Ultrasound Versus Traditional Palpation to Guide Radial Artery Cannulation in Critically Ill Children: A Randomized Trial

Effectiveness of head-mounted ultrasound display for radial arterial catheterisation in paediatric patients by anaesthesiology trainees: A randomised clinical trial

BACKGROUND

The effectiveness of head mounted real-time ultrasound displays (hereafter referred to as 'smart glasses') in improving hand-eye coordination in less experienced individuals, such as trainees in anaesthesia, is unclear.

OBJECTIVES

To compare the first-attempt success rate of smart glasses-assisted ultrasound-guided paediatric radial artery catheterisation with conventional ultrasound guided catheterisation performed by anaesthesiology trainees.

DESIGN

Prospective randomised controlled trial.

SETTINGS

Tertiary university hospital from September 2021 to February 2023.

PATIENTS

One hundred and twenty-two paediatric patients (age <7 years, weight ≥3 kg) who required radial artery cannulation during general anaesthesia.

INTERVENTIONS

The participants were randomly assigned to either the ultrasound screen group (control) or the smart glasses group prior to radial artery catheterisation.

MAIN OUTCOME MEASURES

The primary outcome was the first attempt success rate. Secondary outcomes included the number of attempts, use of transfixion technique, overall complication rate, and clinical anaesthesiology (CA) year of the operators.

RESULTS

A total of 119 paediatric patients were included in the analysis. The smart glasses group exhibited higher first-attempt success rate than did the control group (89.8% [53/59] vs. 71.7% [43/60]; P  = 0.023; odds ratio (OR) 3.49; (95% confidence interval (CI) 1.27-9.6). The overall number of attempts [median, 1; interquartile range (IQR), 1-1; range, 1-3 vs. median, 1; IQR, 1-2; range, 1-4; P   =  0.006], use of transfixion technique (12/59 [20.3%] vs. 28/60 [46.7%]; P  = 0.002), and overall complication rate (6.8% [4/59] vs. 30.0% [18/60]; P  = 0.002) were lower in the smart glasses group than in the control group. However, among paediatric anaesthesiology fellows (CA 5 years), the first- (89.3% [25/28] vs. 80.8% [21/26]; P  = 0.619) and second-attempt success rates (96.4% [27/28] vs. 80.8% [21/26]; P  = 0.163) did not differ between the two groups.

CONCLUSIONS

Smart glasses-assisted ultrasound guided radial artery catheterisation improved the first attempt success rate among anaesthesiology trainees, reducing the number of attempts and overall complication rates in small paediatric patients. Smart glasses were more effective for anaesthesia residents (CA 2-4 years) but were not effective for paediatric anaesthesiology fellows (CA 5 years).

TRIAL REGISTRATION

ClinicalTrials.gov (NCT05030649) ( https://classic.clinicaltrials.gov/ct2/show/NCT05030649 ).

Comparison of procedural time with two different ultrasound-guided approaches for dorsalis pedis artery cannulation in adult patients: A randomized trial

BACKGROUND

In adult patients, there has never been an evaluation of short-axis out-of-plane versus long-axis in-plane approaches of ultrasound-guided dorsalis pedis artery cannulation. This research was conducted to compare these two techniques to cannulate the dorsal pedis artery.

METHODS

In this trial, 128 adult patients undergoing surgery and necessitating arterial cannulation were examined. Dorsalis pedis artery cannulation was performed utilizing an ultrasound by long-axis in-plane approach (group L) or short-axis out-of-plane (group S) techniques.

RESULTS

Group S had a higher first attempt success rate than group L (46.9% vs 28.6%, p = 0.039). The S group had a lower assessment time than the L group (11.48 ± 3.07 vs 19.68 ± 2.79 s; p = 0.000). Cannulation time was higher in the S group (18.91 ± 1.92 s) compared to the L group (12.48 ± 1.61 s; p = 0.000). Nevertheless, the total procedure time was comparable between the L group and the S group (32.16 ± 2.95 vs 30.42 ± 4.07 s; p = 0.107).

CONCLUSIONS

In adults, both views of ultrasonography can be used to guide DPA cannulation. The cannulation time for the DPA in L group was less than the S group, whereas the assessment time was less in S group. The total procedure time, however, was similar between both the groups.

