ABSTRACT
Background:
Classically subclavian vein catheterization is done in neutral arm position; recently, it has been done in different arm positions to compare success rate and catheter misplacement. There is a paucity of literature for comparing abducted and neutral arm position for right infraclavicular subclavian vein cannulation.
Aim:
Comparison of success rate of abducted and neutral arm position for right infraclavicular subclavian vein cannulation under real-time ultrasound guidance in patients undergoing elective neurosurgery under general anesthesia.
Design:
Randomized comparative study.
Materials and Methods:
After approval from Institutional Review Board and Ethical Committee, 100 patients of 18–70 years of age, of either sex, posted for elective neurosurgery under general anesthesia, requiring right subclavian vein cannulation were included in our study. They were randomly divided into two groups: abducted arm position (group 1-AG) and neutral arm position (group 2-NG) using sealed envelope technique.
Results:
First attempt success rate was higher in AG group compared to NG group (P value- 0.741). Times taken (seconds) for cannulation in NG and AG group, catheter misplacement and hematoma (P value- 0.37, P value- 0.37, P value- 1, respectively) were lesser in AG Group.
Conclusion:
For USG-guided infraclavicular subclavian vein cannulation, abducted arm position, and neutral arm position in terms of first attempt success rate, number of attempts and associated complications has comparable results; however, further studies with larger group of patients are required to assess the overall advantage of abducted arm position over neutral arm position.
Keywords: Central venous catheter, subclavian vein, ultrasonography
INTRODUCTION
In the current clinical era, central venous catheterization is frequently carried out. It is carried out in the body’s main central veins, such as the femoral vein, subclavian vein, and internal jugular vein.[1] It is used to monitor central venous pressure (CVP), administer medications, provide total parenteral nutrition (TPN), aspirate air emboli, gain access to patients with poor peripheral veins, insert transcutaneous pacing leads, administer renal replacement therapy, perform cardiac catheterization, and other procedures.[2-4] There are several benefits of infraclavicular subclavian vein cannulation over other central venous cannulation sites[5] (internal jugular vein and femoral vein), including ease of insertion in trauma patients who are immobilized due to a cervical spine injury, less interference with airway management during cardiopulmonary resuscitation, catheter stabilization over wide anatomical areas, decreased risk of catheter-related infections,[6] comfort for a patient without movement restrictions, and lower risk of catheter displacement.
There are two approaches to cannulate the subclavian vein: either infraclavicular or supraclavicular.[7,8] Operating rooms and intensive care units frequently use the infraclavicular approach because it has been proven to be a rather safe technique. Real-time ultrasonography or the landmark approach can be used to cannulate the subclavian vein.
Classically subclavian vein catheterization is done in neutral arm position but recently multiple studies[9,10] have been done in different arm position to compare success rate and catheter misplacement. Although there are many studies focusing on the efficacy and safety of ultrasound-guided subclavian venous catheterization, there are not many studies addressing the efficacy and characteristics of various arm positions. This randomized study was designed to compare neutral versus 90-degree abducted arm positions under USG guidance for right infraclavicular subclavian vein cannulation in patients undergoing elective surgery under general anesthesia.
MATERIALS AND METHODS
The study was conducted in the Department of Anaesthesiology, after taking approval from Institutional Review Board and Institutional Ethical Committee, over a period of 18 months. 100 patients (50 each group) were taken for our study. The sample size was calculated with taking 80% power of study and 5% level of significance. Taking these values as reference, bused on study by Ahn & colleages[10] the minimum required sample size with 80% power of study and 5% level of significance is 1086 patients in each study group. So total sample size taken was 2172 patients. For finite sample size taking population as 100, total sample size calculated was 96. To reduce margin of error, total sample size taken was 100 (50 per group).
Formula used is:-
SS1 ≥ ((pc*(1-pc) + pe*(1-pe))*(Z@ + Zβ) 2)/(pc-pe)2
n ≥ SS/(1+ [(SS – 1)/Pop])
With
Pc = success rates of complete catheterization in neutral group
Pe = success rates of complete catheterization in abduction group
Pop is population
where Zα is value of Z at two-sided alpha error of 5% and Zβ is value of Z at power of 80%
Calculations:-SS1≥ ((.971*(1-.971) +.988*(1-.988)) *(1.96+.84) 2)/(.971-.988) 2 ≥ 1085.53 = 1086 (approx.)
