Speed Matters: Landmark Guided Left Subclavian Vein Central Venous Catheter Insertion & the "Deep Spot"

Recently, I got permission from a patient to video a subclavian line insertion.  This patient was absolutely terrified of any line insertion as he had had many in the past and a lot of them had been traumatic, prolonged, and painful.  I offered a bedside subclavian as an alternative to a PICC line or a right internal jugular in Interventional Radiology, promising that the entire procedure could be done in under 10 minutes.  It took just over 2 minutes, excluding prepping, draping, locally anesthetizing, and suturing.  These aspects would have added about another 3-4 minutes to the task.  Before the video started, I had infiltrated the area generously with 2% lidocaine, after prepping and draping in the usual careful fashion.

Before you watch the video, I should describe the essence of subclavian landmarking and several mandates of the procedure.  The key anatomical landmark is a spot seen in the photo accompanying this post that I call "the deep spot."  This is a spot along the inferior border of the clavicle, about 4 inches from the suprasternal notch (SSN).  It is important because it is the spot where soft tissue adjacent to the inferior border of the clavicle can be depressed the deepest, allowing the needle the easiest access to the subclavian region while being inserted "FLAT, FLAT, FLAT, FLAT, FLAT" under the clavicle with respect to the ground, i.e., parallel to the ground.  Entering the subclavicular region in this spot and remaining flat/parallel to the ground are keys to both success and avoidance of the oh-so-feared (but rare!) pneumothorax.

This spot can be found by making the middle finger and the thumb of the non-dominant hand into a comfortable "C" shape as seen in the photo.  The middle finger and thumb will be parallel to each other when in the "C" shape and will be about 4-5 inches apart depending on your fingers and the patient's anatomy.  With the middle finger in the SSN, the thumb finds the spot along the inferior border of the clavicle where the skin can be depressed the deepest.  If you're too medial, you will be atop ribs and "too high not deep enough" and if you're too lateral from the SSN, you will start climbing up the humeral head and deltoid and be "too high, not deep enough".  If you are too close to the clavicle or atop it, you will not be in the "deep spot" (it is a finger breadth or so inferior) and if you go too inferior from the clavicle, you will climb atop the pectoralis/breast and not be in the deepest spot.  Find the "deep spot"!  Again, the point (no pun intended) is to find the spot where the tissues near the clavicle can be depressed the deepest to facilitate the insertion of the needle under the clavicle and parallel to the ground.  This cannot be overemphasized, and you can feel for that spot on yourself or a willing companion for practice.

Once this spot is located, you anesthetize and then use the needle to confidently identify the clavicle and by advancing the needle towards the SSN, you can press down with your thumb on the needle (even the part under the skin) to depress it so that when advanced, it is parallel to the ground towards the SSN and it goes easily under the clavicle.  You should never "dive" to try to get under the clavicle, or use the clavicle as a fulcrum, bending the needle downward.  Watch the video carefully to see how I'm using several tactile inputs to determine where the clavicle is as I guide the needle under it.  You will see that the first several "pokes" or short advancements of the needle hit the clavicle (it happens fast, watch carefully!) which is a very important tactile confirmation of where you are, and then I push the inserted needle down with the left thumb to allow the advancement to proceed below the clavicle.

As seen in the video, the SCV is often entered when the needle is maximally inserted ("hubbed") with the skin invaginating, or upon withdrawal.  Notice too in the video that the flash was subtle at first and too rapid a withdrawal might have missed it.  Also in the video, the flash was highly positional, and the exact optimal position had to be found by iterative advancement and withdrawal and then maintained by carefully pinching the hub of the needle with the hand referenced to the patient's chest to allow the wire to be fed without inadvertent and unrecognized migration of the needle out of the vessel.

