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How [not] to place a central line (part 2)

As an intern, I’ve done a few IJ lines and a few femoral lines, but last night I did my first subclavian.  My coworker put in a right IJ, and the patient got agitated and pulled it out.  I put in the subclavian, and I knew something was wrong when I advanced the line over the guidewire.  It just felt like it was directed too superiorly.  I fully expected it to be up in the neck when I got the chest xray – a complication I had seen several times before.  This is what I got:

subclavian cxr

subclavian cxr

The radiologist’s report was: “Interval insertion of right central venous catheter with tip in the region of the left subclavian”

I inserted a guidewire and redirected it into the SVC with flouroscopic guidance – what a pain in the ass…

2 Comments to “How [not] to place a central line (part 2)”

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  On October 3rd, 2009 at 7:40 pm
  Scott Geiger Says:
   

  One of the tips given to me for subclavian lines is to have the bevel down (towards the direction you ultimately want the catheter to go) and to align the pigtail the same way. That way the pigtail will preferentially go down the SVC. He says since he started doing them this way, he hasn’t had a catheter go the wrong way.
  Haven’t had an opportunity to test drive this tip yet.

• 
   
  On October 3rd, 2009 at 11:23 pm
  Brian Says:
   

  Just read an awesome article about the supraclavicular approach to the subclavian line in the May 2009 issue of Western Journal of Emergency Medicine. It sounds pretty appealing – less incidence of misplaced lines, fewer pneumos, easier to perform during CPR, etc.

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