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Placing of a subclavian line: Insertion of the guide wire

E.Papazissis

Place your thumb over the acromioclavicular joint and your index over the jugular. Insert your needle vertically through the middle of this distance and just below the clavicle. Feel the needle ‘touch and slide’ under the clavicle.

As soon as the needle tip passes the clavicle, without advancing at all, use the syringe as a handle to turn the needle completely horizontal, so that it points to your index finger which is always placed onto the patient’s jugular.

While aspirating continuously advance the needle, always pointing towards the jugular.

At one point you will feel resistance. It is the sternoclavicular joint. Pull back 1-2 mm and direct very slightly down. Advance the needle. It will pass ‘adjacent’ under the sternoclavicular joint. Advance the needle slowly, while aspirating continuously and pointing steadily to your index which is placed always on the jugular.

As soon as blood returns into the syringe, the needle has entered the subclavian vein. During the whole process, the hand holding the syringe must be steadied over the chest wall. This ensures that you have absolute stability of movement and complete immobility of the needle, as soon as it enters the vein.

Using your other hand hold the plastic end of the needle firmly, while stabilizing your hand onto the patient’s chest, to ensure that the needle remains completely still.
Loosen the syringe from the needle with very careful slow movements and then remove it. Naturally blood should be returning from the needle.

Attention: if blood is spurting out, it means that you have entered an artery. Remove the needle immediately and apply pressure for a few minutes.

Introduce the wire guide into the needle, at least 20-30cm.

Alternatively you could introduce the wire guide through the syringe plunger, by passing it through the hole found on the back of it. In this case however you must be absolutely sure that you have not entered an artery!

Remove the needle, while pressing down with gauze over the point of penetration, so that the guide is not pulled out. Make sure that until the needle is completely removed from the chest wall, the guide wire remains in place.

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