The voice overlay of the video gives several other useful tips and I hope you enjoy watching it.  The SCV central line is one of the final remaining procedures where use of ultrasound guidance (USG) confers minimal, if any benefit, and USG markedly prolongs this (and all) procedures.  Over my career during the past 20 years, I estimate I have done 500 or more SCV catheters all guided by landmark, most in critically ill patients.  I had *one* pneumothorax (PTX), in 2011 in a patient with severe COPD.  (I also supervised a resident once where there was a PTX, and to this day I don't understand how it happened.)  In properly trained hands, this procedure is incredibly safe, is the preferred location for a central venous catheter in terms of patient comfort, and infection and thrombosis risks, can be performed with a very high success rate using landmarks alone, and can be done very speedily.  Speed is the final frontier: Safety, Success, Speed.

Here is the NEJM.org video, for comparison:  https://www.youtube.com/watch?v=braNvVl8-QU

And here is a Right Internal Jugular HD Catheter insertion using landmarks by The Phlegmfighter (yours truly).

The Lost Art of Landmarking: Right Internal Jugular Insertion Video

I have long wanted to post a video of central line insertion using the traditional landmarks method, and recently I was afforded the perfect opportunity.  The patient needed a dialysis catheter.  He had had one inserted a few months ago and it had been a disaster for him.  First, the inserting physician mistakenly installed a Cordis Introducer instead of a dialysis catheter, using ultrasound guidance and causing a good deal of pain by transecting the belly of the sternocleidomastoid (SCM) muscle, then it was rewired to a dialysis catheter that would not flow, then, finally, a working catheter was installed in a new site.  I assured the patient that this go at it would be much easier and he was very interested in having the experience recorded so he could later see it, and others could learn from it.

I previously observed that in the current training atmosphere, trainees are paying no attention to anatomical landmarks, rather they are just poking wherever they see the vein on the ultrasound image, traversing whatever structures lie between the surface and the target, without any care whatever.  It is my belief that the SCM muscle should never be split/transected with a dilator or line unless absolutely necessary.  Thus even if ultrasound is used, the landmarks ought to be identified and respected.

Several points in the video need further explication here.  (Beyond the facts that my nose did not fit under the mask, I did not wear eye protection, and that I failed to lay out the components of the tray beforehand.)

• The importance of properly and confidently identifying the bellies/heads of the SCM cannot be overemphasized.  I will at some point do another video to go through that process specifically in detail.
• I always keep 0.5-1.0 cc of liquid (lidocaine or flush) in the syringe during needle passes.  In my experience, it minimizes clotting in the needle and the risk of passing through the vessel without flash due to clot.
• In contrast to what is suggested in the NEJM video for RIJ CVC insertion, I do not hold the needle at 45 degrees to the floor plane when going after the IJ.  Doing this makes you have to insert the needle much deeper, increasing the risk of pneumothorax.  I prefer an angle of 60-90 degrees.
• In this patient, the IJ was deeper than usual and than I expected, thus I did not hit it with the "seeker" needle.
• When the fingers of my left hand are on the neck, I am not palpating the carotid pulse.  I could care less about the carotid.  I am feeling that medial belly of the SCM as a landmark and ever so gently pushing it to the left to increase exposure of the IJ underneath of it.
• When entering the skin with the large bore needle, I poke to and fro rapidly to keep it from "breaking through" the skin and plunging too deep.
• Notice that each centimeter or so that I enter with the large bore needle, I pause and pull back a bit to see if I get flash in case the vessel is compressed on the forward pass.  In the video, I get flash on the second or third pull back.
• After I get flash, I then lay the needle back to 45 degrees to facilitate guidewire passage
• This patient's skin and subcutaneous tissue was tougher than I expected and I did not make a generous enough stab incision into the subcutaneous tissues to make a tract for the dilator.  Usually I use a regular 7.0 French triple lumen CVC kit dilator first, then the smaller of the two dilators that come with the larger 12 French dialysis catheter.  This is a new all-inclusive kit that we began using which contains only the large dilators.
• The bleep is to protect privacy

Stay tuned for the subclavian vein CVC insertion video next!

[Formal written consent was obtained from this patient to make this video and to publish it for educational purposes.]

Special thanks to Clayton MS4 for filming this and helping with editing.  Other medical students are encouraged to participate in future web and social media initiatives.  I have several in mind.