832 | Correspondence
addition to this, PECS-1 block (depositing local anaesthetic be- epidural spread in standard- vs low-volume ultrasound-
tween pectoralis major and minor) can be combined to block the
lateral pectoral nerve in the same probe position if the acromio-
clavicular joint is being operated upon concomitantly. For the
sub-omohyoid block, the same linear high-frequency (6–13 MHz)
ultrasound probe is placed over the supraclavicular fossa to
identify the subclavian artery, brachial plexus and the inferior
belly of the omohyoid muscle (Fig. 1C). Using an in-plane lateral-
to-medial needle approach, 5 ml of the local anaesthetic solu-
tion (ropivacaine 0.5%) is deposited above the clavicle, under the
inferior belly of omohyoid, to cover the suprascapular nerve (Fig.
1C). This fascial plane between the inferior belly of omohyoid
and the strap muscles of the neck is closely related to the supra-
scapular nerve along its course until the suprascapular notch.
Viewing of easily identifiable structures, such as the bony
landmarks and muscle layers around the shoulder joint, should
make this technique feasible even by novices compared with pe-
ripheral nerve blocks. We have been using this technique for an-
algesia in patients with respiratory disease undergoing shoulder
surgery along with ultrasound assessment of diaphragmatic
function at our institute after preliminary anatomical studies of
injectate spread in fresh cadavers were promising. Additionally,
as these intermuscular planes can be appreciated arthroscopi-
cally, the performance of this technique may even be feasible by
the surgeons using conventional or liposomal formulations of lo-
cal anaesthetics.10
Combined subscapularis plane and sub-omohyoid injections
may serve as an alternative to peripheral nerve blocks for shoul-
der analgesia, with minimal impact on phrenic nerve function.
Further well-designed randomized studies are required to evalu-
ate this method in comparison to other analgesic modalities.
Declaration of interest
None declared.
References
1. Stundner O, Meissnitzer M, Brummett CM, et al. Comparison
of tissue distribution, phrenic nerve involvement, and
Evaluation of artery and vein differentiation methods using ultrasound
imaging among medical students
N. Komasawa*, R. Mihara, K. Hattori, T. Minami
Osaka, Japan
*E-mail:ane078@osaka-med.ac.jp
Editor—Central venous catheters (CVCs) provide vascular access
for fluid resuscitation, drugs, and antibiotics and allow haemo-
dynamic monitoring and cardiac pacing. Central venous cath-
eters also help to achieve higher peak drug concentrations and
shorter circulation times compared with peripheral venous ad-
ministration. Recently, the ultrasound-guided CVC (US-CVC)
technique has become available, which allows differentiation
between veins and arteries and improves CVC safety with a
visible guidewire to facilitate catheter progression.1 However,
novices and medical students with less experience may
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on 07 September 2017
guided interscalene plexus block using contrast magnetic
resonance imaging: a randomized, controlled trial. Br J
Anaesth 2016; 116: 405–12
2. Mian A, Chaudhry I, Huang R, Rizk E, Tubbs RS, Loukas M.
Brachial plexus anesthesia: a review of the relevant anat-
omy, complications, and anatomical variations. Clin Anat
2014; 27: 210–21
3. Conroy PH, Awad IT. Ultrasound-guided blocks for shoulder
surgery. Curr Opin Anaesthesiol 2011; 24: 638–43
4. Verelst P, van Zundert A. Respiratory impact of analgesic strate-
gies for shoulder surgery. Reg Anesth Pain Med 2013; 38: 50–53
5. Bergmann L, Martini S, Kesselmeier M, et al. Phrenic nerve
block caused by interscalene brachial plexus block: breath-
ing effects of different sites of injection. BMC Anesthesiol
2016; 16: 45
6. Aszmann OC, Dellon AL, Birely BT, McFarland EG.
Innervation of the human shoulder joint and its implications
for surgery. Clin Orthop Relat Res 1996; 330: 202–7
7. Dhir S, Sondekoppam RV, Sharma R, Ganapathy S, Athwal
GS. A comparison of combined suprascapular and axillary
nerve blocks to interscalene nerve block for analgesia in ar-
throscopic shoulder surgery: an equivalence study. Reg
Anesth Pain Med 2016; 41: 564–71
8. Panero AJ, Hirahara AM. A guide to ultrasound of the shoul-
der, part 2: the diagnostic evaluation. Am J Orthop (Belle Mead
NJ) 2016; 45: 233–38
9. Battaglia PJ, Haun DW, Dooley K, Kettner NW. Sonographic
measurement of the normal suprascapular nerve and omo-
hyoid muscle. Man Ther 2014; 19: 165–68
10. Lee JJ, Hwang JT, Kim DY, et al. Effects of arthroscopy-
guided suprascapular nerve block combined with
ultrasound-guided interscalene brachial plexus block for
arthroscopic rotator cuff repair: a randomized controlled
trial. Knee Surg Sports Traumatol Arthrosc Advance Access
published on June 16, 2016, doi: 10.1007/s00167-016-4198-7
doi: 10.1093/bja/aew370
find it difficult to distinguish between veins and arteries,
which is the first important step. Here, we conducted a survey on
the subjective difficulty of ultrasound-based methods to distin-
guish between veins and arteries among medical students.
