Comparative evaluation of subclavian vein catheterisation using supraclavicular versus infraclavicular approach.

BACKGROUND AND AIMS: Infraclavicular (IC) approach of subclavian vein (SCV) catheterisation is widely used as compared to supraclavicular (SC) approach. The aim of the study was to compare the ease of catheterisation of SCV using SC versus IC approach and also record the incidence of complications related to either approach, if any.
METHODS: In the study, 60 patients enrolled were randomly divided into two groups of 30 patients each. In Gp. SC right SCV catheterisation was performed using SC approach and in Gp. IC catheterisation was performed using IC approach. Access time, success rate of cannulation, number of attempts to cannulate vein, ease of guidewire and catheter insertion and length of catheter inserted and any associated complications were recorded.
RESULTS: The mean access time in group SC for SCV catheterisation was 4.30 ± 1.02 min compared to 6.07 ± 2.14 min in group IC. The overall success rate in catheterisation of the right SCV using SC approach (29 out of 30) was better as compared with group IC (27 out of 30) using IC approach. First attempt success in the SC group was 75.6% as compared with 59.25% in the IC group. All successful subclavian vein  catheterisations in SC group and IC group were associated with smooth insertion of guidewire following subclavian venipuncture.
CONCLUSION: The SC approach of SCV catheterisation is comparable to IC approach in terms of landmarks accessibility, success rate and rate of complications.

RCT Entities:   Population Interventions Outcomes

INTRODUCTION

Central venous catheterisation (CVC) is a time tested technique of rapidly accessing the central venous system. With the use of invasive monitoring technologies and aggressive haemodynamic resuscitation, central venous access protocols have increased. Therefore, the ability to gain rapid and accurate vascular access has become an imperative skill that critical and emergency care physicians must possess.[1]

Various methods of CVC placement have evolved, each with its own advantages and disadvantages. Subclavian vein (SCV) is important site for CVC. Advantages of subclavian venous catheterisation include a lower risk of infection as compared with internal jugular or femoral sites, ease of insertion in trauma patients who may be immobilised in a cervical collar, less interference with airway management during cardiopulmonary cerebral resuscitation (CPCR) and less patient discomfort, especially for long-term intravenous therapy such as hyper alimentation and chemotherapy.[2345]

The anatomic advantages of the SCV for central venous access include its large diameter (1-2 cm), absence of valves and ability to remain patent as it is thought to be held open by surrounding tissue and a relatively constant position. Subclavian catheters are easier to secure, which reduces subsequent dislodgement. It should be avoided in patients with abnormal coagulation profile since it is difficult to apply pressure to subclavian artery following arterial puncture.[6]

Infraclavicular (IC) approach and supraclavicular (SC) approach are the two techniques of subclavian venous catheterisation that have been described in the literature.[78910] IC approach is most widely practised technique among the two but the SC approach to the SCV catheterisation has some distinct advantages. It has a well-defined landmark (the clavisternomastoid angle), a shorter distance from skin to vein and a straighter path to the superior vena cava, less proximity to the lung and fewer complications of arterial or pleural puncture, i.e., less chances of pneumothorax. In addition, the SC approach less often necessitates interruption of CPCR or tube thoracotomy than the IC method. Furthermore, fewer incidence of malposition are reported with SC approach.[11]

IC approach of SCV catheterisation is widely used as compared to SC approach. Further, there is a paucity of data available comparing two approaches of SCV catheterisation in terms of ease of insertion and complications associated with them.

The aim of this study was to compare the ease of catheterisation of SCV using SC versus IC approach and record the incidence of complications related to either approach, if any.

METHODS

The study was conducted in the department of anaesthesia of a teaching hospital after approval by hospital Ethical Committee. A total of 60 adult patients of either sex, with physical status of Grade-I, Grade-II or III according to American Society of Anaesthesiologists (ASA), scheduled for elective or emergency surgery under general anaesthesia where central venous catheterisation was indicated were enrolled in the study. Patients with infection at puncture site, deranged coagulation profile, contralateral pneumothorax, trauma to clavicle and upper ribs, distorted anatomy of the neck or clavicle and cervical spine trauma were excluded from the study.

