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Background: Perioperative hypotension is frequently observed following the initiation of general anesthesia administration, often associated with adverse outcomes. This study assessed the effect of subclavian vein (SCV) diameter combined with perioperative fluid therapy on preventing post-induction hypotension (PIH) in patients with lower ASA status. Methods: This two-part study included patients aged 18 to 65 years, classified as ASA physical status I or II, and scheduled for elective surgery. The first part (Part I) included 146 adult patients, where maximum SCV diameter (dSCVmax), minimum SCV diameter (dSCVmin), SCV collapsibility index (SCVCI) and SCV variability (SCVvariability) assessed using ultrasound. PIH was determined by reduction in mean arterial pressure (MAP) exceeding 30% from baseline measurement or any instance of MAP < falling below 65 mmHg for ≥ a duration of at least 1 min during the period from induction to 10 min after intubation. Receiver Operating Characteristic (ROC) curve analysis was employed to determine the predictive values of subclavian vein diameter and other relevant parameters. The second part comprised 124 adult patients, where patients with SCV diameter above the optimal cutoff value, as determined in Part I study, received 6 ml/kg of colloid solution within 20 min before induction. The study evaluated the impact of subclavian vein diameter combined with perioperative fluid therapy by comparing the observed incidence of PIH after induction of anesthesia. Results: The areas under the curves (with 95% confidence intervals) for SCVCI and SCVvariability were both 0.819 (0.744–0.893). The optimal cutoff values were determined to be 45.4% and 14.7% (with sensitivity of 76.1% and specificity of 86.7%), respectively. Logistic regression analysis, after adjusting for confounding factors, demonstrated that both SCVCI and SCVvariability were significant predictors of PIH. A threshold of 45.4% for SCVCI was chosen as the grouping criterion. The incidence of PIH in patients receiving fluid therapy was significantly lower in the SCVCI ≥ 45.4% group compared to the SCVCI < 45.4% group. Conclusions: Both SCVCI and SCVvariability are noninvasive parameters capable of predicting PIH, and their combination with perioperative fluid therapy can reduce the incidence of PIH. [ABSTRACT FROM AUTHOR]

Background and objectives: The subclavian vein is frequently cannulated using ultrasound. There are two techniques of subclavian vein catheterization (SVC): Supraclavicular (SC) and infraclavicular (IC). Though the IC route is often preferred, the SC approach offers several distinct advantages. This study was planned to compare the technique of SVC using SC and IC approaches in terms of catheterization technique and complications in elective surgeries in adults. Methods: Sixty American Society of Anesthesiologists (ASA) 1, 2, or 3 adult patients posted for elective surgeries under general anesthesia were recruited. Patients were divided into SC or IC groups randomly. Right-sided subclavian vein was cannulated in both the groups (n = 30). Visualization time, Likert scale, subclavian vein diameter, skin-to-subclavian vein depth, number of attempts, puncture time, ease of guidewire insertion, catheter insertion time, and total procedural time were observed. A comparison of complications for each approach was noted. Results: Total procedural time, time to visualization of the subclavian vein, and puncture time was lower for group SC and higher for group IC. Catheter insertion time was higher with the IC approach than with the SC approach. Better ultrasound view scores were seen in group SC than in group IC. The first attempt success rate was higher in group SC than in group IC. Comparatively, lower complications both during and after the procedure were noted in the SC approach than the IC approach. Conclusion: Ultrasonography (USG) guidance guided SC approach to access the subclavian vein is quicker, relatively secure, and a better technique than the IC approach. Additionally, the SC approach is associated with comparatively fewer immediate and delayed complications. [ABSTRACT FROM AUTHOR]

Introduction: Femoral-femoral Veno-Venous ExtraCorporeal Life Support (V-V ECLS) has been associated with higher infections rates, vascular site bleeding complications, and restricted patient mobility. Jugular or bicaval dual lumen V-V ECLS conceptually overcomes some of these adverse factors, but experience has shown that jugular vein cannulation still limits mobility and has increased bleeding complications. Technique and outcomes of subclavian vein single-cannulation with Crescent jugular dual-lumen V-V ECLS is described. Method: five patients with COVID-19 related acute respiratory distress syndrome (ARDS) underwent right subclavian vein V-V ECLS placement with the Crescent 32 French jugular dual-lumen V-V ECLS catheter. A standardized percutaneous technique was developed that allowed efficient insertion without need for any specialized imaging (i.e. transesophageal echocardiogram) and outcomes assessed. Results: Mean age of the five patients was 41.2 years, all obese with an average basal mass index of 45.2 kg/m2 and mean days to decannulation of 24.2 days. Outcomes discovered included; improved patient mobility allowing physical rehabilitation, no vascular access site related complications requiring surgery or endovascular intervention, and none had evidence of superior vena cava syndrome. One patient had subclavian/axillary vein thrombosis with resolution after 3 months of direct-acting oral anticoagulants, and one patient had blood cultures positive at day 37, nearing decannulation. Conclusion: Subclavian vein access for crescent jugular dual lumen V-V ECLS catheter appears to be safe and feasible with added benefits of decreased bleeding and increased mobility over jugular or femoral-femoral access site for long term V-V ECLS support in COVID-19 related ARDS patients. [ABSTRACT FROM AUTHOR]

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Background: A previous study on mechanical complications after central venous catheterisation demonstrated differences in complication rates between male and female operators. The objective of this subgroup analysis was to further investigate these differences. The hypothesis was that differences in distribution of predefined variables between operator genders could be identified. Methods: This was a subgroup analysis of a prospective, multicentre, observational cohort study conducted between March 2019 and December 2020 including 8 586 patients ≥ 16 years receiving central venous catheters at four emergency care hospitals. The main outcome measure was major mechanical complications defined as major bleeding, severe cardiac arrhythmia, pneumothorax, arterial catheterisation, and persistent nerve injury. Independent t-test and χ2 test were used to investigate differences in distribution of major mechanical complications and predefined variables between male and female operators. Multivariable logistic regression analysis was used to determine association between operator gender and major mechanical complications. Results: Female operators had a lower rate of major mechanical complications than male operators (0.4% vs 0.8%, P =.02), were less experienced (P <.001), had more patients with invasive positive pressure ventilation (P <.001), more often chose the internal jugular vein (P <.001) and more frequently used ultrasound guidance (P <.001). Male operators more often chose the subclavian vein (P <.001) and inserted more catheters with bore size ≥ 9 Fr (P <.001). Multivariable logistic regression analysis showed that male operator gender was associated with major mechanical complication (OR 2.67 [95% CI: 1.26–5.64]) after correction for other relevant independent variables. Conclusions: The hypothesis was confirmed as differences in distribution of predefined variables between operator genders were found. Despite being less experienced, female operators had a lower rate of major mechanical complications. Furthermore, male operator gender was independently associated with a higher risk of major mechanical complications. Future studies are needed to further investigate differences in risk behaviour between male and female operators. Trial registration: Clinicaltrials.gov identifier: NCT03782324. Date of registration: 20/12/2018. [ABSTRACT FROM AUTHOR]

