What to do if a central line is placed in the brachiocephalic vein?

Management of Central Line in the Brachiocephalic Vein

A central line placed in the brachiocephalic vein can be safely maintained and used for intended purposes as this is a viable and acceptable central venous access site. 1, 2

Assessment of Catheter Position

• Confirm proper tip position via chest X-ray - the tip should be in the lower third of the superior vena cava, at the atrio-caval junction, or in the upper portion of the right atrium 1
• Check for signs of proper function including:
  • Ability to aspirate blood from all lumens 1
  • Normal pressure waveform 1
  • Absence of pain on injection 1
• Look for signs of malposition such as:
  • Difficulty aspirating blood from one or more lumens 1
  • Abnormal pressure waveform 1
  • Pain on injection 1
  • Arterial pattern blood gas on sampling 1

Management Options

If Properly Positioned and Functioning:

• Continue using the catheter for its intended purpose 1
• Maintain proper catheter care including:
  • Use of 2% chlorhexidine as skin antiseptic for dressing changes 1
  • Appropriate dressing of the exit site 1
  • Disinfection of hubs, stopcocks and needle-free connectors 1
  • Regular change of administration sets 1

If Malpositioned but Still Within Venous System:

• Consider the following options:
  1. Use the device if it is safe to do so and functioning properly 1
  2. Manipulate the position under X-ray guidance 1
  3. Replace the catheter using fluoroscopic guidance or other imaging as required 1

Evidence Supporting Brachiocephalic Vein Access

• The brachiocephalic vein is a viable alternative to traditional central venous access sites 1, 3
• Studies show comparable or lower complication rates compared to internal jugular vein access:
  • Similar overall failure rates (3.5% vs 3.4%) 3
  • Lower procedural difficulty compared to internal jugular approach 3
  • Lower risk of catheter-related bloodstream infections and thrombosis in pediatric populations 4, 5

Advantages of Brachiocephalic Vein Access

• The supraclavicular approach to the brachiocephalic vein offers excellent in-plane needle visualization not interrupted by bony structures 2
• Allows visualization of the distal end of the subclavian and brachiocephalic veins 2
• May be associated with lower risk of catheter-related complications compared to other sites 4, 6
• Well-tolerated in both pediatric and adult populations 7, 3

Potential Complications and Monitoring

• Monitor for common complications of central venous access:
  • Infection at insertion site or catheter-related bloodstream infection 1
  • Venous thrombosis 1
  • Catheter dislodgement 6
  • Catheter malfunction 6

When to Remove or Replace

• Remove the catheter when:
  • It is no longer required 1
  • It is causing problems (infection, thrombosis, malfunction) 1
  • For removal technique:
    • Position patient flat with exit site below the heart to reduce risk of air embolism 1
    • Apply firm digital pressure for at least 5 minutes followed by an occlusive dressing 1
    • Consider a skin stitch if persistent bleeding occurs 1

Key Pitfalls to Avoid

• Failing to confirm proper tip position before use 1
• Ignoring signs of catheter malfunction or malposition 1
• Inadequate sterile technique during catheter maintenance 1
• Unnecessary removal of a properly functioning catheter 1, 2