A total of 60 patients were randomly assigned, by drawing a slip from a bunch of 60 slips, into two groups: Group SC included 30 patients where right SCV catheterisation was performed using SC approach. Group IC included 30 patients where right SCV catheterisation was performed using IC approach.

A prior informed consent was taken from all the participants after the goals of the study and consequences of participation were explained. All patients were subjected to detailed clinical history, complete general physical and systemic examination. Routine investigations such as complete haemogram, bleeding time, clotting time, urine examination, coagulation profile, electrocardiogram and chest X-ray (PA view) were carried out in all patients.

After the arrival of the patient in the OR, intravenous line was established and routine monitoring was performed comprising of electrocardiography, pulse oximetry (SpO2), non-invasive blood pressure and respiratory rate. Baseline readings were recorded. Just before administration of general anaesthesia, landmarks of either technique were marked with a marker pen. Trendelenburg position was used for both the techniques. For infraclaviculr approach medial 1/3 and lateral 2/3 of the clavicle, about 1 cm below the clavicle was used as the puncture point. In this technique, bevel was kept inferomedially so that the J-tipped guidewire would not go either towards the opposite vessel or upto the internal jugular vein (IJV).

In supraclavicular approach the point of needle insertion was 1 cm cephalad and 1 cm lateral to the junction of the lateral margin of clavicular head of sternocleidomastoid (SCM) muscle with the superior margin of clavicle which forms the clavisternomastoid angle.[10] The bevel was kept upwards to prevent trapping against the inferior vessel wall and after successful aspiration of blood it was turned downwards so as to prevent J-tipped guidewire to go upwards into IJV. This technique is different from low IJV approach where the point of puncture is 0.5-1 cm above the clavicle near the sternal head of SCM with needle angulation 30-40° to the coronal plane and parallel to sagittal plane.

Cannulation was performed using modified Seldinger technique. The optimal length of the catheter was determined by overlaying the catheter from the puncture site to second intercostals space. Post-procedure chest X-ray was obtained in all patients to confirm catheter position and to rule out any complication. In all patients procedure was performed by same trained anaesthesiologist.

Demographic characteristics such as age, gender, height, weight and body mass index of all the patients was recorded. The measured parameters were recorded in terms of access time (defined as the time between the first skin puncture until successful placement of catheter), success rate of cannulation by either approach, number of attempts to cannulate vein (the procedure was abandoned after two attempts and alternate route of CVC was chosen), ease of guidewire and catheter insertion (smooth or failed) and length of catheter inserted. The tip of catheter, any malpositioning or kinking of catheter was observed on chest X-ray and repositioning if needed was done. Associated complications such as arterial puncture, pneumothorax, haemothorax and others, were recorded. Patients were observed for next 24 h to rule out any complications. The results of the study were compiled, tabulated and compared statistically. The results within both groups were analysed using unpaired T-test and Pearson's Chi-square test.

RESULTS

Table 1 shows the distribution of age, weight and height in two groups. The mean access time in group SC for SCV catheterisation was 4.30 ± 1.02 min compared with 6.07 ± 2.14 min in group IC. When statistically calculated by using student t-test (P = 0.00) was found to be highly statistically significant [Table 2]. The overall success rate in catheterisation of right SCV using SC approach was better (29 out of 30) as compared with group IC using IC approach (27 out of 30). On comparing the overall results of successful catheterisation, the difference was found to be statistically non-significant [Table 3]. First attempt success in the SC group 75.6% (22 out of 29) as compared with 59.25% (16 out of 27) in the IC group [Table 4]. All successful SCV catheterisations, i.e., 29 patients in SC group and 27 patients in IC group, were associated with smooth insertion of guidewire following subclavian venipuncture. The optimal length of catheter inserted was determined by overlaying the catheter from the site of puncture to second intercostal space. The average length of catheter in group SC was 10.86 cm and in group IC was 11.29 cm. The catheter tip location was confirmed by post-procedure X-ray in all the patients where successful catheterisation of right SCV was done. In both groups, the catheter tip was found to be in proper position. No malposition of the catheter was noted in any patient of either group. However, kinking of catheter was observed in one patient of IC group. Complications related to either of the techniques were not significant [Table 5].

Table 1

Demographic profile

Table 2

Comparison of access time between SC and IC approaches

Table 3

Comparison of successful SCV catheterisation

Table 4

Attempts of SCV catheterisation using SC and IC approach

Table 5

Failures and complications

DISCUSSION

The use of central venous access in the emergency department and intensive care settings has increased in conjunction with newer technologies and more invasive approaches to patient care. Several large central veins, such as the subclavian, jugular and femoral, all have predictable relationships to easily identified landmarks and can be cannulated within minutes.[4] We conducted a study to evaluate the ease of SCV catheterisation using SC and IC approach.

In our study, demographic characteristics were comparable in both the groups. Access time was calculated in both the approaches and time taken for SCV catheterisation was far less in SC approach (4.30 ± 1.02 min) and was statistically significant when compared to IC approach (6.07 ± 2.149 min) (P = 0.000). Dronen et al. also documented that SC approach of SCV catheterisation was a better technique than IC approach. They found that SC approach was associated with fewer failures, less difficulty in catheter insertion, a higher incidence of proper catheter tip location and less interference with CPCR.[12]

As far as successful catheterisation and number of attempts are concerned SC approach is better than IC approach but no statistically significant difference was observed in number of attempts in both groups in the present study. Kores et al. observed overall success of 97% in the SC and 94% in the IC approach. First attempt success in the SC group was 73% as compared to 68% in the IC approach.[13] Success rate of 90% in group SC and 84% in group IC was also observed by Drone et al. The relatively lower success rate in their study can be attributed to the fact that the SCV catheterisation was done during management of cardiopulmonary arrest.[12] Sterner et al. documented an overall success rate of 84.5% in group SC and 80% in group IC. These results are variable from our study and can be because of the inclusion of large number of patients in their study (n = 255).[14]

In our study, no problem was encountered during guidewire as well as catheter insertion by either approach. In all successful catheterisations, i.e., 29 patients in SC group and 27 patients in IC group, guidewire and catheter insertion was smooth with no resistance encountered at any step. These results are in concordance with study of Kores et al. who had no difficulty in threading the catheter by either catheter over needle or the Seldinger technique.[13]

The length of catheter inserted in our study was determined by laying the catheter over the chest from the puncture site to second intercostal space as proposed by McGee et al.[15] Placement was confirmed by post-procedure chest X-ray and was found to be at appropriate position, i.e. just above the carina. Hence, we reached an inference that overlaying can be considered as a reliable method to determine the catheter length in Indian population.

Subclavian venous catheter placement is associated with complications such as pneumothorax, haemothorax, subclavian artery puncture and haematoma at the puncture site. Catheter embolisation, subsequent adverse events occur frequently following embolisation and include arrhythmias, venous thrombosis, endocarditis, myocardial perforation and pulmonary embolus are known complication associated with subclavian venous catheterisation.

In our study, we observed haematoma at the puncture site in 3.3% of patients in group SC. Arterial puncture occurred in about 3.3% patients in group IC. No incidence of arrhythmias, pneumothorax, haemothorax, catheter embolisation was found during the study. Kores et al. noted incidence of 2.8% subclavian artery puncture in both groups. However in contrast, 1.4% of patients in group SC had haematoma at the puncture site and haemopneumothorax, each. Furthermore, 1.4% patients in group IC had pneumothorax.[13] Dronen et al. similarly had a single patient where subclavian artery puncture was observed, which was not associated with any problem. No other complication such as pneumothorax, haemothorax or air embolism was noted by them. Sterner et al. too had similar results with only 2.04% patients having any complication in group SC. In group, IC only 5.09% patients had any complication as observed by them.[12]

Czarnik et al. in their study of SCV catheterisation using SC approach observed subclavian artery puncture in only 0.8% of the patients. No life-threatening complication occurred during the study.[16]

These complications can be minimised these days with the use of ultrasound guided central venous catherisation. However in developing countries, due to the financial constraints, ultrasound machine may not be available in all the set ups/units. Landmark based technique was hence used in this study as there was non-availability of ultrasound machine in our institution. Moreover, use of ultrasound requires expertise and training before the physician can routinely use it.

CONCLUSION

We conclude that SC approach of SCV catheterisation is comparable to IC approach in terms of landmarks accessibility, success rate and rate of complications. Access time in SC approach is less as compared to IC approach which is important where quick as well as immediate access of the central venous system is required. It can be safely performed in centres where ultrasound machine is not available in operation theatre complex.