Ultrasound-guided subclavian venous catheterisation - is this the way forward? A narrative review

Comparison of ultrasound-guided internal jugular vein and supraclavicular subclavian vein catheterization in critically ill patients: a prospective, randomized clinical trial

Background

The aim of this study was to compare the effectiveness and safety of ultrasound-guided out-of-plane internal jugular vein (OOP-IJV) and in-plane supraclavicular subclavian vein (IP-SSCV) catheterization in adult intensive care unit.

Methods

A total of 250 consecutive patients requiring central venous catheterization, were randomly assigned to undergo either ultrasound-guided OOP-IJV or IP-SSCV cannulation. All catheterizations were carried out by three physicians. The primary outcome was the first attempt success rate. Ultrasound scanning time, venous puncture time, insertion time, overall access time, number of puncture attempts, number of needle redirections, success rate, guidewire advancing difficulties, venous collapse and adverse events were also documented.

Results

The first attempt success rate was significantly higher in IP-SSCV group (83.2%) compared to OOP-IJV group (63.2%) (p = 0.001). The IP-SSCV group was associated with a longer ultrasound scanning time (16.54 ± 13.51 vs. 5.26 ± 4.05 s; p < 0.001) and a shorter insertion time (43.98 ± 26.77 vs. 53.12 ± 40.21 s; p = 0.038). In the IP-SCCV group, we recorded a fewer number of puncture attempts (1.16 ± 0.39 vs. 1.47 ± 0.71; p < 0.001), needle redirections (0.69 ± 0.58 vs. 1.17 ± 0.95; p < 0.001), difficulties in guidewire advancement (2.4% vs. 27.4%; p < 0.001), venous collapse (2.4%, vs. 18.4%; p < 0.001) and adverse events (8.8% vs. 13.6%; p = 0.22).

Conclusions

The IP-SSCV approach is an effective and a safe alternative to the classic OOP-IJV catheterization in critical adult patients.

Trial registration: Clinicaltrials.gov, NCT03879954. Registered March 19, 2019—Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03879954.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-022-01065-x.

Practice Patterns of Central Venous Catheter Placement and Confirmation in Pediatric Critical Care

Optimal practices for the placement of central venous catheters (CVCs) in critically ill children are unclear. This study describes the clinical practice of pediatric critical care medicine (PCCM) providers regarding CVC placement, including site selection, confirmation practices and assessment of complications. Two-hundred fourteen PCCM providers responded to an electronic survey, including 170 (79%) attending physicians, 30 (14%) fellow physicians, and 14 (7%) advanced practice providers. PCCM providers most commonly place internal jugular (IJ) and femoral CVCs, with subclavian CVCs and peripherally inserted central catheters (PICCs) placed less commonly (IJ 99%, femoral 95%, subclavian 40%, PICC 19%). The IJ is the most preferred site (128/214 (60%)); decreased infection risk is the most common reason for preferring this site. The subclavian is the least preferred site (150/214 [70%]) due to concern for increased risk of complications (51%) and personal discomfort with the procedure (49%). One-hundred twenty-six (59%) of respondents reported receiving formal ultrasound (US) or echocardiography training. Respondents reported using dynamic US guidance for placement in 90% of IJ, 86% of PICC, 78% of femoral, and 12% of subclavian CVCs. Plain radiography (X-ray) was the most preferred modality for confirming CVC tip position (85%) compared with US (9%) and no imaging (5%). Most providers reported using X-ray to evaluate for pneumothorax following upper extremity CVC placement, with only 5% reporting use of US and none relying on physical exam alone. This study demonstrates wide variability in PCCM providers' CVC placement practices. Potential training gaps exist for placement of subclavian catheters and use of US.

Ultrasound-guided proximal versus distal axillary vein puncture in elderly patients: A randomized controlled trial

BACKGROUND

Ultrasound-guided axillary vein catheterization is now widely used in hospital, but it remains uncertain whether the distal axillary vein approach is more beneficial for seniors than the proximal axillary vein approach. This study aims to compare the puncture success rate and anatomical characteristics between these two approaches.

