TY - JOUR
AU - Lampotang,, Samsun
AB - Abstract In a study with 76 anesthesia providers on a mixed reality simulator, central venous access via the supraclavicular approach to the subclavian vein, without ultrasonography required less attempts compared to the infraclavicular approach. Participants had shorter times to venous access and larger improvements in confidence. Results from this simulation-based study indicate that the supraclavicular approach may deserve consideration as an alternative approach for central venous access in deployed military environments. The use of ultrasonography during the supraclavicular approach to the subclavian vein is also described which may improve its safety profile. This technique could be more appropriate in scenarios when central venous access is preferred over intraosseous access for patients being transported to another location for further care. INTRODUCTION Military medical triage and emergent resuscitative protocols are in a constant state of evolution as the nation adapts to new challenges and objectives. Military deployments are changing rapidly, as the USA has reached a “critical inflection point” in how it deploys special operations forces. Mounting budget concerns combined with the reality of maintaining large-scale wars have prompted reliance on smaller, more cost-effective operations.1 Classically defined transitions from point of injury to arrival at tertiary care facilities have been blurred, as evidenced by new programs designed to augment care delivery in austere locations. The United States Air Force’s TCCET program is an example of one of these programs.2 As capabilities, reliance on conventional resources, and timelines for treatment evolve, addressing classical challenges with alternative options to venous access may be beneficial. The supraclavicular approach to the subclavian vein, first described by Yoffa et al in 1965, offers many advantages compared to other approaches to accessing the central venous system.3 When accessing the subclavian vein via the supraclavicular approach, the skin puncture site is closer to the target because the subclavian vein is more superficial, the needle trajectory intersects a larger cross-sectional area of the vein, the vein is farther from the lung pleura, and complication rates are potentially lower.4–6 It is associated with a 78.9% first attempt success rate, an overall success rate of 79–100% (median 95%), and a complication rate of 0.8–13.3% (median 2.1%).4,7 The supraclavicular approach has been found to be particularly advantageous during care of arrested patients who receive cardiopulmonary resuscitation.6 Complications associated with the supraclavicular approach to the subclavian vein include arterial puncture and pneumothorax.4 Additionally, this approach has been identified as safe and appropriate for pediatric populations.8 The largest barrier to use of the supraclavicular approach to the subclavian vein in clinical practice is probably the lack of familiarity with the technique compared to accessing the subclavian by the infraclavicular route, as well as accessing the internal jugular (IJ) or femoral veins. The use of ultrasonography with the supraclavicular technique may increase its safety profile and improve the provider’s ability to learn the technique. To find the subclavian vein with ultrasound for the supraclavicular approach, hold the ultrasound probe in the coronal plane over the common jugular. Follow the common jugular by sweeping the ultrasound probe caudally. At the level of the clavicle, tilt the probe caudally until the confluence with the subclavian vein is in view. To obtain a cross-sectional view of the subclavian vein, rotate the ultrasound probe counter-clockwise to about 45 degrees to the sagittal plane, keeping an eye on your image for optimization (Fig. 1). This will help facilitate needle access to the vein in an out-of-plane