Ultrasound has been used to place internal jugular (IJ) lines for many years now, and when done right, it has been shown to be helpful in reducing complication rates, number of attempts, and the amount of time needed for successful line placement. The femoral vein, although easily viewed with ultrasound, has largely fallen out of favor because of-concerns regarding possible central line-associated bloodstream infections (CLABSI). But the subclavian vein (SCV) has remained the last line to be predominantly placed with the landmark-guided approach because of the perceived technical difficulties and the preference of many physicians.
Limiting the incidence of CLABSI continues to be a focus, although rates of infection have decreased with emphasis on sterilization precautions. A recent article looked at infection rates based on the site of placement, comparing infection rates from using the IJ, SCV, and femoral veins in more than 3,471 patients. (N Engl J Med 2015;373:1220.) Perhaps not surprisingly, the subclavian vein was associated with a reduced risk of CLABSI when compared with the femoral vein but, interestingly, also when compared with the IJ. Based on the findings of this large trial, as well as smaller ones, there has been an increased interest in the SCV as a preferred site for central line placement.
Ultrasound visualization of the SCV is limited by the overlying clavicle. Due to the shadow that the clavicle creates, using ultrasound for real-time guidance of the traditional landmark approach is not possible and the technique must be altered. The SCV can be accessed under ultrasound guidance with an infraclavicular approach by moving the transducer lateral to the genu of the clavicle. It should be noted that the physician attempting placement is actually accessing the axillary vein at this point, although the difference is inconsequential. The SCV can also be accessed from a supraclavicular approach, as I described in a previous column. (“Think SUPRAclavicular for Subclavian Lines,” EMN 2013;35:8; http://bit.ly/2oy5mCS.)
Knowing that ultrasound can be used to visualize and guide central line placement, how does it compare with the landmark approach? Studies are limited in comparing these approaches head to head, but one such study looked at this. More than 400 patients were randomly assigned to receive an ultrasound-guided line placed via the infraclavicular approach or by the standard landmark approach. (Crit Care Med 2011;39:1607.) All lines were placed by physicians with more than six years of experience in central line placement. When comparing the two groups, the authors found that the ultrasound-guided group had a higher percentage of overall success (100% versus 87.5%), decreased access time and number of attempts, and a statistically significant decreased incidence of complications. Interestingly, the practitioners involved in the study rated the ultrasound technique as more technically challenging than the landmark-guided technique, suggesting that more training may be required than with ultrasound-guided IJ line placement.
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