METHODS

Senior patients requiring central venous catheterization were enrolled and randomized to the proximal axillary vein group (n = 49) or the distal axillary vein group (n = 50). Proximal axillary vein and distal axillary vein location time, venous depth, maximum diameter, and collapse index (defined as the percentage change in vein width caused by respiration) were recorded for all patients. The rate of puncture success and operation time were compared between groups.

RESULTS

Mean venous depth was 1.93 ± 0.45 cm for proximal axillary vein and 1.79 ± 0.46 cm for distal axillary vein (p < 0.001). Maximum diameter was 0.80 ± 0.33 cm for proximal axillary vein and 0.61 ± 0.33 cm for distal axillary vein (p < 0.001). Collapse indices were 20% ± 27% and 56% ± 34%, respectively (p < 0.001). Also, location time was significantly shorter for proximal axillary vein than for distal axillary vein (p < 0.001). One attempt and overall success rates were significantly higher in the proximal axillary vein group, compared with the distal axillary vein group (71.4% vs 42.0%, p = 0.003; 79.6% vs 54.0%, p = 0.007).

CONCLUSION

For catheterization under ultrasound guidance in elderly patients, the proximal axillary vein approach is superior to the distal axillary vein approach.

'Stop sign' position for subclavian ultrasound: a single-blinded observational study of subclavian vein dimensions

OBJECTIVE

Right subclavian vein (SCV) dimensions were evaluated on ultrasound and whether these change when the right upper limb is in a neutral position compared with the 'stop sign' position (shoulder abducted and externally rotated to 90°, elbow flexed to 90°), and when patients were positioned 30° head-up compared with lying supine.

METHODS

Images of transverse and longitudinal views of the right SCV in patients ≥18 years, presenting with a range of conditions to a Regional Hospital Emergency Department, were recorded by two physicians in a randomly assigned, nonsequential order and measured blinded. Data were analysed with paired Student's t tests. N = 62.

RESULTS

Primary outcome: cross-sectional area (CSA) of the right SCV in transverse images.

SECONDARY OUTCOMES

depth of SCV to skin and diameter of SCV on longitudinal images. There was no significant difference in CSA of the SCV in supine patients when the arm was in the stop sign position compared with neutral (mean CSA: 1.20 ± 0.42 and 1.15 ± 0.39 cm, respectively; P = 0.3). In patients positioned 30° head-up, the stop sign position significantly increased CSA from 0.65 ± 0.33 to 1.00 ± 0.38 cm (P < 0.0001).

CONCLUSIONS

Utilizing the stop sign position does not change SVC dimensions when patients are supine, however, may improve dimensions when lying supine is contraindicated.

Ultrasound- versus landmark-guided subclavian vein catheterization: a prospective observational study from a tertiary referral hospital

This was a single-center, observational, prospective study designed to compare the effectiveness of a real-time, ultrasound- with landmark-guided technique for subclavian vein cannulation. Two groups of 74 consecutive patients each underwent subclavian vein catheterization. One group included patients from intensive care unit, studied by using an ultrasound-guided technique. The other group included patients from surgery or emergency units, studied by using a landmark technique. The primary outcome for comparison between techniques was the success rate of catheterization. Secondary outcomes were the number of attempts, cannulation failure, and mechanical complications. Although there was no difference in total success rate between ultrasound-guided and landmark groups (71 vs. 68, p = 0.464), the ultrasound-guided technique was more frequently successful at first attempt (64 vs. 30, p < 0.001) and required less attempts (1 to 2 vs. 1 to 6, p < 0.001) than landmark technique. Moreover, the ultrasound-guided technique was associated with less complications (2 vs. 13, p < 0.001), interruptions of mechanical ventilation (1 vs. 57, p < 0.001), and post-procedure chest X-ray (43 vs. 62, p = 0.001). In comparison with landmark-guided technique, the use of an ultrasound-guided technique for subclavian catheterization offers advantages in terms of reduced number of attempts and complications.