approach to the subclavian vein. FIGURE 1. View largeDownload slide Positioning of ultrasound probe to assist with accessing the subclavian vein using the supraclavicular approach. FIGURE 1. View largeDownload slide Positioning of ultrasound probe to assist with accessing the subclavian vein using the supraclavicular approach. The purpose of this study is to compare errors and complications associated with the supraclavicular approach to accessing the subclavian vein with the more commonly used approaches, ultrasound-guided IJ and infraclavicular. We will also examine whether training on the simulator produces increased confidence to perform supraclavicular access as an alternative for ease of insertion. METHODS After IRB02 approval (2013-U-1025), 76 volunteers consented to receive training and also take part in a study with the University of Florida Central Venous Access Mixed Reality (UF_CVA_MR) simulator in accessing the IJ using ultrasonography and accessing the subclavian vein without ultrasonography using both the infraclavicular and supraclavicular approach. Inclusion criteria for participation in the study were being either a current house officer at the University of Florida, an attending anesthesiologist at the University of Florida, or a current anesthesia extender working at UFHealth. Individuals were free to refuse to take part in the study and were excluded from the study if they wanted to receive training for central venous access (CVA) but did not wish to participate in the study. A full description of the methodology for the supraclavicular portion has previously been published.9 Since participants have had prior experience with the infraclavicular approach to the subclavian vein and the anterior approach to the IJ vein, an additional attempt (compared to the supraclavicular approach to the subclavian vein) was evaluated prior to any instructions to garner a true baseline. For the rest of this manuscript, baseline will refer to after scripted instructions were given, but prior to the use of any augmented reality 3D visualization in all three approaches. The simulator used for the study is designed for austere environments in concordance with a DoD Medical Practice Initiative Augmented Reality for Medical Applications so that it may be used by deployed military medical personnel. The simulator does not require wireless connection, internet access, or wet fluids. It is anatomically correct, using 3D-printed plastic to mimic bony structures and silicone for soft tissue. The mixed reality component allows for teaching and learning, practice, and debriefing participants’ attempts to obtain central venous access with and without ultrasound guidance. Videos of the simulator can be accessed at http://simulation.health.ufl.edu/research/augmentmixedsim.php and https://www.youtube.com/watch?v=P6yU7Uzwuvo&feature=youtu.be. The simulator uses mixed reality via an anatomically authentic CT scan-based 3D-printed physical mannequin of an actual human; the simulator has a corresponding virtual model of the anatomy of the neck and upper chest. It simulates the placement of a central venous line from the identification of relevant anatomy, to the aspiration of blood from the target blood vessel prior to insertion of a wire when using the Seldinger technique. Handheld instruments such as a needle, an ultrasound probe, and a virtual camera controller (aka Tangible User Interface) are directly manipulated by the trainee and tracked with sub-millimeter resolution via miniature magnetic sensors. The instruments are interoperable between compatible procedural simulators, including for different ultrasound-guided needling procedures like regional anesthesia. An automated scoring algorithm and a replay system allow self-debriefing.10,11 During this study, participants were given scripted instructions on accessing the IJ vein with ultrasound guidance and