Percutaneous innominate vein catheterisation: a new technique for venous access in the critically ill

Venous access in the critically ill can be a major problem despite the wide variety of methods now available. A new technique is described involving percutaneous catheterisation of the innominate vein via a right second intercostal space approach. It has been successful in five patients over a four-year period. While there have been no major complications, it is advocated for use only when access is necessary for life-saving administration of fluids or drugs. Venous access can be obtained in the majority of patients by a variety of safe and accepted measures such as peripheral venepuncture, central vein catheterisation by the subclavian or internal jugular vein, or by a cutdown. There remains, however, a small subgroup of patients with venous thrombosis from a previous catheter insertion or intravenous drug abuse for whom a number of ingenious methods have been devised. These include cutdowns on the intercostal vein; the middle thyroid vein in infants; and on the inferior epigastric vein, the azygos vein, the iliac vein, and even the inferior vena cava in adults. Access for patients suffering from haemorrhagic shock can be facilitated by multiple catheters in one or more subclavian veins. Even more rarely, these methods may be unsuccessful or contraindicated because of vein thrombosis, infection overlying the insertion site, or patient instability. A new method has been developed allowing percutaneous catheterisation of the innominate vein.