Step 1: Field Preparation
As with any procedure or surgery in medicine, the key to success starts with the preparation phase before the patient’s skin is touched by a needle or scalpel. For ultrasound access, visualization is of utmost importance. Thus, the operator should drape the surgical field making sure that the clavicle is exposed up to its superior edge and that there is enough room available to create an adequate pocket. Having the clavicle within the field of view ensures the ability to image the axillary vein on ultrasound medially until it disappears under the shadow of the clavicle to become the subclavian vein. This gives the operator the ability to choose how medial or how lateral the access sites will be in relation to the clavicle (Video 1).
After the rest of the surgical draping is complete, the ultrasound probe should be dropped by an assistant into a sterile sleeve containing ultrasound gel held by the operator and then secured to the drape near the access site. The ultrasound machine should be placed where the operator can easily view the screen without having to strain or look over any obstacles. This is usually at the head of the bed or across the bed from the operator. All access wires should be within easy reach to minimize the operator’s movements once access is obtained with the needle.