accessing the subclavian vein “blindly” using an infraclavicular and supraclavicular approach. All attempts were recorded virtually and scored using a proprietary scoring algorithm. Factors impacting the final score include time to access, trajectory of the advancing needle, and proximity to other structures. Complications that occurred during each attempt were also recorded. All participants completed a post-study questionnaire and were debriefed. Statistically significant differences in time to access, by trial and approach, were evaluated by computing the mean, standard deviation, and 95% confidence interval. A confidence interval provides a range of values for the population mean and non-overlapping confidence intervals are evidence of a statistically significant difference. The Wilcoxon sign test was used to determine whether the difference in the number of errors and complications (backwall, pneumothoraces, arterial punctures, and additional attempts) was statistically significant comparing the supraclavicular approach to the two more commonly used approaches, i.e., ultrasound-guided IJ and subclavian (infraclavicular) access. Confidence gains were assessed with the dependent samples t-test. All statistical analyses were conducted using SAS v. 9.4 (SAS Institute Inc, Cary, NC, USA). After completion of the study, additional ultrasound images were obtained from volunteers with permission. Cross-sectional areas were estimated using SketchAndCalc.com (iCalc Inc, Palm Coast, FL) by tracing the perimeters of the vessels. RESULTS Successful access of the vein for each trial and approach is reported in Table I. The Chi-square test of independence with exact p-values shows no difference in successful vein access at baseline trial (χ2 = 4.9, p = 0.15) or final trial (χ2 = 5.3, p = 0.13) for the three approaches. Descriptive statistics for time required to achieve access, measured in seconds, are also reported in Table I. At baseline trial, the mean time to access (with 95% confidence interval) for the supraclavicular approach was 18.0 seconds (14.9, 21.1). This was faster than both the IJ approach [M = 47.5 s (35.3, 59.8)] and the infraclavicular approach [M = 63.3 s, (47.7, 78.9)]. There was no difference in time to access between IJ and infraclavicular approaches (t = 0.39, p = 0.70). After simulator training, at final trial, participants on average obtained faster access with the supraclavicular approach than with both the IJ and the infraclavicular approach. Obtaining access via IJ was also statistically significantly faster than using the infraclavicular approach (95 % CI was 15.6–20.2 seconds versus 24.5–56.1 seconds) In addition, time to access decreased from baseline to final trial for the supraclavicular and IJ approach, but not the infraclavicular approach. TABLE I. Percent Successful Vein Access and Time to Access by Approach and Trial Supraclavicular Internal Jugular Subclavian (Infraclavicular) Time to Access (seconds) Time to Access (seconds) Time to Access (seconds) Trial Vein Access (%) M (SD) 95% CI Vein Access (%) M (SD) 95% CI Vein Access (%) M (SD) 95% CI Baseline 98.7 18.0 (13.8) (14.9, 21.1) 97.4 47.5 (54.5) (35.3, 59.8) 92.1 63.3 (70.1) (47.7, 78.9) Final 100.0 9.8 (7.9) (8.1, 11.6) 98.7 17.9 (10.3) (15.6, 20.2) 94.7 40.3 (70.6) (24.5, 56.1) Supraclavicular Internal Jugular Subclavian (Infraclavicular) Time to Access (seconds) Time to Access (seconds) Time to Access (seconds) Trial Vein Access (%) M (SD) 95% CI Vein Access (%) M (SD) 95% CI Vein Access (%) M (SD) 95% CI Baseline 98.7 18.0 (13.8) (14.9, 21.1) 97.4 47.5 (54.5) (35.3, 59.8) 92.1 63.3 (70.1) (47.7, 78.9) Final 100.0 9.8 (7.9) (8.1, 11.6) 98.7 17.9 (10.3) (15.6, 20.2) 94.7 40.3 (70.6) (24.5, 56.1) TABLE I. Percent Successful Vein Access and Time to Access by Approach and Trial Supraclavicular Internal Jugular Subclavian (Infraclavicular) Time to Access (seconds) Time to