Ultrasound guided infraclavicular axillary vein cannulation, coming of age

Influence of arm position on the first pass success rates of ultrasound-guided infraclavicular axillary vein cannulation in spontaneously breathing patients: A randomised clinical trial

BACKGROUND

Significant collapsibility during spontaneous respiration, deeper location, and smaller vein size are key challenging factors to safe infraclavicular axillary vein cannulation. Arm abduction reduces collapsibility, but interventional data supporting this observation is lacking. This study investigates the effect of neutral and abducted arm position on the first pass success rate of infraclavicular axillary vein cannulation in spontaneously breathing patients.

METHODS

One hundred and twelve patients were randomly assigned to two arm positions, neutral or abducted by 90° at the shoulder joint. Under ultrasound guidance, the infraclavicular axillary vein was cannulated using an in-plane approach. The primary outcome was the first pass success rate of guidewire placement in the infraclavicular axillary vein. The secondary outcome measures were the number of attempts for successful cannulation, failure rate, and catheter tip malposition.

RESULTS

Fifty-two patients in the neutral arm and fifty-six patients in the arm abduction group were compared according to the intention to treat analysis. The abducted arm position was associated with a higher first pass success rate (RR = 3.39, 95% CI = 1.47-7.85; p = 0.004) with fewer attempts (p = 0.005), lower failure rate (RR = 1.37, 95% CI = 1.16-1.61; p = 0.000) and lower catheter tip malposition (1.5 vs 15.8%; p = 0.012) when compared to the neutral arm position.

CONCLUSION

Abducted arm position resulted in a significantly higher first pass success rate with a lower failure rate and catheter tip malposition during ultrasound-guided infraclavicular axillary vein cannulation in spontaneously breathing patients.

Axillary vein as an alternative venous access site for VV-ECMO cannulation: a case report

BACKGROUND

Ultrasound-guided percutaneous axillary vein cannulation can reduce cannulation failure and mechanical complications, is as safe and effective as internal jugular vein cannulation, and is superior to subclavian vein cannulation using landmark technique. As far, reports of venovenous extracorporeal membrane oxygenation (VV-ECMO) with percutaneous axillary vein cannulation are rare.

CASE PRESENTATION

A 64-year-old man presenting with dyspnea and chest tightness after aspirating sewage was admitted to the emergency department. Computed tomography (CT) showed diffuse exudation of both lungs and arterial blood gas analysis showed an oxygenation index of 86. He was diagnosed with aspiration pneumonia-induced acute respiratory distress syndrome (ARDS) and intubated for deteriorated oxygenation. Despite the combination therapy of protective mechanical ventilation and prone position, the patient's oxygenation deteriorated further, accompanied with multiple organ dysfunction syndrome, which indicated the requirement of support with VV-ECMO. However, vascular ultrasound detected multiple thrombus within bilateral internal jugular veins. As an alternative, right axillary vein was chosen as the access site of return cannula. Subsequently, femoral-axillary VV-ECMO was successfully implemented under the ultrasound guidance, and the patient's oxygenation was significantly improved. Unfortunately, the patient died of hyperkalemia-induced ventricular fibrillation after 36 h of VV-ECMO running. Despite the poor prognosis, the blood flow during ECMO run was stable, and we observed no bleeding complication, vascular injury, or venous return disorder.

CONCLUSIONS

Axillary vein is a feasible alternative access site of return cannula for VV-ECMO if internal jugular vein access were unavailable.

Ultrasound-guided, long-axis, in-plane, infraclavicular axillary vein cannulation: A 6-year experience

BACKGROUND

Despite its potential advantages, ultrasound-guided cannulation of the axillary vein in the infraclavicular area is still rarely used as an alternative to other techniques. There are few large series demonstrating the safety and feasibility of this approach.

METHODS

Retrospective analysis of data on patients undergoing ultrasound-guided, long-axis, in-plane infraclavicular axillary vein cannulation for the incidence of complications and the failure rate from two secondary-care hospitals.

RESULTS

The analysis included 710 successful attempts of axillary vein long-axis, in-plane, US-guided cannulation, and 24 (3.3%) failed attempts. We recorded a 96.7% success rate with an overall incidence of complications of 13%, mainly malposition (8.1%). There was one case of pneumothorax (0.14%), five cases of arterial puncture (0.7%), and two cases of brachial plexus injury.

