Author: Brian T. Gierl, M.D.
Anesthesiology 2 2018, Vol.128, 423.
To the Editor:
In reading “Examining the Edges of Extravasation”1 I noticed that the subclavian catheter enters the skin quite laterally. A more lateral cannulation often tunnels through the pectoral musculature, the tail of the breast in a female patient, and a thicker portion of adipose tissue than would a more medially placed catheter. These structures are mobile and allow for the distance from the skin to the vessel to change as patients are positioned, bathed, perform physical therapy, or move of their own volition. Such motion may result in a significant portion of the proximal catheter, and thus the proximal port, leaving the vessel and causing the subsequent extravasation.
The authors do not specify the method of cannulation, but a subclavian catheter that is placed via landmarks is usually located quite medially while a more lateral approach is preferred with the use of ultrasound guidance so that the vein is not in the shadow of the clavicle. Technically, ultrasound guidance often results in cannulation of the axillary vein rather than the subclavian vein proper. A systematic review and meta-analysis2 and a prospective study3 of ultrasound guidance for subclavian cannulation concluded that ultrasound guidance reduced the frequency of complications, such as artery puncture and hematoma, hemothorax, pneumothorax, and nerve injury relative to internal jugular vein cannulation. Ultrasound is also a means to check for a pneumothorax without the costs associated with a traditional chest roentgenogram. Although the ultrasound technique does purport many benefits, Bronshteyn and Bittner’s case demonstrates one specific complication that can also occur with a more lateral cannulation, such as often occurs with the use of ultrasound guidance.
Brian T. Gierl, M.D., University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
Bronshteyn, YS, Bittner, EA . Examining the edges of extravasation. Anesthesiology 2017; 126:716
Lalu, MM, Fayad, A, Ahmed, O, Bryson, GL, Fergusson, DA, Barron, CC, Sullivan, P, Thompson, C ; Canadian Perioperative Anesthesia Clinical Trials Group: Ultrasound-guided subclavian vein catheterization: A systematic review and meta-analysis. Crit Care Med 2015; 43:1498–507
Fragou, M, Gravvanis, A, Dimitriou, V, Papalois, A, Kouraklis, G, Karabinis, A, Saranteas, T, Poularas, J, Papanikolaou, J, Davlouros, P, Labropoulos, N, Karakitsos, D . Real-time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients: A prospective randomized study. Crit Care Med 2011; 39:1607–12