Infraclavicular Subclavian Vein Cannulation in a Pediatric Patient without Ultrasonographic Guidance prior to a Colon Interposition in Honduras during a Surgical Mission
Main Text
Table of Contents
Central venous access is a crucial aspect in the management of patients requiring long-term therapies, particularly surgical patients. These therapies include the administration of therapeutic agents, fluid administration, antibiotic therapy, parenteral nutrition, etc. The procedure involves the placement of a catheter into a venous great vessel. Three main sites for central venous access are: internal jugular vein, common femoral vein, and subclavian veins.1
The use of central venous access devices presents a risk of complications, with many devices being removed prematurely before the end of the prescribed therapy. These complications can include cardiac arrhythmia, bleeding, malpositioning, air embolism, injury to vessels or nerves, and pneumothorax. Long-term complications include catheter occlusion, venous thromboembolism, bloodstream infection, migration, or mechanical dysfunction. These complications can be minimized with the experience of the clinician inserting the catheter, the use of ultrasound-guided access, adherence to maximum sterile precautions, and training of nurses and related professionals involved in catheter care.2
Continuous cardiac rhythm and pulse oximetry monitoring are essential during central venous access procedures. This is to ensure the safety of the patient and to quickly address any complications that may arise during the procedure. The room should be equipped with supplemental oxygen in case it becomes necessary, and for some patients, nasal oxygen administration may be prudent before covering the patient’s head with drapes.3
The choice of access location depends on various factors such as the patient's anatomy, the urgency of the procedure, and the presence of an alternative for venous access. The anatomical landmarks of the subclavian area are relatively consistent, making it a viable option when ultrasound guidance is not available. Despite the risk of pneumothorax, the subclavian veins are chosen for their lower infection rates and patient comfort, especially when long-term catheter placement is required. Therefore, in settings without sonographic control, the subclavian vein can be a practical and safe choice for central venous access.5
This is a case of a 5-year-old boy with a long-gap esophageal atresia. The patient had undergone a cervical esophagostomy and a gastrostomy following birth and was fed via gastrostomy until a colon interposition could replace his absent esophagus. Central venous access is imperative in the management of pediatric patients undergoing complex surgical procedures, such as colon interposition.4 The colon interposition technique is employed when the esophagus is absent or injured, necessitating the utilization of a segment of the colon to restore the ability to swallow and facilitate enteral nutrition. The provision of intravenous nutrition, antibiotics, and electrolytes is crucial for the successful recovery and postoperative care of these patients.5-8
In resource-constrained settings, healthcare professionals must rely on their clinical practice and proficiency in performing procedures without the aid of advanced imaging modalities. One such procedure is the infraclavicular subclavian vein cannulation, which can be performed without ultrasonographic guidance, providing a reliable means of obtaining central venous access.
The infraclavicular subclavian vein cannulation technique involves a distinct approach to accessing the subclavian vein without the need for ultrasonographic guidance. In this technique, the position of the needle's bevel is aligned with the green piece of the needle cannula. The wire is tested to ensure it goes anteriorly, as the bevel is facing upwards. If the needle is rotated, the wire will follow the new orientation.
The operator stabilizes the clavicle and scrapes beneath it, aspirating the entire way until the subclavian vein is located. Once venous access is confirmed, the guidewire is threaded through the needle, establishing a pathway for the subsequent insertion of the central venous catheter. To facilitate the insertion of the catheter, a dilator is advanced over the guidewire, gradually enlarging the tract and minimizing the risk of vessel injury or trauma. A small incision is made in the skin to allow the passage of the dilator. After successful placement, the dilator is removed, and pressure is applied over the wire at the incision site to prevent bleeding.
Utmost care is taken when advancing the catheter, as there is no guidance to visualize the process. Monitoring the cardiac rhythm is crucial to detect any aberrant electrical activity that may indicate complications. The catheter is advanced approximately 6 cm from the sternal angle.
Each catheter lumen is flushed properly. This step confirms the functionality of the lines intended for administering intravenous fluids, and antibiotics, and monitoring vital signs. The guidewire is then carefully removed and reintroduced into the guide from which it originated. To secure the central line, a large transparent medical dressing is cut in half, with one portion placed over the insertion site and the other half used to stabilize the three catheter lines.
The infraclavicular subclavian vein cannulation technique demonstrated in this video holds significant importance for several reasons. In resource-limited settings where advanced imaging modalities are unavailable, this approach offers an accurate way to get central venous access. Also, this technique is particularly valuable in the pediatric population, where obtaining central venous access can be challenging due to smaller vessel sizes and anatomical variations. The ability to perform this procedure without ultrasonographic guidance expands the options available to healthcare professionals. During surgical missions in developing countries or areas with limited resources, healthcare professionals must rely on their clinical skills and expertise. This technique allows medical teams to overcome resource constraints and deliver essential care to patients in need.3
Overall, this video is a valuable educational resource for healthcare professionals․ Witnessing the step-by-step demonstration can improve practitioners' skills and confidence.
The parents of the patient referred to in this video have given their informed assent for surgery to be filmed and were aware that information and images will be published online.
