Ultrasound-guided supraclavicular approach to the subclavian vein in infants and children

Abstract

Editor'We read with interest the article describing the new method for ultrasound-guided supraclavicular approach to the brachiocephalic vein in children.1Breschan C Platzer M Jost R et al.Consecutive, prospective case series of a new method for ultrasound-guided supraclavicular approach to the brachiocepalic vein in children.Br J Anaesth. 2011; 106: 732-737Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar We routinely cannulate the subclavian vein by a supraclavicular approach under ultrasound guidance in children undergoing surgery for congenital cardiac defects.2Kulkarni V Mulavisala KP Mudunuri RK Byalal JR Ultrasound guided catheterization of the subclavian vein by supraclavicular approach in infants and children. Poster Number 8.Australia New Zealand Intensive Care Society Conference, Singapore. 2011; (April 22–24)Google Scholar In our series of 150 children, the right subclavian was accessed in 140 and the left side was used in 10 patients. The age range was 12 days to 14 yr and weight ranged from 2.7 to 35 kg. There were two (1.33%) arterial punctures with one (0.67%) periarterial haematoma, one (0.67%) pneumothorax, two (1.33%) malpositions into the opposite innominate vein and we were not able to cannulate on two (1.33%) instances. We agree with the authors on the following points: (i)During the time course of the study, there is an improvement in the puncture success rate.(ii)Ultrasound images of the brachiocephalic vein and subclavian vein were easily visualized using the supraclavicular approach.Our technique is different from that described in the following aspects: (i)The operators stood at the head end rather than by the side of the patients and as all of them were right handed, 93.5% were placed in the right supraclavicular vein.(ii)We use an open-ended ethylene oxide sterilized plastic sheath for sterile handling of the ultrasound probe. Once the probe emerges out of the sheath, it is covered with sterile Tegaderm (transparent medical dressing), ensuring that no air bubbles are entrapped. No gel is used in between the probe and Tegaderm.(iii)We use a few drops of sterile saline as coupling gel. The quality of images was similar to when agent was used.The authors have not mentioned the length of the cannula inserted and the incidence of unintentional decannulation on the right side. This is important as the right brachiocephalic vein is very close to the superior vena cava–right atrium junction in very small babies. The authors have also not mentioned the incidence of damage to the thoracic duct3Kwon SS Falk A Mitty HA Thoracic duct injury associated with left internal jugular vein catheterization: anatomic considerations.J Vasc Intervent Radiol. 2002; 13: 337-339Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar while cannulating the left brachiocephalic vein. None declared. Reply from the authorsBritish Journal of AnaesthesiaVol. 108Issue 1PreviewEditor'We thank Dr Kulkarni and colleagues for their interest in our study.1 We totally agree with all their points favouring subclavian over internal jugular venous access. In addition, the subclavian and brachiocephalic veins are much less compressed by the approaching needle as seen very well via ultrasound. Furthermore, the catheter-associated infection rate may also be lower for subclavian venous catheters.2 First, I want to mention that it is not always clear whether the subclavian or brachiocephalic vein has been punctured by the needle entrance when using the approach as described in our manuscript. Full-Text PDF Open Archive