenberg position is recommended to decrease risk of air embolus and to potentially help distend the vein, as the subclavian vein is not bound by fascia on its superior aspect. The right side is preferred because of the lower pleural dome, more direct route to the superior vena cava, and absence of thoracic duct. ![]() 5 The needle bisects the clavisternomastoid angle as it 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. 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 and 15 degrees below the coronal plane aiming toward the contralateral nipple. Active raising of the patient’s head may make this landmark more apparent. The key to success, according to Yoffa, 1 is correct identification of the clavisternomastoid angle formed by the junction of the lateral head of the sternocleidomastoid muscle and the clavicle. The objective of the supraclavicular technique is to puncture the subclavian vein in its superior aspect just as it joins the internal jugular vein. 1 This supraclavicular route to the subclavian vein has some distinct advantages over the infraclavicular approach however it is less often taught and utilized for reasons that are not clear. In 1965 an alternate supraclavicular approach was described by Yoffa. Since Aubaniac’s original description in 1952, 4 subclavian vein catheterization via the infraclavicular approach has become a well-established technique. 1, 2 Subclavian catheterization also carries a lower risk of catheter-related infection and thrombosis than femoral or internal jugular vein catheterization. Several anatomic advantages of the subclavian vein for central access include its large diameter, absence of valves, and ability to remain patent and in a relatively constant position. Various methods of placement have evolved, each with its own advantages and potential complications. The proper choice of insertion site is essential for success. Central lines are typically introduced into the internal jugular, subclavian, or femoral veins. INTRODUCTIONĬentral venous catheterization is a vital intervention in critically ill patients for a variety of purposes, including volume resuscitation, central venous pressure monitoring, transvenous cardiac pacing, hemodialysis access, and hypertonic or irritant substance infusion. The landmarks and relative merits of the procedure are described in this paper. ![]() Although randomized trials are lacking, the best evidence suggests that the supraclavicular approach has a number of important advantages to the infraclavicular approach. While the supraclavicular approach to the subclavian vein has been described since 1965, it is generally employed much less often than the “traditional” infraclavicular approach.
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