Implementation of an ultrasound-guided approach for arterial line placements in neonates-quality improvement project

OBJECTIVE

Our goal was to improve placement success rates for peripheral arterial line (PAL) placements by introducing an ultrasound-guided (USg) approach. Our aim was to maintain success rates over 70% within 18 months.

STUDY DESIGN

Interventions included development of a training curriculum, and procedure standardization. Among 302 patients, 115 underwent USg catheter placement; the traditional method was used in 187 patients. Outcome measures were first-attempt and overall success rates. Process measures were proportion of PALs placed under US guidance, trainer availability, and trainee sign-off. Line complications were balancing measures. Statistical process control charts were used to monitor metrics.

RESULTS

Sustained improvement was seen with the USg approach. The USg approach had first and overall attempt success by the trainers (i.e., independent users) of 83.7% (77/92) and 96.5% (111/115), compared to 50.3% (82/163) and 73.8% (138/187) with the traditional approach.

CONCLUSION

Introducing the USg approach had a significant impact on PAL placement success in neonatal patients.

Comparison of radial, dorsalis pedis, and posterior tibial arteries for ultrasound-guided arterial catheterisation with dynamic needle tip positioning in paediatric patients: a randomised controlled trial

BACKGROUND

Arterial catheterisation in children can be challenging and time-consuming. We aimed to compare the success rates of ultrasound-guided arterial catheterisation utilising the short-axis out-of-plane approach with dynamic needle tip positioning in the radial, dorsalis pedis, and posterior tibial arteries in paediatric patients. We also examined the factors influencing the catheterisation success using dynamic needle tip positioning.

METHODS

Paediatric patients (aged <3 yr) undergoing cardiac surgery were randomly assigned to three groups based on puncture sites: radial artery (Group R), dorsalis pedis artery (Group D), and posterior tibial artery (Group P). The first-attempt and overall success rates of arterial catheterisation were compared, followed by multiple logistic regression analysis (dependent variable: first-attempt success; independent variables: body weight, diameter and depth of the artery, targeted artery, and trisomy 21).

RESULTS

The study included 270 subjects (n=90 per group). There was no significant difference in the first-attempt (Group R: 82%, Group D: 76%, and Group P: 81%) and overall success rates (Group R: 94%, Group D: 93%, and Group P: 91%) among the three groups. The diameter of the artery (per 0.1 mm) (odds ratio: 1.32, 95% confidence interval: 1.09-1.60) and trisomy 21 (odds ratio: 0.43, 95% confidence interval: 0.20-0.92) were independent predictors of first-attempt success or failure.

CONCLUSION

The first-attempt and overall success rates of arterial catheterisation of the dorsalis pedis and posterior tibial arteries were not inferior to those in the radial artery when using dynamic needle tip positioning. These two lower extremity peripheral arteries present viable alternative catheterisation sites in paediatric patients.

CLINICAL TRIAL REGISTRATION

UMIN000042847.

Ultrasound-guided arterial cannulation in the paediatric population

BACKGROUND

In arterial line cannulation in children and adolescents, traditional methods of locating the artery include palpation and Doppler auditory assistance. It is unclear whether ultrasound guidance is superior to these methods. This is an update of a review originally published in 2016.

OBJECTIVES

To evaluate the benefits and harms of ultrasound guidance compared with traditional techniques (palpation, Doppler auditory assistance) for assisting arterial line placement at all potential sites in children and adolescents.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, and Web of Science from inception to 30 October 2022. We also searched four trials registers for ongoing trials, and we checked the reference lists of included studies and relevant reviews for other potentially eligible trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing ultrasound guidance versus other techniques (palpation or Doppler auditory assistance) to guide arterial line cannulation in children and adolescents (aged under 18 years). We planned to include quasi-RCTs and cluster-RCTs. For RCTs with both adult and paediatric populations, we planned to include only the paediatric population data.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the risk of bias of included trials and extracted data. We used standard Cochrane meta-analytical procedures, and we applied the GRADE method to assess the certainty of evidence.

