Subclavian Access
(continued)

Step 2: Scan above the clavicle for subclavian vein. Administer Lidocaine approximately 1-2 cm lateral to the mid-point of the clavicle. Consider landmarks of the sterna notch and the point where clavicle begins to curve downward.

Step 3: Insert needle bevel up (with syringe attached) 1 cm inferior to the clavicle while aiming toward the sterna notch using a very low 5-10 degree angle of insertion. Keep needle pointed cephlad, toward the clavicle so needle gently glides along the bottom edge of the clavicle. During insertion, continuously aspirate to confirm entry into subclavian vein. If first attempt is unsuccessful, retract needle without exiting the skin and redirect needle further in the cephlad direction.

Step 4: Once aspiration of blood is confirmed, hold needle steady. Turn needle half turn (this directs the bevel down so the wire feeds into the SVC). Disconnect syringe and immediately place finger over hub of needle to prevent entrance of air.

Step 5: If using a Raulerson syringe, insert wire through the opening in the distal part of plunger. Otherwise, time removal of syringe with patient expiration and insertion of wire through needle hub. Gently insert wire into vein approximately 10 to 20 centimeters or half the length of the wire feeling for wire advancement through vein.

Maintain control of the wire at all times and respect the angle of the wire. Do not pull back against bevel of needle at any time as this could cause kinking, shearing and/or breaking of the wire leading to wire embolism. While stabilizing the wire in the vessel, remove the needle.

Step 6: Maintaining wire stabilization, remove the needle.

Step 7: Perform a skin nick if necessary. Maintain the angle of the wire. Dilate the skin and venous tissue to make room for the catheter by fitting dilator over the wire. Advance the dilator by pushing and rotating it into the tissue until it enters the vein.

Step 8: Remove dilator and stabilize the wire. Slowly thread the catheter over the wire. The wire will exit the distal lumen. Grasp wire, maintaining control. Gently advance catheter to premeasured internal length. Remove wire and immediately place thumb over hole. Withdraw blood to confirm placement within vessel. Flush well with saline.

Step 9: Place needleless connector on catheter lumens. Clean the insertion site to prepare for dressing and securement. Suture catheter through catheter wings using curved needle or apply sutureless securement device. Apply sterile dressing in keeping with facility policy.

Step 10: Confirm catheter terminal tip placement in the distal superior vena cava (SVC), ideally at the cavo-atrial junction, using x-ray, fluoroscopy or electrocardiogram (EKG) per facility policy.