A Modified Approach to Supraclavicular Subclavian Vein Catheter Placement: The Pocket Approach

BACKGROUND: Central venous access is often necessary for the administration of fluids, blood products, and medications. Several approaches to supraclavicular subclavian venous access have been described. This study examines the effectiveness of central venous catheter placement utilizing an alternative set of anatomic landmarks for supraclavicular subclavian vein access. METHODS: This was a two phase study. The first portion involved subclavian vein cannulation using a supraclavicular approach in 28 cadavers. The specific set of anatomic landmarks for the supraclavicular approach, termed the “pocket approach,” is described. Cadavers were subsequently dissected to verify appropriate line placement. The second portion was a chart review of Emergency Department (ED) patients who underwent attempted subclavian vein catheter placement utilizing the pocket approach. Charts were extracted following education of the ED faculty and resident staff to determine: 1) Success of subclavian line placement, 2) The incidence of pneumothorax, and 3) The use of supraclavicular subclavian access in the trauma setting, during cardiopulmonary resuscitation (CPR), and in patients who had cervical collars. RESULTS: In 28 cadavers, the success rate of the pocket approach was 100% (34/34; 95% CI 90% to 100%). Chart review of the 68 patients revealed a success rate of 90% (61/68; CI 80% to 96%). No pneumothoraces were recorded (0/68; CI 0% to 5%). The pocket approach was used successfully in 11 patients with cervical collars, (100%, CI 72% to 100%) and in 15 of 16 patients undergoing CPR (94%, CI 70% to 100%). In four fresh cadavers, the average distance from the posterior subclavian vein to the subclavian artery was 0.40cm, and the dome of the pleura was 1.75cm posterior to the vein. CONCLUSION: Our data suggest that the supraclavicular pocket approach to subclavian vein cannulation is a useful and safe method of adult central venous catheterization, with complication and success rates comparable to more common approaches. The anatomic advantage of a great vein that is closer to the skin and farther from the pleural dome makes this an approach worthy of further investigation

Heterogeneity in cancer guidelines: should we eradicate or tolerate?

Background: Heterogeneity in aspects of development, structure and context of oncology guidelines was not evaluated. We analysed and critically examined its implications. Materials and methods: Nine cancer clinical practice guidelines were selected on the basis of popularity among oncologists. The relevant Web sites and publications on three tumours were examined and characteristics grouped in the data domains: producing organisation, methodology, guideline structure and content, implementation and evaluation and scientific agreement. Results: ASCO, ESMO, NICE, SIGN, START, NHMRC, NCI, NCCN and CCO guidelines were examined. Development was initiated by stakeholders or authorised bodies, run by task forces with varying degrees of multidisciplinarity, with rare endorsement of external guidelines. Recommendation formulation was on the basis of evidence, shaped via interactive processes of expert review and public consultation-based modifications. Guidelines varied in comprehensiveness per tumour type, number, size, format, grading of evidence, update and legal issues. Orientation for clinic use or as reference document, end-users and binding or elective nature also varied. Standard dissemination strategies were used, though evaluation of adoption and of impact on health outcomes was implemented with considerable heterogeneity. Conclusions: Heterogeneity in development, structure, user and end points of guidelines is evident, though necessary in order to meet divergent demands. Crucial for their effectiveness are adherence to methodological standards, a clear definition of what the guideline intends to do for whom and a systematic evaluation of their impact on health car