Citations
- Practice Guidelines for Central Venous Access 2020: An Updated Report by the American Society of Anesthesiologists Task Force on Central Venous Access. Anesthesiology. 2020;132(1):8-43. doi:10.1097/ALN.0000000000002864.
- Akhtar N, Lee L. Utilization and complications of central venous access devices in oncology patients. Current Oncology. 2021; 28(1):367-377. doi:10.3390/curroncol28010039.
- Clare CS. Selection and management of central venous access devices. Nurs Stand. Published online July 21, 2020. doi:10.7748/ns.2020.e11559.
- Galloway S, Bodenham A. Ultrasound imaging for central venous catheterization: an updated review of evidence and best practices. B J Anesth. 2004;92(3):306-315.
- Bannon MP, Heller SF, Rivera M. Anatomic considerations for central venous cannulation. Risk Manag Healthc Policy. 2011;4:27-39. doi:10.2147/RMHP.S10383.
- Keir I, Rhodes J. Infraclavicular subclavian vein catheterization in children: a review of experience and technique. Anaesthesia. 2012;67(11):1238-1245.
- Arul GS, Lewis N, Bromley P, Bennett J. Ultrasound-guided percutaneous insertion of Hickman lines in children. Prospective study of 500 consecutive procedures. J Pediatr Surg. 2009 Jul;44(7):1371-6. doi:10.1016/j.jpedsurg.2008.12.004.
- Mian, A, Solomon R. Esophageal atresia and tracheoesophageal fistula. Ped Surg. 2018;33(1):1-9.
Cite this article
Sang YY, Lemus CA, Alvear D. Infraclavicular subclavian vein cannulation in a pediatric patient without ultrasonographic guidance prior to a colon interposition in Honduras during a surgical mission. J Med Insight. 2024;2024(290.14). doi:10.24296/jomi/290.14.
Procedure Outline
Table of Contents
Transcription
CHAPTER 1
This is a different technique for central line placement. She's got a different method than what you've learned. The bevel of the needle - it's indicated to be the same position as that bevel in the green piece of the needle, the cannula. So we tested the wire. Right, you should make sure that that goes anteriorly because the bevel is up. And if she rotates it, then it will follow it down. Now this is a technique that I - has maybe changed now from when I was a resident. This is different from what I was taught. What you learned? Okay. Yeah.
CHAPTER 2
So, watch this. You'll see. It goes at the junction. And you're aspirating the entire way? Yeah, that's what it's doing. Yep. So she's stabilizing the clavicle and scraping beneath it, yeah? There, you found it. Yeah.
CHAPTER 3
And then you thread the wire. It should, the… You guys have…
CHAPTER 4
Take the needle out, then you insert the cannula. Pressure immediately beneath the clavicle so that it doesn't bleed. And then we're putting in the dilator? Yes, that's what she's doing. And then she's make a nick on the skin. Make a small incision in the skin to pass the dilator. Removing the dilator, placing pressure back over the wire in the incision.
CHAPTER 5
Okay, so when you're passing the catheter you want to be sure that there's no aberrant electrical activity from the heart. We don't have fluoroscopy to see it, so we're not actually visualizing what we're seeing. So, extremely important to notice what's going on with the cardiac rhythm. The wire is out. And then you can advance the catheter. 6 cm from the sternal angle.
CHAPTER 6
She's flushing each line to be sure that it withdraws and you can push forward. This is slick. Aspirates, sorry, thank you - yeah, flush - I've never seen it that way. You learn from her. So she feeds the wire back into the - guide from which it came. These are the three lumens - antibiotics, IV, and a heart bpm. Mmm. She is very efficient. Mmm. No huss, no fuss, no muss, no fuss.
CHAPTER 7
She's really slick. So if you want to be good, learn from her. She's really slick in doing central line. I've never seen anybody so slick than her. Yeah. See, all her movements are all purposeful here. There's reason for every movement. I told you, it's not the speed, it's based upon quality of motion. Mm hmm. And every motion she has has quality, there's a reason for it. No wasted motion. That makes you a good surgeon. Mmm. You see all the fuss we do in the States? Mm hmm. Big fuss, for nothing. Mm hmm. We waste so much time, we waste too much technology, we waste a lot of money. Mmm. That's not necessary. For a simple thing like that. That should be simple. Right. Mm hmm. So you've got to learn from her how to do it that way. This is amazing. This is really slick. Yeah, if you're feeling it. Yeah, sure. So if we can teach our staff how to do it this way, we could save a lot of trouble in the United States. Okay. What you saw, you won't see it anywhere. You can go to any medical center, medical school right now, you won't see that. True, true. So this method that she showed to us is her technique. Si, she says it's a... Because I've not seen - I've not seen that method before - what she's showing you. And it's a gutsy technique, all right? It's blind, but it's safe because she's done it many times. Mm-hmm. She says it's a combination of techniques that she's acquired over the years. Right. So the dressing involves a large Tegaderm cut in half placed over the site. And then she puts the other half to stabilize the three lines. Okay. Gracias.