Background Central venous catheterization is an important device that is frequently performed for various purposes in operating theatres and intensive care units, there are many different sites that are commonly used for central venous catheterization, and each site has its own advantages, disadvantages, and possible complications. To avoid catheterization failure and mechanical complications, ultrasound guidance is currently recommended in several guidelines and is widely used for central venous catheterization. It has been shown to reduce the incidence of arterial puncture, hematoma formation, pneumothorax, hemothorax, and catheterization failure. The subclavian vein (SCV) catheterization is more comfortable for patients than other sites but has a higher risk of some complication as pneumothorax. The aim of this study was to compare the Supraclavicular and Infraclavicular approaches for ultrasonographic guided right subclavian venous catheterization as regard the accessibility and the safety of both approaches. Methods This randomized controlled study was conducted in Sohag University Hospital after local ethical committee approval, 210 patients had a right subclavian vein catheterization by either the supraclavicular or the infraclavicular approach (105 for each group), using a two dimensional high-frequency ultrasound guide were enrolled in the study regarding the accessibility (time to first puncture and number of punctures) and the complications like arterial puncture, hematoma formation, arrhythmia, and catheter misplacement. Results The infraclavicular approach is more accessible, regarding the number of punctures, for the Supraclavicular approach there were 56 (53.3%) cases needed only one puncture to achieve successful venous puncture and 27 (25.7%) cases needed 2 punctures and 5 (4.8%) needed 3 punctures and 17 (16.2%) failed in catheterization, for the Infraclavicular approach there were 79 (75.2%) of cases in these group needed only one puncture to achieve successful venous puncture and 17 (16.2%) cases needed 2 punctures and 9 (8.6%) failed in catheterization with a significant difference between both groups P value was 0.003. As regard the puncture time, for the Supraclavicular approach 83 (79%) cases successes in less than 3 min, and 22 (21%) cases needed more than 3 min, in the infraclavicular approach 94 (89.5%) cases succeeded in less than 3 min and 11 (10.5%) cases needed more than 3 min at P value 0.037 and had a lower rate of complications than the supraclavicular approach, like arrhythmia, arterial puncture, hematoma formation, catheter misplacement, and postcatheterization infection, but a higher rate of pneumothorax formation however in a nonsignificant way. Conclusion The infraclavicular approach for ultrasound-guided right subclavian venous catheterization is better than the supraclavicular approach due to a higher chance of first pass success rate and a lower rate of complications. [ABSTRACT FROM AUTHOR]

A study published in the European Heart Journal compared two techniques for implanting cardiac implantable electronic devices (CIEDs): ultrasound-guided axillary vein access (AVA) and cephalic vein cutdown access (CVA). The study found that intra-pocket ultrasound-guided AVA had a higher success rate and lower rates of complications compared to CVA alone and CVA combined with intrathoracic subclavian vein access. However, more evidence is needed to determine if intra-operative ultrasound guidance is superior to transcutaneous ultrasound guidance. The choice of technique should be based on the operator's confidence and experience. The article emphasizes that the opinions expressed in the text may not necessarily reflect the views of the editors or the society. [Extracted from the article]

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; I 2 = 55%; low certainty) and complication rates (RR = 0.32; [95% CI 0.22–0.47]; p < 0.00001; I 2 = 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; I 2 = 0%; low certainty), reduced the total number of attempts (MD = –0.45 [95% CI –0.57 to –0.34]; p < 0.00001; I 2 = 0%; low certainty), and access time (MD = –10.14 s; [95% CI –17.34 to –2.94]; p = 0.006; I 2 = 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. [ABSTRACT FROM AUTHOR]

Background: Perioperative hypotension increases postoperative complication rates and prolongs postoperative recovery time. Whether Passive Leg Raising test (PLR) and Subclavian Vein Diameter (DSCV) can effectively predict post-anesthesia hypotension remains to be tested. This study aimed to identify specific predictors of General Anesthesia (GA)induced hypotension by measuring DSCV in the supine versus PLR position. Methods: A total of 110 patients who underwent elective gynecological laparoscopic surgery under general anesthesia, were enrolled in this study. Before anesthesia, DSCV and theCollapsibility Index of DSCV(DSCV-CI) were measured by ultrasound, and the difference in maximal values of DSCV between supine and PLR positions was calculated, expressed as ΔDSCV. Hypotension was defined as Mean Blood Pressure (MBP) below 60mmhg or more than 30% below the baseline. Patients were divided into two groups according to the presence (Group H) or absence (Group N) of postanesthesia hypotension. The area under the receiver operating characteristic curve (ROC) and logistic regression analyses were used to evaluate the predictability of DSCV and other parameters for predicting preincision hypotension. Results: Three patients were excluded due to unclear ultrasound scans, resulting in a total of 107 patients studied. Twenty-seven (25.2%) patients experienced hypotension. Area under the ROC curve of ΔDSCV was 0.75 (P < 0.001) with 95% confidence interval (0.63–0.87), while DSCV and DSCV-CI were less than 0.7. The odds ratio (OR)of ΔDSCV was 1.18 (P < 0.001, 95%CI 1.09–1.27) for predicting the development of hypotension. ΔDSCV is predictive of hypotension following induction of general anesthesia. Conclusions: ΔDSCV has predictive value for hypotension after general anesthesia. Trial registration: The trial was registered in the Chinese Clinical Trial Registry on 04/10/2021. [ABSTRACT FROM AUTHOR]

Background: Clinicians trained in point-of-care ultrasound (POCUS) use the tool to enhance diagnostic capabilities at the bedside, often excluding or diagnosing conditions that are suspected based on the history and physical examination. Thoracic outlet syndrome (TOS) involves compression of arteries and nerves between the clavicle and first rib causing pain and paresthesia in the affected limbs. To our knowledge, use of POCUS to diagnose TOS in the literature has not been described.Case Report: A 46-year-old man presented with left upper extremity (LUE) edema, pain, and paresthesia, which was progressive over 3 weeks. Examination of the LUE revealed diffuse swelling without erythema and a left radial pulse present on Doppler only. A subsequent POCUS examination of the LUE was performed to exclude a deep vein thrombosis, and enlarged and turbulent veins distal to the internal jugular vein were found, which suggested venous compression external to the veins. Additional imaging confirmed narrowing of the subclavian vein and a diagnosis of venous thoracic outlet syndrome (vTOS) was made. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Failure to promptly diagnose and treat TOS can lead to long-term chronic upper extremity pain and even permanent disability. Diagnosis of vascular TOS is often made using computed tomography to identify impinged vessels, although color Doppler sonography can be an excellent choice for initial imaging in patients with suspected vTOS. Although POCUS is being used increasingly as a diagnostic tool and for procedural guidance, our case represents a novel application of POCUS in the diagnosis of vTOS. [ABSTRACT FROM AUTHOR]

Background: Many techniques exist for venous access (VA) during cardiac implantable electronic device (CIED) implantation. Objective: We sought to evaluate the learning curve with ultrasound (US) guided axillary vein access (USAA). Methods: Single‐center prospective randomized controlled trial of patients undergoing CIED implantation. Patients were randomized in a 2:1 fashion to USAA versus conventional VA techniques. The primary outcomes were the success rates, VA times and 30‐day complication rates. Results: The study included 100 patients (age 68 ± 14 years, BMI 27 ± 4 kg/m2). USAA was successful in 66/70 implants (94%). Initial attempts at conventional VA included 47% axillary (n = 14), 30% (n = 9) cephalic, and 23% (n = 7) subclavian. The median access time was longer for USAA than conventional access (8.3 IQR 4.2–15.3 min vs. 5.2 IQR 3.4–8.6 min, p =.009). Among the five inexperienced USAA implanters, there was a significant improvement in median access time from first to last tertile of USAA implants (17.0 IQR 7.0–21.0 min to 8.6 IQR 4.5–10.8 min, p =.038). The experienced USAA implanter had similar access times with USAA compared with conventional access (4.0 IQR 3.3–4.7 min vs. 5.2 IQR 3.4–8.6 min, p =.15). Venograms were less common with USAA than conventional access (2% vs. 33%, p <.0001). The 30‐day complication rate was similar with USAA (n = 4/70, 6%) versus conventional (n = 3/30, 10%, p =.44). Conclusion: Although the success rate with USAA was high, there was a significant learning curve. Once experienced with the USAA technique, there is the potential for reduced complications without adding to the procedure duration. [ABSTRACT FROM AUTHOR]

