Before embarking on this procedure, be sure to set up your tray with the necessary equipment and/or medication in an aseptic manner.

Ensure that the plunger of the Raulerson syringe moves freely.

Pick up the guidewire and ensure that it is sitting completely within the delivery system. Retract it until just the tip is protruding through its housing.

Attach a disposable bag to the tray for depositing your used non-sharp materials.

The infraclavicular approach requires identification of the following landmarks:

• Clavicle. The junction of the medial and middle thirds of the clavicle corresponds to the needle puncture site.
• Suprasternal notch. The needle must be aimed towards the suprasternal notch during its insertion into the subclavian vein.

Position the patient in the Trendelenberg position.

Place a rolled towel or sandbag beneath the shoulders, between the scapulae.

If an assistant is available, ask them to pull down on the arm to displace the humeral head and allow better access to the subclavian vein.

Take universal precautions.

Use an aseptic technique.

Cleanse the skin over the puncture site with Chlorhexidine (see reference) (or Povidone iodine) solution.

Drape the puncture site exposing an area of approximately 10 x 10 cm (4 x 4 in).

Once again identify the anatomical landmarks.

If the patient is conscious or semi-conscious, infiltrate the puncture site with approximately 1 to 1.5 mL of local anesthetic. Aspirate for blood before injecting.

Insert the needle 2 cm (1 in) below the junction of the medial and middle thirds of the clavicle.

With the bevel of the needle pointing upwards, insert the needle and Raulerson syringe beneath the clavicle and aim it towards the suprasternal notch.

Apply a little suction to the syringe and continue with the insertion until you enter the vein. This is confirmed by the following:

• There is a palpable change in pressure
• There is a flashback of blood into the syringe
• The flashback or a change in pressure occurs after inserting the needle a distance of 2 to 3 cm (1 in)

Use your non-dominant hand to maintain the position of the needle and syringe.

With your other hand gently insert the guidewire through the back of the syringe into the subclavian vein. Use the markings on the guidewire to advance it to a depth of 15 to 20 cm (6-8 in).

Whilst holding initially the tip and then the bottom of the wire, remove the syringe and needle.

Use the scalpel blade to make a small skin incision adjacent to the wire.

Continue to hold the guidewire firmly.

Pass the dilator over the guidewire and dilate the skin incision and the tract into the vein.

Remove the dilator. 

Thread the catheter over the guidewire and retract the wire until the tip exits one of the ports.

Whilst holding the tip of the wire, insert the catheter into the subclavian vein. Using the markings on the catheter, insert the catheter to at least 15 to 20 cm (6-8 in) at the skin (15-17 cm (6 in) on the right side and 18-20 cm (8 in) on the left side). The depth of insertion depends on the patient's size. 

Hold the catheter firmly in place and remove the guidewire.

Occlude the port where the guidewire exited with your thumb. This helps to minimize the risk of air embolism.

Use the 20 mL syringe and normal saline to aspirate and flush each port. This confirms that all the port openings are within the lumen of the vein. If there is no aspiration of blood in any of the ports, the catheter should be advanced a little further until there is.

Use non-absorbable sutures to secure the catheter to the skin.

Apply a transparent sterile dressing over the insertion site.

Postprocedure considerations