Fragou M, Gravvanis A, Dimitriou V, et al. Real-time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients: A prospective randomized study

Γενικό Νοσοκομείο Ασκληπιείο Βούλας, Βούλα, Attica, Greece
Critical care medicine (Impact Factor: 6.31). 07/2011; 39(7):1607-12. DOI: 10.1097/CCM.0b013e318218a1ae
Source: PubMed


Subclavian vein catheterization may cause various complications. We compared the real-time ultrasound-guided subclavian vein cannulation vs. the landmark method in critical care patients.
Prospective randomized study.
Medical intensive care unit of a tertiary medical center.
Four hundred sixty-three mechanically ventilated patients enrolled in a randomized controlled ISRCTN-registered trial (ISRCTN-61258470).
We compared the ultrasound-guided subclavian vein cannulation (200 patients) vs. the landmark method (201 patients) using an infraclavicular needle insertion point in all cases. Catheterization was performed under nonemergency conditions in the intensive care unit. Randomization was performed by means of a computer-generated random-numbers table and patients were stratified with regard to age, gender, and body mass index.
No significant differences in the presence of risk factors for difficult cannulation between the two groups of patients were recorded. Subclavian vein cannulation was achieved in 100% of patients in the ultrasound group as compared with 87.5% in the landmark one (p < .05). Average access time and number of attempts were significantly reduced in the ultrasound group of patients compared with the landmark group (p < .05). In the landmark group, artery puncture and hematoma occurred in 5.4% of patients, respectively, hemothorax in 4.4%, pneumothorax in 4.9%, brachial plexus injury in 2.9%, phrenic nerve injury in 1.5%, and cardiac tamponade in 0.5%, which were all increased compared with the ultrasound group (p < .05). Catheter misplacements did not differ between groups. In this study, the real-time ultrasound method was rated on a semiquantitative scale as technically difficult by the participating physicians.
The present data suggested that ultrasound-guided cannulation of the subclavian vein in critical care patients is superior to the landmark method and should be the method of choice in these patients.

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    • "Several studies have shown ultrasound guided CVC of the Subclavian vein to be a plausible technique.22–24 Fragou et al,22 performed a study comparing an ultrasound guided infraclavicular approach to the Subclavian vein with the standard landmark technique and showed ultrasound guidance to be superior in procedural success and complication rates. However, while there was greater success with ultrasound guidance, the proceduralists involved in the study rated this approach an 8 on a 10-point Lickert scale for difficulty, where 0 was “simple” and 10 was “complex.” "
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    ABSTRACT: 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.
    The western journal of emergency medicine 07/2014; 15(4):536-40. DOI:10.5811/westjem.2014.1.16305
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    • "It has become clear that ultrasound approaches have potential applicability in central venous catheterization. All previous reports, however, have evaluated parts of the procedure time during real-time ultrasound guidance [7]. The times of preparation of the transducer, which is covered with ultrasonic gel and wrapped in an intraoperative sterile sheath, and of the ultrasound guidance itself have not been yet evaluated. "
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    ABSTRACT: Background: Central venous catheters play an important role in patient care. Real-time ultrasound-guided subclavian central venous (SCV) cannulation may reduce the incidence of complications and the time between skin penetration and the aspiration of venous blood into the syringe. Ultrasonic diagnosis of catheter misplacement and pneumothorax related to central venous catheterization is rapid and accurate. It is unclear, however, whether ultrasound real-time guidance and examination can reduce procedure times and complication rates when compared with landmark guidance and radiographic examination for SCV catheterization. Methods/design: The Subclavian Central Venous Catheters Guidance and Examination by UltraSound (SUBGEUS) study is an investigator-initiated single center, randomized, controlled two-arm trial. Three hundred patients undergoing SCV catheter placement will be randomized to ultrasound real-time guidance and examination or landmark guidance and radiographic examination. The primary outcome is the time between the beginning of the procedure and control of the catheter. Secondary outcomes include the times required for the six components of the total procedure, the occurrence of complications (pneumothorax, hemothorax, or misplacement), failure of the technique and occurrence of central venous catheter infections. Discussion: The SUBGEUS trial is the first randomized controlled study to investigate whether ultrasound real-time guidance and examination for SCV catheter placement reduces all procedure times and the rate of complications. Trial registration: Identifier: NCT01888094.
    Trials 05/2014; 15(1):175. DOI:10.1186/1745-6215-15-175 · 1.73 Impact Factor
    • "The point of entry is often more lateral compared to the blind technique as the medial part of the subclavian vein lies under the clavicle, making it inaccessible to ultrasound imaging. In a randomized controlled trial that compared blind versus real-time ultrasound guided subclavian vein cannulation using the “in plane” technique, catheterization was successful in 100% of cases compared to 87.5% with the landmark technique; complications including arterial puncture, hematomas, pneumothorax, hemothorax, phrenic nerve injury, and cardiac tamponade were all significantly more with the landmark technique.[7] "
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    ABSTRACT: There is increasing interest in the use of ultrasound to assess and guide the management of critically ill patients. The ability to carry out quick examinations by the bedside to answer specific clinical queries as well as repeatability are clear advantages in an acute care setting. In addition, delays associated with transfer of patients out of the Intensive Care Unit (ICU) and exposure to ionizing radiation may also be avoided. Ultrasonographic imaging looks set to evolve and complement clinical examination of acutely ill patients, offering quick answers by the bedside. In this two-part narrative review, we describe the applications of ultrasonography with a special focus on the management of the critically ill. Part I explores the utility of echocardiography in the ICU, with emphasis on its usefulness in the management of hemodynamically unstable patients. We also discuss lung ultrasonography - a vastly underutilized technology for several years, until intensivists began to realize its usefulness, and obvious advantages over chest radiography. Ultrasonography is rapidly emerging as an important tool in the hands of intensive care physicians.
    Indian Journal of Critical Care Medicine 05/2014; 18(5):301-309. DOI:10.4103/0972-5229.132492
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