Background and Aims: Ultrasound-guided subclavian vein cannulation has two approaches: supraclavicular and infraclavicular. The aim of this study was to compare the ease of cannulation by recording the puncture time of the subclavian vein with the two approaches in adult patients. Material and Methods: This study was approved by our institutional ethics committee, and a written informed consent was obtained from the patients. This prospective randomized trial recruited patients aged 18 to 80 years with definite indications of subclavian vein cannulation. Real-time in-plane ultrasound-guided technique was used, and the subclavian vein was punctured at the junction of the brachiocephalic and IJV in supraclavicular approach (SC) and in oblique axis below the border of the clavicle in infraclavicular approach (IC). Results: A total of 96 patients were randomly allocated equally into two groups of 48 each, but only 45 patients in each group could be successfully cannulated. Median puncture times were comparable; 15 (9–39) s in SC and 21 (5–80) s in IC group. The first attempt success rate was 82.2% and 62.2%, and the mean total access time was 99.11 ± 34.66 s and 103.44 ± 50.27 s in SC and IC approaches, respectively and were comparable. The attempts of needle puncture were significantly higher in IC approach (1.40 ± 0.54 vs 1.20 ± 0.46 in SC approach; P = 0.04). The complication rates were comparable and less than 5%. Conclusion: Ease of cannulation of the subclavian vein using ultrasound-guided supraclavicular and infraclavicular approach is comparable as no statistically significant difference is noted in the puncture time and first-attempt success rate. The increased number of needle punctures reported in our study with the IC approach did not translate to an increased complication rate. [ABSTRACT FROM AUTHOR]

The distance from the skin surface to the cephalic vein may be measured to assess the need for a subsequent superficialization procedure.12,13 If the cephalic vein in the forearm is found to be inadequate for fistula creation, other veins in the forearm may be examined in a similar fashion to determine whether they are adequate. The American Institute of Ultrasound in Medicine (AIUM) is a multidisciplinary association dedicated to advancing the safe and effective use of ultrasound in medicine through professional and public education, research, development of clinical practice parameters, and accreditation of practices performing ultrasound examinations. Note that in case of more central cephalic vein thrombosis or hypoplasia, the forearm portion of the cephalic vein may drain preferentially via a large antecubital vein into the basilic or brachial veins. [Extracted from the article]

Background/Aim: To compare the outcomes of totally implantable central venous access device (TIVAD) insertions by surgical residents (SRs) with those by experienced surgeons (ESs) and establish the safety of percutaneous TIVAD insertion by SRs. Patients and Methods: A total of 700 insertions were successfully performed between January 2015 and December 2019 in our Department. The puncture site conversion and complication rates were compared, and risk factors related to complications were analysed. Results: In total, 84 and 616 insertions were performed in the SR and ES groups, respectively. SRs mainly punctured the internal jugular vein (IJV), and ESs punctured the subclavian vein (SV). The conversion rate from the IJV to SV was similar, whereas that from the SV to IJV was higher by SRs than ESs. Overall, early, and delayed complications were similar between the two groups. Conclusion: Percutaneous TIVAD inserted into the IJV by an SR was demonstrated to be safe. [ABSTRACT FROM AUTHOR]

Summary: Central venous catheter misplacement is common (approximately 7%) after right subclavian vein catheterisation. To avoid it, ultrasound‐guided tip navigation may be used during the catheterisation procedure to help direct the guidewire towards the lower superior vena cava. We aimed to determine the number of central venous catheter misplacements when using the right supraclavicular fossa ultrasound view to aid guidewire positioning in right infraclavicular subclavian vein catheterisation. We hypothesised that the incidence of catheter misplacements could be reduced to 1% when using this ultrasound technique. One ‐hundred and three adult patients were prospectively included. After vein puncture and guidewire insertion, we used the right supraclavicular fossa ultrasound view to confirm correct guidewire J‐tip position in the lower superior vena cava and corrected the position of misplaced guidewires using real‐time ultrasound guidance. Successful catheterisation of the right subclavian vein was achieved in all patients. The guidewire J‐tip was initially misplaced in 15 patients, either in the ipsilateral internal jugular vein (n = 8) or in the left brachiocephalic vein (n = 7). In 12 patients it was possible to adjust the guidewire J‐tip to a correct position in the lower superior vena cava. All ultrasound‐determined final guidewire J‐tip positions were consistent with the central venous catheter tip positions on chest X‐ray. Three out of 103 catheters were misplaced, corresponding to an incidence (95%CI) of 2.9 (0.6–8.3) %. Although the hypothesis could not be confirmed, this study demonstrated the usefulness of the right supraclavicular fossa ultrasound view for real‐time confirmation and correction of the guidewire position in right infraclavicular subclavian vein catheterisation. [ABSTRACT FROM AUTHOR]

Background: Management of acute decompensated heart failure (ADHF) requires accurate assessment of relative intravascular volume, which may be technically challenging. Inferior vena cava (IVC) collapsibility with respiration reflects intravascular volume and right atrial pressure (RAP). Subclavian vein (SCV) collapsibility may provide an alternative. Hypothesis: The purpose of this study was to examine the relationship between SCV collapsibility index (CI) and IVC CI in ADHF. Methods: This was a prospective study of non‐ventilated patients with ADHF who had paired IVC and SCV ultrasound assessments. As SCV CI is highly position‐dependent, measurements were performed supine at 30–45°. Results: Thirty‐three patients were included with 36 encounters. The sample size was adequately powered for receiver‐operator characteristic (ROC) analysis. SCV CI correlated with IVC CI during relaxed breathing (R =.65, n = 36, p <.001) and forced inhalation (R =.47, n = 36, p =.0036). SCV CI < 22% and >33% corresponded to IVC CI < 20% and >50% suggesting hypervolemia (sensitivity/specificity: 72%) and hypovolemia (sensitivity/specificity: 78%), respectively. Moderate to severe tricuspid regurgitation (TR) compared to less than moderate TR was associated with lower SCV CI (medians: 12.4% vs. 25.3%, p =.022) and IVC CI (medians: 9.6% vs. 35.6%, p =.0012). SCV CI and IVC CI were not significantly different among chronic kidney disease stages. Conclusion: In non‐ventilated ADHF, SCV CI at 30–45° correlates with paired IVC CI, and may provide an alternative to IVC CI for assessment of relative intravascular volume, which may facilitate clinical management. Moderate to severe TR decreases SCV CI and IVC CI and may result in overestimation of relative intravascular volume. [ABSTRACT FROM AUTHOR]

