US Probe: Ultrasound Guided Subclavian/Axillary Vein Catheterization

Author: Lap Woon Cheung, MB ChB, FHKCEM (@lawrche, International Emergency Ultrasound Fellow, Icahn School of Medicine at Mount Sinai) // Edited by: Stephen Alerhand MD (@SAlerhand, Instructor of Emergency Medicine and Ultrasound Fellow, Icahn School of Medicine at Mount Sinai) and Manpreet Singh, MD (@MPrizzleER – Assistant Professor in Emergency Medicine / Department of Emergency Medicine – Harbor-UCLA Medical Center)

Case

A 58 year-old male with history of intravenous (IV) drug use, cervical stenosis with myelopathy, and hypertension presented to the Emergency Department with fever and right thigh pain for 3 days. He admitted to IV heroin injection over the right groin region 1 week ago.

Vital signs were: BP 89/45, Pulse 110, SpO2 98%, RR 14, Temperature 102 F.

On physical exam, he looked generally weak and malnourished. The rest of the exam was notable for needle marks over the groins bilaterally and cellulitic changes over the right upper thigh.

A quick bedside ultrasound showed a hyperdynamic left ventricle and an inferior vena cava with significant respiratory variation. There was also no sign of groin abscess or pseudoaneurysm, nor any non-compressible vein in the femoropopliteal region suggestive of deep vein thrombosis. In view of his sepsis and dehydration, the plan for antibiotics and aggressive fluid resuscitation was initiated.

Peripheral IV access attempts by nursing colleagues failed due to thrombosing veins. Central venous access via the femoral vein (overlying cellulitis) and internal jugular vein (limited neck mobility due to cervical stenosis with myelopathy) were deemed inappropriate or challenging. Subclavian/axillary vein catheterization — a not commonly performed ED procedure — using ultrasound guidance was next proposed.

Anatomy and Clinical Relevance

After passing the lower border of the teres major, the basilic vein becomes the axillary vein. Once it passes the lateral border of the first rib, the axillary vein then becomes the subclavian vein posterior to the clavicle (1) (Figure 1). It tracks medially and inferiorly to join the internal jugular vein as they merge into the brachiocephalic vein. The axillary vein and subclavian vein accompany  their corresponding arteries along their course with some variation in anatomical relationship (2), so the traditional landmark approaches may not be reliable.

Figure 1. Axillary vein (from Gray’s Anatomy http://www.ganfyd.org/index.php?title=File:Veins_of_axilla.png)

In the traditional infraclavicular landmark approach to subclavian vein access, the needle is directed posterior to the clavicle, just underneath the midclavicular line, and toward the suprasternal notch. This access site is typically incompressible. It carries the potential risk of pneumothorax due to its close proximity to the pleura. In moving the ultrasound probe laterally, the vein (now the axillary vein) emerges from behind the clavicle along with its accompanying artery. Here, it is further from the pleura, becomes more compressible, and importantly, is better visualized with ultrasound (3). (Figure 2)

Figure 2. Axillary vein (from https://commons.wikimedia.org/wiki/File:Text-book_of_massage_and_remedial_gymnastics_(1916)_(14577724869).jpg)

Technical Infraclavicular Approach

1.Use the high-frequency (5.0-10.0 MHz) linear transducer, which offers the the highest resolution for this relatively superficial structure.

2. Start by placing the transducer in the sagittal plane over the middle third of the clavicle, with the transducer marker facing cephalad (Figure 3). Visualize the clavicle and pleural line as landmarks (Figures 4 & 5).

Figure 3. Position of the transducer in the sagittal plane over the middle third of the clavicle, with marker facing cephalad.

 
Figures 4 & 5. The subclavian vein (blue) and artery (red) can be identified. The clavicle and pleura serve as landmarks.

3. Slide laterally until the acoustic shadowing of the clavicle is no longer obscuring the underlying structures. Identify the axillary vein and artery in short-axis, as well as the pleural line. Differentiate the vein from artery with the help of color Doppler (Figure 6).

Figure 6. Axillary vein (blue) and axillary artery (red) are identified.

4. Follow the axillary vein laterally until it is not longer overlapping the artery, and the pleura remains at a distance.

5. Rotate the probe 90 degrees into the long-axis view and direct the needle safely, as with other central venous catheterizations (Figures 7 & 8).

 
Figures 7 & 8. Longitudinal view of the axillary vein.