Access (seconds) Time to Access (seconds) Trial Vein Access (%) M (SD) 95% CI Vein Access (%) M (SD) 95% CI Vein Access (%) M (SD) 95% CI Baseline 98.7 18.0 (13.8) (14.9, 21.1) 97.4 47.5 (54.5) (35.3, 59.8) 92.1 63.3 (70.1) (47.7, 78.9) Final 100.0 9.8 (7.9) (8.1, 11.6) 98.7 17.9 (10.3) (15.6, 20.2) 94.7 40.3 (70.6) (24.5, 56.1) Supraclavicular Internal Jugular Subclavian (Infraclavicular) Time to Access (seconds) Time to Access (seconds) Time to Access (seconds) Trial Vein Access (%) M (SD) 95% CI Vein Access (%) M (SD) 95% CI Vein Access (%) M (SD) 95% CI Baseline 98.7 18.0 (13.8) (14.9, 21.1) 97.4 47.5 (54.5) (35.3, 59.8) 92.1 63.3 (70.1) (47.7, 78.9) Final 100.0 9.8 (7.9) (8.1, 11.6) 98.7 17.9 (10.3) (15.6, 20.2) 94.7 40.3 (70.6) (24.5, 56.1) The simulator’s scoring algorithm can detect and record errors and complications. Table II reports the number of each error/potential complication and the error rate for baseline and final trials. In addition, the Wilcoxon sign test was conducted and the p-values are reported comparing differences in performance between supraclavicular vs. IJ and supraclavicular vs. subclavian (infraclavicular) approaches. There was a statistically significant difference in backwall errors, in which the needle passes through both the anterior and posterior wall of the vein, between supraclavicular and both IJ and subclavian (p < 0.05) at baseline (after scripted instructions); there were no differences after simulator training. More participants caused a pneumothorax at baseline using the infraclavicular approach. The error rate, 11.8%, was substantial but the difference did not reach statistical significance. More participants punctured the artery with the IJ approach than with the supraclavicular approach on the baseline trial. More participants required additional attempts to achieve access using the infraclavicular approach on the baseline trial, with 55% of participants (42 of 76) needing more than one attempt to access the vein compared to 4% for supraclavicular and 7% for IJ. Mean (SD) number of attempts was 1.17 (0.99) for supraclavicular, 1.37 (1.94) for IJ and 3.84 (5.24) for SC and the number of extra attempts required for SC CVA ranged from 2 to 28. The number of participants requiring extra attempts to achieve infraclavicular access decreased from 53% to 29% (22 of 76, ranging from 2 to 38 participants) on the final trial. This was still significantly more than for the supraclavicular approach, where only one participant required more than one attempt, or the IJ approach, where only two participants needed more than one attempt to obtain venous access on the final trial. TABLE II. Errors and Complications During Central Venous Access by Approach and Trial Central Venous Access Approacha Error/Complication Supraclavicular Internal Jugular Supra vs. IJ Wilcoxon Sign Test Subclavian (Infraclavicular) Supra vs. SC Wilcoxon Sign Test Number Error rateb (%) Number Error rateb (%) p-Value Number Error Rateb (%) p-Value Backwall  Baseline 8 10.5 18 23.7 0.04 11 14.5 0.04  Final 3 3.9 8 10.5 0.27 4 5.3 0.38 Pneumothorax  Baseline 3 3.9 1 1.3 0.63 9 11.8 0.15  Final 1 1.3 0 0.0 1.00 2 2.6 1.00 Arterial puncture  Baseline 1 1.3 7 9.2 0.04 1 1.3 1.00  Final 1 1.3 3 3.9 0.63 1 1.3 1.00 Extra attempts  Baseline 3 3.9 5 6.6 0.69 42 55.3 <0.0001  Final 1 1.3 2 2.6 1.00 22 28.9 <0.0001 Central Venous Access Approacha Error/Complication Supraclavicular Internal Jugular Supra vs. IJ Wilcoxon Sign Test Subclavian (Infraclavicular) Supra vs. SC Wilcoxon Sign Test Number Error rateb (%) Number Error rateb (%) p-Value Number Error Rateb (%) p-Value Backwall  Baseline 8 10.5 18 23.7 0.04 11 14.5 0.04  Final 3 3.9 8 10.5 0.27 4 5.3 0.38 Pneumothorax  Baseline 3 3.9 1 1.3 0.63 9 11.8 0.15  Final 1 1.3 0 0.0 1.00 2 2.6 1.00 Arterial puncture  Baseline 1 1.3 7 9.2 0.04 1 1.3 1.00  Final 1 1.3 3 3.9 0.63 1 1.3 1.00 Extra attempts  Baseline 3 3.9 