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• W4296175855 abstract "The subclavian vein puncture is recommended to be performed under ultrasound guidance to prevent complications. It is also recommended that the subclavian vein be dilated with positive intravenous pressure to facilitate puncture and prevent air embolism (1Merrer J. De Jonghe B. Golliot F. et al.Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial.JAMA. 2001; 286: 700-707Crossref PubMed Scopus (962) Google Scholar). The Valsalva method and the Trendelenburg position are the most commonly used methods for venous dilation (2McGee D.C. Gould M.K. Preventing complications of central venous catheterization.N Engl J Med. 2003; 348: 1123-1133Crossref PubMed Scopus (1596) Google Scholar, 3Kwon M.Y. Lee E.K. Kang H.J. et al.The effects of the Trendelenburg position and intrathoracic pressure on the subclavian cross-sectional area and distance from the subclavian vein to pleura in anesthetized patients.Anesth Analg. 2013; 117: 114-118Crossref PubMed Scopus (11) Google Scholar, 4Lim K.J. Lee J.M. Byon H.J. et al.The effect of full expiration on the position and size of the subclavian vein in spontaneously breathing adults.Anesth Analg. 2013; 117: 109-113Crossref PubMed Scopus (14) Google Scholar). Although the Valsalva method is a useful technique for dilating the subclavian vein, unconscious patients, elderly patients, and patients with dementia are often unable to follow the instructions to perform a respiratory arrest. The Trendelenburg position is a well-known method for dilating the veins in patients who find it difficult to follow the instructions, such as holding their breath. However, the Trendelenburg position has a limited effect on the dilation of the subclavian vein (4Lim K.J. Lee J.M. Byon H.J. et al.The effect of full expiration on the position and size of the subclavian vein in spontaneously breathing adults.Anesth Analg. 2013; 117: 109-113Crossref PubMed Scopus (14) Google Scholar). Therefore, the purpose of this study was to evaluate the oblique position method to dilate the subclavian vein. This single-center, prospective, observational study was approved by the institutional review board (Watanabe Hospital) and conducted in accordance with the World Medical Association’s Code of Ethics (Declaration of Helsinki), and informed consent was obtained from all patients. Between November 2020, and April 2021, 67 patients with dementia (24 men, 43 women; age, 83 ± 7.1 years) who required high-calorie infusion because of difficulty with oral intake were enrolled. Patients with severe heart failure, severe dehydration, administration of circulatory agonists, severe skin infections, or a history of radiotherapy were excluded. A patient was placed on a mattress, and a cushion was placed under the left or right side of the mattress to tilt the patient’s body by 30°. The patients were placed in the right anterior oblique (RAO) position by elevating the right side of the patient and in the left anterior oblique (LAO) position by elevating the left side. No cushion was used to place the patient in the anteroposterior (AP) position (Fig 1). The long axis of the subclavian vein was visualized by US in the RAO, AP, and LAO positions, and the maximum anterior–posterior diameter of the vein was measured at maximum exhalation during natural respiration (Fig 2). All measurements of the subclavian vein diameters in all patients were performed by the same radiologist (N.K.). The subclavian vein diameters in the RAO, AP, and LAO positions were compared by t tests. Multiple comparisons among the 3 positions were performed using the Bonferroni method; the corrected P value was .017 (.05/3). Statistical analysis was performed using JMP Pro 14.1 (SAS Institute, Cary, North Carolina).Figure 2Measurement of the subclavian vein diameter. The maximum anterior–posterior diameter (inner wall to inner wall) of the subclavian vein was measured on a long-axis ultrasound image (double-headed arrow). (a) The left subclavian vein in the right anterior oblique position; (b) the left subclavian vein in the left anterior oblique position.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The diameters of both subclavian veins were measured in all 67 patients. In 6 patients, both subclavian veins were excluded because of heart failure. In 5 patients, both subclavian veins were excluded because of administration of vasopressors, and in 1 patient, the right subclavian vein was excluded because of a skin infection. The diameters of 55 right subclavian veins and 56 left subclavian veins were compared (Table). The mean ± standard deviation (95% confidence interval) diameter of the right subclavian vein was 7.2 mm ± 4.0 (6.1–8.2 mm) in the RAO position, 10.9 mm ± 4.0 (9.8–11.9 mm) in the AP position, and 16.9 mm ± 5.1 (15.5–18.3 mm) in the LAO position. The diameter of the left subclavian vein was 16.0 mm ± 4.3 (14.8–17.1 mm) in the RAO position, 11.6 mm± 3.8 (10.6–12.6 mm) in the AP position, and 8.9 mm ± 4.6 (7.7–10.1 mm) in the LAO position (Fig 3). The diameters of both subclavian veins were significantly different among the 3 positions (P < .001).TableThe Subclavian Vein Diameter in the 3 PositionsPositionRight subclavian vein diameter (mm)Left subclavian vein diameter (mm)Right anterior oblique7.2 ± 4.0 (6.1–8.2)16.0 ± 4.3 (14.8–17.1)Anteroposterior10.9 ± 4.0 (9.8–11.9)11.6 ± 3.8 (10.6–12.6)Left anterior oblique16.9 ± 5.1 (15.5–18.3)8.9 ± 4.6 (7.7–10.1)Note–Values are reported as mean ± standard deviation (95% confidence interval). Open table in a new tab Note–Values are reported as mean ± standard deviation (95% confidence interval). Puncturing of the subclavian vein has been discouraged in recent years because of the risk of serious complications, such as hemothorax, pneumothorax, pinch off syndrome, and superior vena cava structure. However, the subclavian vein has a low risk of infection and thrombotic occlusion (1Merrer J. De Jonghe B. Golliot F. et al.Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial.JAMA. 2001; 286: 700-707Crossref PubMed Scopus (962) Google Scholar,2McGee D.C. Gould M.K. Preventing complications of central venous catheterization.N Engl J Med. 2003; 348: 1123-1133Crossref PubMed Scopus (1596) Google Scholar). In this study, the results showed that the subclavian vein dilated significantly when it was lowered in the oblique position, but it narrowed significantly when it was elevated. A possible reason for the significant change in the venous diameter in the oblique position is the effect of gravity. This study has 4 limitations to discuss. First, dehydration and congestion may reduce the dilating effect of the oblique position on the subclavian vein; however, they were not evaluated in this study. Second, when the patient is placed in the oblique position, the forward protrusion of the lower shoulder means it is more difficult to perform the puncture. Therefore, the patient’s shoulder must be fixed to the mattress. Third, the oblique position method was not compared with the Valsalva method or Trendelenburg position. However, the oblique position can be used in combination with these methods. Fourth, this study only evaluated the diameter of the subclavian veins and did not compare puncture success rates. In conclusion, the oblique position method effectively dilated the subclavian vein prior to attempting central venous access. The findings of this study suggest that, when puncturing the subclavian vein, it may be helpful to lower the puncture side to increase intravenous pressure and venous diameter." @default.
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• W4296175855 date "2022-12-01" @default.
• W4296175855 modified "2023-10-16" @default.
• W4296175855 title "Oblique Positioning to Facilitate Venous Access into the Subclavian Vein" @default.
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• W4296175855 doi "https://doi.org/10.1016/j.jvir.2022.09.011" @default.
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