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Ultrasound-guided in-plane supraclavicular approach for central venous catheterisation in patients with underlying bleeding disorders.

The use of real-time ultrasound guidance is recommended as a safety measure when performing central venous catheter (CVC) insertion (1). Central venous catheter with ultrasound guidance is often performed with a short axis view of the vein and an out-of-plane approach of the needle. However, the needle tip cannot be visible continuously with the out-of-plane approach, so there is a risk of an accidental artery puncture (2). An accidental artery puncture potentially results in more severe consequences in patients with underlying coagulation disorder. We describe a method for CVC at the supraclavicular region using a needle with an in-plane ultrasound imaging approach (using the needle parallel to the ultrasound beam) with a semi-axial view of the internal jugular vein. This approach enables a CVC to be inserted with real-time continuous visualisation of the entire needle path.

A CVC was scheduled in 15 patients with a coagulation disorder (platelet count under 50000 /[micro]l and/or International Normalised Ratio >1.5). Other more common CVC sites were not used due to the risks of infection, artery puncture and/or difficulty in the patient assuming the supine position. Patients were placed in the supine position if possible; a semi-sitting position was used if the supine position could not be tolerated due to pain or respiratory distress. Each patient's ipsilateral arm was at the side, and the patient's head was turned slightly to the left side. The operator stood on the right side of the patient. A Sonosite M-turbo ultrasound system with a 6 to 13 MHz linear probe was used (Sonosite Inc., Bothell, WA USA). The probe was placed on the supraclavicular region parallel to and just rostral to the medial right clavicle. Initially, the scanning was performed perpendicular to the body where the internal jugular vein was imaged as an oval shape close to the carotid artery. As the scanning is directed caudally, the carotid artery separates from the internal jugular and subclavian veins, and the right brachiocehalic vein appears. The puncture was performed in the plane where the junction of the internal jugular and subclavian veins were scanned and the carotid artery remained separated from the veins. The lateral wall of the internal jugular vein near the junction of the subclavian veins was the target point for puncture. The puncture site of the skin was 1 cm lateral to the sternocleidomastoid muscle, which is a conventional puncture site for CVC insertion using the classical supraclavicular approach without the ultrasound (3). A 27 gauge 38 mm needle was used for local anaesthesia. After 3 to 5 mm insertion of the needle with the angle of 10[degrees] to theskin, the ultrasound probe was placed over the puncture site and the whole needle including the tip was visualised on the ultrasound monitor. The needle was then directed to the targeted vein with the angle to the skin being less than 30[degrees] and the whole needle being easily recognised on the monitor. The single wall puncture modified Seldinger technique using a 12 gauge catheter kit was adopted. The targeted vein was punctured with the 18 gauge needle with ultrasound guidance from the same site of the skin and in the same way as the local anaesthesia (Figure 1). All CVCs were performed without difficulty and no adverse events such as artery puncture, bleeding or pneumothorax occurred.

An in-plane imaging approach is not usually used for CVC insertion because the simultaneous visualisation of the needle and vein is difficult with an in-plane approach; a long axis view where a vein is imaged longitudinally. Our target vein is superficially located in the supraclavicular region, and can be visualised easily with the semi-short axis of the vein when the ultrasound probe is placed on the supraclavicular region. Furthermore, the caudal direction of the needle enables the catheter to easily pass into the superior vena cava without a tendency to the catheter migrating in the cranial direction. There is a report of CVC using ultrasound with an in-plane approach at the supraclavicular region for adult patients (4). The authors described that ultrasound-guided subclavian venous cannulation can be performed just as it is for internal jugular or femoral central lines4. Our method differs from theirs. First, we used a linear probe, which is easier to use and provides a clearer image than an endocavitary probe which they used. Second, their target is the subclavian vein which is located deeper than our target point. We feel that it is easier and safer to use a linear probe and our target point for the patient with difficulties or complications.


Some special considerations are necessary for CVC insertions in the supraclavicular region. First, the thoracic duct enters at the junction of the internal jugular and subclavian veins on the left side, so it is safer to avoid the left side if possible. Second, if the carotid artery is punctured in this area, direct external pressure is difficult. To prevent this complication, the needle should not be moved when the needle tip is not visible on the monitor. We recommend that an ultrasound-guided in-plane supraclavicular approach should be considered as an option for CVC insertion, especially in patients with underlying bleeding disorders.


(1.) National Institute for Clinical Excellence. Guidance on the use of ultrasound locating devices for placing central venous catheters. NICE technology appraisal guidance No 49: London: NICE, 2002. Available from ultrasound_49_GUIDANCE.pdf

(2.) Blaivas M, Adhikari S. An unseen danger: frequency of posterior vessel wall penetration by needles during attempts to place internal jugular vein central catheters using ultrasound guidance. Crit Care Med 2009; 37:2345-2349; quiz 2359.

(3.) Patrick SP, Tijunelis MA, Johnson S, Herbert ME. Supraclavicular subclavian vein catheterization: the forgotten central line. West J Emerg Med 2009; 10:110-114.

(4.) Mallin M, Louis H, Madsen T. A novel technique for ultrasound-guided supraclavicular subclavian cannulation. Am J Emerg Med 2010; 28:966-969.




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Title Annotation:Correspondence
Author:Takechi, K.; Tubota, S.; Nagaro, T.
Publication:Anaesthesia and Intensive Care
Article Type:Viewpoint essay
Date:Nov 1, 2011
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