MAIN RESULTS

We included nine RCTs reporting 748 arterial cannulations in children and adolescents (under 18 years of age) undergoing different surgical procedures. Eight RCTs compared ultrasound with palpation, and one compared ultrasound with Doppler auditory assistance. Five studies reported the incidence of haematomas. Seven involved radial artery cannulation and two involved femoral artery cannulation. The people performing arterial cannulation were physicians with different levels of experience. The risk of bias varied across studies, with some studies lacking details of allocation concealment. It was not possible to blind practitioners in any case; this adds a performance bias that is inherent to the type of intervention studied in our review. Compared to traditional methods, ultrasound guidance probably causes a large increase in first-attempt success rates (risk ratio (RR) 2.01, 95% confidence interval (CI) 1.64 to 2.46; 8 RCTs, 708 participants; moderate-certainty evidence) and probably causes a large reduction in the risk of complications such as haematoma formation (RR 0.26, 95% CI 0.14 to 0.47; 5 RCTs, 420 participants; moderate-certainty evidence). No studies reported data about ischaemic damage. Ultrasound guidance probably improves success rates within two attempts (RR 1.78, 95% CI 1.25 to 2.51; 2 RCTs, 134 participants; moderate-certainty evidence) and overall rate of successful cannulation (RR 1.32, 95% CI 1.10 to 1.59; 6 RCTs, 374 participants; moderate-certainty evidence). In addition, ultrasound guidance probably reduces the number of attempts to successful cannulation (mean difference (MD) -0.99 attempts, 95% CI -1.15 to -0.83; 5 RCTs, 368 participants; moderate-certainty evidence) and duration of the cannulation procedure (MD -98.77 seconds, 95% CI -150.02 to -47.52, 5 RCTs, 402 participants; moderate-certainty evidence). More studies are needed to confirm whether the improvement in first-attempt success rates is more pronounced in neonates and younger children compared to older children and adolescents.

AUTHORS' CONCLUSIONS

We identified moderate-certainty evidence that ultrasound guidance for arterial cannulation compared with palpation or Doppler auditory assistance improves first-attempt success rate, second-attempt success rate and overall success rate. We also found moderate-certainty evidence that ultrasound guidance reduces the incidence of complications, the number of attempts to successful cannulation and the duration of the cannulation procedure.

Scale ultrasound-guided radial artery cannulation in infant: A randomized controlled trial

BACKGROUND

Cannulation of the radial artery can be extremely challenging in infants. Scale ultrasound can provide accurate arterial location and guidance for operators. We hypothesized that scale ultrasound helps increase the initial success rate of radial artery cannulation in this population.

METHOD

Seventy-six infants aged 0-3 months who needed arterial puncture after general anesthesia were randomly divided into two groups (1:1 ratio): the scale ultrasound group and the traditional ultrasound group. The primary endpoints were the success rate of the first attempt and the total success rate of arterial cannulation. The secondary endpoints were the time during arterial puncture and the incidence of vascular complications.

RESULTS

The success rate of the first attempt and the total success rate of arterial cannulation were 92.1% (35/38) versus 50% (19/38) and 100% (38/38) versus 86.8% (33/38) in the scale ultrasound and traditional ultrasound group (p < 0.005), respectively. The median time to ultrasound location, needle entry into the radial artery, and successful cannulation in the scale ultrasound group were significantly shorter than those in the traditional ultrasound group: 10 (8.0, 17.2) s, 15 (11.7, 20) s, and 65 (53.8, 78.5) s vs 30 (26.5, 43.5) s, 35 (23, 51) s, and 224.5 (123.5, 356) s (p < 0.001), respectively. The incidence of hematoma was higher in the traditional group (p < 0.005).

CONCLUSIONS

Scale ultrasound-guided radial arterial cannulation can significantly improved initial success rate and overall success rate, shorten puncture time in infant, compared with that achieved with the use of traditional ultrasound guidance.