5 6.6 0.69 42 55.3 <0.0001  Final 1 1.3 2 2.6 1.00 22 28.9 <0.0001 aParticipants performed all three techniques on the same simulator. bFor baseline and final trials, 76 participants attempted access via all three approaches (n = 76). TABLE II. Errors and Complications During Central Venous Access by Approach and Trial Central Venous Access Approacha Error/Complication Supraclavicular Internal Jugular Supra vs. IJ Wilcoxon Sign Test Subclavian (Infraclavicular) Supra vs. SC Wilcoxon Sign Test Number Error rateb (%) Number Error rateb (%) p-Value Number Error Rateb (%) p-Value Backwall  Baseline 8 10.5 18 23.7 0.04 11 14.5 0.04  Final 3 3.9 8 10.5 0.27 4 5.3 0.38 Pneumothorax  Baseline 3 3.9 1 1.3 0.63 9 11.8 0.15  Final 1 1.3 0 0.0 1.00 2 2.6 1.00 Arterial puncture  Baseline 1 1.3 7 9.2 0.04 1 1.3 1.00  Final 1 1.3 3 3.9 0.63 1 1.3 1.00 Extra attempts  Baseline 3 3.9 5 6.6 0.69 42 55.3 <0.0001  Final 1 1.3 2 2.6 1.00 22 28.9 <0.0001 Central Venous Access Approacha Error/Complication Supraclavicular Internal Jugular Supra vs. IJ Wilcoxon Sign Test Subclavian (Infraclavicular) Supra vs. SC Wilcoxon Sign Test Number Error rateb (%) Number Error rateb (%) p-Value Number Error Rateb (%) p-Value Backwall  Baseline 8 10.5 18 23.7 0.04 11 14.5 0.04  Final 3 3.9 8 10.5 0.27 4 5.3 0.38 Pneumothorax  Baseline 3 3.9 1 1.3 0.63 9 11.8 0.15  Final 1 1.3 0 0.0 1.00 2 2.6 1.00 Arterial puncture  Baseline 1 1.3 7 9.2 0.04 1 1.3 1.00  Final 1 1.3 3 3.9 0.63 1 1.3 1.00 Extra attempts  Baseline 3 3.9 5 6.6 0.69 42 55.3 <0.0001  Final 1 1.3 2 2.6 1.00 22 28.9 <0.0001 aParticipants performed all three techniques on the same simulator. bFor baseline and final trials, 76 participants attempted access via all three approaches (n = 76). Participants were administered parallel surveys with demographic items and questions that probed experience level with the three approaches prior to and following the training session. For each of the three approaches, participants were asked to rate their confidence in obtaining central venous access for each technique. The response scale was end-point anchored where a rating of 1 indicated not at all confident and a rating of 10 indicated completely confident. Statistically, confidence improved significantly for both supraclavicular and infraclavicular approaches to accessing the subclavian vein (Table III). Confidence for IJ was significantly higher than for the other approaches prior to training and did not improve after training. TABLE III. Confidence Gains in Performing Three Approaches to Central Venous Access Following Training with the UF_CVA_MR Simulator Confidence Rating Mean SD 95% CI t p Supraclavicular  Pre-simulation training 1.62 1.13 1.36 1.88  Post-simulation training 7.20 1.92 6.76 7.65  Post–Pre 5.58 1.92 5.14 6.03 25.06 <0.0001 Internal Jugular  Pre-simulation training 7.11 2.73 6.47 7.74  Post-simulation training 7.23 2.27 6.70 7.76  Post–Pre 0.12 3.68 0.73 0.97 0.28 0.78 Subclavian (infraclavicular)  Pre-simulation training 3.70 2.78 3.06 4.35  Post-simulation training 7.61 2.05 7.13 8.08  Post–Pre 3.91 3.11 3.18 4.63 10.80 <0.0001 Confidence Rating Mean SD 95% CI t p Supraclavicular  Pre-simulation training 1.62 1.13 1.36 1.88  Post-simulation training 7.20 1.92 6.76 7.65  Post–Pre 5.58 1.92 5.14 6.03 25.06 <0.0001 Internal Jugular  Pre-simulation training 7.11 2.73 6.47 7.74  Post-simulation training 7.23 2.27 6.70 7.76  Post–Pre 0.12 3.68 0.73 0.97 0.28 0.78 Subclavian (infraclavicular)  Pre-simulation training 3.70 2.78 3.06 4.35  Post-simulation training 7.61 2.05 7.13 8.08  Post–Pre 3.91 3.11 3.18 4.63 10.80 <0.0001 Note: 74 of 76 participants had complete responses for all six survey questions on the pre-simulation and post-simulation surveys. Results are for the dependent samples t-test, t. Response scale: 1 = not at all confident. 