We present a case of a severe mechanical complication (superior vena cava [SVC] perforation) that developed after subclavian vein catheterization using an ultrasound-guided static approach in a patient who underwent right lower lobectomy with video-assisted thoracic surgery. The use of ultrasound during catheterization is reported to reduce mechanical complications. Despite the use of ultrasound in our patient, surgical exploration showed that the catheter placed in the right subclavian vein penetrated the superior portion of the SVC. At the end of the surgery, the catheter was removed under direct visualization. The surgeon attempted to stop bleeding in the SVC by compressing with gauze. However, bleeding could only be stopped by administering a hemostatic matrix. It is concluded that to reduce the incidence or size of iatrogenic perforation of the SVC, catheters with the smallest possible diameter should be used, and the dilator should only be inserted deep enough to enter the vein. If the static approach is used, the modifiedSeldinger technique is useful and to provide training to improve the ultrasound experience, especially if the dynamic approach is used. [ABSTRACT FROM AUTHOR]

Purpose: To develop and implement a comprehensive program to train providers to place subclavian central venous catheters (CVCs) using real-time ultrasound guidance. Study design: Simulation-based prospective study at an academic medical center. Of 228 anesthesia providers and intensivists eligible to participate, 106 participants voluntarily enrolled. The training program consisted of a didactic module, hands-on instruction and practice using a CVC simulator and a standardized patient. The success of the program was measured by pre and post knowledge tests and direct observation during the hands-on sessions. Results: Of 106 participants who enrolled, 70 successfully completed the program. Out of 20 possible procedure steps, an average of 17.8 ± 2.9 were correctly performed in the simulated environment. The average time to needle insertion, defined by positive aspiration of stained saline, was 3.35 ± 3.02 min and the average time to wire insertion with ultrasound confirmation was 3.85 ± 3.12 min. Conclusions: Participants learned how to successfully perform ultrasound-guided catheterization of the subclavian vein. Since ultrasound-guided subclavian CVC placement is a useful clinical skill that many practitioners are unfamiliar with, increasing competence and comfort with this procedure is an important goal. Other centers could consider adopting an approach similar to ours to train their providers to perform this technique. [ABSTRACT FROM AUTHOR]

This article is a response to a technical report on ultrasound-guided subclavian vein cannulation. The authors express concern about the terminology used in the report, stating that the visualized vein is actually the infraclavicular part of the axillary vein (IAV) and not the subclavian vein. They also disagree with the reported technique's use of a neutral arm position, citing previous studies that suggest arm abduction by 90° as the optimal position for cannulation. The authors propose renaming the technique as "infraclavicular axillary vein cannulation" and suggest that introducing the term "open door" could enhance its instructional value. [Extracted from the article]

Background and Aims: Subclavian vein (SCV) cannulation can be performed using either supraclavicular (SC) or infraclavicular (IC) long-axis approach under ultrasound guidance (USG). However, their relative efficacy remains debatable. The aim of this study was to compare these two approaches in terms of safety, ease, success rate, and record the incidence of complications. Methods: We studied 90 adult patients distributed into two groups of 45 each. Data regarding the time taken for first venous puncture, the time required for inserting the catheter, the total number of attempts, the incidence of guidewire misplacement, and other mechanical complications were compared using Student's t-test for quantitative data and Chi-square test for qualitative value. Results: Mean puncture time was significantly lesser in group SC than IC (P-value < 0.001). Mean catheter insertion time taken was also significantly less in group SC than IC (P-value = 0.003). The first attempt rate was higher in group SC than IC (P = 0.013). Guidewire misplacement was seen in the IC group, P = 0.001. No pneumothorax, haemothorax, or arterial puncture were noted in our study in any of the groups. Conclusion: We conclude that for right-sided SCV cannulation using USG in the long axis, the SC approach is superior to the IC approach in terms of overall ease of cannulation. It was associated with a relatively shorter procedure time, higher success rate in the first attempt, lesser incidence of guidewire misplacement, and other complications. It should be considered as an alternative approach to the IC approach in patients requiring central line insertion. [ABSTRACT FROM AUTHOR]

Background: After insertion of a central venous catheter (CVC) the catheter position must be controlled and a pneumothorax ruled out.Objective: The aim was to examine whether the use of two standard acoustic windows known from emergency sonography examination techniques is feasible to 1) verify the correct intravenous localization and direction of the guidewire before final CVC insertion and 2) correctly predict the required CVC length for positioning of the catheter tip in the lower third of the superior vena cava.Material and Methods: This single center prospective observational study included adult patients (age ≥18 years) with an indication for CVC insertion after institutional ethics approval was obtained. Puncture sites were restricted to bilateral internal jugular and subclavian veins and except for duplicate examinations no further exclusion criteria were defined. After vessel puncture and insertion of the guidewire, the vena cava was displayed by an additional ultrasound examiner (sector scanner 1.5-3.6 MHz) using the transhepatic or subcostal acoustic window to localize the guidewire. For positioning of the CVC tip, the required catheter length in relation to the cavoatrial junction was measured using the guidewire marks during slow retraction and consecutive disappearance of the J‑shaped guidewire tip from each acoustic window. From the resulting insertion length of the guidewire 4 cm was subtracted for the transhepatic and 2 cm for the subcostal window under the assumption that this length correlates to the distance from the cavoatrial junction. The CVC was finally inserted and a chest radiograph was performed for radiological verification of the CVC position.Results: Of 100 included patients, 94 could finally be analyzed. The guidewire could be identified in the vena cava in 91 patients (97%) within a time period of 2.2 ± 1.9 min. In three patients, the wire could not be visualized, although two catheters had the correct position, while one catheter was incorrectly positioned in the opposite axillary vein. In the second study part, positioning of the CVC was evaluated in 44 of the 94 patients. In 5 of these 44 patients, the correct direction and disappearance of the guidewire from the acoustic window could also be reliably visualized; however, with the left subclavian vein as the puncture site, the respective catheters were up to 6 cm too short for correct positioning. Thus, these 5 patients were excluded from this analysis. In the remaining 39 patients, the position of the CVC tip was optimally located in the lower third of the superior vena cava according to the chest radiograph in 20 patients (51%), while it was relatively too high in 5 patients (13%) and too low (entrance of the right atrium) in 9 patients. In the other 5 patients, disappearance of the guidewire from the acoustic window was not definitely detectable.Conclusion: The presented intraprocedural ultrasound-based method using two standard acoustic windows is reliable for verification of the correct intravenous location and direction of the guidewire even before dilatation of the vessel puncture site for insertion of the catheter. Furthermore, the method allows the clinically acceptable measurement of the required length for catheter positioning. A chest radiograph can be waived provided the ultrasound examination (identification of the guidewire and exclusion of puncture-related complications such as pneumothorax) is unambiguous. [ABSTRACT FROM AUTHOR]

However, the reader should be aware that this result referred to real-time ultrasound-guided axillary vein cannulation and not cannulation of the subclavian vein, which still needs to be approached using the landmark technique below the clavicula. This means that comparing axillary vein cannulation with ultrasound versus subclavian vein cannulation with the landmark technique is like "saying one thing but meaning another.". [Extracted from the article]

The article describes a technique used in a study to access the axillary vein outside of the thoracic cavity using in plane, real-time, ultrasound guidance in mechanically-ventilated patients. Highlights include assessment of the vein's patency with Doppler and/or color flow, the need for training, supervision, and competence acquisition with the axillary access, and baseline attributes and outcomes of axillary vein puncture in 59 patients.

