Optimization of Cannula Visibility during Ultrasound-Guided Subclavian Vein Catheterization, via a Longitudinal Approach, by Implementing Echogenic Technology

Comparative evaluation of ultrasound guided supraclavicular and infraclavicular subclavian venous catheterizations in adult patients

Background and Aims

Ultrasound-guided subclavian vein cannulation has two approaches: supraclavicular and infraclavicular. The aim of this study was to compare the ease of cannulation by recording the puncture time of the subclavian vein with the two approaches in adult patients.

Material and Methods

This study was approved by our institutional ethics committee, and a written informed consent was obtained from the patients. This prospective randomized trial recruited patients aged 18 to 80 years with definite indications of subclavian vein cannulation. Real-time in-plane ultrasound-guided technique was used, and the subclavian vein was punctured at the junction of the brachiocephalic and IJV in supraclavicular approach (SC) and in oblique axis below the border of the clavicle in infraclavicular approach (IC).

Results

A total of 96 patients were randomly allocated equally into two groups of 48 each, but only 45 patients in each group could be successfully cannulated. Median puncture times were comparable; 15 (9-39) s in SC and 21 (5-80) s in IC group. The first attempt success rate was 82.2% and 62.2%, and the mean total access time was 99.11 ± 34.66 s and 103.44 ± 50.27 s in SC and IC approaches, respectively and were comparable. The attempts of needle puncture were significantly higher in IC approach (1.40 ± 0.54 vs 1.20 ± 0.46 in SC approach; P = 0.04). The complication rates were comparable and less than 5%.

Conclusion

Ease of cannulation of the subclavian vein using ultrasound-guided supraclavicular and infraclavicular approach is comparable as no statistically significant difference is noted in the puncture time and first-attempt success rate. The increased number of needle punctures reported in our study with the IC approach did not translate to an increased complication rate.

Comparative evaluation of success of ultrasound-guided internal jugular vein cannulation using needle with guard: A randomized, controlled study

Background and Aims:

We devised a guard which can be slid and fixed over the central venous puncture needle at a desired length (measured through ultrasound) preventing the needle from penetrating deeper into the skin beyond this guard. This randomized, single blinded, controlled study was designed to evaluate the success of ultrasound guided internal jugular vein (IJV) cannulation using measured guided needle with guard in terms of success and occurrence of complications.

Material and Methods:

After ethical approval and written informed consent from the patients ultrasound-guided right-sided IJV cannulation was done with a conventional puncture needle (length of 6.4 cm) in the control group (n = 210) and with a conventional puncture needle with a guard fixed proximal to the bevel at a distance equal to the distance between the skin entry point and the midpoint of IJV measured with the help of USG in the study group (n = 210). The primary outcome studied was the number of attempts for successful cannulation. The secondary outcomes studied were complications and ease of cannulation.

Results:

419 patients were randomized into control (n = 209) and study groups (210). Successful IJV cannulation in the first attempt (primary endpoint) in the study group was significantly higher compared to the control group (98.6 vs. 85.7%, P = 0.007). Posterior venous wall puncture was reduced in the study group, that is, 0.5% (1/210) compared to control group, that is, 8.61% (18/209) (P = 0.001). Common carotid artery puncture was 7.18% (15/209) in control group and 0% (0/210) in study group (P = 0.001). Operators rated better ease in study group (P < 0.001).

Conclusions:

The use of measured guided needle with guard significantly improved the accuracy, success and ease of USG guided IJV cannulation and decreased complications.

A comparison of longitudinal and transverse approaches to ultrasound-guided axillary vein cannulation by experienced operators

BACKGROUND

The axillary vein is an easily accessible vessel that can be used for ultrasound-guided central vascular access and offers an alternative to the internal jugular and subclavian veins. The objective of this study was to identify which transducer orientation, longitudinal or transverse, is better for imaging the axillary vein with ultrasound.

METHODS

We analyzed 236 patients who had undergone central venous cannulation of axillary vein in this retrospective study. Patients were divided into two groups, the longitudinal approach group (n=120) and transverse approach group (n=116). Recorded the one-attempt success rate, operation time, arterial puncture rate and pneumothorax rate. We perform chest radiography to confirm pneumothorax on all patients. We compared the one-attempt success rate, operation time, arterial puncture rate and pneumothorax rate between the two groups.

RESULTS

The two groups were comparable with clinical characters of patients. The overall success rates of the longitudinal group and the transverse group were both 100%. The rate of one-attempt success in the longitudinal approach group is higher than the transverse approach group (91.7% vs. 82.8%, P=0.040). The transverse approach group had shorter operation time than the longitudinal group (184.7±8.1 vs. 287.5±19.6 seconds, P=0.000). The two groups had lower postoperative complications. Arterial puncture occurred in 1 of 120 longitudinal and 2 of 116 transverse attempts and this difference was no significant (P=0.541). No pneumothorax occurred in the two groups.

CONCLUSIONS

The longitudinal approach during ultrasound-guided axillary vein cannulation is associated with greater one-attempt success rate compared with the transverse approach by experienced operators. The transverse approach has shorter operation time. The two groups have lower postoperative complications and are comparable with pneumothorax and arterial puncture.

Comparison between marked versus unmarked introducer needle in real-time ultrasound-guided central vein cannulation: A prospective randomized study

INTRODUCTION

Introducer needle tip is not clearly visible during the real-time ultrasound (US)-guided central vein cannulation (CVC). Blind tip leads to mechanical complications. This study was designed to evaluate whether real-time US-guided CVC with a marked introducer needle is superior to the existing unmarked needle.

METHODOLOGY

Sixty-two critically ill patients aged 18-60 years of either sex were included in the study. The patients were randomized into two groups based on whether a marked or unmarked introducer needle was used. Both groups underwent real-time US-guided CVC by a single experienced operator. Aseptically, introducer needle was indented with markings spaced 0.5 cm (single marking) and every 1 cm (double marking). This needle was used in the marked group. Approximate depths (centimeter) of the anterior and posterior wall of the internal jugular vein, anterior wall of the internal carotid artery, and lung pleura were appreciated from the midpoint of the probe in short-axis view at the level of the cricoid cartilage. Access time (seconds) was recorded using a stopwatch. A number of attempts and complications such as arterial puncture, hematoma, and pneumothorax of either procedure were compared.

RESULTS

Both marked needle and unmarked needle groups were comparable with regard to age, gender, severity scores, platelet counts, prothrombin time, and distance from the midpoint of the probe to the vein, artery, and pleura and skin-to-guide wire insertion access time. However, an average number of attempts (P = 0.03) and complications such as hematoma were significantly lower (P = 0.02) with the marked introducer needle group. Pneumothorax was not reported in any of the groups.

CONCLUSION

Our study supports the idea that marked introducer needle can further reduce the iatrogenic complications of US-guided CVC.

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.