10 = completely confident. TABLE III. Confidence Gains in Performing Three Approaches to Central Venous Access Following Training with the UF_CVA_MR Simulator Confidence Rating Mean SD 95% CI t p Supraclavicular  Pre-simulation training 1.62 1.13 1.36 1.88  Post-simulation training 7.20 1.92 6.76 7.65  Post–Pre 5.58 1.92 5.14 6.03 25.06 <0.0001 Internal Jugular  Pre-simulation training 7.11 2.73 6.47 7.74  Post-simulation training 7.23 2.27 6.70 7.76  Post–Pre 0.12 3.68 0.73 0.97 0.28 0.78 Subclavian (infraclavicular)  Pre-simulation training 3.70 2.78 3.06 4.35  Post-simulation training 7.61 2.05 7.13 8.08  Post–Pre 3.91 3.11 3.18 4.63 10.80 <0.0001 Confidence Rating Mean SD 95% CI t p Supraclavicular  Pre-simulation training 1.62 1.13 1.36 1.88  Post-simulation training 7.20 1.92 6.76 7.65  Post–Pre 5.58 1.92 5.14 6.03 25.06 <0.0001 Internal Jugular  Pre-simulation training 7.11 2.73 6.47 7.74  Post-simulation training 7.23 2.27 6.70 7.76  Post–Pre 0.12 3.68 0.73 0.97 0.28 0.78 Subclavian (infraclavicular)  Pre-simulation training 3.70 2.78 3.06 4.35  Post-simulation training 7.61 2.05 7.13 8.08  Post–Pre 3.91 3.11 3.18 4.63 10.80 <0.0001 Note: 74 of 76 participants had complete responses for all six survey questions on the pre-simulation and post-simulation surveys. Results are for the dependent samples t-test, t. Response scale: 1 = not at all confident. 10 = completely confident. The supraclavicular approach provides faster and more consistent access to the vein and is less likely to require additional attempts. Although only 2 of 76 participants reported any experience with the supraclavicular approach on the pre-training survey, after training on the UF_CVA_MR simulator, participants demonstrated statistically significant improvement in their confidence. DISCUSSION This study showed a reduction in time to access, fewer additional attempts to access, and greater gains in confidence when accessing the subclavian vein using the supraclavicular approach compared to using the infraclavicular approach and the IJ approach on this particular simulator. These findings may suggest that the supraclavicular approach is easier to attempt than the other two. However, this study failed to show a reduction in errors or complications when comparing the three approaches. A review of the literature by Patrick et al found a reduction in complications when using this technique.4 These findings, when combined with the increase in confidence, could potentially translate to easier and safer access in the field. Of note, our study was conducted without the use of ultrasonography when accessing the subclavian vein. Thus, the supraclavicular approach may be safe even when ultrasonography is not used because of limitations in an austere environment; however, this safety margin may be enhanced further with the addition of ultrasound. The volunteer (height, weight, gender, BMI) in Figure 1 was placed in Trendelenberg position and the subclavian vein was imaged using the technique described above. The image obtained had a cross-sectional area of 6.5 cm2 (Fig. 2). An image of the IJ was obtained on the same side as in Figure 2 at the level of the thyroid cartilage in the coronal plane (Fig. 3). The cross-sectional area of the IJ was 2.8 cm2. Figure 4 shows the subclavian vein at the midclavicular line, in approximately the location where a needle would access the subclavian vein using an infraclavicular approach. The cross-sectional area of the subclavian vein was 2.7 cm2. In this participant, the cross-sectional area of the subclavian vein in the supraclavicular fossa was at least double the area of the two more commonly used central venous access sites. The most superficial point of the vein in Figures 2–4 (depicting the ultrasound view with the supraclavicular, IJ, and infraclavicular approaches) was in the supraclavicular fossa. These two anatomical differences could potentially lead to easier access when placing a central line after venous access via the