Technical Points to Note

The above technique describes the infraclavicular approach of axillary vein catheterization. Different approaches have also been described. For instance, the supraclavicular approach enables visualization of the subclavian vein with the linear or endocavitary probe. This approach has the advantage of a more direct angle towards the superior vena cava (4). The long-axis method is superior to the short-axis method with regards to greater first-attempt success, fewer needle redirections, and fewer arterial punctures (5). Another approach called the Pleural Avoidance with Rib Trajectory (PART) technique targets the axillary vein at a point where it traverses over the second rib during needle advancement (Figure 9). It provides a protective rib shield between the vein and pleura (Figure 10). It has been shown to reduce the risk of pneumothorax and allows for compression in case of bleeding (Figure 9. PART method (6)

Figure 10. Axillary vein (in long-axis) overlying the 2nd rib

Indications

  1. Emergency venous access for fluid and drug administration
  2. Central venous pressure and oxygenation monitoring
  3. Introduction of transvenous cardiac pacing and pulmonary artery catheter
  4. Long-term central venous access (preferable to internal jugular and femoral vein access as it allows for neck movement and ambulation without discomfort)
  5. Other central veins not accessible or contraindicated

Contraindications

  1. Coagulopathy
  2. Combative or uncooperative patients
  3. Overlying infection, chest wall deformity or trauma
  4. Ipsilateral vein cannulation in the presence of an implantable pacemaker
  5. Ipsilateral vein cannulation in patients relying on a single lung
  6. Intraluminal thrombosis visualized by ultrasound

Bottom Line

Compared with internal jugular and femoral vein access, subclavian/axillary vein cannulation has the lowest infection rate (7). It is suggested as the central line access of choice by the Centers for Disease Control and Prevention guidelines for the prevention of catheter-related bloodstream infections (CRBSI) in adult patients (8). Though the practice may be hindered by the feared complication of pneumothorax (9), studies have shown an increased success rate, decreased time to achieve access, and decreased number of attempts with ultrasound guidance (10). There are also occasional situations where internal jugular and/or femoral vein approaches are contraindicated, e.g. anatomic distortions and suspected injuries of the respective structures. Subclavian/axillary vein catheterization has a role in emergency care, and emergency physicians should be familiar with the indications and proper technique.

FOAMed Resources

References

  1. Snell RS. Clinical Anatomy by Regions. 9th Ed. Lippincott Williams & Wilkins; 2011.
  2. Yeow KM, Kaufman JA, Rieumont MJ, et al: Axillary vein puncture over the second rib. Am J Roentgenol 1998;170(4):924–926.
  3. Galloway S, Bodenham A: Ultrasound imaging of the axillary vein – anatomical basis for central venous access. Br J Anaesth 2003;90(5):589–595.
  4. Stachura MR, Socransky SJ, Wiss R, Betz M. A comparison of the supraclavicular and infraclavicular views for imaging the subclavian vein with ultrasound. Am J Emerg Med. 2014; 32(8):905-908.
  5. Sommerkamp, SK, Romaniuk, VM, Witting, MD, Ford, DR, Allison, MG, Euerle, BD. A comparison of longitudinal and transverse approaches to ultrasound-guided axillary vein cannulation. Am J Emerg Med. 2013;31(3):478–481.
  6. Senussi MH, Kantamneni PC, Omranian A et al. Revisiting Ultrasound-Guided Subclavian/Axillary Vein Cannulations: Importance of Pleural Avoidance With Rib Trajectory J Intensive Care Med. 2017; 32(6):396-399.
  7. Lorente L, Henry C, Martín MM, Jiménez A, Mora ML. Central venous catheter-related infection in a prospective and observational study of 2,595 catheters. Crit Care. 2005; 9(6):R631–5.
  8. Guidelines for the Prevention of Intravascular Catheter-Related Infections (2011) https://www.cdc.gov/infectioncontrol/guidelines/bsi/recommendations.html
  9. Parienti, JJ, Mongardon, N, Mégarbane, B. Intravascular complications of central venous catheterization by insertion site. N Engl J Med. 2015;373(13):1220–1229.
  10. Fragou M, Gravvanis A, Dimitriou V, et al. Real-time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients: a prospective randomized study. Crit Care Med. 2011; 39(7):1607–1612.