CONCLUSIONS

The US-guided axillary central venous cannulation (CVC) access technique can be undertaken successfully in patients, even in challenging circumstances. Taken together with existing work on the utility and safety of this technique, we suggest that it should be adopted more widely in clinical practice.

Real-Time Ultrasound Guidance as Compared With Landmark Technique for Subclavian Central Venous Cannulation: A Systematic Review and Meta-Analysis With Trial Sequential Analysis

OBJECTIVES

We conducted a systematic review and meta-analysis to assess the effectiveness of real-time dynamic ultrasound-guided subclavian vein cannulation as compared to landmark technique in adult patients.

DATA SOURCES

PubMed and EMBASE until June 1, 2022, with the EMBASE search restricted to the last 5 years.

STUDY SELECTION

We included randomized controlled trials (RCTs) comparing the two techniques (real-time ultrasound-guided vs landmark) for subclavian vein cannulation. The primary outcomes were overall success rate and complication rate, whereas secondary outcomes included success at first attempt, number of attempts, and access time.

DATA EXTRACTION

Independent extraction by two authors according to prespecified criteria.

DATA SYNTHESIS

After screening, six RCTs were included. Two further RCTs using a static ultrasound-guided approach and one prospective study were included in the sensitivity analyses. The results are presented in the form of risk ratio (RR) or mean difference (MD) with 95% CI. Real-time ultrasound guidance increased the overall success rate for subclavian vein cannulation as compared to landmark technique (RR = 1.14; [95% CI 1.06-1.23]; p = 0.0007; I2 = 55%; low certainty) and complication rates (RR = 0.32; [95% CI 0.22-0.47]; p < 0.00001; I2 = 0%; low certainty). Furthermore, ultrasound guidance increased the success rate at first attempt (RR = 1.32; [95% CI 1.14-1.54]; p = 0.0003; I2 = 0%; low certainty), reduced the total number of attempts (MD = -0.45 [95% CI -0.57 to -0.34]; p < 0.00001; I2 = 0%; low certainty), and access time (MD = -10.14 s; [95% CI -17.34 to -2.94]; p = 0.006; I2 = 77%; low certainty). The Trial Sequential Analyses on the investigated outcomes showed that the results were robust. The evidence for all outcomes was considered to be of low certainty.

CONCLUSIONS

Real-time ultrasound-guided subclavian vein cannulation is safer and more efficient than a landmark approach. The findings seem robust although the evidence of low certainty.

Determination of the optimal length of insertion for central venous catheterization via axillary vein cannulation using preoperative chest X-ray- A prospective feasibility study

Background and Aims

Ensuring safe central venous catheter tip placement is important. Multiple techniques are available to estimate the length of catheter insertion for subclavian and internal jugular approaches. However, the methods to determine the length of insertion for the axillary route have not been validated. The purpose of this feasibility study was to evaluate a simple method for the calculation of catheter length to be inserted and assess whether it accurately predicts the correct tip placement.

Material and Methods

A total of 102 patients requiring preoperative central venous cannulation were evaluated, out of which 60 had successful axillary vein (AxV) cannulation. The length of insertion was calculated using the formula: (2/3* A + B) +Y (A: Clavicular length on chest radiograph [CXR], B: Vertical distance between the sternal head and carina on CXR, Y: Perpendicular distance from the skin to the AxV on ultrasound). A postoperative CXR was used to assess the accurate tip placement (2 cm above the carina to 0.5 cm below it). The primary outcome of the study was the rate of successful placement of the central venous catheter (CVC) in terms of the correct position of the tip of the catheter when the length of the catheter inserted was predicted by the formula described previously.

Results

Optimal placement was observed in 83.33% of the cases. A higher rate of accuracy was seen in the females (P value = 0.03) and shorter patients (P value = 0.01). A Bland-Altman plot depicted a high degree of agreement.

Conclusion

Use of the formula using a CXR and ultrasound allowed P successful placement of the CVC tip at the desired location in 83.33% of the cases.

Ultrasound-Guided Infraclavicular Axillary Vein Versus Internal Jugular Vein Cannulation in Critically Ill Mechanically Ventilated Patients: A Randomized Trial

OBJECTIVES

This clinical trial aimed to compare the ultrasound-guided in-plane infraclavicular cannulation of the axillary vein (AXV) and the ultrasound-guided out-of-plane cannulation of the internal jugular vein (IJV).

