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A D V E R T I S E M E N T
A D V E R T I S E M E N T
Central access can be achieved through the subclavian vein both below and above the clavicle, but the latter route is more risky and seldom used. Access to the internal jugular vein is possible between the heads of the sternocleidomastoid muscles and posterior to the border of that muscle. These routes are suitable for acute monitoring but present logistical problems for situating long-term catheters.
A D V E R T I S E M E N T
The subclavian vein crosses the first rib at the anterior not between the clavicle and first rib as is conventionally taught. Therefore it is not logical to aim for the sternal notch when trying to puncture the vein. The vein is compressed between the clavicle and scalene when the shoulder is displaced posteriorly and downward. Thus it is advantageous to have the shoulder in neutral position with no roll in order to keep the vein wide open.
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A D V E R T I S E M E N T
Two structures connect the medial part of the clavicle to the costal cartilage of the first rib: the costoclavicular (Halsted's) ligament and the tendon of the subclavius muscle. By aiming toward the sternal notch with the needle, one penetrates these structures and will not find the subclavian vein. One will eventually encounter periosteum which is extremely sensitive and painful to the patient. The traditional teaching of "walking" posteriorly off the periosteum in addition to being painful, blunts the needle tip and causes a ragged entry into the vein when it is finally encountered in its posterior location.
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This page was last modified on 3/1/1999.
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