Ultrasound-guided short-axis out-of-plane approach with or without dynamic needle tip positioning for arterial line insertion in children: A systematic review with network meta-analysis

The efficacy of the short-axis out-of-plane (SA-OOP) approach with and without dynamic needle tip positioning (DNTP) remains unclear. This systematic review with network meta-analysis aimed to compare the success rate of arterial line insertion in children using the SA-OOP approach with and without DNTP and the palpation technique. We searched MEDLINE (via PubMed) and the Cochrane Central Register of Controlled Trials. We included randomized controlled trials that compared two of the following techniques for arterial line insertion in children: (1) the ultrasound-guided SA-OOP approach with DNTP; (2) the ultrasound-guided SA-OOP approach without DNTP; and (3) the palpation technique. A network meta-analysis was performed. The outcomes were first-attempt and overall success rates. Eight studies were finally included in this network meta-analysis. The ultrasound-guided SA-OOP approach with DNTP was associated with increased first-attempt (relative risk RR = 3.45 [95% confidence interval (CI) 2.51-4.74]) and overall success rates (RR = 1.81 [1.41-2.32]) when compared with palpation. The same approach performed without DNTP was also associated with increased first-attempt (RR = 1.96 [1.59-2.42]) and overall success rates (RR = 1.25 [1.05-1.49]) when compared with palpation. The ultrasound-guided SA-OOP approach with DNTP was associated with increased first-attempt (RR = 1.76 [1.26-2.44]) and overall success rates (RR = 1.45 [1.10-1.91]) when compared with the same approach performed without DNTP. DNTP should be performed during the ultrasound-guided SA-OOP approach for arterial line insertion in children, as this can help increase first attempt and overall success rates.

Ultrasound guidance for arterial (other than femoral) catheterisation in adults

BACKGROUND

Arterial vascular access is a frequently performed procedure, with a high possibility for adverse events (e.g. pneumothorax, haemothorax, haematoma, amputation, death), and additional techniques such as ultrasound may be useful for improving outcomes. However, ultrasound guidance for arterial access in adults is still under debate.

OBJECTIVES

To assess the effects of ultrasound guidance for arterial (other than femoral) catheterisation in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, LILACS, and CINAHL on 21 May 2021. We also searched IBECS, WHO ICTRP, and ClinicalTrials.gov on 16 June 2021, and we checked the reference lists of retrieved articles.

SELECTION CRITERIA

Randomised controlled trials (RCTs), including cross-over trials and cluster-RCTs, comparing ultrasound guidance, alone or associated with other forms of guidance, versus other interventions or palpation and landmarks for arterial (other than femoral) guidance in adults.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, extracted data, assessed risk of bias, and assessed the certainty of evidence using GRADE.