Ethical approval was deemed unnecessary by the Research
Ethics Committee of Osaka Medical College. From December
2015 to February 2016, we conducted a questionnaire survey of
31 fifth year medical students who had no experience with in-
ternal jugular vein ultrasound imaging as a part of their routine
training at Osaka Medical College. At our institution, we teach

100
90
# pulse methods (P < 0.001 each). The Valsalva method was less
80
Visual analog scale (mm)
70
60
50
40
30
20
10
0
Pulse Colour Doppler Compression
Fig 1 Comparison of the four methods (pulse, colour Doppler, compres-
sion, and Valsalva methods) to differentiate between the common carotid
artery and the internal jugular vein.
artery (common carotid artery) and vein (internal jugular vein)
differentiation in healthy volunteers using an ultrasound system
with a 5–10 MHz transducer (iLookTM; SonoSite, Inc., Bothell, WA,
USA). We introduced the following four differentiation methods:
arterial pulse (pulse), colour Doppler, compression (vein reduc-
tion), and Valsalva (vein expansion) methods. At the end of
training, participants rated the difficulty of the four methods on
a visual analog scale, which ranged from 0 (extremely easy) to
100 mm (extremely difficult).2 Results obtained from each trial
were compared using one-way repeated measures analysis
of variance. A value of P < 0.05 was considered statistically
significant.
Unusual position of J-guide wire during ultrasound-guided subclavian
vein catheterization
T. Saranteas*, I. Koliantzaki
Athens, Greece
*E-mail: thsaranteas@gmail.com
Editor—We conducted a retrospective analysis of all the
ultrasound-guided catheterizations in which unusual J-guide
wire atypical positions had been identified.
The protocol included ultrasound, long-axis viewing of the
J-guide wire,1 2 always before dilatation of the axillary/subcla-
vian vein. The catheterization of the subclavian veins was per-
formed according to the technique of Fragou and colleagues.1
All ultrasound-guided venous catheterizations were per-
formed by a competent consultant anaesthetist with great expe-
rience in this technique. Manual ultrasound examinations were
conducted using a high-frequency, linear transducer on a porta-
ble ultrasound unit (CX 50, Phillips Healthcare, The Netherlands;
or Vivid I, GE Healthcare, Waukesha, WI, USA).
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by Reed Elsevier, SpecialContentSolutions@elsevier.com
on 07 September 2017
Correspondence | 833
The subjective difficulty of each differentiation method is
shown in Fig. 1. There was no significant difference in subjective
difficulty between pulse and colour Doppler methods (P ¼ 0.99).
The compression method was easier than colour Doppler and
difficult compared with the other three (P < 0.001 vs pulse or col-
our Doppler).
* Differentiation between the internal jugular vein and the
common carotid artery is the first and most important step in
US-CVC. According to our survey, medical students found arter-
ial pulse and colour Doppler methods more difficult than other
ultrasound image-based methods. This might be associated with
the fact that the vein often shows pulsatory motion with artery,
and colour Doppler also captures venous flow. In contrast, vein
collapse by the compression method and vein enlargement by
Valsalva the Valsalva method were considered relatively easy even for
novices. A combination of the compression and Valsalva meth-
ods may be effective for novice doctors to differentiate between
the internal jugular vein and the common carotid artery on
ultrasound images.
Declaration of interest
None declared.
References
1. Tokumine J, Lefor AT, Yonei A, Kagaya A, Iwasaki K, Fukuda
Y. Three-step method for ultrasound-guided central vein
catheterization. Br J Anaesth 2013; 110: 368–73
2. Komasawa N, Mihara R, Fujiwara S, Minami T. Significance of
basic airway management simulation training for medical
students. J Clin Anesth 2016; 32: 29
doi: 10.1093/bja/aew371
The central venous catheterizations took place on patients in
the postoperative acute care unit, operating theatres, and the
cardiothoracic care unit. Owing to the retrospective design of the
study, formal research ethics committee approval and patients’
written informed consent for publication of this manuscript and
accompanying images were deemed unnecessary.
According to our results, throughout a 70 month period, 220
subclavian ultrasound-guided catheterizations were conducted,
and all the potential complications were recorded in our ar-
chives. The J-guide wire was clearly seen in 220 out of 220 (100%)
patients. In 13 out of 220 (5.9%) subclavian vein catheterizations,
unusual J-wire positions in the lumen of the subclavian vein
were acknowledged. Unusual positions of the J-wire included the