Introduction of ultrasound-guided axillary vein approach for central venous catheterization in severely injured trauma patients: characteristics and concerns

Abstract

Background: The ultrasound-guided axillary vein approach for central venous catheterization (UAVC) demonstrates high success rates and low complications; however, its utilization in trauma care settings remains limited. This study aimed to characterize UAVC practices in a trauma intensive care unit (TICU) at a tertiary teaching hospital, specifically investigating optimal catheter positioning, procedure-related complications, and risk factors associated with catheter inaccurate placement and venous thromboembolism (VTE) development.

Methods: A retrospective analysis was performed on trauma patients who underwent UAVC between October 2021 and April 2023. This analysis was based on electronic medical records. Details of patients, procedures, and instances of catheter misplacement were carefully documented. The immediate complications after UAVC, including pneumothorax, hemothorax, hematoma, arteriovenous fistula, arterial dissection, and skin infection, were recorded. Moreover, late-onset complications such as VTE and catheter-related bloodstream infections (CRBSI) were also noted. Logistic regression was utilized to determine the independent risk factors for non-optimal catheter tip placement and VTE.

Results: A total of 132 UAVC cases were analyzed, with 113 (85.6%) performed by resident physicians and no immediate complications observed. The VTE incidence was 27.3%, particularly higher in elderly patients (≥ 65 years, 43.4%), and fever during TICU stay was noted in 55.3% of cases. Catheter-related infections occurred at a rate of 3.38 per 1,000 catheter days, with eight cases (6.06%) of catheter misplacement. Accurate placement was achieved in 29.8% of 121 patients, predominantly on the right side (40.4%). Factors influencing inaccurate placement included patient age [odds ratios (OR) 1.06, 95% confidence interval (CI) 1.02-1.10], obesity (OR 9.31, 95% CI 2.58-33.56), and left-side placement (OR 133.04, 95% CI 21.66-817.29), while patient age (>54 years), fever, and ventilation duration (>6.6 days) were associated with VTE development.

Conclusion: In severely injured trauma patients, UAVC is associated with a high incidence of VTE and a low rate of optimal catheter tip positioning. Our findings underscore the necessity of standardized protocols to refine catheter tip placement and warrant further investigation through randomized controlled trials.

Keywords: axillary vein; central venous catheterization; multiple trauma; ultrasound; venous thromboembolism.

Figure 1

Representative steps for ultrasound-guided axillary vein approach for central venous catheterization (UAVC). (A,B) Long-axis (in-plane approach) ultrasound view of the axillary vein, with one hand resting against the shoulder to stabilize the view and reduce compression of the axillary vein. (C,D) The UAVC procedure is performed using an in-plane technique, clearly displaying the hyperechoic puncture needle within the vessel lumen. (E,F) Confirm the placement of the guidewire with ultrasound before inserting the catheter.

Figure 2

Flow diagram of study patients.

Figure 3

Representative images of catheter malposition in three trauma patients. (A) Misplacement of the catheter tip into the right internal jugular vein; (B) misplacement of the catheter tip into the left internal jugular vein; (C) subcutaneous catheter misplacement due to distortion.

Figure 4

Receiver operating characteristic (ROC) curves for predicting venous thromboembolism (VTE) in trauma patients undergoing ultrasound-guided axillary vein catheterization (UAVC). Age (A) exhibited an AUC of 0.692 (p < 0.001) for VTE prediction. At the optimal cutoff of >54 years, the model demonstrated 91.7% sensitivity but 46.9% specificity, supporting utility for screening but with a risk of overdiagnosis. Duration of mechanical ventilation (B) showed superior performance (AUC 0.799, p < 0.001). At the optimal cutoff of >6.63 days, it achieved 69.4% sensitivity and 81.2% specificity, outperforming age in differentiating VTE from non-VTE cases.