supraclavicular approach. FIGURE 2. View largeDownload slide Ultrasound image of the subclavian vein in the supraclavicular fossa. FIGURE 2. View largeDownload slide Ultrasound image of the subclavian vein in the supraclavicular fossa. FIGURE 3. View largeDownload slide Ultrasound image of the internal jugular vein and carotid artery at the level of the thyroid cartilage. FIGURE 3. View largeDownload slide Ultrasound image of the internal jugular vein and carotid artery at the level of the thyroid cartilage. FIGURE 4. View largeDownload slide Ultrasound image of the subclavian vein at the midclavicular line. FIGURE 4. View largeDownload slide Ultrasound image of the subclavian vein at the midclavicular line. It is generally accepted that intraosseous devices are ideal for timely access of the circulatory system; they have been successfully utilized in the pre-hospital, acute care, and emergent care environments. The risks and benefits of intraosseous catheter placement are well recognized. The risks include extravasation, infection, dislodgement, and compartment syndrome.12,13 Intraosseous catheters remain an excellent emergent option as a bridge to definitive access. Obtaining alternative IV access (generally central venous access for patients who remain unstable or critically ill) after the initial critical resuscitation should be accomplished as soon as possible, as intraosseous devices are not a substitute for central venous catheterization. Additionally, there are international and service-specific practice variations and the supraclavicular approach is not often discussed. The availability, operator training and comfort, and subsequent utilization of ultrasound have further evolved approaches to IV access. Hulse & Thomas reviewed the current literature on the benefits and complications of each vascular access method. They concluded that intraosseous devices are best for quick access to the circulation, with central venous access via the subclavian route indicated for large-volume resuscitation and low complication rates. Our study in a simulated setting suggests that the supraclavicular approach to the subclavian vein should be re-evaluated and given due consideration.14 CONCLUSIONS The supraclavicular approach to the subclavian vein is a reasonable choice when obtaining central venous access. It is reasonable to incorporate this technique into the medical warfighter’s toolkit as a safe technique with a high success rate and rapid cannulation time when ultrasound is not available. Furthermore, it is well described, has a larger cross-sectional area target than the IJ and infraclavicular approach to the subclavian vein, and potentially results in fewer complications when attempted. It also may be relatively easy to teach and learn, with trainees achieving quicker time to access and showing large improvements in confidence within a short training session. Previous Presentations Presented as an oral talk at the 2017 Military Health System Research Symposium, August 2017, Kissimmee, FL; abstract # MHSRS-17–1720. Funding Research reported in this publication was partly supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under award numbers UL1TR000064 and UL1TR001427 and by U.S. Army Medical Research Acquisition Activity. This work was supported by the Assistant Secretary of Defense for Health Affairs endorsed by the Department of Defense under Award No. W81XWH-14-1-0113 and by the National Institutes of Health/National Center for Advancing Translational Sciences Clinical and Translational Science Award to the University of Florida no. UL1 TR000064. This supplement was sponsored by the Office of the Secretary of Defense for Health Affairs. Acknowledgments None. References 1 Robinson L : The Future of U.S. Special Operations Forces. Council Special Report No. 66. April 2013 : 3. 