Central venous catheterization -- an anatomical review of a clinical skill -- Part 1: subclavian vein via the infraclavicular approach

Evaluation of a Novel Bony Landmark-Based Method for Teaching Percutaneous Insertion of Subclavian Venous Catheters in Pediatric Patients

BACKGROUND

Surgical trainees performing subclavian vein (SCV) cannulation often incorrectly perceive needle trajectory and anatomical relations. As surface landmark-based methods derived from adult surgical practice may be less effective in younger patients, we developed and evaluated a novel bony landmark-based method for teaching SCV cannulation for central venous access device (CVAD) placement in children.

METHODS

Over 2 sequential 3-year periods, pediatric surgical trainees were taught infraclavicular SCV cannulation via surface- and bony-landmark approaches, respectively. We prospectively recorded patient, surgeon and operative details on all Hickman line and port-a-cath insertions placed by trainees as the first surgeon via percutaneous infraclavicular SCV puncture and compared procedural outcomes and complications across both periods.

RESULTS

Of 271 cases included in the study, trainees performed 52 (50.5%) and 92 (54.8%) procedures in the first and second periods, respectively. Patients in both periods did not differ by gender, disease, CVAD device, or prior CVAD, chemotherapy or infection status. In the second (bony landmark) period, although patients were younger (6.0 vs. 8.7 years, P = 0.003) mean procedural duration was shorter (42.5 vs. 58.3 min, P < 0.001). Also, cannulation attempts and complication rates did not differ significantly between study periods (P = 0.257 and 1.0, respectively).

CONCLUSIONS

With the bony landmark approach, trainees could perform the procedures faster despite operating on younger patients, without impacting complication rates and cannulation attempts. Bony landmarks may better approximate SCV position across a range of ages, thus improving the consistency of SCV cannulation in CVAD placements in children.

Central venous catheters: Indications, techniques, and complications

Central venous catheters (CVC) are commonplace in the management of critically ill patients and serve a variety of purposes. Venous access is important for the administration of fluid and medications as well as blood procurement needed for lab analyses. However, not every critically ill patient requires a CVC. This article highlights the key considerations, pitfalls and evidence-based practices regarding the use pediatric central venous catheters.

The correlation between ATLS and junior doctors' anatomical knowledge of central venous catheter insertion at a major trauma centre in South Africa

OBJECTIVE

To review the ability of junior doctors (JDs) in identifying the correct anatomical site for central venous catheterization (CVC) and whether prior Advanced Trauma Life Support (ATLS) training influences this.

DESIGN

We performed a prospective, observational study using a structured survey and asked a group of JDs (postgraduate year 1 [PGY1] or year 2 [PGY2]) to indicate on a photograph the exact site for CVC insertion via the internal jugular (IJV) and the subclavian (SCV) approach. This study was conducted in a large metropolitan university hospital in South Africa.

RESULTS

A total of 139 JDs were included. Forty-four per cent (61/139) were males and the mean age was 25 years. There were 90 PGY1s (65%) and 49 PGY2s (35%). Overall, 32% (45/139) were able to identify the correct insertion site for the IJV approach and 60% (84/139) for the SCV approach. Of the 90 PGY1s, 34% (31/90) correctly identified the insertion site for the IJV approach and 59% (53/90) for the SCV approach. Of the 49 PGY2s, 29% (14/49) correctly identified the insertion site for the IJV approach and 63% (31/49) for the SCV approach. No significant difference between PGY1 and 2 were identified. Those with ATLS provider training were significantly more likely to identify the correct site for the IJV approaches [OR=4.3, p=0.001]. This was marginally statistically significant (i.e. p>0.05 but <0.1) for the SCV approach.

CONCLUSIONS

The majority of JDs do not have sufficient anatomical knowledge to identify the correct insertion site CVCs. Those who had undergone ATLS training were more likely to be able to identify the correct insertion site.

Congenital Anatomical Variant of the Clavicle

The aim of this study is to present a rare abnormality of the clavicle (Code: SGS01) that was discovered in an ossuary in the Church of San Gaetano (Sulmona, central Italy; XVII-XIX centuries CE). In the middle third, the clavicle had three areas with losses of substance in the form of oval-shaped foramina with maximum diameters of 1-2 cm that were located in the anterior and superior surfaces of the diaphysis. The margins of these foramina were well defined and rounded, and the surfaces of the canal walls were smooth. Additionally, there were no zones of bony activity or reactive changes around the foramina. This new congenital anomaly of the clavicle and blood vessels is consistent with a variant that might have originated during fetal growth in which the subclavian vein or artery remained included during the process of ossification of the clavicle. Anat Rec, 300:1401-1408, 2017. © 2017 Wiley Periodicals, Inc.

