Subclavian Vein Catheterization Research Articles

Comparative evaluation of subclavian vein catheterisation using supraclavicular versus infraclavicular approach.

Background and Aims:Infraclavicular (IC) approach of subclavian vein (SCV) catheterisation is widely used as compared to supraclavicular (SC) approach. The aim of the study was to compare the ease of catheterisation of SCV using SC versus IC approach and also record the incidence of complications related to either approach, if any.Methods:In the study, 60 patients enrolled were randomly divided into two groups of 30 patients each. In Gp. SC right SCV catheterisation was performed using SC approach and in Gp. IC catheterisation was performed using IC approach. Access time, success rate of cannulation, number of attempts to cannulate vein, ease of guidewire and catheter insertion and length of catheter inserted and any associated complications were recorded.Results:The mean access time in group SC for SCV catheterisation was 4.30 ± 1.02 min compared to 6.07 ± 2.14 min in group IC. The overall success rate in catheterisation of the right SCV using SC approach (29 out of 30) was better as compared with group IC (27 out of 30) using IC approach. First attempt success in the SC group was 75.6% as compared with 59.25% in the IC group. All successful subclavian vein catheterisations in SC group and IC group were associated with smooth insertion of guidewire following subclavian venipuncture.Conclusion:The SC approach of SCV catheterisation is comparable to IC approach in terms of landmarks accessibility, success rate and rate of complications.

Iatrogenic rupture of undiagnosed blood blister-like aneurysm during aneurysmal neck clipping.

Iatrogenic rupture of undiagnosed blood blister-like aneurysm during aneurysmal neck clipping.

Successful anesthesia in a patient with a history of cardiac arrest following rocuronium injection.

Successful anesthesia in a patient with a history of cardiac arrest following rocuronium injection.

English

Objective: This study is to evaluate the feasibility and safety of intracardiac radiofrequency catheter ablation (RFCA) of the atrioventricular node (AVN) and pacemaker implantation using transthoracic echocardiography. Methods: Eleven patients ‐ six males and five females (mean age 66 years) ‐ with persistent or permanent atrial fibrillation/atrial flutter received RFCA of AVN and VVI pacemaker implantation (paces and senses the ventricle and is inhibited if it senses ventricular activity). Under transthoracic echocardiography, the electrode catheters were positioned intracardiac, and target ablation was performed, with the permanent pacemaking catheter in the left subclavian vein and the ablation catheter in the right femoral vein. The multi-view imaging and dynamic observation applied during the stable AV dissociation were successful. Results: Atrioventricular node ablation and permanent pacemaker implantation in 11 patients were completed successfully without X-ray exposure. The operation success rate was 100%. All patients recovered well within the follow-up period. Conclusions: Radiofrequency catheter ablation of AVN and VVI pacemaker implantation under transthoracic echocardiography guidance is a safe, easy and feasible approach. This procedure could be an important supplemental measure to catheter ablation of arrhythmia under routine X-ray fluoroscopy.

Coiling of central venous catheter in right internal jugular vein.

Sir, We read with interest the article written by Goyal et al.[1] describing a case of coiling of central venous catheter (CVC) in left subclavian vein. The authors have reported it as a rare complication, and we do not agree with this statement. Malatinský et al.[2] in 1976 presented a series of 378 radiographically controlled CVC placements and reported pure loop formations (coiling) in 2.9% of the cases. Supraclavicular subclavian approach was used in the majority of the patients and the authors explain this as a reason for relatively low incidence rates in their series as compared to other studies.[2] We report a case of coiling of central venous catheter in right internal jugular vein (IJV) in a 36-year-old patient admitted postoperatively in intensive care unit (ICU) following evacuation of large extradural hematoma. The CVC was placed in the operation theatre under ultrasound guidance. Intraoperatively the waveform was damped, and the flow of fluids was slow, but it was considered secondary to rotation of the neck and labeled as “positional”. Just after admission to the ICU a “flush test” was performed, and it was positive; 5–10 mL of normal saline was injected with force using a syringe and fluid thrill was felt in the ipsilateral neck region with the palmer aspect of the hand.[3] Subsequent chest X-ray confirmed coiling of CVC in right IJV [Figures ​[Figures1a1a and ​andbb]. Figure 1 (a) Chest X-ray anteroposterior view with coiled central venous catheter in right internal jugular vein, (b) Coiled central venous catheter after removal Factors predisposing to coiling and catheter malpositions are: Retrograde venous flow secondary to IJV valve incompetence in patients with chronic obstructive pulmonary disease, primary pulmonary hypertension and prior cannulations and catheterizations of the IJV[4,5] Retrograde venous flow in patients with high intrathoracic and intrabdomical pressures Seldinger technique: The catheter is inserted over the guidewire and placed in the central vein. During this procedure sometimes the guidewires are removed before the CVC are properly positioned in the superior vena cava. Resistance encountered in inserting the CVC then leads to excessive pressure applications, which then predisposes to malpositioning. Common sites of resistance are the junction of first rib and clavicle for the subclavian vein and the junction of venous tributaries for the IJV and brachiocephalic vein.