Comparative Analysis of Ultrasound Guided Central Venous Catheterization Compared to Blind Catheterization

INTRODUCTION

Central venous catheterization is performed by the landmark method and ultrasound guided method. The purpose of the study was to compare the success, average number of attempts, average time to return of blood, and complication rate between the two methods.

MATERIAL AND METHODS

This was a prospective study done in the Intensive Care Unit of the Acibadem Sistina Clinical Hospital, in Skopje. There were 400 patients in need of central venous catheter and they were prospectively randomized in two groups. The patients randomized in the examined-ultrasound group underwent real-time ultrasound-guided catheterization and the patients randomized in the control-landmark group were catheterized using the landmark method. Internal Jugular, Subclavian and Femoral vein were catheterized in both groups. The Overall success, success on the first attempt, time to the return of blood, number of attempts and complications at the moment of catheterization such as arterial puncture, pneumothorax and hematoma formation were the main outcome measures.

RESULTS

The catheterization using the landmark method was successful in 90.5% of patients, 60.5% of which during the first attempt. The cannulation using real-time ultrasound guidance was successful in 98% of patients with a first pass success of 77%. The complication rate with the landmark method was 14.5% versus 4% with real-time ultrasound guidance p<0.05(p=0.0008).

CONCLUSION

Real-time ultrasound guidance improves success, decreases number of attempts, decreases average time to the return of blood and reduces mechanical complications rate.

Supraclavicular approach for subclavian vein catheterization in pediatric anesthesia: The reborn of an ancient technique with the ultrasound's assistance

The insertion of a central venous catheter is a procedure frequently performed in paediatric anaesthesia. The most frequent approach for this procedure is the internal jugular vein. However, some specific factors in children, such as the short neck and the easy collapse of this vein, which is accentuated in situations such as hypovolaemia and changes in the respiratory pattern, can lead to greater difficulty. The supraclavicular approach of the subclavian vein was described more than 50 years ago. However, it is not often considered nowadays, even after the introduction of ultrasound, and despite the obvious advantages with respect to the internal jugular approach due to the lower incidence of thrombosis and infection. This document reviews the considerations of the supraclavicular approach according to the available evidence in paediatric anaesthesia, discusses the feasibility and safety of the procedure, and finally describes the technique of ultrasound--guided puncture.

Transitioning from anatomic landmarks to ultrasound guided central venous catheterizations: guidelines applied to clinical practice

Introduction

Centrally inserted central catheter (CICC) insertion is a commonly performed procedure that may give rise to different complications. Despite the suggestion of guidelines to use ultrasound guidance (USG) for vascular access, not all centers use it systematically. The aim of this study is to illustrate the experience with ultrasound in CICC placement at a high-volume oncological center, in a country where the landmark technique is standard.

Methods

Retrospective analysis of a prospective database was performed on CICC placement under USG in the Central Venous Catheter Unit of Instituto Português de Oncologia de Lisboa Francisco Gentil, from 2012 to 2015.

Results

Three thousand five hundred and seventy-two procedures were recorded. From 2728 CICC placements, 1187 (43.5%) were done using USG. The majority of CICC placements were successful without immediate complications (96.1%). In 55 cases (4.6%), more than three attempts were necessary to puncture the vein. Pneumothorax occurred in 5 cases (0.4%) and arterial puncture was registered in 41 cases (3.5%). An increasing use of USG for placing CICCs was planned and observed over the years and, in the last year of the study, 67.3% of the CICC placements were with USG.

Conclusions

CICC placement with USG is a safe and effective technique. Despite some resistance that is observed, these results support that it is worth following the guidelines that advocate the use of the USG in the placement of CICC.

