vein catheterisaton - Europe PMC

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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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S S Ubhi et al.

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

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