So SS = 1086 * 2 = 2172
n ≥ 2172/(1+ [(2172 – 1)/100]) =95.64 = 96 (approx.)
Adults of age 18–70 years of either sex posted for elective neurosurgery procedures under general anesthesia, requiring right subclavian vein cannulation were included in our study. Patients with B.M.I. >30 kg/m2, history of previous central venous catheterization of the right subclavian vein, pneumothorax, coagulopathy, distorted anatomy of the neck and clavicle, H/o radiotherapy, past surgery over site of catheterization were excluded from the study. After taking written and informed consent from patients or their relatives in their vernacular language, patients were divided into two groups: abducted arm position is group 1 (AG) and neutral arm position is group 2 (NG) using sealed envelope technique.
For induction of general anesthesia Inj. Fentanyl 2 microgram per kilogram, Inj. Propofol 1–2 milligrams per kilogram, Inj. Vecuronium 0.1 milligram per kilogram, then patients were intubated and mechanically ventilated. Following this central venous cannulation was performed using real-time ultrasound guidance by longitudinal view or in-plane approach. The ultrasound machine used is sonosite turbo, screen size 7”/17.8 cm high-resolution display, linear probe was used for ultrasonography with a frequency of 6–13 megahertz. Ultrasonography was performed by skilled and experienced operator with an experience of more than 20 years. Patient was kept in supine position on flat operating table without putting any shoulder roll or head pillow or head lowering position. Group 1: Right arm of patient was kept in 90-degree abducted position. Group 2: Right arm of patient placed in neutral position by the side of the body. After that following methodology, catheter was placed using Seldinger’s technique. Post-surgery chest X-ray was taken for confirmation of central venous catheter tip. Outcomes were assessed as first attempt success rate, site of catheter placement, cannulation time (total time taken from skin puncture to completely placing the catheter at junction of SVC and right atrium), and any complications.
RESULTS AND OBSERVATION
This randomized comparative study was conducted in the Department of Anaesthesiology, from January 1, 2021–May 31, 2022. 100 patients of age 18–70 years of either gender, posted for elective surgery under general anesthesia requiring central venous cannulation were included in the study. Subjects were randomly divided into two groups: neutral group (n = 50) and abducted arm group (n = 50). The study subjects taken were comparable with respect to age, gender, and BMI. [Table 1]. First attempt success rate was comparable between neutral arm and abducted arm group (Failure: 12% vs 8%, respectively, Success: 88% vs 92%, respectively) with P value = 0.741, which is not significant [Table 2]. Number of attempts was comparable between neutral arm and abducted arm group. (1:88% vs 92%, respectively, 2:8% vs 6%, respectively, 3:4% vs 2%, respectively) with P value of 0.784, which is not significant.
Table 1.
Comparison between neutral arm and abducted arm groups for demographic data
| Variable | Neutral arm group (n=50) | Abducted arm group (n=50) | P |
|---|---|---|---|
| Age (years) | 41.98±13.14 | 43.44±15.96 | 0.619 |
| Gender | |||
| Male | 31 (62%) | 29 (58%) | 0.683 |
| Female | 19 (38%) | 21 (42%) | |
| BMI (kg/m2) | 26.98±2.59 | 26.25±2.4 | 0.144 |
Table 2.
Comparison of first attempt success rate between neutral arm and abducted arm group
| First attempt success rate | Neutral arm group (n=50) | Abducted arm group (n=50) | Total | P |
|---|---|---|---|---|
| Failure | 6 (12%) | 4 (8%) | 10 (10%) | 0.741* |
| Success | 44 (88%) | 46 (92%) | 90 (90%) | |
| Total | 50 (100%) | 50 (100%) | 100 (100%) |
Mean ± SD of cannulation time (seconds) in neutral arm group was 178.18 ± 41.35, and abducted arm group was 171.66 ± 30.14 with no significant difference between them, with P value of 0.37, which is not significant as depicted in [Table 3].