DESIGN

A prospective, single-blinded, open label, parallel-group, randomized trial.

SETTING

Two university-affiliated ICUs in Poland (Opole and Lublin).

PATIENTS

Mechanically ventilated intensive care patients with clinical indications for central venous line placement.

INTERVENTIONS

Patients were randomly assigned into two groups: the IJV group ( n = 304) and AXV group ( n = 306). The primary outcome was to compare the IJV group and AXV group through the venipuncture and catheterization success rates. Secondary outcomes were catheter tip malposition and early mechanical complication rates. All catheterizations were performed by advanced residents and consultants in anesthesiology and intensive care.

MEASUREMENTS AND MAIN RESULTS

The IJV puncture rate was 100%, and the AXV was 99.7% (chi-square, p = 0.19). The catheterization success rate in the IJV group was 98.7% and 96.7% in the AXV group (chi-square, p = 0.11). The catheter tip malposition rate was 9.9% in the IJV group and 10.1% in the AXV group (chi-square, p = 0.67). The early mechanical complication rate in the IJV group was 3% (common carotid artery puncture-4 cases, perivascular hematoma-2 cases, vertebral artery puncture-1 case, pneumothorax-1 case) and 2.6% in the AXV group (axillary artery puncture-4 cases, perivascular hematoma-4 cases) (chi-square, p = 0.79).

CONCLUSIONS

No difference was found between the real-time ultrasound-guided out-of-plane cannulation of the IJV and the infraclavicular real-time ultrasound-guided in-plane cannulation of the AXV. Both techniques are equally efficient and safe in mechanically ventilated critically ill patients.

Ultrasound guided axillary vein catheterization versus subclavian vein cannulation with landmark technique: A PRISMA-compliant systematic review and meta-analysis

BACKGROUND

Although ultrasound (US) guided axillary vein (AV) catheterization has been well described, evidence for its efficacy and safety compared with conventional infraclavicular landmark guided subclavian vein (SCV) cannulation have not been comprehensively appraised. Thus, we conducted a systematic review and meta-analysis to determine whether US guided AV catheterization reduces catheterization failures and adverse events compared to SCV puncture based on landmark technique.

METHODS

We searched the PubMed, Embase, Cochrane Library, CINAHL, Web of Science, SCOPUS, China Biology Medicine, China National Knowledge Infrastructure, Wan Fang, and Wei Pu databases for randomized controlled trials (RCTs) studies published from inception to May 2021. Two investigators reviewed and extracted data on study design, number and type of inclusion criteria. Study quality was assessed using the Jadad scale. Outcomes included the puncture success rates and the incidence of adverse events.

RESULTS

Data of 1852 patients from five RCTs were included in this meta-analysis. The analysis showed that US guided AV catheterization increased the first (risk ratio (RR), confidence interval (CI)) (RR = 1.17, 95% CI = 1.13~1.22, P < .01) and overall (RR = 1.09, 95% CI = 1.04~1.15, P < .01) puncture success rate, and reduce the occurrence of adverse events, including the risk of arterial puncture (RR = 0.18, 95% CI = 0.06~0.55, P < .01), pneumo-and hemothorax (RR = 0.12, 95% CI = 0.02~0.64, P = .01).

CONCLUSION

This meta-analysis indicates that US guided AV catheterization reduces catheterization failures and mechanical complications compared with conventional landmark guided SCV puncture.

Comparison of the proximal and distal approaches for axillary vein catheterization under ultrasound guidance (PANDA) in cardiac surgery patients susceptible to bleeding: a randomized controlled trial

BACKGROUND

The present study aimed at comparing the success rate and safety of proximal versus distal approach for ultrasound (US)-guided axillary vein catheterization (AVC) in cardiac surgery patients susceptible to bleeding.

METHODS

In this single-center randomized controlled trial, cardiac surgery patients susceptible to bleeding and requiring AVC were randomized to either the proximal or distal approach group for US-guided AVC. Patients susceptible to bleeding were defined as those who received oral antiplatelet drugs or anticoagulants for at least 3 days. Success rate, catheterization time, number of attempts, and mechanical complications within 24 h were recorded for each procedure.