Major neurovascular complications of clavicle fracture surgery

Clavicle fracture fixation is becoming an increasingly common operation, with good clinical outcomes and a low rate of significant complications. However, there are several reports of rare but potentially life or limb threatening, neurovascular complications. Arterial injuries are usually pseudoaneurysms associated with prominent screws. These may be clinically silent for several years before presenting as subcritical upper limb ischaemia. Venous injuries are a result of tearing of the vessel wall by fracture manipulation, drills or implants. This produces intra-operative haemorrhage and potentially air embolism, which can be fatal if not rapidly recognized and managed. Brachial plexopathy is the result of traction on adherent plexus or impingement by fracture fragments or callus. It presents as severe arm pain and paralysis immediately postoperatively. Neurovascular injuries can be avoided by a combination of pre-operative planning, communication with anaesthetic staff and strategic surgical technique. The plane of the surgical exposure, release of the soft tissues, drill direction and depth and screw length are all important factors.

The influence of the direction of J-tip on the placement of a subclavian catheter: real time ultrasound-guided cannulation versus landmark method, a randomized controlled trial

BACKGROUND

It has been reported that the direction of the guidewire J-tip is associated with misplacement of a central venous catheter. We hypothesized that real-time ultrasound-guided infraclavicular subclavian venous cannulation would be less influenced by the direction of guidewire J-tip compared to landmark method.

METHODS

Sixty adult patients who required subclavian venous catheterization for neurosurgery were enrolled in this prospective randomized controlled study. Patients were randomly divided into a landmark group (n = 30) or an ultrasound group (n = 30). After the subclavian vein was punctured, the guidewire was advanced with the guidewire J-tip directed cephalad. Misplacement or advancement failure of the guidewire was regarded as an unsuccessful placement. Postoperative chest radiography was performed to confirm pneumothorax and the location of the catheter tip.

RESULTS

The two groups were comparable with respect to age, gender, height, and weight distribution. The incidence of unsuccessful guidewire placement was lower in the ultrasound group than in the landmark group (13% vs. 47%, P = 0.01). Among the unsuccessful guidewire placements, the incidence of misplacement were comparable between the groups and were all located in the ipsilateral internal jugular vein (7% vs. 7%). However, the incidence of advancement failure was significantly higher in landmark group (40% vs. 7%, P = 0.005). There were no complications such as pneumothorax or hemothorax.

CONCLUSIONS

The proper placement of guidewire was less influenced by the direction of the guidewire J-tip with ultrasound-guided subclavian venous cannulation than with the landmark approach.

Clinical effect of improved subclavian vein catheterization versus internal jugular vein catheterization in patients with alimentary canal neoplasms

AIM: To evaluate the clinical effect and application value of improved subclavian vein catheterization in patients with alimentary canal neoplasms.

METHODS: One hundred and thirty patients with alimentary canal neoplasms who required deep vein catheterization were divided into either an observation group or a control group. The observation group underwent improved subclavian vein catheterization, while the control group underwent internal jugular vein catheterization. The success rate of catheterization, catheterization time, applicator replacement times, patient discomfort, patient preference, catheterization-related infections, catheter migration, and inadvertent arterial puncture were compared between the two groups.

RESULTS: Both groups had a high success rate of catheterization, and there was no significant difference in the success rate of catheterization between the two groups (98% vs 100%, P > 0.05). The average catheterization time (19.7 d ± 5.2 d vs 11.5 d ± 4.2 d, P < 0.05), average applicator replacement times (2.6 times/wk ± 0.7 times/wk vs 3.7 times/wk ± 1.1 times/wk, P < 0.05), and the number of patients developing treatment discomfort (13 vs 65, P < 0.05) differed significantly between the observation group and control group. In addition, the incidences of catheter-related infections, catheter migration, inadvertent arterial puncture, cardiac arrhythmia, pneumothorax, puncture site bleeding or exudate were better in the observation group than in the control group (all P < 0.05).

CONCLUSION: Compared to internal jugular vein catheterization, improved subclavian vein catheterization is associated with longer catheterization time and fewer complications in patients with alimentary canal neoplasms.

Simplifying subclavian vein cannulation using innovative landmarks: a radiologic, anatomic, and clinical study

The objective of this study was to investigate novel and optimal landmarks for subclavian vein (SV) cannulation. We conducted the study in three phases: (a) Various possible markers for SV cannulation were evaluated by anatomic measurements in patients from intensive care unit and the course of SV was evaluated by radiologic means; (b) Results acquired by the two means were compared and adjusted, then innovative landmarks and a new approach for SV cannulation was proposed; (c) The efficacy of new approach for SV cannulation was compared with that of a traditional one by a prospective, randomized, controlled study. Point A (the junction of the lateral border of sternocleidomastoideus clavicular head and inferior border of clavicle), point B (a point on the lower border of clavicle just above the middle of the line joining the coracoid process and midline of the body), and point D (where SV crosses the inferior border of clavicle) were close in proximity. Points A and B could be considered as innovative landmarks for SV cannulation. Beginners using the new method had significantly higher success rate (86.9% vs. 70.2%, p = 0.008); the time consumed by new method was significant shorter than that by traditional one (5.9 vs. 10.4 min, p = 0.001). Points A and B could be considered as landmarks for identifying puncture site for SV cannulation. Beginners using innovative landmarks for SV cannulation could significantly reduce operation time and increase success rate.

