The influence of the direction of J-tip on the placement of a subclavian catheter: real time ultrasound-guided cannulation versus landmark method, a randomized controlled trial

Abstract

BackgroundIt has been reported that the direction of the guidewire J-tip is associated with misplacement of a central venous catheter. We hypothesized that real-time ultrasound-guided infraclavicular subclavian venous cannulation would be less influenced by the direction of guidewire J-tip compared to landmark method.MethodsSixty adult patients who required subclavian venous catheterization for neurosurgery were enrolled in this prospective randomized controlled study. Patients were randomly divided into a landmark group (n = 30) or an ultrasound group (n = 30). After the subclavian vein was punctured, the guidewire was advanced with the guidewire J-tip directed cephalad. Misplacement or advancement failure of the guidewire was regarded as an unsuccessful placement. Postoperative chest radiography was performed to confirm pneumothorax and the location of the catheter tip.ResultsThe two groups were comparable with respect to age, gender, height, and weight distribution. The incidence of unsuccessful guidewire placement was lower in the ultrasound group than in the landmark group (13% vs. 47%, P = 0.01). Among the unsuccessful guidewire placements, the incidence of misplacement were comparable between the groups and were all located in the ipsilateral internal jugular vein (7% vs. 7%). However, the incidence of advancement failure was significantly higher in landmark group (40% vs. 7%, P = 0.005). There were no complications such as pneumothorax or hemothorax.ConclusionsThe proper placement of guidewire was less influenced by the direction of the guidewire J-tip with ultrasound-guided subclavian venous cannulation than with the landmark approach.

Direction of the J-Tip of the Guidewire to Decrease the Malposition Rate of an Internal Jugular Vein Catheter

“…The real-time ultrasound technique has been rated as technically difficult by participating physicians [6]. As previously suggested, the benefits of the ultrasound technique may not be realized until after a significant learning period [15]. Third, we initially inserted J-tip in the cephalad direction to maximize the chance of the guidewire going up into the IJV, although this is not a good clinical practice when using landmark technique.…”

Practice Guidelines for Central Venous Access 2020

“…188,191,[194][195][196]199,200,[202][203][204][205] For the subclavian vein, RCTs report fewer insertion attempts with real-time ultrasound-guided venipuncture (Category A2-B evidence), 206,207 and higher overall success rates (Category A2-B evidence). [206][207][208] When compared with a landmark approach, findings are equivocal for arterial puncture 207,208 and hematoma (Category A2-E evidence). 207,208 For the femoral vein, an RCT reports a higher first-attempt success rate and fewer needle passes with real-time ultrasound-guided venipuncture compared with the landmark approach in pediatric patients (Category A3-B evidence).…”

“…[206][207][208] When compared with a landmark approach, findings are equivocal for arterial puncture 207,208 and hematoma (Category A2-E evidence). 207,208 For the femoral vein, an RCT reports a higher first-attempt success rate and fewer needle passes with real-time ultrasound-guided venipuncture compared with the landmark approach in pediatric patients (Category A3-B evidence). 209 Meta-analyses of RCTs comparing static ultrasound with a landmark approach yields equivocal evidence for improved overall success for internal jugular insertion (Category A1-E evidence), 190,202,[210][211][212] overall success irrespective of insertion site (Category A1-E evidence), 182,190,202,[210][211][212] or impact on arterial puncture rates (Category A1-E evidence).…”

Ultrasound-Guided Cannulation: Time to Bring Subclavian Central Lines Back

“…At this point, it enters the thorax as it unites with the IJV behind the sterno-clavicular joint. 10 , 21 , 25 SCV visualization via US is possible in the clavipectoral triangle, 2–3cm distal to the point where the SCV crosses below the clavicle. As a result, US-guided SCV cannulation using an infraclavicular approach is positioned near the border of the axillary vein, which is noticeably lateral to the LM approach.…”

“… 9 , 17 Additionally, real-time longitudinal views lead to a significantly increased overall success rate, with fewer attempts, redirections, or malpositioned catheters. 10 , 16 , 25 In a prospective study by Fragou et al, 401 sedated and mechanically ventilated patients were randomized to either real-time US guidance (n=201) or LM technique (n=200) for placement of subclavian catheters by experienced operators. 10 This study found the time to obtain vascular access and number of attempts were significantly lower using real-time US guidance (p<0.05).…”