Table 3.
Comparison of cannulation time (seconds) between neutral arm and abducted arm group
| Cannulation time (seconds) | Neutral arm group (n=50) | Abducted arm group (n=50) | Total | P |
|---|---|---|---|---|
| Mean±SD | 178.18±41.35 | 171.66±30.14 | 174.92±36.15 | 0.37‡ |
| Median (25th-75th percentile) | 175 (148.5-197) | 170 (156-188) | 172 (150-194) | |
| Range | 112-280 | 118-255 | 112-280 |
Distribution of tip of CVC on CXR was comparable between neutral arm and abducted arm group. (Just above carina:- 92% vs 96%, respectively, Ipsilateral jugular vein:- 4% vs 2%, respectively, contralateral left subclavian vein:- 4% vs 2%, respectively) (P value = 0.71) as shown in Table 4.
Table 4.
Comparison of tip of CVC on CXR between neutral arm and abducted arm group
| Tip of CVC on CXR | Neutral arm group (n=50) | Abducted arm group (n=50) | Total | P |
|---|---|---|---|---|
| Just above carina | 46 (92%) | 48 (96%) | 94 (94%) | 0.71* |
| Ipsilateral jugular vein | 2 (4%) | 1 (2%) | 3 (3%) | |
| Contralateral left subclavian vein | 2 (4%) | 1 (2%) | 3 (3%) | |
| Total | 50 (100%) | 50 (100%) | 100 (100%) |
*Fisher’s exact test
The various complications observed between the two groups were comparable. None of the patients had pneumothorax in both groups. Hematoma was comparable between neutral arm and abducted arm group. (No hematoma:- 96% vs 98%, respectively, Hematoma:- 4% vs 2%, respectively) (P value = 1). None of the patients had arterial puncture misplacement of catheter was comparable between neutral arm and abducted arm group. (No misplacement:- 92% vs 96%, respectively, misplacement present:- 8% vs 4%, respectively) (P value = 0.678) [Table 5]. None of the patients had hemothorax. All of the patients had venipuncture.
Table 5.
Comparison of misplacement of catheter between neutral arm and abducted arm group
| Misplacement of catheter | Neutral arm group (n=50) | Abducted arm group (n=50) | Total | P |
|---|---|---|---|---|
| No misplacement | 46 (92%) | 48 (96%) | 94 (94%) | 0.678* |
| Misplacement present | 4 (8%) | 2 (4%) | 6 (6%) | |
| Total | 50 (100%) | 50 (100%) | 100 (100%) |
*Fisher’s exact test
Distribution of thread guidewire was comparable between neutral arm and abducted arm group. (Failure:- 4% vs 0%, respectively, Success:- 96% vs 100%, respectively) (P value = 0.495).
DISCUSSION
Subclavian vein catheterization via the infraclavicular approach is one of the most commonly used cannulation techniques for inserting catheters into a central vein. Recent studies suggest that abduction of the arm during ultrasound-guided subclavian vein cannulation increases the cross-sectional area of the visualized vein in comparison with neutral arm position.[9] Also, abducted arm position moves the clavicle cephalad and allows ultrasonographic visualization of infraclavicular axillary vein approximately 2 cm more proximally than with adducted arm.[11] In our study, 100 patients were enrolled and randomly divided into group 1 (n = 50) and group 2 (n = 40) and compared the abducted versus neutral arm position for infraclavicular right subclavian vein cannulation under real-time ultrasound guidance in patients undergoing elective surgery under general anesthesia in terms of success rate (both overall and the first attempt), number of attempts, cannulation time, and safety profile (mechanical complications). Demographic variables (age, gender, and BMI) among the two study groups were comparable without any statistically significant difference (P value >0.05) [Table 1].
