Clinical Images

Aim For the Bubbles: Agitated Saline Injection as an Adjunct Technique to Ultrasound-Guided Subclavian Vein Cannulation

Faris G. Araj, MD;  Jose Pena, BSN, RN; Julie Cox, BSN, RN, BS

Faris G. Araj, MD;  Jose Pena, BSN, RN; Julie Cox, BSN, RN, BS

J INVASIVE CARDIOL 2019;31(7):E232.

Key words: agitated saline technique, ultrasound


The benefits of subclavian vein central line placement for long-term intravenous (IV) access or long-term hemodynamic monitoring include lower risks of infection and thrombosis, as well as greater patient comfort. Ultrasound-guided central vein cannulation is the technique of choice for many operators in the catheterization laboratory or at bedside. The use of all available methods to accurately identify the subclavian vein during ultrasound-guided procedures helps reduce complications, such as pneumothorax and arterial puncture. This is especially true in patients with hypotension, severe tricuspid regurgitation, and continuous non-pulsatile blood flow (as in a patient with a left ventricular assist device), whereby differentiation of the artery from the vein is not straightforward. A simple technique that can be used in the catheterization laboratory or at bedside to safely identify the subclavian vein is the injection of agitated saline (Figure 1A) through a peripheral IV located in the ipsilateral arm. This results in opacification of the target vessel within a few seconds (Figure 1B and Video 1).

The use of agitated saline during central line placement is not a novel procedure, and has been described to verify appropriate catheter tip location. To our knowledge, this is the first description of this method for the specific purpose of identifying the subclavian vein during ultrasound-guided procedures. We believe this technique can be easily taught and executed, increases operator confidence in localizing the vessel, and reduces complication rates.


From the University of Texas Southwestern Medical Center, Dallas, Texas.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted December 12, 2018.

Address for correspondence: Faris Araj, MD, University of Texas Southwestern Medical Center, 5939 Harry Hines Blvd, Professional Office Bldg 2, Suite 600, Dallas, TX 75390. Email: Faris.Araj@UTSouthwestern.edu

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