Background: To compare the rates of success and the complications that can develop during the central venous catheterizations with ultrasonography and Landmark methods, usually used in the intensive care unit. Methods: This study was conducted retrospectively by scanning the files of 100 patients. Patients were divided into two groups as Ultrasonography (n=49) and Landmark (n=51). The distribution of the catheter diameters with the information obtained from the files based on groups, from which artery the operation was made based on the groups, the distribution of gender based on the groups, and the complications that occurred were compared. Results: In our study, the distribution of the thickness of the catheters used for CVCs did not vary by group, there was no variation in terms of gender distribution in the groups, the CVC was not entered with the USG method, 1 multiple-operation was tried in the IJV catheterization with the USG method, and no other complications were experienced. Conclusions: USG method is a reliable, practical, and applicable method in ICU for CVC (excepted SCV(subclavian vein) ) application. [ABSTRACT FROM AUTHOR]

Background: Ultrasound (US)-guided internal jugular vein (IJV) cannulation is a widely accepted standard procedure. The axillary vein (AV) in comparison to the subclavian vein is easily visualized, but its cannulation is not extensively studied in cardiac patients.Aims: This study is an attempt to study the efficacy of real-time US-guided axillary venous cannulation as a safe alternative for the time-tested US-guided IJV cannulation.Design: This is a prospective randomized controlled study.Materials and Methods: A total of 100 adult patients scheduled for cardiac surgery were divided equally in Group A-US-guided IJV cannulation, and Group B-US-guided axillary venous cannulation. Under local anesthesia and real-time US guidance the IJV or AV was secured. The access time, guidewire time, and procedure time were noted. Furthermore, the number of needle attempts, malposition, change of site, and complications were noted.Results: The data were analyzed for 49 patients in Group A and 48 patients in the Group B due to exclusions. The access time and the guidewire time were comparable in both groups. The first attempt needle puncture was successful for the IJV group in 98% of patients in comparison to 95% of patients in Group B. Guidewire was passed in the first attempt in 94% in Group A and 89% in the Group B. Except for arterial puncture in one case in group A, the complications were insignificant in both groups.Conclusion: The study shows that the US-guided AV cannulation may serve as an effective alternative to the IJV cannulation in cardiac surgery. [ABSTRACT FROM AUTHOR]

Background: Axillary venous access with ultrasound guidance for pediatric transvenous lead implantation may reduce risks for pneumothorax and hemothorax. The objective was to retrospectively evaluate ultrasound‐guided axillary vein access as an alternative to the subclavian approach. Methods: The technique consists of ultrasonographic identification of the axillary vein at the deltopectoral groove after initial contrast venography. A micropuncture kit is used for initial ultrasound‐guided percutaneous access with fluoroscopic confirmation of wire position. Pocket creation is performed, and sheath insertion and lead implantation proceed as usual. Demographic, procedural, and radiation exposure data were collected and analyzed. Results: Sixteen patients (median age = 13 years, 8‐50 years; median weight = 56 kg, 29‐77 kg) underwent lead implantation; two additional patients required fluoroscopy due to poor acoustic windows (89% success). Fifteen of 21 leads (71%) were ventricular; 50% of implants were pacemakers, and 31% were dual chamber. Median time to venous access was 13 min (interquartile range (IQR) = 9.25‐20.25) and median implant procedure time was 156 min (IQR = 112‐172). Median fluoroscopy time was 18.0 min (IQR = 11.9‐29.6), median air kerma was 9.0 mGy (IQR = 3.0‐28.5), and median dose‐area product was 30.2 Gy‐cm2 (IQR = 16.1‐234.5). One patient required generator pocket revision 2 days postprocedure without lead dislodgement. There were no other complications encountered. Conclusions: Transvenous pacemaker and implantable cardioverter‐defibrillator lead implantation in the pediatric and adult congenital population through ultrasound‐guided axillary venous access is safe and efficacious. This technique may provide a low‐risk alternative for vascular access for pediatric implantation procedures. [ABSTRACT FROM AUTHOR]

The article presents questions and answers related to large-caliber central access via the subclavian vein, including situations that require inserting a large-caliber central venous line, patient positioning and the benefits of an ultrasound-guided internal jugular or femoral line.

Background: Vascular access is a top priority in the critically ill patients. Cannulation – venous and/or arterial – is the first step in any emergency situation. Ultrasound (US)-guided vascular cannulation was found to have a higher success rate and a decreased incidence of mechanical complications as compared with the landmark one. Aim: This study aims to compare subclavian vein (SCV) access through supraclavicular (SC) approach by endocavitary (EC) probe technique versus linear array high-frequency probe technique. Settings and Design: A prospective, randomized controlled study conducted on 60 patients. Patients and Methods: Study was carried out on 60 adult patients presenting for the surgical intensive care unit in Fayoum University Hospital. Patients were classified into two groups: Group (A) (n = 30): Catheter was inserted using the EC probe and Group (B) (n = 30): Catheter was inserted using the linear array high-frequency probe. Statistical Analysis Used: Student's t-test was applied for calculation of normally distributed variables and Mann–Whitney U-test for nonnormally distributed variables. Categorical data between the groups were compared using Chi-squared test. P < 0.05 indicated a statistically significant difference. Results: The frequency of successful cannulation of the SCV at first attempt was significantly higher in Group A compared to Group B (P = 0.044). The number of attempts and the time needed for venous access were significantly lower in Group A compared to Group B (P = 0.038, <0.001 respectively). No significant difference was found regarding the incidence of posterior wall puncture, arterial puncture, or hematoma, (P = 0.671, 0.055, 1 respectively). Conclusion: The use of EC probe technique for Subclavian venous access through the SC approach significantly increased the success rate compared to the linear array high-frequency probe. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate whether a single-operator ultrasound-guided, right-sided, central venous catheter insertion verifies proper placement and shortens time to catheter utilization.Design: Prospective observational study with historical controls.Setting: Adult ICUs.Patients: Sixty-four consecutive patients undergoing ultrasound-assisted right-sided central venous catheterization compared with 92 serial historic controls who had unassisted central catheter insertion at the same sites.Interventions: Subcostal transthoracic echocardiography during catheter insertion.Measurements and Main Results: The primary outcome was the correct placement of the catheter tip determined by postprocedural chest radiography. The subclavian site was used in 41 patients (64%) (inserted without ultrasound guidance) in the ultrasound-assisted group and 62 (67%) in the control group, whereas the jugular vein was used in the remaining patients. The tip was accurately positioned in 59 of 68 patients (86.7%) in the ultrasound-assisted group compared with 51 of 94 (54.8%) in the control group (p < 0.001). The median time from end of the procedure to catheter utilization after chest radiography approval was 2.4 hours.Conclusions: A single-operator ultrasound-guided central venous catheter insertion is effective in verifying proper tip placement and shortens time to catheter utilization. [ABSTRACT FROM AUTHOR]

Central line placement is a common procedure, routinely performed by junior residents in medical and surgical departments. Before this project, no standardized instructional course on the insertion of central lines existed at our institution, and few interns had received formal ultrasound training. Interns from five departments participated in a simulation-based central line insertion course. Intern familiarity with the procedure and with ultrasound, as well as their prior experience with line placement and their level of comfort, was assessed. Of the 99 interns in participating departments, 45 per cent had been trained as of October 2015. Forty-one per cent were female. The majority (59.5%) had no prior formal ultrasound training, and 46.0 per cent had never placed a line as primary operator. Scores increased significantly, from a precourse score mean of 13.7 to a postcourse score mean of 16.1, P < 0.001. All three of the self-reported measures of comfort with ultrasound also improved significantly. All interns reported the course was "very much" helpful, and 100 per cent reported they felt "somewhat" or "much" more comfortable with the procedure after attendance. To our knowledge, this is the first hospital-wide, standardized, simulation-based central line insertion course in the United States. Preliminary results indicate overwhelming satisfaction with the course, better ultrasound preparedness, and improved comfort with central line insertion. [ABSTRACT FROM AUTHOR]

