How I do it A loop technique for the safe, secure, and convenient fixation of subclavian central venous catheters to the chest wall Patrick R. Reardon, M.D.*, Gerald P. McKinney, M.D., E. Stirling Craig, B.A., Michael J. Reardon, M.D. The Methodist Hospital, and Departments of Surgery, Cardiovascular, and Thoracic Surgery, University of Texas at Houston Medical School, 6550 Fannin, Suite 2435, Houston, TX 77030, USA Manuscript received April 29, 2002; revised manuscript October 16, 2002 Abstract Central venous catheters are placed frequently at our institution. Residents are taught the technique of subclavian line placement starting in their first year of training. Frequently the teaching stops once the line is in the vein. We have developed a method of fixation for subclavian central venous catheters that provides a safe, secure, and convenient means of fixation to the chest wall. The central venous catheter can be inserted by that technique with which the physician is the most comfortable and familiar. © 2003 Excerpta Medica, Inc. All rights reserved. Keywords: Fixation; Central venous catheter; Subclavian catheter; Loop Central venous catheters are frequently used by surgeons. We teach the technique of central venous catheter insertion to interns. This is one of the first skills they are expected to master. When surgeons write about the technique of insertion of these catheters, they write long, detailed descriptions. Para- graphs of minute detail are given. The exact patient position, the exact number of degrees of Trendelenburg position, the exact point of insertion, down to the centimeter, are all de- scribed in exquisite detail. How to secure the catheter is de- scribed in a single, short sentence [1,2]. Surgical technique The fixation technique is depicted in Fig. 1. The central venous catheter has already been inserted into the left sub- clavian vein in this illustration. A fixation suture (fs1) is placed into the skin of the chest wall at a point directly behind the catheter and very close to the skin entry site (Fig. 1A). A small loop should be created to keep the suture from causing skin ischemia and necrosing through the skin. A stack of 5 throws is tied to create a short “umbilical.” Without cutting the suture, the same suture is then secured to the catheter near its skin entry site, as depicted in Fig. 1A. The distance between the skin entry site and the point of attachment to the catheter should be kept short to minimize any to-and-fro motion of the catheter. It is important to note that the suture is not cut at this time. The catheter is then coiled, as depicted in Fig. 1B, until the catheter hub overlies the fixation suture, which is still uncut and tied to the catheter. This coiling is facilitated by a clockwise twisting motion of the catheter, if it has been placed on the left side, as depicted. For catheters placed on the right side, the set up is a mirror image of Fig. 1 and a counterclockwise twisting motion is used. The fixation su- ture is then passed through the medial hole in the hub and tied securely. A second fixation suture (fs2) is then placed through the skin of the chest wall, just below the lateral hole, and secured to the lateral hole. Again, leaving a small loop, as depicted in Fig. 1A, will prevent skin necrosis. A final fixation suture (fs3) is then placed at the inferior-most portion of the loop. This is illustrated in Fig. 1B. Comments The advantages of this configuration are several. First, it is extremely difficult to inadvertently pull out a catheter secured with this configuration, as long as all of the fixation * Corresponding author. Tel.: +1-713-790-3140; fax: +1-713-790- 3235. E-mail address: reardonp@texmist.com The American Journal of Surgery 185 (2003) 536 –537 0002-9610/03/$ – see front matter © 2003 Excerpta Medica, Inc. All rights reserved. doi:10.1016/S0002-9610(03)00071-0