Internal Jugular Versus Subclavian Vein Catheterization for Central Venous Catheterization in Orthotopic Liver Transplantation

Background: Real-time ultrasound (US) guidance facilitates central venous catheterization in intensive care unit (ICU). New magnetic needle-pilot devices could improve efficiency and safety of central venous catheterization. This simulation trial was aimed at comparing venipuncture with a new needle-pilot device to conventional US technique. Methods: In a prospective, randomized, simulation trial, 51 ICU physicians and residents cannulated the right axillary vein of a human torso mannequin with standard US guidance and with a needle-pilot system, in a randomized order. The primary outcome was the time from skin puncture to successful venous cannulation. The secondary outcomes were the number of skin punctures, the number of posterior wall puncture of the axillary vein, the number of arterial punctures, the number of needle redirections, the failure rate, and the operator comfort. Results: Time to successful cannulation was shorter with needle-pilot US-guided technique (22 s (interquartile range (IQR) = 16–42) vs 25 s (IQR = 19–128); median of difference (MOD) = −9 s (95%-confidence interval (CI) −5, −22), p < 0.001). The rates of skin punctures, posterior wall puncture of axillary vein, and needle redirections were also lower ( p < 0.01). Comfort was higher in needle-pilot US-guided group on a 11-points numeric scale (8 (IQR = 8–9) vs 6 (IQR = 6–8), p < 0.001). Conclusions: In a simulation model, US-guided axillary vein catheterization with a needle-pilot device was associated with a shorter time of successful cannulation and a decrease in numbers of skin punctures and complications. The results plea for investigating clinical performance of this new device.

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Inadvertent arterial puncture involving the subclavian artery and the aorta during central venous catheterization: a case report

Journal of Medical Case Reports ◽

10.1186/s13256-021-02871-w ◽

2021 ◽

Vol 15 (1) ◽

Author(s):

Mark Henry Alon

Keyword(s):

Case Report ◽

Diabetic Ketoacidosis ◽

Subclavian Vein ◽

Ultrasound Guidance ◽

Central Venous Catheterization ◽

Arterial Puncture ◽

Central Venous ◽

Vein Cannulation ◽

Venous Catheterization ◽

Catheter Tip

Abstract Background This case report describes a subclavian vein cannulation that inadvertently led to an arterial puncture with the catheter tip radiologically seen at the level of the aorta. This case emphasizes the importance of postprocedural imaging and the disadvantages of not using ultrasound guidance in central venous catheterization. Case presentation A 24-year-old Caucasian man with diabetes mellitus type 1 presented himself to the emergency department due to abdominal pain accompanied by nausea and vomiting. The patient’s vital signs revealed blood pressure of 84/53 mmHg, heart rate of 103 beats per minute, respiratory rate of 18 breaths per minute, and temperature of 98.2 °F (36.7 °C). On physical examination, he was found to have dry oral mucosa with poor skin turgor, with diagnostics showing that he was in diabetic ketoacidosis after running out of insulin for 2 days. The patient was transferred to the intensive care unit to receive a higher level of care. Unfortunately, due to difficulty of peripheral line placement, only a gauge-22 cannula was secured at the left dorsum of the hand. Efforts to replace the current peripheral line were unsuccessful, and a decision to perform a central vein cannulation via the internal jugular vein was made. This was futile as well due to volume depletion, prompting a subsequent right subclavian vein route attempt. The procedure inadvertently punctured the arterial circulation, leading to the catheter tip being visible at the level of the aorta on postprocedure X-ray. The subclavian line was immediately removed with no adverse consequences for the patient. A right femoral line was successfully placed, and continuous management of the diabetic ketoacidosis ensued until normalization of the high anion gap was achieved. Conclusion Utilization of real-time ultrasound guidance via the subclavian approach could have allowed for direct visualization of needle insertion to the anatomical structures, guidewire location, and directionality, all of which can lead to decreased complications and improved cannulation success compared with the landmark technique. A leftward direction of the catheter seen on postprocedural X-rays should raise high suspicion of inadvertent catheter placement and immediate correction. This complication should have been prevented if ultrasound guidance had been used.

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