2 Bigge L : Air Force Medicine: Anytime, anywhere in the world. June 22, 2017. Available at https://www.af.mil/News/Article-Display/Article/1225446/air-force-medicine-anytime-anywhere-in-the-world/; accessed October 31, 2018. 3 Yoffa D : Supraclavicular subclavian venipuncture and catheterisation . Lancet 1965 ; 2 : 614 – 7 . Google Scholar Crossref Search ADS PubMed 4 Patrick SP , Tijunelis MA , Johnson S , Herbert ME : Supraclavicular subclavian vein catheterization: the forgotten central line . West J Emerg Med 2009 ; 10 : 110 – 4 . Google Scholar PubMed 5 Conroy JM , Rajagopalan PR , Baker JD 3rd , Bailey MK : A modification of the supraclavicular approach to the central circulation . South Med J 1990 ; 83 : 1178 – 81 . Google Scholar Crossref Search ADS PubMed 6 Dronen S , Thompson B , Nowak R , Tomlanovich M : Subclavian vein catheterization during cardiopulmonary resuscitation. A prospective comparison of the supraclavicular and infraclavicular percutaneous approaches . JAMA 1982 ; 247 : 3227 – 30 . Google Scholar Crossref Search ADS PubMed 7 Czarnik T , Gawda R , Perkowski T , Weron R : Supraclavicular approach is an easy and safe method of subclavian vein catheterization even in mechanically ventilated patients: analysis of 370 attempts . Anesthesiology 2009 ; 111 : 334 – 9 . Google Scholar Crossref Search ADS PubMed 8 Byon HJ , Lee GW , Lee JH , et al. : Comparison between ultrasound-guided supraclavicular and infraclavicular approaches for subclavian venous catheterization in children – a randomized trial . Br J Anaesth 2013 ; 111 : 788 – 92 . Google Scholar Crossref Search ADS PubMed 9 Sappenfield JW , Smith WB , Cooper LA , et al. : Visualization Improves Supraclavicular Access to the Subclavian Vein in a Mixed Reality Simulator . Anesth Analg. 2018 Jul; 127 ( 1 ): 83 – 9 . Google Scholar Crossref Search ADS PubMed 10 Lampotang S , Lizdas D , Rajon D , et al. : Mixed Simulators: Augmented Physical Simulators with Virtual Underlays. Presentation at IEEE Virtual Reality 2013 Meeting, Orlando, FL. Available at http://ieeexplore.ieee.org/document/6549348/; accessed January 5, 2018 . 11 Lampotang S , Bova FJ , Lizdas DE , et al. : A subset of mixed simulations: augmented physical simulations with virtual underlays. Presented at 2012 Interservice/Industry Training, Simulation, and Education Conference, Orlando, FL. Available at https://www.researchgate.net/publication/236025289_A_Subset_of_Mixed_Simulations_Augmented_Physical_Simulations_with_Virtual_Underlays; accessed January 5, 2018 . 12 Hansen M , Meckler G , Spiro D , Newgard C : Intraosseous line use, complications, and outcomes among a population-based cohort of children presenting to California hospitals . Pediatr Emerg Care 2011 ; 27 : 928 – 32 . Google Scholar Crossref Search ADS PubMed 13 Ngo AS , Oh JJ , Chen Y , Yong D , Ong ME : Intraosseous vascular access in adults using the EZ-IO in an emergency department . Int J Emerg Med 2009 ; 2 : 155 – 60 . Google Scholar Crossref Search ADS PubMed 14 Hulse EJ , Thomas GO : Vascular access on the 21st century military battlefield . J R Army Med Corps 2010 ; 156 : 385 – 90 . Google Scholar Crossref Search ADS PubMed Author notes The U.S. Army Medical Research Acquisition Activity, 820 Chandler Street, Fort Detrick, MD 21702–5014 is the awarding and administering acquisition office. Opinions, interpretations, conclusions, and recommendations are those of the authors and are not necessarily endorsed by the Department of Defense. © Association of Military Surgeons of the United States 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - Reduced Complications of Supraclavicular Approach in Simulated Central Venous Access: Applicability to Military Medicine
JO - Military Medicine
DO - 10.1093/milmed/usy381
DA - 2019-03-01
UR - https://www.deepdyve.com/lp/oxford-university-press/reduced-complications-of-supraclavicular-approach-in-simulated-central-0wi0IwW3Eb
SP - 329
VL - 184
IS - Supplement_1
DP - DeepDyve
ER -