Nov 13, 1990 - special emphasis on the treatment both surgical and medical. Oxford Handbook of Clinical Surgery by G R. McLatchie. 877 pages, illustrated ...
Annals of the Royal College of Surgeons of England (1991) vol. 73, 227-228
Ultrasound guided subclavian vein catheterisaton Sukhbir S Ubhi FRCS Research Fellow
Yvonne Rees FRCR Consultant Radiologist
Peter S Veitch BSc FRCS Consultant Surgeon
Departments of Surgery and Radiology, Leicester General Hospital, Leicester
Key words: Ultrasound; Subclavian vein; Catheter
The percutaneous placement of central venous catheters for central venous monitoring, angioaccess or parenteral nutrition has become a routine procedure both in and out of the intensive care unit. Infraclavicular subclavian venous catheterisation is the most common technique used. However, it is associated with a variety of potential complications, including Correspondence to: Sukhbir S Ubhi, Department of Surgery, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW
pneumothorax, subclavian artery puncture, air embolism, atrial or caval perforation and thoracic duct injury (1,2). The reported incidence of complications ranges from 0.4% to 9.9% (3) and is dependent on the experience of the operator (4). Despite successful venepuncture the catheter tip may be improperly positioned in up to 32% of cases (5). Many of the complications may be avoided by accurate localisation of the vein during venepuncture and correct placement of the catheter tip. We describe a method of subclavian vein catheterisation employing a combination of ultrasonography to
Guide vwire Figure 1. Ultrasound of the left subclavian vein with the needle entering the vein from the left and the guidewire running along the back wall of the vein.
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locate the vein and fluoroscopy to place the catheter tip accurately.
Method The patient is positioned 150 head down and the subclavian area is prepared and draped in the usual sterile manner. The subclavian vein is identified with an Aloka SSD-630 real-time ultrasound machine fitted with a 5 MHz intraoperative T-shaped probe. The vein lies above the artery and collapses upon deep inspiration. Local anaesthetic is infiltrated intradermally and subcutaneously in the direction of the vein. The path of the needle is directed by ultrasound. The vein is then punctured with a 14G needle attached to a 10 ml syringe, using ultrasound control. Flashback of venous blood into the syringe confirms the position of the needle in the vein. A guidewire is inserted through the needle into the vessel and the passage of the guidewire is followed by ultrasound (Fig. 1). The needle is then withdrawn over the guidewire and the central venous catheter, cut to approximate length, is advanced over the guidewire. The guidewire is removed and the position of the catheter tip confirmed by fluoroscopy. Once the catheter tip is in a satisfactory position the catheter is secured in position and an erect P/A chest radiograph is taken to exclude a pneumothorax.
We use this method routinely for all elective central venous catheterisations and have had no complications in 15 consecutive subclavian vein catheterisations. We suggest that this technique, combining ultrasonographic localisation of the vein with fluoroscopic assisted placement of the catheter tip, is safe and minimises the potential of serious complications associated with the 'blind' percutaneous method.
References I Feliciano D, Mattox K, Graham J, Beall A, Jordan G. Major complications of percutaneous subclavian vein catheters. Am J Surg 1979;138:869-74. 2 Campistol JM, Cases A, Lopez-Pedret J, Revert L. Thoracic duct injury: An unusual complication following subclavian catheterisation for hemodialysis. Nephron 1987;46:390-1. 3 Borja AR. Current status of infraclavicular subclavian vein catheterisation. Ann Thorac Surg 1972;13:615-25. 4 Bernard RW, Stahl WM. Subclavian vein catheterisations: A prospective study. I. Non-infectious complications. Ann Surg 1984;173: 191-200. 5 Conces DJ, Holden RW. Aberrant locations and complications in initial placement of subclavian vein catheters. Arch Surg 1984;119:293-5.
Received 13 November 1990
Notes on books Carcinomas of the Head and Neck: Evaluation and Management edited by Charlotte Jacobs. 291 pages, illustrated. Kluwer Academic Publishers, Boston. 1990. £87.95. ISBN 0 7923 0668 6 Recent advances in staging, primary treatment, rehabilitation, chemotherapy and the clinical applications of basic biology in the problem of head and neck carcinoma are the topics discussed.
Trigeminal Neuralgia edited by Richard L Rovit, Raj Murali and Peter J Jannetta. 288 pages, illustrated. Williams and Wilkins, Baltimore. 1990. £70.00. ISBN0 683 07393 1
Tic douloureux has been recognised for some three centuries. The cause is still uncertain. This volume summarises the present state of knowledge of this fascinating condition with special emphasis on the treatment both surgical and medical.
Oxford Handbook of Clinical Surgery by G R McLatchie. 877 pages, illustrated, flexicovers. Oxford University Press, Oxford. 1990. £12.95. ISBN 0 19 261710 9 A new pocketbook aimed at medical students and house officers which will no doubt become as popular as its medical companion. Each topic is dealt with in a single page with alternate pages left blank to accommodate notes. There are sections on
anatomy for surgeons, general, plastic, vascular, paediatric, endocrine and orthopaedic surgery. There are also chapters on practical procedures and basic operative techniques. Excellent value for money.
Grabb's Encyclopaedia of Flaps edited by S Strauch, L 0 Vasconez and Elizabeth J Hall-Findlay. 3 volumes. 1818 pages, illustrated. Little Brown and Company, Boston. 1990. £325.00. ISBN 0 316 81897 6 By any account this production is monumental and a tribute to the three editors who have collated 424 chapters, originally written in several different languages and styles by almost 400 different authors. Each chapter has been reorganised into a simple format: introduction, anatomy, flap design and dimensions, operative technique and clinical results. Each chapter has a relevant but not overbearing list of references. Illustrations are a combination of clinical photographs and line drawings. The result is a masterly reference work providing choices for the closure of defects throughout the body. Volume 1 is devoted to head and neck, Volume 2 to upper extremities and Volume 3 to the torso, pelvis and lower extremities. The editors hope that the work will serve as a stimulus to experienced surgeons as well as showing trainees in plastic surgery the numerous options available when choosing the most appropriate operation for a particular defect. There is no doubt that the editors have succeeded magnificently in their intention.