Brachial Plexopathy: Complication of Subclavian Vein Catheterization

ABSTRACT Central venous catheters (CVCs) are often used in critical care setting for resuscitation and monitoring and as a temporary access for hemodialysis. The increased risk of complications associated with CVCs chronic kidney disease (CKD) patients is not recognized widely. Neurological complications are extremely rare with only few cases reported. Brachial plexus injury may occur by direct needle injury or by compressive effects of a hematoma. Prompt evacuation of hematoma is warranted to prevent permanent neurological sequelae. We describe a case of brachial plexopathy after subclavian vein cannulation attempt with full recovery on conservative treatment. Prevention of such complications is the best way to reduce morbidity in CKD patients. For this timely creation of an arteriovenous fistula in CKD patients, ultrasound-guided insertion of CVCs, use of internal jugular vein as the preferred route, and close watch on coagulation defects due to uremic state is recommended. Key messages Chronic kidney disease (CKD) patients should have a permanent vascular access (arteriovenous fistula) well in advance of anticipated time of initiation of dialysis. How to cite this article Beniwal P, Malhotra V, Mathur M. Brachial Plexopathy: Complication of Subclavian Vein Catheterization. Panam J Trauma Crit Care Emerg Surg 2014;3(2):76-78.

Comparison of the Complications between Left Side and Right Side Subclavian Vein Catheter Placement in Patients Undergoing Coronary Artery Bypass Graft Surgery.

Introduction: Percutaneous subclavian vein catheterization is one of the most common invasive procedures performed in cardiac surgery. The aim of this study was to compare left and right subclavian vein catheter placement via the infraclavicular approach in patients who undergo coronary artery bypass graft (CABG) surgery. Methods: This prospective, randomized clinical trial was performed in193 patients. The technique applied for cannulation was infraclavicular approach for both the right and the left sides. Subclavian vein of other side was attempted only when catheterization at initial side was unsuccessful at two attempts. The success and complication rates were compared for the two sides. Results: On193 patients, catheterization attempts were performed. Overall 177 catheterizations (91.7%) were successful during the first attempt, 105 (92.1%) on the right side and 72 (91.1%) on the left side. There was no significant difference between success rate and side of catheterization. Malposition of the catheter tip on the right side (9.6%) was significantly more than the left side (0%) (P= 0.003). The differences in other complications on two sides were statistically insignificant. Conclusion: Compared with the right side, insertion of the cannula on the left side resulted in fewer catheter tip misplacements. Incidence of cannulation failure and other complications were similar on both sides.

Subclavian or Internal Jugular Tunneled Dialysis Catheter: Can we Divulge the Location?

