ABSTRACT
For all infraclavicular approaches, we recommend standing at the side of the bed. The important anatomic landmarks are the clavicle and the suprasternal notch. Multiple initial skin punctures along the clavicle beginning within the distal third and progressing out toward the lateral third have been described. We have had the most success beginning with a point at the mid-clavicle, particularly where the clavicle begins to bend cephalad and the bulk of the insertion of the pectoralis muscle can be felt. These two structures, the clavicle on top and the pectoralis on bottom, form the head of an arrow that aims at the suprasternal notch (Figure 23.8). The cannulating needle is grasped such that the tip of the needle is controlled by the index finger. The needle is then inserted directly in line with the arrowhead formed by the clavicle and the major insertion of the pectoralis muscle approximately 1 cm lateral to the clavicle so that it can easily be slipped underneath. The purpose of controlling the tip with the index finger is so that the needle-syringe apparatus can be pressed down toward the patient’s bed and the needle advanced under the clavicle with minimal lifting of the syringe. The plane in which the needle travels is as close to parallel to the plane of the floor as possible. If the clavicle is encountered and the hub of the syringe needs to be picked up so that the needle can slide underneath the clavicle, we do not recommend picking the syringe up by any more than 30° off the horizontal plane. Angles above this are much more likely to proceed into deeper structures, such as the subclavian artery and the pleura. It is significantly easier and less risky in
these circumstances to choose an insertion point slightly more lateral so that the tip of the needle can be slipped under the clavicle without having to angle the syringe up significantly. The direction of needle travel is now toward the suprasternal notch; constant aspiration on the syringe is maintained as the needle is advanced. In obese patients or those with significant muscle mass, it is not uncommon to have to place the entire length of the needle through the skin, and even encounter dimpling of the skin before the vein is entered.
