Supraclavicular route bests infraclavicular route for subclavian vein catheterization

A common invasive technique used to evaluate central venous pressure or administer drugs continuously is central venous catheterization (CVC). Annually, the United States performs around 5 million CVC surgeries. Internal jugular (IJ) and femoral catheterization are known to cause more occurrences of infection, thrombosis, and patient discomfort than subclavian vein catheterization (SVC). However, due to worries of pneumothorax, poor positioning, and subclavian arterial puncture, SVC may be avoided.

SVC typically uses either the supraclavicular (SC) or infraclavicular (IC) techniques. The clavi-sternomastoid angle, a close proximity between the body surface and the vein, a larger target vein domain, a less angular path to the vein, and a greater distance from the lung are all anatomical advantages of the SC approach over the IC approach. To conclusively prove the superiority of the SC technique, a full systematic review employing the GRADE criteria was recently released and used to establish the superiority of the SC strategy.

In May 2022, authors looked for randomised controlled studies to compare the two strategies in the databases of Embase, MEDLINE, CENTRAL, ClinicalTrials.gov, and WHO-ICTRP. 2482 instances from 17 trials were included. The SC approach may slightly reduce the incidence of arterial puncture and pneumothorax (RR, 0.59; 95% CI, 0.29-1.22; I2 = 0%) with low evidence, and it is likely to reduce the failure proportion (relative risk [RR], 0.63; 95% confidence interval [CI], 0.47-0.86; I2 = 5%) and the incidence of malposition (RR, 0.23; 95% CI, 0.13-0.39; I2 = 0%). The SC strategy may shorten access times and boost first-attempt success rates in the secondary outcomes.

The research demonstrated that, with reasonable evidence, the SC technique decreased the failure percentage and incidence of malposition more than the IC strategy. The SC technique may also marginally improve the first-attempt success rate while lowering access time, arterial puncture, and pneumothorax occurrence rates. Strong evidence for the efficacy and safety of the SC method utilizing the GRADE approach is provided by this revised systematic review. This study's clinical implications suggest that when catheterizing the subclavian vein, the SC method should be used. The clavi-sternomastoid angle, for example, is a well-known insertion site that makes it simple to employ the landmark technique in the SC approach. The short distance from the body surface to the vein also makes it simple to see the vein under ultrasound guidance. In addition to providing reliable ultrasound pictures, the vein's superficial placement makes it simple to insert a needle into the vein. The vein is very simple to cannulate and has a broad target area. In light of these anatomical features, the SC method could see fewer failures and quicker access times. In addition, the SC technique, unlike the IC method, does not enter the pectoralis major and makes it simpler to get a long-axis picture and go straight to the vein. The additional anatomical characteristics mentioned above are thought to induce less malpositioning as a consequence. When the CVC is completed by skilled operators, the incidence of problems like pneumothorax has reportedly decreased. Operators who have a lot of expertise with the IC technique may thus find it appropriate. For fresh subclavian venepunctures, people without such expertise should adopt the SC method.

This revised meta-analysis demonstrates that there is modest evidence that the SC technique, as compared to the IC approach, lowers the failure percentage and incidence of malposition.

Reference –

Imai, Eriya1,2,; Watanabe, Jun2,3,4; Okano, Hiromu2,5; Yokozuka, Motoi1. Efficacy and safety of supraclavicular versus infraclavicular approach for subclavian vein catheterisation: An updated systematic review and meta-analysis of randomised controlled trials. Indian Journal of Anaesthesia 67(6):p 486-496, June 2023. | DOI: 10.4103/ija.ija_837_22