MAIN RESULTS

We included 48 studies (7997 participants) that tested palpation and landmarks, Doppler auditory ultrasound assistance (DUA), direct ultrasound guidance with B-mode, or any other modified ultrasound technique for arterial (axillary, dorsalis pedis, and radial) catheterisation in adults. Radial artery Real-time B-mode ultrasound versus palpation and landmarks Real-time B-mode ultrasound guidance may improve first attempt success rate (risk ratio (RR) 1.44, 95% confidence interval (CI) 1.29 to 1.61; 4708 participants, 27 studies; low-certainty evidence) and overall success rate (RR 1.11, 95% CI 1.06 to 1.16; 4955 participants, 28 studies; low-certainty evidence), and may decrease time needed for a successful procedure (mean difference (MD) -0.33 minutes, 95% CI -0.54 to -0.13; 4902 participants, 26 studies; low-certainty evidence) up to one hour compared to palpation and landmarks. Real-time B-mode ultrasound guidance probably decreases major haematomas (RR 0.35, 95% CI 0.23 to 0.56; 2504 participants, 16 studies; moderate-certainty evidence). It is uncertain whether real-time B-mode ultrasound guidance has any effect on pseudoaneurysm, pain, and quality of life (QoL) compared to palpation and landmarks (very low-certainty evidence). Real-time B-mode ultrasound versus DUA One study (493 participants) showed that real-time B-mode ultrasound guidance probably improves first attempt success rate (RR 1.35, 95% CI 1.11 to 1.64; moderate-certainty evidence) and time needed for a successful procedure (MD -1.57 minutes, 95% CI -1.78 to -1.36; moderate-certainty evidence) up to 72 hours compared to DUA. Real-time B-mode ultrasound guidance may improve overall success rate (RR 1.13, 95% CI 0.99 to 1.29; low-certainty evidence) up to 72 hours compared to DUA. Pseudoaneurysm, major haematomas, pain, and QoL were not reported. Real-time B-mode ultrasound versus modified real-time B-mode ultrasound Real-time B-mode ultrasound guidance may decrease first attempt success rate (RR 0.68, 95% CI 0.55 to 0.84; 153 participants, 2 studies; low-certainty evidence), may decrease overall success rate (RR 0.93, 95% CI 0.86 to 1.01; 153 participants, 2 studies; low-certainty evidence), and may lead to no difference in time needed for a successful procedure (MD 0.04 minutes, 95% CI -0.01 to 0.09; 153 participants, 2 studies; low-certainty evidence) up to one hour compared to modified real-time B-mode ultrasound guidance. It is uncertain whether real-time B-mode ultrasound guidance has any effect on major haematomas compared to modified real-time B-mode ultrasound (very low-certainty evidence). Pseudoaneurysm, pain, and QoL were not reported. In-plane versus out-of-plane B-mode ultrasound In-plane real-time B-mode ultrasound guidance may lead to no difference in overall success rate (RR 1.00, 95% CI 0.96 to 1.05; 1051 participants, 8 studies; low-certainty evidence) and in time needed for a successful procedure (MD -0.06 minutes, 95% CI -0.16 to 0.05; 1134 participants, 9 studies; low-certainty evidence) compared to out-of-plane B-mode ultrasound up to one hour. It is uncertain whether in-plane real-time B-mode ultrasound guidance has any effect on first attempt success rate or major haematomas compared to out-of-plane B-mode ultrasound (very low-certainty evidence). Pseudoaneurysm, pain, and QoL were not reported. DUA versus palpation and landmarks DUA may lead to no difference in first attempt success rate (RR 1.01, 95% CI 0.90 to 1.14; 666 participants, 2 studies; low-certainty evidence) or overall success rate (RR 0.99, 95% CI 0.92 to 1.07; 666 participants, 2 studies; low-certainty evidence) and probably increases time needed for a successful procedure (MD 0.45 minutes, 95% CI 0.20 to 0.70; 500 participants, 1 study; moderate-certainty evidence) up to 72 hours compared to palpation and landmarks. Pseudoaneurysm, major haematomas, pain, and QoL were not reported. Oblique-axis versus long-axis in-plane B-mode ultrasound Oblique-axis in-plane B-mode ultrasound guidance may increase overall success rate (RR 1.27, 95% CI 1.05 to 1.53; 215 participants, 2 studies; low-certainty evidence) up to 72 hours compared to long-axis in-plane B-mode ultrasound. It is uncertain whether oblique-axis in-plane B-mode ultrasound guidance has any effect on first attempt success rate, time needed for a successful procedure, and major haematomas compared to long-axis in-plane B-mode ultrasound. Pseudoaneurysm, pain, and QoL were not reported. We are uncertain about effects in the following comparisons due to very low-certainty evidence and unreported outcomes: real-time B-mode ultrasound versus palpation and landmarks (axillary and dorsalis pedis arteries), real-time B-mode ultrasound versus near-infrared laser (radial artery), and dynamic versus static out-of-plane B-mode ultrasound (radial artery).

AUTHORS' CONCLUSIONS

Real-time B-mode ultrasound guidance may improve first attempt success rate, overall success rate, and time needed for a successful procedure for radial artery catheterisation compared to palpation, or DUA. In addition, real-time B-mode ultrasound guidance probably decreases major haematomas compared to palpation. However, we are uncertain about the evidence on major haematomas and pain for other comparisons due to very low-certainty evidence and unreported outcomes. We are also uncertain about the effects on pseudoaneurysm and QoL for axillary and dorsalis pedis arteries catheterisation. Given that first attempt success rate and pseudoaneurysm are the most relevant outcomes for people who underwent arterial catheterisation, future studies must measure both. Future trials must be large enough to detect effects, use validated scales, and report longer-term follow-up.

Effects of ultrasound-guided techniques for radial arterial catheterization: A meta-analysis of randomized controlled trials

OBJECTIVE

This study aimed to evaluate whether ultrasound-guided techniques are superior compared to traditional palpation techniques in patients undergoing radial artery catheterization (RAC).