A randomized clinical trial of ultrasound-guided infra-clavicular cannulation of the subclavian vein in cardiac surgical patients: short-axis versus long-axis approach

PURPOSE

The aim of this study was to compare the success rate and safety of short-axis versus long-axis approaches to ultrasound-guided subclavian vein cannulation.

METHODS

A total of 190 patients requiring central venous cannulation following cardiac surgery were randomized to either short-axis or long-axis ultrasound-guided cannulation of the subclavian vein. Each cannulation was performed by anesthesiologists with at least 3 years' experience of ultrasound-guided central vein cannulation (>150 procedures/year, 50% short-axis and 50% long-axis). Success rate, insertion time, number of needle redirections, number of separate skin or vessel punctures, rate of mechanical complications, catheter misplacements, and incidence of central line-associated bloodstream infection were documented for each procedure.

RESULTS

The subclavian vein was successfully cannulated in all 190 patients. The mean insertion time was significantly shorter (p = 0.040) in the short-axis group (69 ± 74 s) than in the long-axis group (98 ± 103 s). The short-axis group was also associated with a higher overall success rate (96 vs. 78%, p < 0.001), first-puncture success rate (86 vs. 67%, p = 0.003), and first-puncture single-pass success rate (72 vs. 48%, p = 0.002), and with fewer needle redirections (0.39 ± 0.88 vs. 0.88 ± 1.15, p = 0.001), skin punctures (1.12 ± 0.38 vs. 1.28 ± 0.54, p = 0.019), and complications (3 vs. 13%, p = 0.028).

CONCLUSIONS

The short-axis procedure for ultrasound-guided subclavian cannulation offers advantages over the long-axis approach in cardiac surgery patients.

A brief history of topographical anatomy

This brief history of topographical anatomy begins with Egyptian medical papyri and the works known collectively as the Greco-Arabian canon, the time line then moves on to the excitement of discovery that characterised the Renaissance, the increasing regulatory and legislative frameworks introduced in the 18th and 19th centuries, and ends with a consideration of the impact of technology that epitomises the period from the late 19th century to the present day. This paper is based on a lecture I gave at the Winter Meeting of the Anatomical Society in Cambridge in December 2015, when I was awarded the Anatomical Society Medal.

Ultrasound-Guided Cannulation: Time to Bring Subclavian Central Lines Back

Despite multiple advantages, subclavian vein (SCV) cannulation via the traditional landmark approach has become less used in comparison to ultrasound (US) guided internal jugular catheterization due to a higher rate of mechanical complications. A growing body of evidence indicates that SCV catheterization with real-time US guidance can be accomplished safely and efficiently. While several cannulation approaches with real-time US guidance have been described, available literature suggests that the infraclavicular, longitudinal “in-plane” technique may be preferred. This approach allows for direct visualization of needle advancement, which reduces risk of complications and improves successful placement. Infraclavicular SCV cannulation requires simultaneous use of US during needle advancement, but for an inexperienced operator, it is more easily learned compared to the traditional landmark approach. In this article, we review the evidence supporting the use of US guidance for SCV catheterization and discuss technical aspects of the procedure itself.

Novel Educational Module for Subclavian Central Venous Catheter Insertion Using Real-Time Ultrasound Guidance

OBJECTIVE

Given increasing evidence supporting a real-time ultrasound (US)-guided approach for subclavian vein (SCV) central venous catheter (CVC) insertion as compared with the traditional landmark approach, we sought to develop a standardized curriculum to offer healthcare providers a means to attain increased competency and confidence in US-guided SCV CVC insertion.

DESIGN

Retrospective review of prospectively collected data.

SETTING

Single institution's American College of Surgeons Level 1 Accredited Education Institute within an academic tertiary care center.

SUBJECTS

A total of 77 residents and midlevel providers working in our surgical intensive care unit.