RESULTS

A total of 198 patients underwent randomization: 99 patients each to the proximal and distal groups. The proximal group had the higher first puncture success rate (75.8% vs. 51.5%, p < 0.001) and site success rate (93.9% vs. 83.8%, p = 0.04) than the distal group. However, the overall success rates between the two groups were similar (99.0% vs. 99.0%; p = 1.00). Moreover, the proximal group had fewer average number of attempts (p < 0.01), less access time (p < 0.001), and less successful cannulation time (p < 0.001). There was no significant difference in complications between the two groups, such as major bleeding, minor bleeding, arterial puncture, pneumothorax, nerve injuries, and catheter misplacements.

CONCLUSIONS

For cardiac surgery patients susceptible to bleeding, both proximal and distal approaches for US-guided AVC can be considered as feasible and safe methods of central venous cannulation. In terms of the first puncture success rate and cannulation time, the proximal approach is superior to the distal approach. Trial registration Clinicaltrials.gov, NCT03395691. Registered January 10, 2018, https://clinicaltrials.gov/ct2/show/NCT03395691?cond=NCT03395691&draw=1&rank=1 .

Pre- and post-review of a standardized ultrasound-guided central venous catheterization curriculum evaluating procedural skills acquisition and clinician confidence

Background:

To evaluate novice and expert clinicians’ procedural confidence utilizing a blended learning mixed fidelity simulation model when applying a standardized ultrasound-guided central venous catheterization curriculum.

Methods:

Simulation-based education and ultrasound-guided central venous catheter insertion aims to provide facility-wide efficiencies and improves patient safety through interdisciplinary collaboration. The objective of this quality improvement research was to evaluate both novice (<50) and expert (>50) clinicians’ confidence across 100 ultrasound-guided central venous catheter insertion courses were performed at a mixture of teaching and non-teaching hospitals across 26 states within the United States between April 2015 and April 2016. A total of 1238 attendees completed a pre- and post-survey after attending a mixed method clinical simulation course. Attendees completed a 4-h online didactic education module followed by 4 h of hands-on clinical simulation stations (compliance/sterile technique, needling techniques, vascular ultrasound assessment, and experiential complication management).

Results:

The use of a standardized evidence-based ultrasound-guided central venous catheter curriculum improved confidence and application to required clinical tasks and knowledge across all interdisciplinary specialties, regardless of level of experience. Both physician and non-physician groups resulted in statistically significant results in both procedural compliance ( p < 0.001) and ultrasound skills ( p < 0.001).

Conclusion:

The use of a standardized clinical simulation curriculum enhanced all aspects of ultrasound-guided central venous catheter insertion skills, knowledge, and improved confidence for all clinician types. Self-reported complications were reported at significantly higher rates than previously published evidence, demonstrating the need for ongoing procedural competencies. While there are growing benefits for the role of simulation-based programs, further evaluation is needed to explore its effectiveness in changing the quality of clinical outcomes within the healthcare setting.

Sonographic visualization and cannulation of the axillary vein in two arm positions during mechanical ventilation: A randomized trial

BACKGROUND

Abduction of the arm has been used for ultrasound-guided infraclavicular axillary vein cannulation. We evaluated the influence of arm position on sonographic visualization and cannulation of the axillary vein in patients receiving mechanical ventilation.

METHODS

Sixty patients scheduled to undergo surgery under general anaesthesia with controlled mechanical ventilation were included in this prospective randomized study. The depth, size and distance of axillary vein to the pleura were recorded at three points: Point A, the most proximal part of the axillary vein visualized with adduction; Point A', Point A in abduction; and Point B, the most proximal part of axillary vein visualized in abduction. Cephalic movement of the clavicle at Point A' and the distance between Point A and Point B were noted. In Group A, cannulation was performed at Point A in the adducted arm and at Point B with the abducted arm in Group B after randomization.

RESULTS

Abduction moved the clavicle cephalad by 2.2 ± 0.6 cm and increased sonographic visualization of the axillary vein by 2.2 ± 0.5 cm in length, when compared with adduction. The distance from the vein to pleura was higher in Point A' (p < 0.001). No differences were found during cannulation in terms of first-pass success rate or number of attempts.

CONCLUSION

Abducted position moved the clavicle cephalad and allowed sonographic visualization of infraclavicular axillary vein approximately 2 cm more proximally than with the adducted arm, with a comparable rate of cannulation success.

Dynamic variation of the axillary veins due to intrathoracic pressure changes: A prospective sonographic study

INTRODUCTION

The ultrasound-guided axillary vein is becoming a compulsory alternative vessel for central venous catheterization and the anatomical position offers several potential advantages over blind, subclavian vein techniques.

