Critical Care Obstetrics part 18 provides expert clinical guidance throughout on how you can maximize the chances of your patient and her baby surviving trauma. In this stimulating text, internationally recognized experts guide you through the most challenging situations you as an obstetrician are likely to face, enabling you to skillfully:Recognize conditions early-on which might prove life threatening, Implement immediate life-saving treatments in emergency situations, Maximize the survival prospects of both the mother and her fetus | Vascular Access Figure Landmarks for subclavian vein cannulation. Using the clavicle the subclavian vein is divided into thirds. The junction of the middle and medial third identifies the location for needle insertion. clavicle touching the bone itself as needed pointing toward the suprasternal notch and parallel to the patient s back. Upon entering the vein the bevel is turned to the 3 o clock position to facilitate passing the catheter. Immediate risks of SCV cannulation include pneumothorax hemothorax and catheter misplacement. The most common of these complications is pneumothorax with an incidence of 1-6 . Pneumothorax is primarily associated with direct subclavian or jugular vein catheterization. Collin and Clarke 56 reviewed the occurrence of delayed or late pneumothorax 48-72 h following central venous catheterization and recommended that postinsertion chest radiographs be expiratory and upright. Expiration results in a decreased volume of air in the lung but not in the pleural space thus magnifying the radiographic appearance of the pneumothorax 57 . Finally repeat or delayed chest radiographs are indicated following catheterizations requiring multiple attempts persistent pleuritic or back pain and respiratory symptoms. The standard treatment for pneumothorax has traditionally consisted of placement of a thoracostomy tube. However in an investigation by Laronga 58 pneumothorax was managed by observation alone and or the insertion of a pigtail catheter French with a Heimlich valve in the outpatient setting. Also in spontaneous breathing patients who have developed a small pneumothorax the use of 100 oxygen therapy for 60 minutes may denitrogenate and attenuate the pneumothorax thus averting chest tube insertion. Hemothorax is an infrequent complication of direct SCV catheterization. Because intrathoracic vascular structures are inaccessible for direct compression subclavian and to a lesser degree IJV direct venous catheterization are .
