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Real-time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients: A prospective randomized study*

Fragou, Mariantina MD; Gravvanis, Andreas MD, PhD; Dimitriou, Vasilios MD, PhD; Papalois, Apostolos MD, PhD; Kouraklis, Gregorios MD, PhD; Karabinis, Andreas MD, PhD; Saranteas, Theodosios MD, DDS, PhD; Poularas, John MD; Papanikolaou, John MD; Davlouros, Periklis MD, PhD; Labropoulos, Nicos MD, PhD; Karakitsos, Dimitrios MD, PhD

doi: 10.1097/CCM.0b013e318218a1ae
Feature Articles

Objective: Subclavian vein catheterization may cause various complications. We compared the real-time ultrasound-guided subclavian vein cannulation vs. the landmark method in critical care patients.

Design: Prospective randomized study.

Setting: Medical intensive care unit of a tertiary medical center.

Patients: Four hundred sixty-three mechanically ventilated patients enrolled in a randomized controlled ISRCTN-registered trial (ISRCTN-61258470).

Interventions: We compared the ultrasound-guided subclavian vein cannulation (200 patients) vs. the landmark method (201 patients) using an infraclavicular needle insertion point in all cases. Catheterization was performed under nonemergency conditions in the intensive care unit. Randomization was performed by means of a computer-generated random-numbers table and patients were stratified with regard to age, gender, and body mass index.

Measurements and Main Results: No significant differences in the presence of risk factors for difficult cannulation between the two groups of patients were recorded. Subclavian vein cannulation was achieved in 100% of patients in the ultrasound group as compared with 87.5% in the landmark one (p < .05). Average access time and number of attempts were significantly reduced in the ultrasound group of patients compared with the landmark group (p < .05). In the landmark group, artery puncture and hematoma occurred in 5.4% of patients, respectively, hemothorax in 4.4%, pneumothorax in 4.9%, brachial plexus injury in 2.9%, phrenic nerve injury in 1.5%, and cardiac tamponade in 0.5%, which were all increased compared with the ultrasound group (p < .05). Catheter misplacements did not differ between groups. In this study, the real-time ultrasound method was rated on a semiquantitative scale as technically difficult by the participating physicians.

Conclusions: The present data suggested that ultrasound-guided cannulation of the subclavian vein in critical care patients is superior to the landmark method and should be the method of choice in these patients.

From the Intensive Care Unit (MF, AG, J Poularas, DK, VD), Microsurgical and Reconstructive Surgical Unit, and Anesthesiology Department, General State Hospital of Athens, Athens, Greece; Surgical Experimental Laboratories ELPEN (AP), Pikermi, Athens, Greece; the Second Department of Propedeutic Surgery (GK), University of Athens School of Medicine, Laiko General Hospital, Athens, Greece; the Intensive Care Unit (AK), Onassis Cardiac Surgery Center, Athens, Greece; the Anesthesiology Department (TS), Attikon University Hospital, Athens, Greece; the Intensive Care Unit (J Papanikolaou), University Hospital of Larissa, Larissa, Greece; the Coronary Care Unit (PD), Cardiology Department, Patras University Hospital, Rion, Greece; and the Vascular Laboratory (NL), Department of Surgery, Stony Brook University Hospital, Stony Brook, NY.

This work was conducted at the Intensive Care Unit of “G. Gennimatas” General State Hospital of Athens, Athens, Greece.

The authors have not disclosed any potential conflicts of interest.

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© 2011 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins