From the Guidelines
The recommended procedure for performing a subclavian vein cutdown involves positioning the patient supine with a rolled towel between the shoulder blades, administering local anesthesia, making a 3-4 cm incision inferior and parallel to the clavicle, and dissecting through the subcutaneous tissue to identify the cephalic vein. This approach is typically used in emergency situations when percutaneous access is impossible due to hypovolemia, trauma, or anatomical variations. The subclavian vein is preferred for its consistent anatomy and lower risk of pneumothorax compared to a direct subclavian puncture, though complications can include bleeding, infection, and injury to surrounding structures 1.
To perform the procedure, the following steps should be taken:
- Position the patient supine with a rolled towel between the shoulder blades to extend the neck and shoulders
- Administer local anesthesia (1-2% lidocaine)
- Make a 3-4 cm incision 1-2 cm inferior and parallel to the clavicle, centered over the deltopectoral groove
- Dissect through the subcutaneous tissue and identify the cephalic vein in the deltopectoral groove
- Isolate the vein using blunt dissection and place proximal and distal ligatures around it
- Make a small venotomy between the ligatures and insert the catheter toward the heart
- Secure the catheter by tying the distal ligature around it, then close the wound in layers and apply a sterile dressing Throughout the procedure, maintain strict aseptic technique and have suction available to manage bleeding. The choice of access site should be based on a careful evaluation of the relative risks and benefits of each site, with consideration of the patient's individual circumstances and the potential for complications, as outlined in guidelines such as those from the American College of Radiology 1.
From the Research
Procedure for Subclavian Vein Cutdown
The procedure for performing a subclavian vein cutdown is not explicitly described in the provided studies. However, the studies discuss the complications and success rates of subclavian vein catheterization using different methods, including percutaneous infraclavicular subclavian vein catheterization and ultrasound-guided technique.
Alternative Methods
- Percutaneous infraclavicular subclavian vein catheterization is a rapid alternative to surgical cutdown for venous access during cardiopulmonary resuscitation, as found in the study by 2.
- Ultrasound-guided technique is recommended to reduce the incidence of failure and mechanical complications, especially in difficult venous access, as noted in the study by 3.
- The choice of arm position, either abducted or neutral, does not significantly affect the success rate of subclavian vein cannulation under real-time ultrasound guidance, as reported in the study by 4.
Complications and Considerations
- Complications associated with subclavian vein catheterization include pneumothorax, hematomas, and catheter-related infections, as mentioned in the studies by 5, 2, and 3.
- The level of expertise of the operator and the number of attempts made to catheterize the vessel can affect complication rates, as found in the study by 2.
- Subclavian catheterization is seldom needed in the emergency room, and any intravenous lines inserted should be changed within 24 hours to minimize infection, as stated in the study by 5.