 

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Time for Child Advocacy – 10 things to keep kids safe

Don't you love it when someone brands something that you've always been doing?  Advocacy is nothing new, but by making a big deal of it, we are all prompted to think about how we can do more of it and do it better.  Every consultation involving a child or young person will tend to include a bit of advocacy.  I am doing it every time I tell a parent that when their febrile child is refusing to drink, that usually means that they are in pain.  Parents sometimes think that paracetamol and Ibuprofen are just for reducing fever.  Part of my job is to put analgesia on the agenda.  It is the perfect time to do it because this is when the parents want their child to feel as well as possible.

Similarly, the impact of safety advice is greatest following an injury.  So when a child or young person comes to me with a mishap, I try to work a bit of prevention in alongside the cure.

Injury is the leading cause of death in children over the age of one in the UK. (1)  So, while we worry about sepsis and meningitis, preventing injury may be the real battleground.  Injury is inherently preventable, as demonstrated by the massive difference between rates in different countries.  It is not just lethal injury that is important.  In fact, to the children themselves it is the debilitating injuries that really matter.  Missing a sporting event or the ability to swim just before a holiday is the end of the world.  Or at least it is when 'the future' is essentially the next month or so.

What I do is to try to throw in something relevant to the presentation.  Whether injury or ingestion, there are lots of ways that we can make the environments of children and young people safer.  Here are a few that are worth spreading the word about to parents and colleagues:

1. Warn parents of babies and toddlers about common choking hazards

Have you ever wondered why pen lids have a hole in the top?  Before that little innovation, these were common choking hazards.  Anything that fits neatly into the windpipe runs the risk of a fatal choking episode.  The list of dangerous things includes many food and playthings that parents readily give to their children.

I think that any household mishap is a good opportunity to warn parents about choking hazards.  Prevention can include avoidance.  Supervision is also great but only if you know what to do, and with choking, prevention really is better than cure.

2. Make sure that children can't get hold of button batteries

If you were not aware of this, button batteries are incredibly dangerous to children.  There is a misunderstanding about these miniature killers.  It is not the contents leaking that are dangerous, it is the electrical current which forms corrosive chemicals outside of the battery.  Button batteries have become more powerful, in order to meet the demands of today's toys and gadgets.  When swallowed, the current may burn a hole in the gut (usually the oesophagus) and bleeding can be fatal.  A swallowed button battery needs to be located as an emergency in case it is stuck, as these carry the highest risk.

I find that many parents don't know about this, so I often mention it when a child has swallowed something concerning but less harmful, like a diamond ring.

3. Make sure that liquid gel detergent capsules are kept away from children

Ask any ophthalmologist what common household item is most dangerous to children's eyes and I am willing to bet that they say liquid gel detergent capsules.  Why?  They are the perfect thing to cause massive damage.  Firstly, they look very appealing to a child.  They are brightly coloured and a bit like something that might be good to eat.  If bitten into, the contents come out under pressure, so the eye has no time to protect itself from the contents.  The contents themselves are a highly concentrated alkali which will burn and dissolve the thin layers of the eyeball.  While the industry has made some moves to warn people to keep these away from children, such messages can be interpreted as a standard bit of advice, which does no justice to the fact that these capsules are far more dangerous than the standard bottles or boxes of detergents.

So when a child has had a mishap with another item, I like to warn parents about other things that they may not have thought about.

4. Recommend that all children with a bike wear a bike helmet.

Heads injuries are the most common cause of fatal injury in children.  Bikes are great fun and a good way for children to keep fit.  Unfortunately, injury is all about physics.  I have yet to see a child run into something and have a significant head injury.  Bicycles however, allow a young person to gain enough momentum to do real damage even if another vehicle is not involved.  While it can be difficult to persuade young people to wear helmets, they are the must have accessory for anyone who likes their brain or their face.  Road rash on the face is not a good look and helmets do a decent job of protecting the face from being badly grazed in a fall from a bike.

I emphasise the facial injury as much as the head injury prevention as it often means more to the young person involved.

5. Advise a bit of trampoline safety


Trampolines are a favourite for all ages.  They are also one of the biggest sources of injuries that come into children's emergency departments.  While I am not suggesting that trampolines should be avoided, the risk of broken bones can be minimised.  One of the common factors in many of the worst trampolining injuries that I have seen is that there has been another person involved.  The worst injuries tend to occur when a small child is on the trampoline with an older child.  I would recommend that younger children in particular should never have someone larger than them on the trampoline.  Ideally, they should be on the trampoline alone, with onlookers cheering them on.