A reliable and safe vascular access is critical for providing life sustaining hemodialysis therapy to patients with end stage renal disease (ESRD). Although a permanent arteriovenous access such as an arteriovenous fistula or arteriovenous graft is preferred, the United States Renal Data System (USRDS) data reports that nearly 80 percent of incident hemodialysis patients initiate treatment with a central venous catheter [1]. While the ability to use a tunneled hemodialysis catheter (THDC) immediately after placement is a significant advantage, it is often offset by a wide array of disadvantages such as increased likelihood of catheter related blood stream infection, catheter thrombosis, and fibrin sheath formation leading to catheter dysfunction resulting in a higher incidence of associated morbidity and mortality. In addition, there is a substantial risk of central venous stenosis (CVS) or occlusion, specially in the setting of long-term use of multiple catheters [2]. The true incidence and prevalence of CVS in the ESRD population are unknown; however, it has been reported to be as high as 3050% with subclavian vein catheters and potentially the lowest (around 10%) with an internal jugular vein (IJ) THDC [2, 3]. Moreover, placement of THDC can permanently compromise future access placement in the ipsilateral extremity. Kidney Dialysis Outcome and Quality Initiative (KDOQI) guidelines recommend use of right internal jugular vein as the preferred site for THDC placement. Based on expert consensus, the catheter tip is usually positioned in the mid ‐ to lower right atrium (Fig. 1). However, there is no agreement with regard to catheter exit site and it often varies depending on the patient’s gender, body habitus and amount of soft tissue in the neck and chest region, and the type and length of the catheter. In general an exit site for an IJ THDC is midway between the humeral head and sternal head of the clavicle, roughly one to two centimeter below the clavicle (Fig. 2). The goal is to achieve a smooth wide curve of the

Comparison between ultrasound-guided supraclavicular and infraclavicular approaches for subclavian venous catheterization in children'a randomized trial

Ultrasound (US)-guided subclavian vein (SCV) catheterization via the supraclavicular (SC) or infraclavicular (IC) approaches can be useful in children. The purpose of this study was to compare the efficacy of these approaches. This prospective, randomized study included 98 children who were <3 years old, and who were divided into two groups: the SC group (n=49) and the IC group (n=49). All SCV catheterizations were guided by US and performed by a single experienced anaesthesiologist. Data regarding puncture time, number of attempts, successful guidewire insertion, catheter insertion time, and complications were analysed. The median puncture time was longer in the IC group than the SC group (48 vs 36 s, P=0.02). Multiple attempts (number of attempts >3) were more frequently required in the IC group than the SC group (24.5 vs 6.1%, P=0.01). The incidence of guidewire misplacement was higher in the IC group than that of the SC group [10 (20.4%) vs 0 (0%), P=0.001]. Catheterization was successfully performed in all patients. No pneumothoraces or arterial punctures occurred in either group. During SCV catheterization under US guidance in paediatric patients, the SC approach yielded a shorter puncture time and decreased the incidence of guidewire misplacement when compared with the IC approach.

Cylothorax Developing Due to Thrombosis in The Subclavian Vein

Chylothorax, which is a rare complication of central venous catheterization, is an accumulation of lymphatic fluid in the pleural space as a result of impairment of the integrity of ductus thoracicus. In this case report, we will look over chylothorax related to thrombus developing following subclavian vein catheterization.

Complication of Right Subclavian Vein Catheterization: Superior Vena Cava Perforation

Sag Subklaviyan Venoz Kateterizasyonun Nadir Bir Komplikasyonu: Superior Vena Kava PerforasyonuSantral venoz kateterizasyon toraks operasyonlarinda rutin kullanilan invaziv bir girisimdir. En sik komplikasyonlar pnomotoraks ve hemotorakstir. Komplikasyon olarak vena kava superior (VKS) perforasyonuna (% 0,5) oldukca ender rastlanmaktadir. Altmis bes yasinda erkek hasta oksuruk sikayeti ile hastanemize basvurdu. Hastada sag akciger alt lobda lokalize akciger epidermoid kanser tespit edildi (Evre IB, T2N0M0). Ameliyat oncesi hazirlik olarak anestezi ekibi tarafindan hastaya endotrakeal entubasyon ve sag subklaviyan ven kateterizasyonu uygulandi. Eksplorasyonda, yerlestirilen santral kateterin sag subklaviyan veni perfore ettigi ve kisa bir mesafe intratorasik boslukta seyrettikten sonra frenik sinirin onunden vena kava superiora girdigi izlendi. Kateter geri cekilerek vena kava superior 5/0 prolen ile onarildi. Hastada postoperaitf donemde herhangi bir problem gelismedi ve sag alt bilobektomi sonrasi sorunsuz olarak taburcu edildi.

