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

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.

Ultrasound-guided central venous catheterization around the neck: Systematic review and network meta-analysis

BACKGROUND

Ultrasound-guided central venous catheterization (CVC) has become the standard of care. However, providers use a variety of approaches, encompassing the internal jugular vein (IJV), supraclavicular subclavian vein (SupraSCV), infraclavicular subclavian vein (InfraSCV), proximal axillary vein (ProxiAV), distal axillary vein (DistalAV), and femoral vein.

OBJECTIVE

This review aimed to compare the first-pass success rate and arterial puncture rate for different approaches to ultrasound-guided CVC above the diaphragm.

METHODS

In May 2023, Embase, MEDLINE, CENTRAL, ClinicalTrials.gov, and World Health Organization International Clinical Trials Platform were searched for randomized controlled trials (RCTs) comparing the 5 CVC approaches. The Confidence in Network Meta-Analysis tool was used to assess confidence. Thirteen RCTs (4418 participants and 13 comparisons) were included in this review.

RESULTS

The SupraSCV approach likely increased the proportion of first-attempt successes compared to the other 4 approaches. The SupraSCV first-attempt success demonstrated risk ratios (RRs) > 1.21 with a lower 95% confidence interval (CI) exceeding 1. Compared to the IJV, the SupraSCV approach likely increased the first-attempt success proportion (RR 1.22; 95% confidence interval [CI] 1.06-1.40, moderate confidence), whereas the DistalAV approach reduced it (RR 0.72; 95% CI 0.59-0.87, high confidence). Artery puncture had little to no difference across all approaches (low to high confidence).

CONCLUSION

Considering first-attempt success and mechanical complications, the SupraSCV may emerge as the preferred approach, while DistalAV might be the least preferable approach. Nevertheless, head-to-head studies comparing the approaches with the greatest first attempt success should be undertaken.

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.

How to improve the efficiency and the safety of real-time ultrasound-guided central venous catheterization in 2023: a narrative review

Central venous catheterization (CVC) is a frequent procedure, practiced by intensivists, anesthesiologists and advanced practice nurses in intensive care units and operative rooms. To reduce CVC-associated morbidity, it is essential to strive for best practices, based on the latest evidence. This narrative review aims to synthesize current knowledge on evidence-based best practices for CVC that improve the use and feasibility of real-time ultrasound-guided insertion procedures. Optimization of the vein puncture technique and the development of new technologies are discussed to reinforce the use of the subclavian vein catheterization as first choice. The search for alternative site of insertions, without increasing infectious and thrombotic risks, deserves further research.

Comparison of ultrasound-guided internal jugular vein and supraclavicular subclavian vein catheterization in critically ill patients: a prospective, randomized clinical trial

Background

The aim of this study was to compare the effectiveness and safety of ultrasound-guided out-of-plane internal jugular vein (OOP-IJV) and in-plane supraclavicular subclavian vein (IP-SSCV) catheterization in adult intensive care unit.

Methods

A total of 250 consecutive patients requiring central venous catheterization, were randomly assigned to undergo either ultrasound-guided OOP-IJV or IP-SSCV cannulation. All catheterizations were carried out by three physicians. The primary outcome was the first attempt success rate. Ultrasound scanning time, venous puncture time, insertion time, overall access time, number of puncture attempts, number of needle redirections, success rate, guidewire advancing difficulties, venous collapse and adverse events were also documented.

Results

The first attempt success rate was significantly higher in IP-SSCV group (83.2%) compared to OOP-IJV group (63.2%) (p = 0.001). The IP-SSCV group was associated with a longer ultrasound scanning time (16.54 ± 13.51 vs. 5.26 ± 4.05 s; p < 0.001) and a shorter insertion time (43.98 ± 26.77 vs. 53.12 ± 40.21 s; p = 0.038). In the IP-SCCV group, we recorded a fewer number of puncture attempts (1.16 ± 0.39 vs. 1.47 ± 0.71; p < 0.001), needle redirections (0.69 ± 0.58 vs. 1.17 ± 0.95; p < 0.001), difficulties in guidewire advancement (2.4% vs. 27.4%; p < 0.001), venous collapse (2.4%, vs. 18.4%; p < 0.001) and adverse events (8.8% vs. 13.6%; p = 0.22).

Conclusions

The IP-SSCV approach is an effective and a safe alternative to the classic OOP-IJV catheterization in critical adult patients.

Trial registration: Clinicaltrials.gov, NCT03879954. Registered March 19, 2019—Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03879954.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-022-01065-x.