Is the landmark technique safe for the insertion of subclavian venous lines?

The complications of central venous line insertion have been highlighted by the recent NICE report advising that ultrasound guidance should be used for central line insertion.

We report a prospective audit of the complications of subclavian vein central venous line insertion for parenteral nutrition over a five-year period when ultrasound guidance was not used.

In total, 201 lines were inserted for parenteral nutrition into a subclavian vein. A single consultant surgeon inserted 120 of the lines and year five or six surgical registrars performed the other line insertions. Five pneumothoraces occurred in four patients who had subclavian lines inserted and a chest drain was required in three cases. Four line tips were found to be going upwards rather than into the superior vena cava. Misplacement was more common with right subclavian insertion. Inability to site the line at that attempt was associated with previous line insertion in four of six patients.

A low complication rate can be achieved for central line insertion for parenteral nutrition. It is likely that this is due to the small number of experienced operators.