In our study, the first attempt success rate was 92% in abducted arm group (group 1) and 88% in neutral arm group (group 2) and the difference between neutral arm and abducted arm group was not statistically significant with P value of 0.741 [Table 2]. A number of patients with two cannulation attempts were 6% in abducted arm group (group 1) and 8% in neutral arm group in neutral arm group (group 2) and with three cannulation attempts were 2% in abducted arm group (group 1) and 4% in neutral arm group (group 2). This distribution of number of attempts between abducted arm group (group 1) and neutral arm group (group 2) was not statistically significant (P value = 0.784). Overall success rate in our study was 100% in both the groups. The mean ± SD of cannulation time (seconds) in neutral arm group was 178.18 ± 41.35, and abducted arm group was 171.66 ± 30.14 with no statistically significant difference between them with P value = 0.37 [Table 3]. In the study conducted by Palepu GB et al.,[12] they reported 1st attempt success rate of 82.4% in neutral arm position under USG guidance. Similarly Sidoti A et al.[13] and Sazdov D et al.[14] reported first attempt success rate of 86.5% and 83.1%, respectively, in neutral arm position under USG guidance for infraclavicular subclavian vein cannulation.
Ahn and colleagues[10] in 2016 conducted a study in which, in abducted arm group, 98.8% of catheterizations were successful, compared to 97.1% in the neutral arm group. There was no statistically significant difference between the two groups, which was similar to our study.
In our study, the difference in the distribution of tip of CVC on CXR between neutral arm and abducted arm group was not statistically significant. In 46 patients (92%), the catheter tip was just above carina in neutral arm group and 48 patients (96%) in abducted arm group. In two patients (4%) in neutral arm position, the catheter tip was at ipsilateral jugular vein and one patient (2%) in abducted arm position. In two patients (4%), in neutral arm group the catheter tip was at contralateral left subclavian vein and 1 (2%) in abducted arm group. In our study, the difference in the distribution of total misplacement of catheter between neutral arm and abducted arm group with four cases (8%) vs two cases (4%) of misplacements respectively was not statistically significant with P value = 0.71. [Table 5]. In a study carried out by Ahn and colleagues[10] in 2016, the catheter misplacement rate was 3.9% in the neutral arm group and 0.4% in the abduction arm group. Incidence of catheter misplacement in the neutral group was higher than in the abduction group 3.9 vs. 0.4 percent, P = 0.01. Right internal jugular vein was the site of the majority of misplaced catheters (neutral, 8/9 vs. abduction, 1/1). The neutral group had just 1 catheter found in the left subclavian vein.
In our study, the difference in the distribution of thread guidewire was not statistically significant between neutral arm and abducted arm group (P value = 0.617). In four patients, we faced the failure to thread the guidewire out of which 3 patients (6%) in neutral arm position and 1 patient (2%) in abducted arm position, which were resulted from kinking of the guidewire followed by forceful insertion of the dilator at a steep angle in patients with BMI ≥28. The explanation was that this patient’s thick skin and pectoral muscles acted as a barrier. In Ahn’s study, they had total six cases of failure to thread and advance the guide wire three in neutral as well as three in abducted arm position.
In our study, the difference in the distribution of hematoma between neutral arm and abducted arm group was not statistically significant (P value = 1). Two patients (4%) in neutral arm position and one patient (2%) in abducted arm position had hematoma. These were the patients who had >1 cannulation attempts. In our study, there was no incidence of arterial puncture, in Ahn’s study arterial puncture occurred in four patients in the neutral group, but none in the abduction group. None of the patients had pneumothorax and hemothorax in both the groups in our study and also in Ahn’s study in either group.
In our study, the complications were lesser in abducted arm group as compared to neutral arm group but the difference was not statistically significant. Thus, the USG-guided infraclavicular subclavian vein cannulation in neutral and abducted arm positions was comparable in terms of success rate, chances of catheter misplacement, and other complications in elective surgery patients under general anesthesia. The lower frequency of complications seen in our study can be attributed to the CVC being inserted during elective surgery under general anesthesia, which offers better and more controlled settings than the ICU and emergency room.
CONCLUSION
For USG-guided infraclavicular subclavian vein cannulation, abducted arm position and neutral arm position in terms of first attempt success rate, number of attempts, and associated complications has comparable results. Thus, further studies with larger group of patients and also the inclusion of emergency surgery and ICU patients are required to assess the overall advantage of abducted arm position over neutral arm position.