METHODS

Electronic databases of PubMed, Embase, and the Cochrane Library were systematically searched to identify randomized controlled trials (RCTs). The relative risks (RRs) or weighted mean differences (WMDs) with corresponding 95% confidence intervals (CIs) were used to calculate the pooled effect estimates using the random effects model for categories and continuous data, respectively.

RESULTS

A total of 19 RCTs comprising a total of 3220 individuals were selected for final analysis. The pooled RR suggested that ultrasound-guided techniques were associated with higher incidence of first attempt success than traditional palpation techniques (RR, 1.39; 95% CI, 1.21-1.59; P < 0.001). Moreover, we noted that ultrasound-guided techniques were associated with fewer mean attempts to success (WMD, -0.80 s; 95% CI, -1.35 to -0.25; P = 0.004) and a shorter mean time to success (WMD, -41.18 s; 95% CI, -75.43 to -6.93; P = 0.018) than traditional palpation techniques. Furthermore, individuals using ultrasound-guided techniques had a reduced risk of hematoma (RR, 0.40; 95% CI, 0.22-0.72; P = 0.003).

CONCLUSIONS

This study indicated that ultrasound-guided techniques were superior compared to traditional palpation techniques for RAC in terms of efficacy and complications.

Application of ultrasound-guided radial artery cannulation in paediatric patients: A systematic review and meta-analysis

BACKGROUND

Numerous studies have demonstrated the benefits and safety of ultrasound guidance in comparison with conventional palpation for radial artery cannulation in adult patients. However, the current evidence for paediatric patients is not fully understood.

OBJECTIVE

The objective of this study was to compare the efficiency and safety of ultrasound guidance with those of traditional palpation for radial artery cannulation in paediatric patients and provide convincing evidence for clinical practice.

METHODS

PubMed, Cochrane Library, ClinicalTrials.gov (Min et al-2019, NCT02795468, Anantasit et al-2017, NCT02668471), China National Knowledge Infrastructure, and Wanfang Data were systematically searched from their inception until December 31, 2019, to identify relevant randomised controlled trials. Data were extracted from the included studies independently by two investigators. The primary outcome of interest was the first-attempt success rate. Review Manager Version 5.3 and trial sequential analysis (beta = 0.9) were applied to analyse the collected data.

RESULTS

A total of eight randomised controlled trials involving 680 paediatric patients were included in this study. The pooled findings showed that ultrasound-guided radial artery cannulation, in comparison with traditional palpation, can significantly improve the first-attempt success rate (relative risk [RR] = 1.65, 95% confidence interval [CI] = 1.36-2.01, P < 0.00001). Trial sequential analysis indicated that this available evidence was conclusive. Moreover, ultrasound guidance was associated with an increased total success rate (RR = 1.38, 95% CI = 1.15-1.66, P = 0.0004), a decreased mean procedural time (standardised mean difference = -0.89, 95% CI = -1.52 to -0.25, P = 0.006), and incidence of haematoma (RR = 0.19, 95% CI = 0.10-0.35, P < 0.00001).

CONCLUSION

Ultrasound-guided radial arterial cannulation in paediatric patients is associated with improved first-attempt success rates, total success rates, and mean procedural time and decreased incidence of haematoma. The current evidence suggests that ultrasound guidance should be the standard of care for radial artery cannulation in clinical practice.

Expert consensus-based clinical practice guidelines management of intravascular catheters in the intensive care unit

