The incidence of malpositioning of subclavian vein catheter varies between 6%- 9% and majority of these misplacements are in the ipsilateral internal jugular vein (IJV). Misplaced catheter enhances the risk of clot formation, thrombophlebitis, catheter erosion and inappropriate delivery of drugs in addition to impaired CVP measurement. Chest radiography is performed to identify the exact location of the catheter, however, it is time consuming requires exposure to radiation and may not be feasible in emergency situations.
Ambesh Maneuver: After successful puncture of subclavian vein with a cannula/needle, a constant pressure is applied in the ipsilateral supraclavicular fossa, with one of the fingers. This effectively compresses the ipsilateral IJV. Now the guidewire is threaded through the cannula into the subclavian vein. If the operator notices the resistance while inserting the guidewire, it means the guidewire is going north into the IJV. The guidewire is removed gently, the direction of the needle bevel is changed caudad by rotating the needle. Guidewire is now rethreaded maintaining the pressure in the supraclavicular fossa. After successful insertion of guidewire, the pressure in fossa is released and the subclavian vein catheter is railroaded over the guidewire up to the desired length. The catheter may now be connected to monitor CVP and other purposes.
Ambesh maneuver is quite simple, inexpensive, instant and a handy bedside technique that prevents misplacement of subclavian vein catheter into the IJV.