Assessing ultrasound-guided axillary vein cannulation using a cumulative sum analysis: A single operator experience

Background: Ultrasound-guided axillary vein (AxV) cannulation has been described as an effective alternative to internal jugular vein cannulation in adult cardiac surgical patients. However, the learning curve for this technique has not yet been addressed. This study aimed to determine the number of cases required to achieve proficiency in performing AxV cannulation among novice anesthesiologists. Methods: This prospective study included the first 60 patients who underwent ultrasound-guided AxV cannulation performed by a single third-year resident who was trained in adult cardiac anesthesia. This study investigated the number of cases required to gain technical proficiency by applying cumulative sum analysis on the learning curve (LC-CUSUM) of ultrasound-guided AxV cannulation. Results: Based on the assessment of the CUSUM plots, a descending inflection point for decreasing the overall procedural time for AxV cannulation was observed after patient 29. Regarding the procedural outcomes, comparing the early-experience group with the late-experience group (29 vs 31 cases), the former group had longer operating time (1526 s vs 1120 s, p < 0.001) and identification time (110 s vs 92 s, p < 0.001) and lower first-attempt success rate (8, 27.6% vs 30, 96.8%, p < 0.001) than the latter group. Conclusions: CUSUM demonstrated that at least 29 successful cases are required to achieve an expertized manipulation in ultrasound-guided AxV cannulation for inexperienced novices. The learning curve for ultrasound-guided AxV cannulation was observed in 29 cases. After adequate training, the overall procedural time and the first-attempt success rate, and puncture-related complications for AxV cannulation improved with increased experience.