Emergency Subclavian Vein Cannulation Through a Modified Supraclavicular Approach in a Patient With a Halo Traction Device

The halo traction device poses a number of problems for anesthesiologists including accessibility to the airway and positioning patients for procedures such as central venous cannulation (CVC). There are multiple case reports on emergent and elective airway management of patients in the halo frame. However, no description exists of any modified CVC technique in such patients.

A 60-year-old woman was admitted to the neurosurgical intensive care unit after transoral odontoidectomy with posterior fixation of the arch of the first cervical vertebrae with the occiput using a cage wire graft. Because the patient was quadriplegic with poor respiratory efforts, she was tracheostomized before surgery in anticipation of prolonged mechanical ventilation and a need for pulmonary toileting. After the surgery, a halo vest assembly was applied to further stabilize the cervical spine in mild flexion (Fig 1). Her lungs were mechanically ventilated. On the 5th postoperative day, the patient developed sudden hemodynamic instability with a blood pressure of 60/36 mmHg and a pulse rate of 106/min. The only venous access present was a poorly functioning 20-G cannula in the right upper limb. Because of pre-existing thrombophlebitis, peripheral venous access could not be secured. An emergent need for central venous access was considered. Because the ultrasound machine was not available immediately, a blind technique for CVC was sought.

A modified supraclavicular approach for cannulation of the right subclavian vein (SCV) was planned. With the patient in the supine position, the head fixed in mild flexion (because of the halo device), and the right arm along the side of the body, the right SCV was located using a 1.5-in, 23-G finder needle. From the entry point at the junction of the medial margin of the clavicular head of the sternocleidomastoid muscle and the clavicle, an 18-G needle was inserted at an angle 30° medially from the sagittal plane and 45° posteriorly from the coronal plane (Fig 2B). The right SCV was located at a depth of 1.5 cm from the skin. Using the Seldinger technique, a double-lumen CVC was inserted under electrocardiographic guidance and fixed at 9 cm. The adequate positioning of the subclavian catheter was further confirmed by central venous pressure (CVP) waveform tracings and a chest radiograph. CVP-guided fluid therapy and dopamine infusion resulted in the prompt restoration of blood pressure.

Our patient, with a halo vest system and tracheostomy, was on mechanical ventilation. Such a case poses a real challenge for the emergent insertion of a CVC. In tracheostomized patients, the subclavian approach generally is preferred because of the reduced infection rate and the easier handling of a tracheostomy and CVC. However, because of the presence of the halo traction device, the infraclavicular approach of subclavian catheter insertion was not possible. Also, adequate positioning with a sandbag in the midscapular region and rotation of the head to 1 side was not possible in this patient. The “classic supraclavicular approach” as proposed by Yoffa was not useful practically in this case. The technique necessitates the insertion of an introducer needle at an angle of 5° to 15° (from the horizontal plane) from the point just lateral to the site of the insertion of the lateral head of the sternocleidomastoid muscle over the clavicle (Fig 2A). Although the approach has been used successfully in patients on mechanical ventilation and in emergency situations like cardiopulmonary resuscitation, the lateral fixation rods of the halo fixation frame (Fig 1) made the procedure impossible in our patient. Numerous modifications of Yoffa's original technique, ranging from simply changing the angle of needle insertion to using a completely different set of anatomic landmarks from the “clavisternomastoid angle,” have been described. However, the lateral fixation rod prevented the necessary needle angulations, and the portion of the vest that crossed the shoulders (Fig 1) obscured the entry sites selected in the classic and modified approaches already described in the literature. The “pocket approach” for subclavian catheter insertion was not useful because there was little room for handling the needle syringe assembly. Although internal jugular venous cannulation was possible, it was difficult because the head was in the neutral position with the body of the mandible and the halo frame preventing proper angulation of the introducer needle.

Ultrasound screening of the SCV before attempted cannulation to identify vessel location and patency has been recommended to increase the success rate and reduce complications. However, the availability and expertise were concerns. Furthermore, the data on the supraclavicular approach warrant consideration of anatomic landmarks and interference of the clavicle as impediments to the use of real-time ultrasound for this approach.^,  Moreover, in a patient with the halo device, there is little room to position the transducer effectively while manipulating the needle.

We speculate that the described modification of the supraclavicular approach can be safely used for blind insertion of a subclavian catheter in patients in the halo frame. We further speculate that the described technique retains all the advantages of Yoffa's approach, such as rapidity and the lack of need for specific positioning. Our technique allows the ipsilateral forearm to be placed by the side of the body. Because the dome of the pleura is located lateral to the site of needle insertion, the risk of pleural injury is minimized further with the modified technique. The use of a smaller-gauge finder needle for localization of the SCV also may reduce the risk of inadvertent arterial puncture and pneumothorax. Our case focuses attention on the modification of the supraclavicular approach for emergent CVP catheter insertion in a patient with the halo device.