Objective To compare the area of the lumen of the axillary and subclavian veins using ultrasound (US) in 50 healthy volunteers. Methods Using an ultrasound device, depth, area, short axis vein length and long axis vein, vein-artery and vein-pleura distances were measured for axillary and subclavian approaches. Results The mean cross-sectional area of the axillary vein was greater than the mean cross-sectional area of the subclavian vein (327 ± 89 mm 2 versus 124 ± 46 mm 2 , P < 0.001). Both the mean transverse (10 ± 2 mm versus 9 ± 2 mm) and longitudinal axes (39 ± 8 mm versus 17 ± 7 mm) of the axillary vein were greater than those of subclavian vein ( P < 0.01, P < 0.001, respectively). The depths of the axillary and subclavian veins were similar (21 ± 6 mm versus 20 ± 6 mm, P = 0.43). The axillary and subclavian arteries were visualised in 3 and 45 volunteers, respectively ( P < 0.001). The pleura was seen in 25 and 37 volunteers with the axillary and subclavian approaches, respectively ( P = 0.01). The distance between the pleura and the subclavian vein was smaller (6 ± 2 mm versus 8 ± 3 mm, P < 0.04). Conclusion The present US study shows that visualisation of the axillary vein under US is greater than that for the subclavian vein, mainly due to a better alignment with the long axis of the axillary vein leading to a greater cross-sectional area of the axillary vein. Trial register number NCT01647815 . [ABSTRACT FROM AUTHOR]

Background: Ultrasound-guidance has become the routine method for internal jugular vein (IJV) catheterization reducing dramatically failure and complication rates for central venous port (CVP) placement. Aims: The aim of this study was to determine the safety and efficacy of ultrasound-guided IJV CVP placement in elderly oncologic patients. Methods: Between January 2013 and December 2015, 101 elderly oncological patients underwent right IJV CVP placement under ultrasound-guidance. The length of catheter introduction ranged from 18 to 21 cm. Intraoperative fluoroscopy (IF) was always performed intraoperatively. Chest X-ray (CXR) was always performed 30 min after the end of the procedure. Results: The morbidity rate was 1.98%; two arterial punctures were reported with one self-limiting hematoma. Two patients (1.98%) had catheter misplacements, recognized by intraoperative IF. No patients (0%) experienced pneumothorax (PNX), confirmed at CXR. Patients were all discharged at maximum 6 h from the procedure. Discussion: The risk of catheter misplacement, PNX, and arterial/nerve puncture remains present with this technique. Lower rates of catheter misplacement have been reported after right IJV puncture, probably for its straight vertical course. Our results are in accordance with literature (1 counter-lateral subclavian vein and 1 counter-lateral internal jugular vein misplacements). All misplacements were detected intraoperatively. The PNX rates after cannulation of the IJV vary between 0.0 and 0.5%. We had no PNX occurrence. Conclusion: Ultrasonography (US) has improved safety and effectiveness of port system placements. While routine post-procedural CXR seems avoidable, IF should be considered mandatory. [ABSTRACT FROM AUTHOR]

This article presents a number of case studies, spanning a 12-month period, associated with peripherally inserted central catheter (PICC) tip location. The aim is to generate debate around the journey PICC tips may take; it is not the purpose of this article to debate technological solutions to the issue of PICC tip location. The discussion of each case illustrates a wide range of potential aberrant PICC tip locations and offers an insight into how the abberant tip location was resolved in each case. [ABSTRACT FROM AUTHOR]

Background The ultrasound (US)-guided supraclavicular approach to subclavian vein (Sup-SCV) catheterisation in children has recently been described and evaluated in a small cohort. The aim of this study was to assess this technique in a large paediatric cohort including neonates. Methods We conducted a prospective observational study between November 2010 and December 2013 which included 615 children divided into two groups according to their weight: Group 1 ≤ 5 kg ( n = 124), Group 2 > 5 kg ( n = 491). All procedures were performed under general anaesthesia by an anaesthesiologist or a supervised resident. The success rates of catheter insertion, the number of punctures required, the procedure time, and the complication rates were analysed. Results Sup-SCV catheterisation was successful in 98% of the cases and was higher in Group 2 than in Group 1 (99.4% versus 92.7%, P < 0.001). The success rate after the first attempt was higher and the incidence of multiple attempts (≥ 3 punctures) was lower in Group 2 than in Group 1 (84.2% versus 64.5%, P < 0.001 and 4.5% versus 19.4%, P < 0.001). The success rate was similar between right and left cannulations ( P = 0.404), and according to physician experience ( P = 1.000). Procedure time was fast in both groups with a median time for all procedures of 40 seconds [30–90]. Among the procedures recorded, only five arterial punctures and no cases of pneumothorax were observed. Conclusion US-guided Sup-SCV catheterisation appears to be fast and safe in children and neonates, even if it remains a little more difficult to achieve in lower-weight patients. [ABSTRACT FROM AUTHOR]

Introduction. The catheter “pinch-off syndrome” has been described to be secondary to crimping of the catheter between the clavicle and the first rib, as well as entrapment of the catheter at the site of penetration of the subclavius muscle. The lateral insertion technique has been recommended to prevent catheter pinch-off, but it is unknown if this technique can prevent entrapment by the subclavius muscle. We undertook this study to evaluate the anatomical relationship of the subclavius muscle and the subclavian vein. Methods. Twenty-eight adult cadavers were studied on both right and left sides. The adherence between the subclavian vein and subclavius muscle was subjectively assessed and the distance between the two structures was measured in mm. Results. The subclavius muscle and subclavian vein were tightly adherent in 72% of specimens, partly adherent in 14% with a mean distance of 4.5 mm and loosely connected in 14% with a mean distance of 6.1 mm. Conclusions. The anatomical relationship between the subclavius muscle and vein was very close in the majority of specimens, suggesting that the lateral insertion technique may not prevent penetration of the muscle, which may contribute to catheter pinch-off. The real-time ultrasound-guided technique may prevent penetration of the subclavius muscle. [ABSTRACT FROM AUTHOR]

Background: Axillary vein catheterization via a distal approach is an alternative to the proximal approach to axillary/subclavian vein catheterization under ultrasound (US) guidance. The aim of this trial was to compare the two approaches.Methods: In a randomized single-centre study, all patients requiring central vein catheterization in intensive care or the operating room were randomly assigned to proximal or distal approach groups. If catheterization failed after two attempts using the approach allocated, the non-allocated approach was used. The primary endpoint was the initial success rate of distal to compared with the proximal approach, using a non-inferiority analysis (lower limit 90% CI greater than -8% non-inferiority margin for group difference). The secondary endpoints were: overall success rates, catheter position and complications.Results: 119/122 included patients were analysed (57 and 62 in the proximal and distal axillary approach groups, respectively). Primary success rates for proximal and distal sites were 87.7 and 85.5%, respectively (difference -2.2%, 90% CI [-12.5-8.1%], non-inferiority P=0.18). The proximal and distal overall success rates were 96.5 and 98.4%, respectively (difference -1.9%, 90% CI [-4.9-8.7%], non-inferiority P<0.01). Thrombogenic catheter positions were 7 (12.3%) in proximal approach group vs 19 (31.7%) in the distal approach group (P=0.01). Complications were comparable in the two groups (2 (3.3%) vs 4 (6.5%), P=0.68).Conclusion: In terms of absolute and overall success rates, a distal approach is not non-inferior to a proximal approach. Although associated with a more thrombogenic catheter extremity position, the distal approach can be considered as a rescue alternative after failure of a proximal approach.Clinical Trial Registration: ClinicalTrials.gov identifier: NCT01543360. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 45‑year‑old male patient who was suffering from acute myeloid leukemia admitted for central venous catheterization for chemotherapy and chest radiograph post-procedure showed catheter to be misdirected into the ipsilateral subclavian vein. The Anesthesiologists Task Force recommends the use of ultrasound in cannulation and repositioning of a misdirected central venous catheter.

