Combined approach versus two conventional approaches in ultrasound-guided central venous catheterization: A randomized controlled trial

Abstract Objective We compared the occurrence of posterior wall puncture using the short-axis out-of-plane and long-axis in-plane approaches with that using the combined short-axis-and-long-axis approach that we previously showed to be effective in observational and manikin studies. Design Randomized controlled study. Setting Single tertiary institution. Participants One hundred and twenty patients who underwent cardiac or vascular surgery under general anesthesia. Interventions The patients were randomly divided into combined short-axis-and-long-axis (n = 40), short-axis out-of-plane (n = 40), and long-axis in-plane (n = 40) groups and received ultrasound-guided central venous catheterization at the right internal jugular vein. Measurements and Main Results Successful guidewire insertion without posterior wall puncture was performed in 40 patients (100%) in the combined short-axis-and-long-axis approach group, 28 (70%) in the short-axis out-of-plane approach group, and 38 (95%) in the long-axis in-plane approach group [combined short-axis-and-long-axis vs short-axis out-of-plane, P = 0.0002 (relative risk = 1.43; 95% confidence interval: 1.17-1.75); combined short-axis-and-long-axis vs long-axis in-plane, P = 0.49 (relative risk = 1.05; 95% confidence interval: 0.98-1.13)]. Procedure durations were 28.5 (24.1-36.4) seconds in the combined short-axis-and-long-axis group, 31.7 (24.4-40.6) seconds in the short-axis out-of-plane group, and 24.3 (20.8-32.1) seconds in the long-axis in-plane group (combined short-axis-and-long-axis vs short-axis out-of-plane, P = 0.53; combined short-axis-and-long-axis vs long-axis in-plane, P = 0.044). Conclusions The combined short-axis-and-long-axis approach for ultrasound-guided central venous catheterization had a lower posterior wall puncture rate than the short-axis out-of-plane approach, but there was no significant difference with the long-axis in-plane approach.