I have used the supraclavicular approach in dozens of patients and it is now my preferred
approach to the subclavian vein. I have used it primarily in adult patients, since I was
residency trained in E.M. and see primarily adults but also a large number of kids (70k/yr vol in
our E.D.). The smallest child in whom I have placed such a line was a 4 m.o. NICU grad with a
complex hx who was in full arrest at the time and CPR did not affect success of the procedure.
The largest patient was > 550 lbs and septic and again there was no problem. The amazing thing
is that I didn't even need the full 3.5" length of the introducer needle to reach the SCV on such
an obese pt. I do modify the "textbook" approach as follows: on the initial insertion of the
introducer needle I stay horizontal (parallel to the bed) and aim for the contra lateral nipple
advancing until I reach the clavicle. Then I withdraw slightly and aim just posterior to the
clavicle and advance. I have seen a 10 degree angle (A-P) described and feel this is about
right, but prefer to "inch " my way there rather than start with a 10 degree angle and the n have
to guess which way to adjust my approach if the first stick is not successful. On the obese
folks the angle may be 20-30 degrees, and again you won't need the whole lenght of the needle to
reach the vein. Hard core heroin addicts will use this approach (shooting the pocket) from what
I have heard, but I have never seen it personally. Hope this is helpful.
jay pershad wrote:
> I was curious if anyone had any experience that they would be willing to
> share with the "supraclavicular" approach for subclavian access in emergent
> situations, especially when CPR is ongoing.
> Recently had a child transferred in from the periphery with one
> of these in place. When I reviewed some literature on it, ( to be specific,
> Hodges' text book on procedures in EM), it is touted as a relatively easy
> approach and does not interfere with chest compressions (since one is out of
> the field, much like the femoral route). Moreover, the risk of a PTX is
> reported as substantially less, since one is anatomically further away from
> the dome of the apical pleura.
> Any thoughts or data would be appreciated.
> Jay Pershad, MD
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