The objective of this prospective, randomised study was to examine the impact of a multi-angle needle guide for ultrasound-guided, in-plane, central venous catheter placement in the subclavian vein. One hundred and sixty patients were randomly allocated to two groups, freehand or needle-guided, and then 159 catheterisations were analysed. Cannulation of the first examined access site was successful in 96.9% of cases with no significant difference between groups. There were three arterial punctures and no other severe injuries. Catheter misplacements did not differ between the groups. Higher success rates within the first and second attempts in the needle-guided group were observed (p = 0.041 and p = 0.019, respectively). Use of the needle guide reduced the access time from a median (IQR [range]) of 30 (18-76 [6-1409]) s to 16 (10-30 [4-295]) s; p = 0.0001, and increased needle visibility from 31.8% (9.7%-52.2% [0-96.67]) to 86.2% (62.5%-100% [0-100]); p < 0.0001. A multi-angle needle guide significantly improved aligning the needle and ultrasound plane compared with the freehand technique when cannulating the subclavian vein. Use of the guide resulted in faster access times and increased success at the first and second attempts. [ABSTRACT FROM AUTHOR]

Objective: Although ultrasound guidance for subclavian vein catheterization has been well described, evidence for its use has not been comprehensively appraised. Thus, we conducted a systematic review and meta-analysis to determine whether ultrasound guidance of subclavian vein catheterization reduces catheterization failures and adverse events compared to the traditional "blind" landmark method. All forms of ultrasound were included (dynamic 2D ultrasound, static 2D ultrasound, and Doppler). Data Sources: Medline, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and CINAHL (from inception to September 2014).Study Selection: Randomized controlled trials of ultrasound compared to landmark technique for subclavian catheterization in adult populations were considered. Outcomes of interest included safety and failure of catheterization. Data Extraction: Adverse event data were analyzed according to Peto's method and expressed as odd ratios and 95% CIs. Failure of catheterization was analyzed with inverse variance random effects modeling and expressed as risk ratios and 95% CI. Data Synthesis: Six hundred and one studies were reviewed and 10 met inclusion criteria (n = 2,168 participants). Six used dynamic 2D ultrasound (n = 719), one used static 2D ultrasound (n = 821), and three used Doppler-guided insertion techniques (n = 628). Overall complication rates were reduced with ultrasound use compared to the landmark group (odd ratio, 0.53; 95% CI, 0.41-0.69). Subgroup analysis demonstrated that dynamic 2D ultrasound reduced inadvertent arterial puncture, pneumothorax, and hematoma formation. No difference in failure of catheterization was noted between the ultrasound group and the landmark method (risk ratio, 0.85; 95% CI, 0.48-1.51). Subgroup analysis of dynamic 2D ultrasound demonstrated a significant decrease in failed catheterization (risk ratio, 0.24; 95% CI, 0.06-0.92). Conclusions: Ultrasound-guided subclavian catheterization reduced the frequency of adverse events compared with the landmark technique. Our findings support the use of dynamic 2D ultrasound for subclavian catheterization to reduce adverse events and failed catheterization. [ABSTRACT FROM AUTHOR]

Background Previous studies have demonstrated that ultrasonographic measurement of the inferior vena cava diameter is a useful tool for the evaluation of intravascular volume status in preoperative patients. However, ultrasonographic measurement of inferior vena cava diameter could be limited by factors including obesity, bowel gas, or complex abdominal wounds. Our study sought to determine whether subclavian vein (SCV) diameter measured by ultrasound correlate with central venous pressure (CVP), as another indicator of intravascular volume status in patients undergoing gastrointestinal surgery. Methods Forty patients (American Society of Anesthesiologists I-II) who underwent elective gastrointestinal surgery and 40 healthy volunteers were enrolled in the study. In the patient group, SCV diameters, during both expiration (dSCVe) and inspiration (dSCVi), were measured with ultrasonography before and after fluid resuscitation. Volunteer baseline measurements were conducted without liquid therapy and the subsequent measurement. Results Forty patients (mean age 46 y; 40% female) and 40 volunteers (mean age 43 y; 45% female) underwent SCV sonographic measurements. The average diameters of the SCVe and SCVi in hypovolemic patients (0.68, 0.48 cm) were significantly lower as compared with the SCVe and SCVi diameters of healthy volunteers (0.92, 0.73 cm), whereas the SCV-collapsibility index (0.35) was higher in the hypovolemic patients as compared with the healthy volunteers (0.20). After fluid resuscitation, the SCVe and SCVi diameters in hypovolemic patients (0.88, 0.67 cm) significantly increased, whereas the SCV-collapsibility index decreased (0.23). The pre-SCVe and the post-SCVe were closely correlated to the CVP (R = 0.612 and R = 0.547, respectively). Similarly, the pre-SCVi and the post-SCVi were correlated to the CVP (R = 0.452 and R = 0.507, respectively). Conclusions SCV diameter is consistently low in patients undergoing gastrointestinal surgery as compared with healthy subjects. Measuring the SCV diameter maybe an important addition to the ultrasonographic evaluation of hypovolemia and other potentially volume-depleted patients. [ABSTRACT FROM AUTHOR]

Objective: To evaluate whether using long-axis or short-axis view during ultrasound-guided internal jugular and subclavian central venous catheterization results in fewer skin breaks, decreased time to cannulation, and fewer posterior wall penetrations. Design: Prospective, randomized crossover study. Setting: Urban emergency department with approximate annual census of 60,000. Subjects: Emergency medicine resident physicians at the Denver Health Residency in Emergency Medicine, a postgraduate year 1-4 training program. Interventions: Resident physicians blinded to the study hypothesis used ultrasound guidance to cannulate the internal jugular and subclavian of a human torso mannequin using the long-axis and short-axis views at each site. Measurements and Main Results: An ultrasound fellow recorded skin breaks, redirections, and time to cannulation. An experienced ultrasound fellow or attending used a convex 8-4 MHz transducer during cannulation to monitor the needle path and determine posterior wall penetration. Generalized linear mixed models with a random subject effect were used to compare time to cannulation, number of skin breaks and redirections, and posterior wall penetration of the long axis and short axis at each cannulation site. Twenty-eight resident physicians participated: eight postgraduate year 1, eight postgraduate year 2, five postgraduate year 3, and seven postgraduate year 4. The median (interquartile range) number of total internal jugular central venous catheters placed was 27 (interquartile range, 9-42) and subclavian was six catheters (interquartile range, 2-20). The median number of previous ultrasound-guided internal jugular catheters was 25 (interquartile range, 9-40), and ultrasound-guided subclavian catheters were three (interquartile range, 0-5). The long-axis view was associated with a significant decrease in the number of redirections at the internal jugular and subclavian sites, relative risk 0.4 (95% CI, 0.2-0.9) and relative risk 0.5 (95% CI, 0.3-0.7), respectively. There was no significant difference in the number of skin breaks between the long axis and short axis at the subclavian and internal jugular sites. The long-axis view for subclavian was associated with decreased time to cannulation; there was no significant difference in time between the short-axis and long-axis views at the internal jugular site. The prevalence of posterior wall penetration was internal jugular short axis 25%, internal jugular long axis 21%, subclavian short axis 64%, and subclavian long axis 39%. The odds of posterior wall penetration were significantly less in the subclavian long axis (odds ratio, 0.3; 95% CI, 0.1-0.9). Conclusions: The long-axis view for the internal jugular was more efficient than the short-axis view with fewer redirections. The long-axis view for subclavian central venous catheterization was also more efficient with decreased time to cannulation and fewer redirections. The long-axis approach to subclavian central venous catheterization is also associated with fewer posterior wall penetrations. Using the long-axis view for subclavian central venous catheterization and avoiding posterior wall penetrations may result in fewer central venous catheter-related complications. [ABSTRACT FROM AUTHOR]

