Real-time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients: a prospective randomized study.

OBJECTIVE Subclavian vein catheterization may cause various complications. We compared the real-time ultrasound-guided subclavian vein cannulation vs. the landmark method in critical care patients. DESIGN Prospective randomized study. SETTING Medical intensive care unit of a tertiary medical center. PATIENTS Four hundred sixty-three mechanically ventilated patients enrolled in a randomized controlled ISRCTN-registered trial (ISRCTN-61258470). INTERVENTIONS We compared the ultrasound-guided subclavian vein cannulation (200 patients) vs. the landmark method (201 patients) using an infraclavicular needle insertion point in all cases. Catheterization was performed under nonemergency conditions in the intensive care unit. Randomization was performed by means of a computer-generated random-numbers table and patients were stratified with regard to age, gender, and body mass index. MEASUREMENTS AND MAIN RESULTS No significant differences in the presence of risk factors for difficult cannulation between the two groups of patients were recorded. Subclavian vein cannulation was achieved in 100% of patients in the ultrasound group as compared with 87.5% in the landmark one (p < .05). Average access time and number of attempts were significantly reduced in the ultrasound group of patients compared with the landmark group (p < .05). In the landmark group, artery puncture and hematoma occurred in 5.4% of patients, respectively, hemothorax in 4.4%, pneumothorax in 4.9%, brachial plexus injury in 2.9%, phrenic nerve injury in 1.5%, and cardiac tamponade in 0.5%, which were all increased compared with the ultrasound group (p < .05). Catheter misplacements did not differ between groups. In this study, the real-time ultrasound method was rated on a semiquantitative scale as technically difficult by the participating physicians. CONCLUSIONS The present data suggested that ultrasound-guided cannulation of the subclavian vein in critical care patients is superior to the landmark method and should be the method of choice in these patients.