INTERVENTIONS

Providers participated in a tiered educational module designed to teach safe US-guided SCV CVC insertion. The education consisted of a multimedia didactic presentation and a hands-on simulation session, including US anatomy on live subjects and anatomical model-based SCV CVC insertion.

MEASUREMENTS AND MAIN RESULTS

Assessment of the effect of education included a written examination and confidence survey, administered pre- and postintervention, and videotaped simulation session graded by blinded expert evaluators. Of the 77 participants, 70 participants completed a posttest with a median 5-point increase in score compared with that of the pretest score (p < 0.0001). Confidence ratings based on a 5-point Likert scale demonstrated an increase in confidence in SCV CVC insertion (p < 0.0001), using the landmark approach (p < 0.0001), using US-guided approach (p < 0.0001), and in use of US to image the SCV (p < 0.0001). Postgraduate year-1 residents had lower mean global rating score (p = 0.010) than any other participants.

CONCLUSIONS

This comprehensive hands-on teaching module-based curriculum enhanced learner knowledge of and confidence in US-guided SCV CVC insertion. This module can be implemented in simulation centers for teaching safe and successful SCV CVC insertion.

Ultrasound-guided subclavian venipuncture is more rapidly learned than the anatomic landmark technique in simulation training

PURPOSE

Both ultrasound-guided subclavian venipuncture (US-SV) and landmark-guided subclavian venipuncture (LM-SV) are important in critical care, because the clinical utility of ultrasound guidance is still debated. Education of residents and medical students should include both techniques. The aim of this study is to compare learning these two techniques in a simulation environment.

METHODS

This study was approved by the research ethics review committee. Trainees included residents and medical students who were instructed using the "Videos in Clinical Medicine" for LM-SV, or a dedicated slide series for US-SV, using the long-axis in-plane with needle-guide technique. After the lecture, trainees attempted to perform venipuncture in a simulator. All participants performed both techniques. The procedure time from initial skin puncture to detecting back-flow of fluid from the simulated vein was measured. A procedure time over 3 min, arterial puncture, or pneumothorax was counted as a failure. The end-point for each trainee was three successive successful venipunctures without a failure. A trainee who reached the end-point was considered as having acquired adequate skill. Statistical analysis of the procedure time comparing the techniques was done using the Mann-Whitney U test.

RESULTS

Twenty trainees participated in this training. Adequate skill to perform US-SV was achieved within three tries, but up to nine attempts were needed for LM-SV. One arterial puncture occurred during LM-SV. No pneumothoraxes occurred during the simulation training.

CONCLUSIONS

US-SV was learned more quickly than LM-SV in a simulation model.

Novel ultrasound guidance system for real-time central venous cannulation: safety and efficacy

INTRODUCTION

Real-time ultrasound guidance is considered to be the standard of care for central venous access for non-emergent central lines. However, adoption has been slow, in part because of the technical challenges and time required to become proficient. The AxoTrack(®) system (Soma Access Systems, Greenville, SC) is a novel ultrasound guidance system recently cleared for human use by the United States Food and Drug Administration (FDA).

METHODS

After FDA clearance, the AxoTrack(®) system was released to three hospitals in the United States. Physicians and nurse practitioners who work in the intensive care unit or emergency department and who place central venous catheters were trained to use the AxoTrack(®) system. De-identified data about central lines placed in living patients with the AxoTrack(®) system was prospectively gathered at each of the three hospitals for quality assurance purposes. After institutional review board approval, we consolidated the data for the first five months of use for retrospective review.

RESULTS

The AxoTrack(®) system was used by 22 different health care providers in 50 consecutive patients undergoing central venous cannulation (CVC) from September 2012 to February 2013. All patients had successful CVC with the guidance of the AxoTrack(®) system. All but one patient (98%) had successful cannulation on the first site attempted. There were no reported complications, including pneumothorax, hemothorax, arterial puncture or arterial cannulation.

CONCLUSION

The AxoTrack(®) system was a safe and effective means of CVC that was used by a variety of health care practitioners.