OBJECTIVE

To determine the degree of dynamic variation of the axillary vein size measured by ultrasound prior to the induction of general anesthesia and after starting controlled mechanical ventilation.

DESIGN

Prospective, observational study.

METHODS

One hundred ten patients undergoing elective surgery were enrolled and classified according to sex, age, and body mass index. Two-dimensional cross-sectional vein diameter, area, and mean flow velocity were performed using ultrasound on both the left and right axillary veins of each subject before and after induction of anesthesia.

RESULTS

There was statistically significant evidence showing that the axillary vein area increases when patients are mechanically ventilated. When considering venous flow velocity as a primary outcome, velocity decreased after patients moved from spontaneous to mechanical ventilation (coefficient = -0.267), but this relationship failed to achieve statistical significance (t = -1.355, p = 0.179).

CONCLUSIONS

Anatomical variations in depth and diameter as well as the collapsibility due to intrathoracic pressures changes represent common challenges that face clinicians during central venous catheterization of the axillary vein. A noteworthy increase in vessel size as patients transition from spontaneous to mechanical ventilation may theoretically improve first-pass cannulation success with practitioners skilled in both ultrasound and procedure. As a result, placing a centrally inserted central catheter after the induction of anesthesia may be beneficial.

Arm position and collapsibility of infraclavicular axillary vein during voluntary breathing: An ultrasound-guided observational study

BACKGROUND

Arm abduction influences cross-sectional area of the infraclavicular axillary vein, yet the effect of arm abduction on collapsibility of the vein has not been quantified. Decrease in collapsibility of the axillary vein can enable successful cannulation and can decrease injury to underlying vital structures.

METHODS

The infraclavicular axillary vein was scanned in 70 patients close to the clavicle with a high-frequency linear transducer in arm adducted position (Point A), after arm abduction at the initial probe position (Point A') and after tracing the vein medially close to clavicle (Point B). Maximum and minimum cross-sectional area and circumference during tidal breathing and collapsibility indices during tidal and deep breathing were measured at three probe positions.

RESULTS

The percentage change with respiration in cross-sectional area, circumference and the collapsibility indices computed from the above measurements were lesser in arm abducted position (p < 0.001). There was decrease in collapsibility index during tidal breathing from 25 at Point A to 7 at Point A' and 3 at Point B. Collapsibility index reduced from 91 at Point A to 30 at Point A' and 35 at Point B during deep breathing.

CONCLUSION

We conclude that the collapsibility of the infraclavicular axillary vein could be reduced by arm abduction, and hence, abduction could be proposed as the ideal arm position for ultrasound-guided infraclavicular axillary vein cannulation.

A modified approach for ultrasound-guided axillary venipuncture in the infraclavicular area: A retrospective observational study

BACKGROUND

Catheterization of the axillary vein in the infraclavicular area has important advantages in patients with long-term, indwelling central venous catheters. The two most commonly used ultrasound-guided approaches for catheterization of the axillary vein include the long-axis/in-plane approach and the short-axis/out-of-plane approach, but there are certain drawbacks to both approaches. We have modified a new approach for axillary vein catheterization: the oblique-axis/in-plane approach.

METHODS

This observational study retrospectively collected data from patients who underwent ultrasound-guided placement of an axillary vein infusion port in the infraclavicular area at the Central Venous Access Clinics of Zhongshan Hospital at Fudan University between March 2014 and May 2017. The patients' demographic data, success rate of catheterization, venous catheterization site, and immediate complications associated with catheterization were recorded.

RESULTS

Between March 2014 and May 2017, a total of 858 patients underwent placement of an axillary vein infusion port in the infraclavicular area at our center. The ultrasound-guided oblique-axis/in-plane approach was used for all patients, and the venipuncture success rate was 100%. Two cases of accidental arterial puncture and one case of local hematoma formation were reported, and no other complications, such as pneumothorax or nerve damage, were reported.

CONCLUSION

The ultrasound-guided oblique-axis/in-plane approach is a safe and reliable alternative to the routine ultrasound-guided approach for axillary venous catheterization.

