Shoulder positioning for subclavian venous catheterization

Jeong HH, et al. A quantitative analysis of the relation between the clavicular tilt angle and subclavian central venous catheter misplacement. Clin Exp Emerg Med. 2014 Dec 31; 1(2):114-119.

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RESULTS: Among all central venous catheterizations (n=1,599), the subclavian route was used 981 times (61.4%). There were 51 misplacements of SCV catheters (5.2%) during the study period. There were no differences in the sex, age, blood pressure, and diagnosis between the two groups. The CTA values were 28.5°±7.3° and 22.6°±6.3° in the misplacement group and control group, respectively (95% confidence interval, 3.6 to 8.1; P<0.001).

CONCLUSION: In this study, the CTA was found to be 5.9° larger in the misplacement group than in the control group. Assuming that CTA indicates the shoulder position, our findings suggest that the chance of SCV catheter misplacement may be reduced by avoiding the shoulder elevated.

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Infection rates of different CVC insertion sites

Arvaniti K, et al. Cumulative Evidence of Randomized Controlled and Observational Studies onCatheter-Related Infection Risk of Central Venous Catheter Insertion Site in ICU Patients: A Pairwise and Network Meta-Analysis. Crit Care Med. 2017 Apr;45(4):e437-e448.

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Data Synthesis: Twenty studies were included; 11 were observational, seven were randomized controlled trials for other outcomes, and two were randomized controlled trials for sites. We evaluated 18,554 central venous catheters: 9,331 from observational studies, 5,482 from randomized controlled trials for other outcomes, and 3,741 from randomized controlled trials for sites. Colonization risk was higher for internal jugular (relative risk, 2.25 [95% CI, 1.84-2.75]; I2 = 0%) and femoral (relative risk, 2.92 [95% CI, 2.11-4.04]; I2 = 24%), compared with subclavian. Catheter-related bloodstream infection risk was comparable for internal jugular and subclavian, higher for femoral than subclavian (relative risk, 2.44 [95% CI, 1.25-4.75]; I2 = 61%), and lower for internal jugular than femoral (relative risk, 0.55 [95% CI, 0.34-0.89]; I2 = 61%). When observational studies that did not control for baseline characteristics were excluded, catheter-related bloodstream infection risk was comparable between the sites.

Conclusions: In ICU patients, internal jugular and subclavian may, similarly, decrease catheter-related bloodstream infection risk, when compared with femoral. Subclavian could be suggested as the most appropriate site, whenever colonization risk is considered and not, otherwise, contraindicated. Current evidence on catheter-related bloodstream infection femoral risk, compared with the other sites, is inconclusive.

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The utility of Trendelenburg position on subclavian port placement

Kwon MY, Lee EK, Kang HJ, et al. The effects of the Trendelenburg position and intrathoracic pressure on the subclavian cross-sectional area and distance from the subclavian vein to pleura in anesthetized patients. Anesth Analg. 2013;117(1):114–118.

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“We evaluated the effects of increased intrathoracic pressure (20 cm H2O) or Trendelenburg position on the CSA and DSCV-pleura during SCV catheterization and general anesthesia, and determined whether their changes were clinically relevant (defined as [DELTA]CSA and [DELTA]DSCV-pleura >=15% vs S-0). Applying positive intrathoracic pressure alone or Trendelenburg position alone provided a statistically increased CSA of the SCV, but this increase did not meet our defined threshold for a relevant degree ([DELTA]CSA of >=15%). Only the combined application of these 2 maneuvers yielded a relevant increase in the CSA ([DELTA]CSA 23.2% vs S-0). No maneuvers provided a relevant change of DSCV-pleura ([DELTA]DSCV-pleura >=15%) despite their statistically significant changes in some conditions.” (Kwon, 2013, p. 116)

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