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

Central venous catheterisation is a commonly performed procedure in anaesthesia, critical care, acute and emergency medicine. Traditionally, subclavian venous catheterisation has been performed using the landmark technique and because of the complications associated with this technique, it is not commonly performed in the United Kingdom - where the accepted practice is ultrasound-guided internal jugular vein catheterisation. Subclavian vein catheterisation offers particular advantages over the internal jugular and femoral vein sites such as reduced rates of line-related sepsis, improved patient comfort and swifter access in trauma situations where the internal jugular vein may not be easily accessible. There is a growing body of evidence to suggest a potential emerging role for ultrasound-guided subclavian vein catheterisation. Barriers to this approach include many physicians still believing that the clavicle obscures imaging of the vein. In this article, we review the evidence supporting ultrasound-guided subclavian vein catheterisation and ask the question whether, in view of it potential advantages, it could be the way forward?

Pediatric Subclavian CVC Placement: Supra- or Infraclavicular Approach Is Reasonable

To determine the best approach for central venous catheter (CVC) insertion in the subclavian vein (SCV), researchers randomized 98 children to catheterization of the right SCV using the supraclavicular or infraclavicular approaches. All patients were younger than 3 years and required general anesthesia and CVC placement. All catheterizations were performed by one experienced anesthesiologist using ultrasound guidance in …

The Speed of Sound

Image 1. Placement of the ultrasound transducer in the transverse orientation to begin a survey of the venous anatomy.Image 2. Ultrasound image of the internal jugular vein and carotid artery in the transverse plane. The internal jugular (IJ) is typically more oval in shape when compared with the rounded, thicker-walled carotid (C).Image 3. Placement of the cannulating needle for “in-plane” access of the subclavian. As the needle enters at the end of the transducer, rather than at its mid-point, the entire needle (including the needle tip) can be visualized as it travels toward the vein. Sterile technique has been omitted for this demonstration, but should be used during this procedure.Image 4. Corresponding view seen under ultrasound guidance. As the needle enters from the end of the transducer, the entire length of the needle is seen as it travels toward the vein. This image is also available as Video 3 on the EMN website. (See FastLinks.)Ultrasound guidance in supraclavicular subclavian vein (SCV) catheterization is a relatively new concept. Traditional infraclavicular SCV catheterization is poorly amenable to ultrasound guidance because of the overlying clavicle, which can make visualization and direct guidance difficult. Supraclavicular SCV catheterization for central line placement has several advantages: practicality in cardiopulmonary arrest, decreased incidence of central line infections, lower risk of pneumothorax, and decreased incidence of thrombosis. The patient should be placed in a neutral supine position with or without Trendelenburg positioning. The anatomy should be surveyed with ultrasound to identify the SVC before beginning the procedure. Place a high-frequency transducer in the transverse orientation just lateral to the trachea to identify the internal jugular vein. (Image 1.) The internal jugular is typically slightly lateral to the carotid artery, is oval or triangular in shape, and may vary in size with respiration or Valsalva maneuvers. (Image 2.) Once the internal jugular is identified, follow it inferiorly to the supraclavicular fossa to identify the point at which it meets the SCV. (See FastLinks for videos demonstrating this technique.) Angling the transducer anteriorly will facilitate this identification, and the SCV will be seen in its longitudinal orientation as a tubular structure. (See FastLinks for additional images online.) Care should also be taken to identify the subclavian artery, which lies slightly deeper and more posterior to the vein. The subclavian artery is pulsatile, and application of color or Doppler flow can be used to differentiate the vessels. Identifying both vessels helps to assure the physician that the vein is cannulated instead of the artery. Once the subclavian vein is identified, the central venous catheter may be placed by dynamic ultrasound guidance. The introducer needle is advanced with gentle negative pressure from the end of the transducer. (Image 3.) This “in-plane” approach allows the operator to visualize the needle and needle tip at all times while advancing toward the vessel. (Image 4; see FastLinks for another video demonstrating this technique.) The needle tip will be seen to pierce the wall of the vessel and a flash of dark blood in the syringe will confirm that access has been obtained. Once venous access is achieved, the remainder of the procedure is performed via the usual Seldinger technique. Ultrasound can also be used to confirm correct wire placement in the SCV. (See FastLinks for additional images online.) Click and Connect! Access the links in EMN by reading this issue on our website or in our iPad app, both available onwww.EM-News.com.FastLinks BONUS! See One, Do One: This article also appears in the EMN Breaking News Blog with three videos and additional images demonstrating these techniques. Visit http://bit.ly/EMNBreakingNews. Read Dr. Butts' past columns at http://bit.ly/ButtsSpeedofSound. Comments about this article? Write to EMN at [email protected]. Questions? We Have Answers Have an ultrasound question? A topic you'd like to see in future Speed of Sound columns? Send your questions and suggestions for Dr. Butts to [email protected].