6. Make sure that parents lock up medicines



Medication packaging always has on it 'keep out of reach of children.'  What this fails to take into account is the incredible resourcefulness of children who may seem to small to get up to cupboards or high shelves.  I can tell you from experience that nowhere is safe.  The only completely safe place for a medicine is in a locked cupboard or box.  Nor can you rely on 'child proof' containers to prevent accidental poisoning.  Child proof containers seem to be adult proof (It can't be just me that struggles with the tops) while children who have time on their hands always seem to get them open in the end.

7. Know about the surprise household poison - plug in air fresheners


Many plug in air fresheners contain essential oils.  These chemicals are potentially incredibly poisonous due to their ability to dissolve into brain tissue.  Parents are frequently surprised by this fact so it is well worth letting people know about this dangerous household item.  People are also surprised by the ability of toddlers to drink the contents of these plug ins if they get hold of them.  I don't know how they do it.  And why won't they eat their vegetables???

8. Warn parents to beware of the sun

When the sun comes out and children quite rightly make the most of it, we often end up seeing children with quite severe sunburn.  Babies are especially at risk due to their thin skin and lack of protection from the sun.  Make sure that people know that children can get deep burns from the sun and that prevention is key.  Children are also vulnerable to the dangers of overheating so hydration and sun avoidance are important when the sun is out.

9.  Remind adolescents to respect water


It is great that young people use the opportunity of time off school to go and have a bit of an adventure.  One way that this sometimes goes very wrong is when water is involved.  Getting into trouble in water is all too easy.  The simplest way to avoid the danger is to make sure that all swimming is done in appropriate areas.  Tempting though it is to jump into a reservoir or an abandoned quarry full of water, this is very high risk.

10.  A surprise danger – twilight

Now for the sciency bit…  Twilight is a very dangerous time for pedestrians and young people are already very much at risk due to their lack of perceived mortality.  Why is it dangerous when the sun rises and sets?  The answer is probably due to a little known chemical (found in the eye) called rhodopsin.  This is the chemical that enables the eye to adjust to lower levels of light.  The trouble is that it takes many minutes to produce the chemical and only seconds for a flash of light to get rid of it completely.  As a result, drivers can have their ability to see reduced very suddenly by a moment of setting or rising sun, allowing a person in the shadows to become almost invisible. (3)

It is important to teach young people road safety, but also to let them know that at certain times of day, drivers may not see them at all.
We're already making every consultation matter.  Giving parents a little suggestion every now and then about how to make their child's environment a bit safer is just another way of adding to the difference we already make.  Paediatrics is so rarely about preventative medicine but when a child has a mishap, we have a golden opportunity to discuss ways to avoid the next accident.

Edward Snelson
Chronic Avoider
@sailordoctor

FOAMed is free.  The clue is in the name.  That said, if anyone would like to celebrate their enjoyment of the free open access education provided by GPpaedsTips by helping children to receive the best possible care, I have set up a donation page where I am raising money for a new Sheffield Children's Hospital Emergency Department.  For more information about this or to donate, click on the link in the Just Giving logo:
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References
  1. RCPCH, "Why children die: death in infants, children and young people in the UK"
  2. AAP, "Prevention of Choking Among Children", February 2010
  3. http://uxblog.idvsolutions.com/2014/01/a-meta-portrait-of-earths-surface.html

    ECG of the Week – 14th May 2018 – Interpretation

    This ECG is from a 68 yr male who presented with 24 hours of dysponea and palpitations.
    No past medical history of note and he takes no regular medications.

    Click to enlarge
    Things to think about
    • What are the key ECG features ?
    • What are the potential reversible causes for these features ?
    • How would you manage this patient ?
    Rate:
    • Ventricular rate 42 bpm
    • Atrial rate 84 bpm
    Rhythm:
    • Regular atrial and ventricular activity
    • 2:1 AV block
    Axis:
    • Normal
    Intervals:
    • PR - Normal (~200ms)
    • QRS - Prolonged (140ms)
    Additional:
    • RBBB Morphology
    • Prominent T wave lead III in relation to QRS height
    Interpretation:
    • 2:1 AV Block
    What happened ?

    The patient was admitted under the cardiology team and telemetry revealed intermittent variable AV block (2nd and 3rd degree) and he underwent an uneventful dual chamber PPM insertion.

    References / Further Reading

    Life in the Fast Lane

    Textbook
    • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.