Infraclavicular, Ultrasound-Guided Percutaneous Approach to the Axillary Artery for Arterial Catheter Placement: A Randomized Trial.

OBJECTIVES: To examine whether an ultrasound-guided infraclavicular cannulation of the axillary artery is noninferior to an ultrasound-guided cannulation of the common femoral artery for arterial catheter placement in critically ill patients. DESIGN: Prospective, investigator-initiated, noninferiority randomized controlled trial. SETTING: University-affiliated ICU in Poland. PATIENTS: Mechanically ventilated patients with indications for arterial catheter placement. INTERVENTIONS: Patients were randomly assigned into two groups. In the axillary group (A group), an ultrasound-guided infraclavicular, in-plane cannulation of the axillary artery was performed. In the femoral group (F group), an ultrasound-guided, out-of-plane cannulation of the common femoral artery was performed. MEASUREMENTS AND MAIN RESULTS: A total of 1,079 mechanically ventilated patients were screened, of whom 110 were randomized. The main outcome was the cannulation success rate. The secondary outcomes included the artery puncture success rate, the first-pass success rate, number of attempts required to puncture, and the rate of early mechanical complications. The cannulation success rate in the A group and F group was 96.4% and 96.3%, respectively. The lower limit of 95% CI for the difference in cannulation success rate was above the prespecified noninferiority margin of-7% demonstrating noninferiority of infraclavicular approach. No significant differences were found between the groups in terms of puncture success rate and the rate of early mechanical complications. CONCLUSIONS: An ultrasound-guided infraclavicular cannulation of the axillary artery is noninferior to the cannulation of the common femoral artery in terms of procedure success rate. We found no significant differences in early mechanical complications between the groups.

Ultrasound-Guided Infraclavicular Axillary Vein Versus Internal Jugular Vein Cannulation in Critically Ill Mechanically Ventilated Patients: A Randomized Trial.

OBJECTIVES: This clinical trial aimed to compare the ultrasound-guided in-plane infraclavicular cannulation of the axillary vein (AXV) and the ultrasound-guided out-of-plane cannulation of the internal jugular vein (IJV). DESIGN: A prospective, single-blinded, open label, parallel-group, randomized trial. SETTING: Two university-affiliated ICUs in Poland (Opole and Lublin). PATIENTS: Mechanically ventilated intensive care patients with clinical indications for central venous line placement. INTERVENTIONS: Patients were randomly assigned into two groups: the IJV group ( n = 304) and AXV group ( n = 306). The primary outcome was to compare the IJV group and AXV group through the venipuncture and catheterization success rates. Secondary outcomes were catheter tip malposition and early mechanical complication rates. All catheterizations were performed by advanced residents and consultants in anesthesiology and intensive care. MEASUREMENTS AND MAIN RESULTS: The IJV puncture rate was 100%, and the AXV was 99.7% (chi-square, p = 0.19). The catheterization success rate in the IJV group was 98.7% and 96.7% in the AXV group (chi-square, p = 0.11). The catheter tip malposition rate was 9.9% in the IJV group and 10.1% in the AXV group (chi-square, p = 0.67). The early mechanical complication rate in the IJV group was 3% (common carotid artery puncture-4 cases, perivascular hematoma-2 cases, vertebral artery puncture-1 case, pneumothorax-1 case) and 2.6% in the AXV group (axillary artery puncture-4 cases, perivascular hematoma-4 cases) (chi-square, p = 0.79). CONCLUSIONS: No difference was found between the real-time ultrasound-guided out-of-plane cannulation of the IJV and the infraclavicular real-time ultrasound-guided in-plane cannulation of the AXV. Both techniques are equally efficient and safe in mechanically ventilated critically ill patients.

Vitamin D kinetics in the acute phase of critical illness: A prospective observational study.

PURPOSE: The objective of this study was to assess the vitamin D kinetics in critically ill patients by performing periodic serum vitamin D measurements in short time intervals in the initial phase of a critical illness. MATERIALS AND METHODS: We performed vitamin D serum measurements: at admission and then in 12-hour time intervals. The minimum number of vitamin D measurements was 4, and the maximum was 8 per patient. RESULTS: A total of 363 patients were evaluated for participation, and 20 met the inclusion criteria. All patients had an initial serum vitamin D level between 10.6 and 39ng/mL. Nineteen patients had vitamin D levels between 10 and 30ng/mL, which means that they had vitamin D insufficiency or deficiency, and only one patient had a normal vitamin D serum plasma level. We observed that the median of the vitamin D level decreases until the fourth measurement then stabilizes around the 4th and 5th measurement and then appears to increase unevenly. The highest drop is at the very beginning. CONCLUSIONS: The vitamin D serum level is changeable in the initial phase of a critical illness. We hypothesize that the serum vitamin D concentration can mirror the severity of illness.