title: Real-time multimodal axillary vein imaging enhances the safety and efficacy of axillary vein catheterization in neurosurgical intensive care patients.
abstract: BACKGROUND
  Controversy exists regarding the increased safety profile when ultrasound is used for central venous catheters inserted in the subclavian or axillary vein. The critically ill neurosurgical patient presents unique considerations for the optimal central line approach.
  
  
  METHODS
  This report is a retrospective chart review of 6 neurosurgical intensive care patients in whom an ultrasound-guided, transpectoral, axillary vein catheterization was attempted. A sterile technique was observed. The anatomy was confirmed using combined transverse, longitudinal, and Doppler flow images. The needle tip was advanced into the axillary vein under real-time ultrasound using an in-plane technique. The central venous catheter was inserted using the Seldinger technique. A chest radiograph was obtained after each line.
  
  
  RESULTS
  Five of the 6 central lines were inserted easily, without complications. The sixth central line was inserted without complications but more proximally because of difficulty in visualizing the axillary vein on account of the patient's morbid obesity and severe hypovolemia.
  
  
  CONCLUSIONS
  This series illustrates new and useful aspects of ultrasound use in transpectoral axillary vein catheterization: it requires minimal additional training; it combines the real time, in-plane technique with transverse, longitudinal, and Doppler color flow images; and it is used safely in the critically ill neurosurgical patient. The data on infraclavicular central venous catheters indicate decreased line sepsis, arterial punctures, and venous thrombosis while improving nursing care and patient comfort. This technique's potential for decreasing the risk of pneumothorax may make it a reasonable option for many critically ill patients in whom other central venous catheter approaches may not be ideal.
authors.affiliation: Department of Anesthesiology, University of Colorado, Aurora, CO 80045, USA. matthew.uhlenkott@ucdenver.edu
authors.forename: Matthew Charles
authors.initials: MC
authors.lastname: Uhlenkott
authors.forename: Subramanian
authors.initials: S
authors.lastname: Sathishkumar
authors.forename: Willie Bosseau
authors.initials: WB
authors.lastname: Murray
authors.forename: Patrick Micheal
authors.initials: PM
authors.lastname: McQuillan
authors.forename: Sanjib
authors.initials: S
authors.lastname: Das Adhikary
mesh_terms: D001367:Axillary Vein / Q000000981:diagnostic imaging*; D002405:Catheterization, Central Venous / Q000379:methods*; D003199:Computer Systems; D003422:Critical Care / Q000379:methods*; D006801:Humans; D017078:Laser-Doppler Flowmetry; D019635:Neurosurgical Procedures / Q000379:methods*; D011030:Pneumothorax / Q000517:prevention & control; D013902:Radiography, Thoracic; D012189:Retrospective Studies; D016683:Supine Position; D035441:Thoracic Wall / Q000000981:diagnostic imaging; D018084:Ultrasonography, Interventional