Ultrasound-guided vascular access in critical illness

Over the past two decades, ultrasound (US) has become widely accepted to guide safe and accurate insertion of vascular devices in critically ill patients. We emphasize central venous catheter insertion, given its broad application in critically ill patients, but also review the use of US for accessing peripheral veins, arteries, the medullary canal, and vessels for institution of extracorporeal life support. To ensure procedural safety and high cannulation success rates we recommend using a systematic protocolized approach for US-guided vascular access in elective clinical situations. A standardized approach minimizes variability in clinical practice, provides a framework for education and training, facilitates implementation, and enables quality analysis. This review will address the state of US-guided vascular access, including current practice and future directions.

Real-time ultrasound-guided axillary vein cannulation in children: a randomised controlled trial

The axillary vein is a good site for ultrasound-guided central venous cannulation in terms of infection rate, patient comfort and its anatomical relationship with the clavicle and lungs. We compared real-time ultrasound-guided axillary vein cannulation with conventional infraclavicular landmark-guided subclavian vein cannulation in children. A total of 132 paediatric patients were randomly allocated to either ultrasound-guided axillary vein (axillary group) or landmark-guided subclavian vein (landmark group). The outcomes measured were success rate after two attempts, first-attempt success rate, time to cannulation and complication rate. The success rate after two attempts was 83% in the axillary group compared with 63% in the landmark group (odds ratio 2.85, 95%CI 1.25-6.48, p = 0.010). The first-attempt success rate was 46% for the axillary group and 40% for the landmark group (p = 0.274) and median time to cannulation was 156 s for the axillary group and 180 s for the landmark group (p = 0.286). There were no differences in complication rates between the two groups, although three episodes of subclavian artery puncture occurred in the landmark group (p = 0.08). We conclude that axillary vein cannulation using a real-time ultrasound-guided in-plane technique is useful and effective in paediatric patients.

A comparison of longitudinal and transverse approaches to ultrasound-guided axillary vein cannulation by experienced operators

BACKGROUND

The axillary vein is an easily accessible vessel that can be used for ultrasound-guided central vascular access and offers an alternative to the internal jugular and subclavian veins. The objective of this study was to identify which transducer orientation, longitudinal or transverse, is better for imaging the axillary vein with ultrasound.

METHODS

We analyzed 236 patients who had undergone central venous cannulation of axillary vein in this retrospective study. Patients were divided into two groups, the longitudinal approach group (n=120) and transverse approach group (n=116). Recorded the one-attempt success rate, operation time, arterial puncture rate and pneumothorax rate. We perform chest radiography to confirm pneumothorax on all patients. We compared the one-attempt success rate, operation time, arterial puncture rate and pneumothorax rate between the two groups.

RESULTS

The two groups were comparable with clinical characters of patients. The overall success rates of the longitudinal group and the transverse group were both 100%. The rate of one-attempt success in the longitudinal approach group is higher than the transverse approach group (91.7% vs. 82.8%, P=0.040). The transverse approach group had shorter operation time than the longitudinal group (184.7±8.1 vs. 287.5±19.6 seconds, P=0.000). The two groups had lower postoperative complications. Arterial puncture occurred in 1 of 120 longitudinal and 2 of 116 transverse attempts and this difference was no significant (P=0.541). No pneumothorax occurred in the two groups.

CONCLUSIONS

The longitudinal approach during ultrasound-guided axillary vein cannulation is associated with greater one-attempt success rate compared with the transverse approach by experienced operators. The transverse approach has shorter operation time. The two groups have lower postoperative complications and are comparable with pneumothorax and arterial puncture.

A manikin-based evaluation of a teaching modality for ultrasound-guided infraclavicular longitudinal in-plane axillary vein cannulation in comparison with ultrasound-guided internal jugular vein cannulation: A pilot study

Background and Aims:

Ultrasound (US)-guided infraclavicular approach for axillary vein (AXV) cannulation has gained popularity in the last decade.

Material and Methods:

In this manikin study, we evaluated the feasibility of a training model for teaching AXV cannulation. The learning pattern with this technique was assessed among attending anesthesiologists and residents in training.

Results:

A faster learning pattern was observed for AXV cannulation among the attending anesthesiologists and residents in training, irrespective of their prior experience with US. It was evident that a training modality for this technique could be easily established with a phantom model and that hands-on training motivates trainees to embrace US-based central venous cannulation.

Conclusion:

A teaching model for US-guided infraclavicular longitudinal in-plane AXV cannulation can be established using a phantom model. A focused educational program would result in an appreciable change in preference in embracing US-based cannulation techniques among residents.