Supraclavicular versus infraclavicular approach for ultrasound-guided right subclavian venous catheterisation: a randomised controlled non-inferiority trial

Kim. Anaesthesia 2022,77(1)59-65; doi.org/10.1111/anae.15525

Clinical Question

• In patients undergoing elective neurosurgery, is a supraclavicular in-plane ultrasound guided approach, compared with an infra-clavicular out-of-plane ultrasound guided approach, non-inferior for catheterisation-related complication?

Background

• The internal jugular, femoral and subclavian veins are commonly used for central venous lines
• The use of subclavian lines is associated with a lower risk of infection but a higher risk of pneumothoraces
• Subclavian lines can be placed either supra or infra-clavicular. Previous single operator RCTs (1, 2) have demonstrated that for a single operator ,ultrasound guided supraclavicular approach was quicker, with similar success rates and fewer complications, compared with an infraclavicular approach
• When an infra-clavicular approach is used the use of the short axis out-of-plane ultrasound has been reported to have significant advantages over the use of long axis in-place ultrasound

Design

• Randomised controlled trial
• Non-inferiority trial
• Computer generated random allocation sequence, 1:1 ratio
• Use of sealed opaque envelopes to maintain allocation concealment
• Sample size calculation: 416 patients. With a false positive rate set at 5%, false negative rate set at 20%, and non-inferiority margin set at 5.9%, 416 patients required assuming a drop-out rate of 5%

Setting

• Single centre, Seoul National University Hospital
• September 2018 – May 2020

Population

• Inclusion:
  • Age 20-79
  • Required central venous catheterisation
  • Undergoing elective general anaesthetic for neurosurgery
• Exclusion:
  • Infection or medical device at the puncture site
  • Right subclavian venous thrombosis
  • Haemostatic disorders or receiving anticoagulant
  • Previous history of surgery that might distort the anatomy of the right subclavian vein
• 416 patients randomised. 8 patients excluded as not appropriately allocated, 4 withdrew consent, and 3 did not meet inclusion criteria, leaving 401 patients included in analysis
• Comparing baseline characteristics of intervention vs. control group
  • Male: 45% vs 49%
  • Age: 53 vs 51 years
  • BMI: 24 vs 25
  • ASA 1/2: 79% vs 80%
  • ASA 3: 17% vs 18%
  • ASA 4: 4% vs 2%

Intervention

• Supra-clavicular approach
  • Long-axis in-plane ultrasound

Control

• Infra-clavicular approach
  • short-axis out-of-plane ultrasound

Management common to both groups

• All other peri-operative management was the same
• Central line inserted after induction of general anaesthesia. Bed in flat position, with pillow removed and head, neck and arms in a neutral position
• VscanTM portable ultrasound machine
• One of four anaesthetists who all had at least 10 successful cannulations with both approaches
• Mechanical ventilation stopped prior to venous puncture, and re-started after successful catheterisation

Outcome

• Primary outcome: proportion of patients with catheterisation-related complications, including catheter misplacement and mechanical complications (arterial puncture, haematoma formation, pneumothorax and haemothorax)
  • 3% in supra-clavicular vs 13.4% in infra-clavicular group
    • Mean difference -10.4% (95% CI -15.7 to -5.1%), OR 0.20 (95% CI 0.8-0.49), p<0.001
• Secondary outcomes:
• Comparing intervention vs. control group
  • No significant difference in
    • Overall success
      • 99.5% vs 99.5%
    • Success at 1st attempt for catheterisation
      • 87% vs 88%
    • Time required for catheterisation
      • 79 vs 78 seconds
    • Incidence of mechanical complications
      • 2% vs 3%
    • Arterial puncture
      • 2% vs 1.5%
    • Pneumothorax
      • 0% vs 1%
    • Rescue ventilation
      • 14.5% vs 12.4%
  • Significantly less in supra-clavicular group
    • Catheterisation related complication
      • 3% vs 13.4%
      • Mean difference -10.4 (95% CI -15.7 to -5.1%), OR 0.2 (0.08-0.49), p<0.001
    • Catheter misplacements
      • 1% vs 10.4%
      • Mean difference -9.4 (95% CI -13.9 to -5), OR 0.09 (0.02-0.37), p<0.001
    • Catheter misplacement into ipsilateral internal jugular vein 0.5% vs 8%
      • Mean difference -7.5 (95% CI -11.4 to -3.6%), OR 0.06 (0.01-0.44), p<0.001
    • Time required for venous puncture
      • 9 vs 13 seconds

Authors’ Conclusions

• The supraclavicular approach seems to be a better approach for ultrasound-guided right subclavian venous catheterisation

Strengths

• Randomised controlled trial
• Multi-operator, all operators were experienced with both techniques
• Allocation concealment maintained

Weaknesses

• The supraclavicular approach used an inplane ultrasound where as the infaclavicular approach used out-of plane ultrasound. Although i understand the reasons for this, this may be a confounding variable
• This was a non-inferiority study and and was not designed to address superiority
• Single centre study in South Korea
• Only included patients who were mechanically ventilated and having elective neurosurgery. Results may not be generalisable to other settings
• Blinding of those inserting lines not possible
• 3.6% of patients randomised not included in analysis

The Bottom Line

• In elective patients undergoing subclavian central line insertion, the use of a supra-clavicular approach with in-plane ultrasound was non-inferior to an infra-clavicular approach with out-of-plane ultrasound.
• The success rates were similar for both approaches where as the rate of catheter related complications was significantly less with the supra-clavicular approach. This was predominately due to a reduction in catheter misplacement

External Links

• [article] Supraclavicular versus infraclavicular approach for ultrasound-guided right subclavian venous catheterisation: a randomised controlled non-inferiority trial
• [further watching] How To: Supraclavicular Approach to Subclavian Vein Cannulation – SonoSite Ultrasound

Metadata

Summary author: @davidslessor
Summary date: 14th Jan 2022
Peer-review editor: @avkwong

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