The French Society of Intensive Care Medicine (SRLF), jointly with the French-Speaking Group of Paediatric Emergency Rooms and Intensive Care Units (GFRUP) and the French-Speaking Association of Paediatric Surgical Intensivists (ADARPEF), worked out guidelines for the management of central venous catheters (CVC), arterial catheters and dialysis catheters in intensive care unit. For adult patients: Using GRADE methodology, 36 recommendations for an improved catheter management were produced by the 22 experts. Recommendations regarding catheter-related infections’ prevention included the preferential use of subclavian central vein (GRADE 1), a one-step skin disinfection(GRADE 1) using 2% chlorhexidine (CHG)-alcohol (GRADE 1), and the implementation of a quality of care improvement program. Antiseptic- or antibiotic-impregnated CVC should likely not be used (GRADE 2, for children and adults). Catheter dressings should likely not be changed before the 7th day, except when the dressing gets detached, soiled or impregnated with blood (GRADE 2− adults). CHG dressings should likely be used (GRADE 2+). For adults and children, ultrasound guidance should be used to reduce mechanical complications in case of internal jugular access (GRADE 1), subclavian access (Grade 2) and femoral venous, arterial radial and femoral access (Expert opinion). For children, an ultrasound-guided supraclavicular approach of the brachiocephalic vein was recommended to reduce the number of attempts for cannulation and mechanical complications. Based on scarce publications on diagnostic and therapeutic strategies and on their experience (expert opinion), the panel proposed definitions, and therapeutic strategies.

Efficacy of ultrasound-guided technique for radial artery catheterization in pediatric populations: a systematic review and meta-analysis of randomized controlled trials

Background

The use of an ultrasound-guided technique for radial arterial catheterization has not been well established in pediatric patients. We conducted a systematic review and meta-analysis to evaluate the efficacy of the ultrasound-guided technique for radial artery catheterization in pediatric populations.

Method

A systematic review of PubMed, Medline, Embase, and the Cochrane library was performed from their date of inception to December 2019. In this meta-analysis, we conducted online searches using the search terms “ultrasonography,” “ultrasonics,” “ultrasound-guided,” “ultrasound,” “radial artery,” “radial arterial,” “catheter,” “cannula,” and “catheterization.” The rate of the first-attempt and total success, mean attempts to success, mean time to success, and incidence of complications (hematomas) were extracted. Data analysis was performed with RevMan 5.3.5.

Results

From 7 relevant studies, 558 radial artery catheterizations were enrolled, including 274 ultrasound-guided and 284 palpation catheterizations. The ultrasound-guided technique could significantly improve the rate of first-attempt and total success (RR 1.78, 95% CI 1.46 to 2.18, P < 0.00001; RR 1.33; 95% CI 1.20 to 1.48; P < 0.00001). However, there was significant heterogeneity for the total success rate among the included studies (I² = 67%). The ultrasound-guided radial artery catheterization was also associated with less mean attempts and mean time to success (WMD − 1.13, 95% CI − 1.58 to − 0.69; WMD − 72.97 s, 95% CI − 134.41 to − 11.52) and lower incidence of the hematomas (RR 0.17, 95% CI 0.07 to 0.41).

Conclusions

The use of the ultrasound-guided technique could improve the success rate of radial arterial catheterization and reduce the incidence of hematomas in pediatric patients. However, the results should be interpreted cautiously due to the heterogeneity among the studies.

[Ultrasound-guided cannulation or by pulse palpation in the intensive care unit]

INTRODUCTION

Ultrasound (US) guidance increases the success rate and decreases complications during central venous catheterisation (CVC). The benefits of US guidance in arterial catheterisation are less clear. The aim of this study is to compare the outcomes of US-guided arterial catheterisation with the traditional landmark (LM) technique in critically ill children.

METHODS

A prospective multicentre study was carried out in 18 Paediatric Intensive Care units in Spain during a 6-months period. Ultrasound guided and landmark techniques were compared in terms of cannulation technical success and immediate mechanical complications.

RESULTS

A total of 161 procedures were performed on 128 patients (78 procedures in the US group and 83 in the LM groups). The median (interquartile range) age and weight of the cohort was 11months (2-52), and 10kg (4-17), respectively. More than half (59.6%) were male. US was used mainly in big (number of beds 11 [8-16] vs 6 [4-10], p < 0,001) and high complexity intensive care units (cardiac surgery program 76.9% vs. 25.6%, P<.001) as well as in smaller children [weight 5.7kg (3.8-13) vs 11.5kg (4.9-22.7), P<.001]. Almost half (49.7%) of the procedures were performed by an inexperienced operator (paediatric resident, or staff with less than 5years of clinical experience in the PICU), and only 24.4% had performed more than 50 US-guided vascular access procedures before the study. There were no significant differences between US and LM techniques in terms of first-attempt success (35.8% vs 33.7%, P=.773), overall success (75.6% vs 71.1%, P=.514), number of puncture attempts [2 (1-4) vs 2 (1-3), P=.667] and complications (16.6% vs 25.6%, P=.243). Adjustment by potential confounders using multivariate regression models did not modify these results. Subgroup analyses showed that US outperformed LM technique in terms of overall success (83.7% vs 62.7%, P=.036) and complications (10,8% vs 32.5%, P=.020) only when procedures where performed by less-experienced operators.