Central venous cannulation of infants may be challenging. Ultrasonography is recommended and has been found superior to classic landmark technique in pediatric central venous cannulation. The cannulation of the subclavian vein using supraclavicular approach under real-time ultrasound guidance is a novel technique. It may have advantages over ultrasound-guided jugular vein cannulation in specific patients. We report a case of 3200-gram 20-day-old anencephalic neonate who had a diffuse generalized edema. The neonate was cannulated successfully via subclavian vein using supraclavicular approach under ultrasound guidance. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background The aim of our study was to describe the anatomic relationships in internal jugular (IJV), subclavian (SCV), and femoral (FV) vein sites. Methods One hundred and forty-two children had a two-dimensional (2D) ultrasound (US) evaluation of IJV, SCV, and FV sites. They were enrolled according to their age: 0–1 month old (n=9), 1 month old to 2 yr old (n=61), 2–6 yr old (n=22), 6–12 yr old (n=32), and 12–18 yr old (n=18). Results We found about 7.7% variation for the IJV. The most common anatomic variations were a lateral (nine children) or anterior (nine children) position of the IJV to the carotid artery. Regardless of the age category, about 9.8% of the anatomic variations were found for the FV. The most common anatomic variation in our study was that the FV ran anteromedially to the femoral artery (17 children). Anatomic variation of the SCV, regardless of age category, was about 7.4%. The most common anatomic variation was the SCV, which ran medially (10 children) to the subclavian artery. Conclusions The relevant percentages of anatomic variations obtained for all these areas support at least a systematic US screening before attempting to obtain central venous access, ideally using a US-guided technique. [ABSTRACT FROM PUBLISHER]

Objective: To evaluate the efficacy, visual outcome and complication following Nd:Yag laser hyaloidtomy for subhyaloid hemorrhage. Methods: This interventional case series was managed at LRBT, Free Base Eye Hospital Karachi from January 2010 to December 2010. It included 30 eyes of 30 patients with subhyaloid hemorrhage due to different causes which underwent Nd: Yag laser sublyaloidotomy. Results: Out of thirty patients, eighteen (60%) were male and twelve (40%) were females. Mean age was 32.57 years. Males pre-dominated the study. Pre laser visual acuity was between counting finger at one meter in 22 patients (73.33%) and between counting finger one meter to hand movement in 8 patients (26.66%). Vision improved to 6/6 in 10 patients (33%), 6/9 - 6/12 in 17 patients (56.66%) and between 6/24 - 6/60 in 3 patients (9.99%) at the end of follow up. Complications were persistent vitreous hemorrhage in one (3.33%) patient, failed drainage in one (3.33%) patient and metamorphopsia in one (3.33%) patient. Conclusion: Nd: Yag laser hyloidotomy is an excellent technique for management of Subhyaloid hemorrhage with early visual recovery provided there is no macular pathology. [ABSTRACT FROM AUTHOR]

Background It has been reported that the direction of the guidewire J-tip is associated with misplacement of a central venous catheter. We hypothesized that real-time ultrasound-guided infraclavicular subclavian venous cannulation would be less influenced by the direction of guidewire J-tip compared to landmark method. Methods Sixty adult patients who required subclavian venous catheterization for neurosurgery were enrolled in this prospective randomized controlled study. Patients were randomly divided into a landmark group (n = 30) or an ultrasound group (n = 30). After the subclavian vein was punctured, the guidewire was advanced with the guidewire J-tip directed cephalad. Misplacement or advancement failure of the guidewire was regarded as an unsuccessful placement. Postoperative chest radiography was performed to confirm pneumothorax and the location of the catheter tip. Results The two groups were comparable with respect to age, gender, height, and weight distribution. The incidence of unsuccessful guidewire placement was lower in the ultrasound group than in the landmark group (13% vs. 47%, P = 0.01). Among the unsuccessful guidewire placements, the incidence of misplacement were comparable between the groups and were all located in the ipsilateral internal jugular vein (7% vs. 7%). However, the incidence of advancement failure was significantly higher in landmark group (40% vs 7%, P = 0.005). There were no complications such as pneumothorax or hemothorax. Conclusions The proper placement of guidewire was less influenced by the direction of the guidewire J-tip with ultrasound-guided subclavian venous cannulation than with the landmark approach. [ABSTRACT FROM AUTHOR]

Abstract: Background: Traditional methods for intravascular volume status assessment are invasive and are associated significant complications. While focused bedside sonography of the inferior vena cava (IVC) has been shown to be useful in estimating intravascular volume status, it may be technically difficult and limited by patient factors such as obesity, bowel gas, or postoperative surgical dressings. The goal of this investigation is to determine the feasibility of subclavian vein (SCV) collapsibility as an adjunct to IVC collapsibility in intravascular volume status assessment. Methods: A prospective study was conducted on a convenience sample of surgical intensive care unit patients to evaluate interchangeability of IVC collapsibility index (IVC-CI) and SCV-CI. After demographic and acuity of illness information was collected, all patients underwent serial, paired assessments of IVC-CI and SCV-CI using portable ultrasound device (M-Turbo; Sonosite, Bothell, WA). Vein collapsibility was calculated using the formula [collapsibility (%) = (max diameter – min diameter)/max diameter × 100%]. Paired measurements from each method were compared using correlation coefficient and Bland–Altman measurement bias analysis. Results: Thirty-four patients (mean age 56 y, 38% female) underwent a total of 94 paired SCV-CI and IVC-CI sonographic measurements. Mean acute physiology and chronic health evaluation II score was 12. Paired SCV- and IVC-CI showed acceptable correlation (R2 = 0.61, P < 0.01) with acceptable overall measurement bias [Bland–Altman mean collapsibility difference (IVC-CI minus SCV-CI) of −3.2%]. In addition, time needed to acquire and measure venous diameters was shorter for the SCV-CI (70 s) when compared to IVC-CI (99 s, P < 0.02). Conclusions: SCV collapsibility assessment appears to be a reasonable adjunct to IVC-CI in the surgical intensive care unit patient population. The correlation between the two techniques is acceptable and the overall measurement bias is low. In addition, SCV-CI measurements took less time to acquire than IVC-CI measurements, although the clinical relevance of the measured time difference is unclear. [Copyright &y& Elsevier]