We don’t often put in subclavian TLCs in the ED because of the increased risk of complications, specifically pneumothorax. Often, it’s difficult to do with US guidance so we turn to placing IJ TLCs instead. However, there are certain patients who might require a subclavian line and in those, anything that makes the subclavian more plump helps increases our chances of success and reduce the risk that we hit surrounding structures.
It turns out that simply turning the head to the ipsilateral side can help increase the area of the vessel!
A small study using was done measuring cross sectional area on ultrasound on 42 healthy volunteers, using the patient as his or her own control. The head was turned to the contralateral side, neutral position (nose straight up), or ipsilateral side. They found the cross sectional area was 0.15 cm2 greater with the head turned 30 degrees ipsilateral to the procedure versus having the head turned 30 degrees to the contralateral side. The cross sectional area was even more increased if the patient was in Trendelenberg.
Caveats to this study: patients were healthy volunteers so we don’t know how this would translate to the sick patient population that would require central lines. However, given there is little risk to turning the head, this is something to try on your next subclavian line.
Source: The Effect of Head Position on the Cross-sectional Area of the Subclavian Vein. Anesth Analg. 2017 Aug 31. doi: 10.1213/ANE.0000000000002446. [Epub ahead of print]
I know the picture is misleading, but I’m just guest posting today so I took some liberties. Also, how cute is my dog???