Anatomic considerations for central venous cannulation

Central venous cannulation is a commonly performed procedure which facilitates resuscitation, nutritional support, and long-term vascular access. Mechanical complications most often occur during insertion and are intimately related to the anatomic relationship of the central veins. Working knowledge of surface and deep anatomy minimizes complications. Use of surface anatomic landmarks to orient the deep course of cannulating needle tracts appropriately comprises the crux of complication avoidance. The authors describe use of surface landmarks to facilitate safe placement of internal jugular, subclavian, and femoral venous catheters. The role of real-time sonography as a safety-enhancing adjunct is reviewed.

Influence of shoulder position on central venous catheter tip location during infraclavicular subclavian approach

BACKGROUND

Infraclavicular approach of the subclavian veins is commonly used for central venous access. However, aberrant catheter tip locations are frequently quoted for this approach. It was hypothesized that with the shoulder pulled downwards, the angle between the internal jugular and subclavian veins may increase, directing subclavian catheters into the internal jugular vein. This prospective study assessed the influence of the shoulder position on proper placement of right infraclavicular subclavian catheters.

METHODS

Patients who required subclavian central venous catheterization for major neurosurgical and thoracic procedures were randomly divided into two groups: neutral (n=180) vs lowered (n=181) shoulder position. The right shoulder was placed and maintained in the neutral or lowered position during venipuncture and guidewire insertion. Postoperative chest radiographs were obtained to identify the location of catheter tips.

RESULTS

There were no differences in gender, age, body weight, and height between the two groups. There were five failures in the neutral position [5/180 (2.8%)] and eight failures in the lowered shoulder position [8/181 (4.0%)] (P=NS). The occurrence of immediate complications such as pneumothorax or arterial puncture was not different. Aberrant placement of the catheter tips was more frequent in the lowered shoulder position [2/173 (1.2%) vs 14/173 (8.1%)] (P<0.01).

CONCLUSIONS

The neutral shoulder position minimizes the number of needle passes and the incidence of catheter misplacement during the infraclavicular approach of the right subclavian vein catheterization.

A complication of subclavian venous catheterization: extravascular kinking, knotting, and entrapment of the guidewire -A case report-

Various complications of central venous catheterization have been reported, some of which are well-known, while others are described as a sporadic events. We experienced a case of left subclavian venous catheterization complicated by extravascular knotting, kinking, and entrapment of the guidewire and the guidewire was removed surgically. Although minimal resistance was encountered during guidewire insertion, the guidewire was advanced approximately 30 cm. Physicians should be aware of these rare potential complications when a guidewire is advanced if any resistance is encountered.

A modified dissection method to preserve neck structures

The neck is not only one of the more challenging anatomical regions to dissect but also has important application to clinical conditions, diseases, and procedures. In this study, we describe two simple modifications for dissection of the neck that (1) aid in the identification and preservation of the cutaneous branches of the cervical plexus and the accessory nerve, and (2) provide wide exposure of the root of the neck. The cutaneous branches of the cervical plexus can be identified with relative ease at the nerve point of the neck, where they are largest. To accomplish this, the skin and platysma are reflected beginning from the anterior border of trapezius and proceeding anteriorly to the midline of the neck, rather than the conventional approach of reflecting the skin from the anterior midline. The accessory nerve is identified by its relationship to the nerve point and its course to the trapezius muscle. To achieve wide exposure of the root of the neck and its contents, the acromioclavicular and sternoclavicular joints are disarticulated, and then the clavicle removed completely, rather than the more common approach of removing only the middle section of the clavicle. These modified procedures can be readily performed by first-year medical students and integrate well with methods described in widely used anatomy dissection manuals.

Pulmonary artery pseudoaneurysm after a vascular access port catheter implantation

Pulmonary artery pseudoaneurysm is an unusual complication of surgically implantable central venous port catheters. We experienced a case of a 57-year-old man with gastric malignancy, in which a port catheter had been previously implanted for chemotherapy. Because of a puncture site that was also medial for the subclavian vein, the catheter tip fractured between the first rib and the clavicle, and embolized in the left pulmonary artery, which caused a 5 x 4 cm pseudoaneurysm that mandated surgical resection with a lobectomy. The diagnostic work-up and a review of the literature are presented.

Central venous catheterization--an anatomical review of a clinical skill. Part 2. Internal jugular vein via the supraclavicular approach

The safe and successful performance of a central venous catheterization (CVC) requires a specific knowledge of anatomy in addition to a working knowledge. Misunderstanding the anatomy may result in failure or complications. This review aims to aid understanding of the anatomical framework, pitfalls, and complications of CVC of the internal jugular veins. CVC is common practice amongst surgeons, anesthesiologists, and emergency room physicians during the preparations for major surgical procedures such as open-heart surgery, as well as for intensive care monitoring and rapid restoration of blood volume. Associated with this technique are certain anatomical pitfalls and complications that can be successfully avoided if one possesses a thorough knowledge of the contraindications, regional anatomy, and rationale of the technique.