How to place subclavian line

Equipment

• Essential: Central line kit (needle, guidewire, dilator, catheter), ultrasound machine with a high-frequency linear transducer, sterile gloves/gown, mask, antiseptic solution, sterile drapes
• Optional: Micropuncture kit or angiocatheter (to reduce needle dislodgement) ¹⁵

Positioning and Landmarks

• Position: Patient supine in a 15–20° Trendelenburg position; if possible, slightly abduct the ipsilateral arm and place a small towel roll between the scapulae to flatten the deltoid ¹²
• Landmarks/US: Identify the subclavian vein just inferior or posterior to the medial third of the clavicle; with ultrasound, visualize the vein in a long axis beneath the clavicle and identify the first rib to minimize pleural injury ²⁵

Analgesia/Sedation

Option	When	Key note
Local anesthetic (1%–2% lidocaine)	Prior to skin puncture	Ensure adequate anesthesia along the needle trajectory
Minimal sedation (if needed)	In anxious patients while maintaining airway precautions	Use caution in hemodynamically unstable patients

Steps

1. Prep and drape the subclavicular area using full sterile technique.
2. Administer local anesthesia along the proposed needle track.
3. Using ultrasound, identify the subclavian vein below the clavicle. Adjust the probe to get a long-axis view if possible.
4. Insert the introducer needle at the selected puncture site with a needle trajectory aimed toward the sternal notch, visualizing the needle tip throughout insertion.
5. Upon obtaining non-pulsatile venous return, thread the guidewire through the needle, ensuring its smooth passage under ultrasound visualization.
6. Remove the needle and use the dilator over the guidewire to gently dilate the tract.
7. Advance the catheter over the guidewire into the vessel.
8. Secure the catheter and cover with a sterile dressing.
9. Confirm catheter placement with a post-procedure chest X-ray to rule out malposition or pneumothorax ¹⁴

Post-procedure

• Confirm: Obtain a chest X-ray to verify catheter tip location and exclude pneumothorax.
• Aftercare: Secure catheter appropriately; flush all lumens and maintain sterile technique.
• Re-check: Monitor the patient’s respiratory status and insertion site for signs of bleeding or hematoma.

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