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Background The aim of this study was to compare the effectiveness and safety of ultrasound-guided out-of-plane internal jugular vein (OOP-IJV) and in-plane supraclavicular subclavian vein (IP-SSCV) catheterization in adult intensive care unit. Methods A total of 250 consecutive patients requiring central venous catheterization, were randomly assigned to undergo either ultrasound-guided OOP-IJV or IP-SSCV cannulation. All catheterizations were carried out by three physicians. The primary outcome was the first attempt success rate. Ultrasound scanning time, venous puncture time, insertion time, overall access time, number of puncture attempts, number of needle redirections, success rate, guidewire advancing difficulties, venous collapse and adverse events were also documented. Results The first attempt success rate was significantly higher in IP-SSCV group (83.2%) compared to OOP-IJV group (63.2%) (p = 0.001). The IP-SSCV group was associated with a longer ultrasound scanning time (16.54 ± 13.51 vs. 5.26 ± 4.05 s; p < 0.001) and a shorter insertion time (43.98 ± 26.77 vs. 53.12 ± 40.21 s; p = 0.038). In the IP-SCCV group, we recorded a fewer number of puncture attempts (1.16 ± 0.39 vs. 1.47 ± 0.71; p < 0.001), needle redirections (0.69 ± 0.58 vs. 1.17 ± 0.95; p < 0.001), difficulties in guidewire advancement (2.4% vs. 27.4%; p < 0.001), venous collapse (2.4%, vs. 18.4%; p < 0.001) and adverse events (8.8% vs. 13.6%; p = 0.22). Conclusions The IP-SSCV approach is an effective and a safe alternative to the classic OOP-IJV catheterization in critical adult patients. Trial registration: Clinicaltrials.gov, NCT03879954. Registered March 19, 2019—Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03879954.

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Negative-pressure pulmonary edema (NPPE) is a rare respiratory complication due to acute upper airway obstruction occurring shortly after extubation. We report a case of NPPE in young adult patient who underwent an eventful general anesthesia. The patient presented laryngospasm followed by acute respiratory distress with pink frothy sputum following. The NPPE was initially misdiagnosed and a preventable tracheostomy was performed. NPPE was managed with mechanical ventilation and diuretics and the patient had full recovery. Every anesthesiologist should be aware of the diagnosis of NPPE. Early recognition and management are essential to prevent the morbidity associated with NPPE in young healthy patients.

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