Supraclavicular Ultrasound-Guided Catheterization of the Subclavian Vein in Pediatric and Neonatal ICUs

To assess the feasibility of ultrasound-guided supraclavicular catheterization of the subclavian vein in pediatric and neonatal ICU. Retrospective cohort. Ten-bed pediatric medicosurgical ICU and 15-bed neonatal ICU. Children and newborns undergoing supraclavicular ultrasound-guided subclavian vein catheterization from March 2010 to September 2010. The placement of central venous catheter in ICU was carried out either by one of the experts in ultrasound-guided puncture of the unit or by a novice completely supervised by the expert. The success and the early complications were recorded. A comparison between novice and expert operators was also made. Forty-two catheters were placed in 40 children. The median age and median weight were, respectively, 6.5 months and 6.5 kg. The success rate was 97.6% (one failure) and the early complication rate was 4.7% (one pneumothorax and one arterial puncture); 61% of children breathed spontaneously during the catheter placement. No significant difference was found between expert and novice operators. Supraclavicular ultrasound-guided catheterization of the subclavian vein in pediatric and neonatal ICU seems to be a promising technique in the context of emergency. It is safe, reliable, with few early complications. Furthermore, it does not compromise the airways of the patient owing to the low level of sedation needed for its placement.

Plasma exchange as a complementary approach to snake bite treatment: An academic emergency department’s experiences

Snake bites are leading causes of morbidity and mortality worldwide, especially in rural areas. Therapeutic plasma exchange has been used in the treatment of many different conditions such as immunologic diseases, toxicologic disorders, and snake envenomation. The aim of this study is to evaluate the efficacy of plasma exchange treatment on clinical status, outcomes, and discharge of patients who were bitten by venomous snakes. The study was conducted retrospectively in the Emergency Department of Gaziantep University from January 2002 to December 2011. Thirty-seven patients were included in the present study. Routine biochemical and hematologic laboratory parameters were studied before and after plasma exchange. Demographic data, clinical status, and outcomes of patients were recorded. Plasma exchange was performed by using centrifugation technology via an intravenous antecubital or subclavian vein catheter access. Human albumin/fresh frozen plasma was used as replacement fluids. A significant correlation was seen between therapeutic plasma exchange and improvement of laboratory results. None of the study patients lost their limbs. Eight patients were sent to the intensive care unit. The mean length of the hospital stay was 12.2 days (4-28). All patients were discharged with good recovery. No complications were seen during the 3 months following discharge. Plasma exchange appears to be an effective treatment intervention for snake bite envenomations, especially in the management of hematologic problems and in limb preservation/salvage strategies. In addition to traditional treatment methods, plasma exchange should be considered by emergency physicians in cases of snake bite envenomation as a therapeutic approach to facilitate rapid improvement.

The Effects of the Trendelenburg Position and Intrathoracic Pressure on the Subclavian Cross-Sectional Area and Distance from the Subclavian Vein to Pleura in Anesthetized Patients

