Practice Guidelines for Ultrasound-Guided Subclavian Vein Catheterization

Abstract

To the Editor Troianos et al.,1 on behalf of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists, recently produced comprehensive practice guidelines for ultrasound (US)-guided vascular cannulation.1 Given the prevalence of US use, these guidelines will undoubtedly help shape future clinical practice; however, we did have some reservations regarding the evidence presented for US-assisted subclavian vein cannulation. First, the authors suggest that a study of 1250 cannulation attempts showed “that the added benefit of US guidance for cannulation of the subclavian vein is less than the benefit of ultrasound during attempted cannulation of the internal jugular vein.” Given that only 2 US-guided subclavian cannulations were included in this series of 1250 attempts, the evidence supporting the stated conclusion is lacking.2 Similiarly, a meta-analysis cited to support US-guided subclavian cannulation had in fact identified only a single study that used 2-dimensional US.3 This would preclude mathematical pooling of results, thus it would be more appropriate to refer to this aspect of the study as a systematic review noting its reliance on a single 2-dimensional US study of subclavian cannulation. Second, no distinction was made between studies that used static US versus dynamic (real-time) US, despite evidence suggesting better success with dynamic US.4,5 This is also supported by an additional randomized controlled trial of 401 patients demonstrating increased efficacy and safety with dynamic US for subclavian US.6 This recent study, however, may not have been available to Troianos et al. at the time the guidelines were drafted. Finally, no explicit distinction was made between articles describing central venous catheterization as compared with permanent/tunneled catheter placement or electrode placement.7,8 Osman Ahmed, BSc Faculty of Medicine Ashraf Fayad, MD, FRCPC Greg Bryson, MD, MSc, FRCPC The Ottawa Hospital University of Ottawa Ottawa, Ontario, Canada Dean Fergusson, MHA, PhD Medicine, Surgery, & Epidemiology and Community Medicine The Ottawa Hospital Research Institute Ottawa, Ontario, Canada Manoj M. Lalu, MD, PhD Department of Anesthesiology University of Ottawa Ottawa, Ontario, Canada [email protected]