title: A modified supraclavicular approach for central venous catheterization by manipulation of ventilation in ventilated patients.
abstract: BACKGROUND
  Because of overuse and multiple implantations of hemodialysis catheters through internal jugular or subclavian vein (SCV) in patients with chronic hemodialysis, these veins often become stenotic or occlude, therefore necessitating alternative access. We introduce a new technique in ventilated patients for placement of tunneled cuffed chronic hemodialysis catheter: modified supraclavicular approach by cease of ventilation.
  
  
  METHODS
  Patients who received implantation of the tunneled cuffed chronic hemodialysis catheters by supraclavicular approach were collected from February 2003 to July 2005. Right subclavian, right innominate or left SCVs were accessed through the supraclavicular approach for catheter insertion. The procedures were performed by certificated anesthesiologists. The following parameters were recorded: co-morbidities, laboratory examinations before the procedure, method for catheterization, duration of procedure, complications related to catheterization and long-term outcome of hemodialysis catheters.
  
  
  RESULTS
  Eleven catheters were inserted in nine patients (two patients received twice) by supraclavicular approach during this period. All patients were mechanically ventilated and these catheters (seven at right and four at left) were implanted using the modified supraclavicular approach with lung deflation during venipuncture, advance of guidewire, and insertion of catheter. There were no procedural complications. The average duration of whole procedure was 36.6 minutes (30-45 minutes) and the mean catheter survival days were 62.1 days (13-152 days). The estimated duration was <1 minute of each period of lung deflation. There were no desaturation or pneumothorax during the whole procedure.
  
  
  CONCLUSIONS
  The modified supraclavicular approach with lung deflation for tunneled cuffed chronic hemodialysis catheter in ventilated patients is at least as effective as traditional approach and can be easily performed by surgeons as well as experienced physicians. Based on the results, this simplified technique using lung deflation may be particularly useful to decrease procedural complications.
authors.affiliation: Department of Anesthesiology, Taipei-Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan, ROC.
authors.forename: Pin-Tarng
authors.initials: PT
authors.lastname: Chen
authors.forename: Chia-Rong
authors.initials: CR
authors.lastname: Yen
authors.forename: Chao-Chun
authors.initials: CC
authors.lastname: Wang
authors.forename: Chun-Sung
authors.initials: CS
authors.lastname: Sung
authors.forename: Wen-Kuei
authors.initials: WK
authors.lastname: Chang
authors.forename: Kwok-Hon
authors.initials: KH
authors.lastname: Chan