The effects of maneuvers to increase intrathoracic pressure and of Trendelenburg position on the cross-sectional area (CSA) of the subclavian vein (SCV) and the relationship between the SCV and adjacent structures have not been investigated. In ultrasonography-guided SCV catheterization (N = 30), the CSA of the SCV and the distance between the SCV and pleura (DSCV-pleura) were determined during 10-second airway opening, and 10-second positive inspiratory hold with 20 cm H2O in the supine position (S-0, and S-20) and the 10° Trendelenburg position (T-0, and T-20). In addition to a statistical significance of P < 0.05, CSA and DSCV-pleura differences of ≥15% were defined as clinically relevant changes. CSA (mean [95% confidence interval]) in S-20, T-0, and T-20 (1.02 [0.95-1.14] cm(2), 1.04 [0.95-1.15] cm(2), and 1.14 [1.04-1.24] cm(2), respectively) was significantly larger than a CSA in S-0 (0.93 [0.86-1.00] cm(2), all P < 0.001). However, only the increase of CSA in T-20 vs S-0 (0.21 cm(2), 23.2%) was clinically meaningful (≥15%). The number of patients who showed CSA increase ≥15% was more in S-0 to T-20 (57%) compared with those in S-0 to S-20 (23%) and S-0 to T-0 (27%). DSCV-pleura measurements (mean) in S-20 and T-20 (0.61 and 0.60 cm) were significantly shorter than those in S-0 (0.70 cm, all P < 0.001), but the reductions of DSCV-pleura were not clinically meaningful (≥15%). The combined application of inspiratory hold and Trendelenburg position provided a greater and more relevant degree of CSA increase without compromising DSCV-pleura, which may facilitate SCV catheterization. Further investigations are needed to determine whether these results affect the success rate of catheterization and the risk of procedural injury.

Size Variation Between Contralateral Infraclavicular Axillary Veins Within Individual Patients—Implications for Subclavian Venous Central Line Insertion*

Vein size and use of dynamic ultrasound guidance have been shown to be directly related to a reduction in insertion failure and complication rates during subclavian vein catheterization. We hypothesized that contralateral infraclavicular axillary vein sizes are significantly different within the same patient. We also aimed to demonstrate the relationship of subject's anthropomorphic indices with vein size and contralateral vein size difference. Prospective observational study. Operating theatre of a tertiary hospital. Fifty adult elective and emergency surgical patients. The largest dimensions of each patient's left and right infraclavicular axillary veins were measured with two-dimensional cross-sectional ultrasound examinations. The absolute difference between sides in individual patients was calculated using a paired difference t test and the relationship between hand dominance and vein size calculated by a paired difference t test of dominant side vein size minus nondominant side vein size Forty-five patients (90%) of patients were right hand dominant. The mean proportional cross-sectional area difference between left and right sides in individual patients was 59.7% (SEM 9.2%), with absolute cross-sectional area difference of 26.7 mm (SEM 2.8 mm). All test statistics reached statistical significance at p < 0.0001. There was no relationship between right hand dominance and ipsilateral infraclavicular axillary vein size (p = 1.0), nor was there any clinically significant correlation between subject's anthropomorphic indices and ipsilateral infraclavicular axillary vein size or contralateral vein size difference (largest Pearson's r = 0.22). Contralateral infraclavicular axillary vein sizes within the same patient are significantly different in the adult surgical population and bear no clear relation to patient hand dominance. The magnitude of contralateral difference or absolute ipsilateral infraclavicular axillary vein size cannot be predicted by a subject's anthropomorphic indices. All patients in whom subclavian central line insertion is planned should have both sides examined by ultrasound to determine which side has the largest vessel.

Subclavian Vein Catheterization During Ear Pain

Subclavian Vein Catheterization During Ear Pain

Comparison of results of placement of cuffed –tunneled hemodialysis catheter in internal jugular vein with subclavian vein for long -term dialysis

was to comparison between internal jugular vs. subclavian vein cuffed tunnel catheter placement for dialysis. Cases who required central venous catheter for dialysis were included in this study. Forty cases were included in this study and divided to two groups. Catheters were placed randomly in internal jugular vein or subclavian. Patients were followed for 6 months. Early and late complications of catheter's placement were recorded. Analysis was done using Spss ver 13.0 (Chicago, IL, USA). There were no significant differences between subclavian and internal jugular vein regarding occurrence of infection resulted in extraction or treatment. Also there were no significant differences regarding occurrence of thrombosis resulted in extraction or treatment. Failure rate was significantly higher in cases with internal jugular vein catheter compared to cases with subclavian vein catheter (p=0.04). Failure rate was significantly higher in cases with internal jugular vein catheter compared to subclavian cathether. Subclavian catheter is more appropriate route for catheter placement.