Limitation
Limitation of our study is that this study was conducted only in patients with BMI <30 kg/m2 and undergoing elective surgery under general anesthesia. So these results cannot be generalized for patients undergoing subclavian vein cannulation in critical care department, general wards, and emergency department.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
- 1.Celinski SA, Seneff MG. Intensive Care Medicine. 4th edition. Philadelphia: Lippincott Williams and Williams; 2008. Central venous catheterization; pp. 19–35. [Google Scholar]
- 2.Czarnik T, Gawda R, Perkowski T, Weron R. Supraclavicular approach is an easy and safe method of subclavian vein catheterization even in mechanically ventilated patients: Analysis of 370 attempts. Anesthesiology. 2009;111:334–9. doi: 10.1097/ALN.0b013e3181ac461f. [DOI] [PubMed] [Google Scholar]
- 3.Gibson F, Bodenham A. Misplaced central venous catheters: Applied anatomy and practical management. Br J Anaesth. 2013;110:333–46. doi: 10.1093/bja/aes497. [DOI] [PubMed] [Google Scholar]
- 4.Roldan CJ, Paniagua L. Central venous catheter intravascular malpositioning: Causes, prevention, diagnosis, and correction. West J Emerg Med. 2015;16:658–64. doi: 10.5811/westjem.2015.7.26248. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Paoletti F, Ripani U, Antonelli M, Nicoletta G. Central venous catheters. Observations on the implantation technique and its complications. Minerva Anestesiol. 2005;71:555–60. [PubMed] [Google Scholar]
- 6.Parienti JJ. Catheter-related bloodstream infection in jugular versus subclavian central catheterization. Crit Care Med. 2017;45:e734–5. doi: 10.1097/CCM.0000000000002400. doi:10.1097/CCM.0000000000002400. [DOI] [PubMed] [Google Scholar]
- 7.Aubaniac R. Subclavian intravenous injection;advantages and technic. Presse Med (1893) 1952;60:1456. [PubMed] [Google Scholar]
- 8.Hussain S, Khan RA, Iqbal M, Shafiq M. A comparative study of supraclavicular versus infraclavicular approach for central venous catheterization. Anaesth Pain Intens Care. 2011;15:13–6. [Google Scholar]
- 9.Sadek M, Roger C, Bastide S, Jeannes P, Solecki K, de Jong A, et al. The influence of arm positioning on ultrasonic visualization of the subclavian vein: An anatomical ultrasound study in healthy volunteers. Anesth Analg. 2016;123:129–32. doi: 10.1213/ANE.0000000000001327. [DOI] [PubMed] [Google Scholar]
- 10.Ahn JH, Kim IS, Shin KM, Kang SS, Hong SJ, Park JH, et al. Influence of arm position on catheter placement during real-time ultrasound-guided right infraclavicular proximal axillary venous catheterization. Br J Anaesth. 2016;116:363–9. doi: 10.1093/bja/aev345. [DOI] [PubMed] [Google Scholar]
- 11.T S, Kulandyan I, Velraj J, Murugesan R, Srinivasan P. Sonographic visualization and cannulation of the axillary vein in two arm positions during mechanical ventilation: A randomized trial. J Vasc Access. 2020;21:210–6. doi: 10.1177/1129729819869504. [DOI] [PubMed] [Google Scholar]
- 12.Palepu GB, Deven J, Subrahmanyam M, Mohan S. Impact of ultrasonography on central venous catheter insertion in intensive care. Indian J Radiol Imaging. 2009;19:191–8. doi: 10.4103/0971-3026.54877. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Sidoti A, Brogi E, Biancofiore G, Casagli S, Guarracino F, Malacarne P, et al. Ultrasound- versus landmark-guided subclavian vein catheterization: A prospective observational study from a tertiary referral hospital. Sci Rep. 2019;9:12248. doi: 10.1038/s41598-019-48766-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Sazdov D, Srceva MJ, Todorova ZN. Landmark versus ultrasound-guided subclavian central venous catheterization with a combined short and long axis approach in an intensive care setting. Mac Med Review. 2017;71:44–9. [Google Scholar]