Anatomical Landmark Guided versus Ultrasound-Guided Technique for Subclavian Vein Cannulation in Critically Ill Patients

Abstract

Background: Central Venous Access (CVA) is a common requirement in the critically ill patient for a variety of indications including Central Venous Pressure (CVP) monitoring, haemodialysis, placement of pulmonary artery catheters, cardiac pacing and for administration of drugs especially vasoactive, chemotherapy agents and parenteral nutrition. Traditionally, Central Venous Catheter (CVC) placement is performed using Landmark (LM) technique and is associated with complications like arterial puncture, pneumothorax, hemothorax, air embolism, catheter embolism, and cardiac arrhythmias. Use of Ultrasound (US) is currently indicated for various clinical situations to reduce complication rate of LM technique. Aim and Objectives: The purpose of this study was to determine whether US guidance could improve the success rate, number of attempts, and rate of acute complications like inadvertent arterial puncture, hematoma formation, and pneumothorax of subclavian venous catheterization. Material and Methods: Sixty patients in need of central venous catheter were prospectively randomized in two groups of 30 each. In the LM group patients were catheterized using the LM method and in US group patients were catheterized by real-time US-guidance. Number of attempts, success rate, access time and complications like accidental subclavian artery puncture, haematoma formation, pneumothorax, were recorded. p values <0.05 were considered statistically significant. Results: In the US group 30 (100%) of patients were successfully cannulated with the US guidance while the landmark technique was successful in 26 (86.66%) of patients. In the US group the success on first attempt was 83.33 % which was a significantly higher from 56.67% achieved in the LM group (p=0.025). The average number of attempts for successful cannulation in the US group was 1.16 ± 0.4, while in the LM group it was 1.56 ± 0.9 with statistically significant difference (p=0.046). Access time was 27.26 ± 04.62 seconds in the US group, while the access time was significantly more in the LM group 36.56 ± 17.35 seconds (p=0.0062). Conclusion: US guidance during subclavian vein catheterization increases overall and first attempt success, improves access time with reduced average number of attempts and complications.

Keywords

• central venous cannulation
• central venous access
• central venous pressure
• subclavian vein
• landmark