Polyurethane elastomer central venous catheters can be easily inserted into the infraclavicular subclavian vein using a Seldinger technique and maintained in place free of bacterial colonization for many weeks. This site is the most comfortable for most patients. This procedure attracted a high incidence of pneumothorax in the early years following its introduction. However, if the correct technique is employed, this complication can be avoided and a major advantage is that there is no risk to the carotid artery and adjacent nerves in the neck. The patient should be relaxed and positioned in a 20° to 30° head-down tilt; it is best to extend the shoulders over a towel or suitable sandbag and turn the head to the contralateral side with the arms lying alongside the thorax. It is wise to have ECG monitoring in place to detect arrhythmias. Right-handed clinicians will find the left subclavian artery the easiest to cannulate. A needle with its attached syringe should be inserted 2 to 3 cm below the clavicle at the junction of its middle and medial thirds with the bevel of the needle facing upwards. The needle should then advance towards the inferior border of the clavicle, aiming for the small space between the clavicle and the first rib. By the time the pectoral muscles are reached, the needle or cannula should be parallel to the coronal plane in order to avoid pleural lacerations. The needle is then advanced slowly along an imaginary line extending from the surgical neck of the humerus, through the junction of the middle and medial thirds of the clavicle to the top of the ipsilateral sternoclavicular joint. The needle should traverse this line in a plane 0.5 to 1 cm posterior to the clavicle and the vein will be entered at the outer border of the first rib. When this technique is used carefully and cautiously, there is no risk of pleural or pulmonary injury since the vein will be entered lateral to the outer edge of the first rib.
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