CONCLUSIONS

In this prospective observational multicentre study, US did not improve arterial cannulation outcomes compared to the traditional LM technique in critically ill children. US-guided arterial cannulation may offer advantages when cannulation is performed by inexperienced operators.

Modified long-axis in-plane ultrasound technique versus conventional palpation technique for radial arterial cannulation: A prospective randomized controlled trial

BACKGROUND

A low first-pass success rate of radial artery cannulation was obtained when using the conventional palpation technique (C-PT) or conventional ultrasound-guided techniques, we; therefore, evaluate the effect of a modified long-axis in-plane ultrasound technique (M-LAINUT) in guiding radial artery cannulation in adults.

METHODS

We conducted a prospective, randomized and controlled clinical trial of 288 patients undergoing radial artery cannulation. Patients were randomized 1:1 to M-LAINUT or C-PT group at Fujian Medical University Union Hospital between 2017 and 2018. Radial artery cannulation was performed by 3 anesthesiologists with different experience. The outcome was the first and total radial artery cannulation success rates, the number of attempts and the cannulation time, and incidence of complications.

RESULTS

Two hundred eighty-five patients were statistically analyzed. The success rate of first attempt was 91.6% in the M-LAINUT group (n = 143) and 57.7% in the C-PT group (n = 142; P < .001) (odds ratio, 7.9; 95% confidence interval, 4.0-15.7). The total success rate (≤5 minutes and ≤3 attempts) in the M-LAINUT group was 97.9%, compared to 84.5% in the palpation group (P < .001) (odds ratio, 8.5; 95% confidence interval, 2.5-29.2). The total cannulation time was shorter and the number of attempts was fewer in the M-LAINUT group than that in the C-PT group (P < .05). The incidence of hematoma in the C-PT group was 19.7%, which was significantly higher than the 2.8% in the M-LAINUT group (P < .001).

CONCLUSIONS

Modified long-axis in-plane ultrasound-guided radial artery cannulation can increase the first and total radial artery cannulation success rates, reduce the number of attempts, and shorten the total cannulation time in adults.

Acoustic Shadowing Facilitates Ultrasound-guided Radial Artery Cannulation in Young Children

Editor’s Perspective

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Background

Arterial cannulation in young children can be challenging. Ultrasound guidance using focused acoustic shadowing may be suitable for guiding radial artery puncture in young children. The present research tested the hypothesis that ultrasound guidance using focused acoustic shadowing helps increase the success rate of radial artery cannulation in this population.

Methods

In a double-blinded, parallel-group trial, 79 young children undergoing surgery under general anesthesia were randomly assigned to two groups (1:1 ratio): the traditional ultrasound group and the novel ultrasound group. Young children in the traditional group underwent conventional ultrasound-guided radial artery puncture, whereas those in the novel ultrasound group underwent radial artery puncture guided by acoustic shadowing ultrasound with double developing lines. All radial artery punctures were performed using the short-axis out-of-plane approach. The primary endpoint was the success rate of cannulation at the first attempt. The secondary endpoints included cannulation failure rate, ultrasound location time, and puncture time.

Results

The success rate of cannulation at the first attempt in the novel ultrasound group (35 of 39 [90%]) was significantly higher than that in the traditional ultrasound group (24 of 40 [60%]; difference: 30% [95% CI, 12 to 48%], P =0.002). None of the patients in the ultrasound with acoustic shadowing group experienced failure of radial artery puncture and cannulation. The ultrasound location time and puncture time in the ultrasound acoustic shadowing group were significantly lower than that in the traditional ultrasound group (location time: median [interquartile range]: 6 [5, 8] vs. 18 [15, 21] s; puncture time: 24 [15, 41] vs. 40 [23, 56] s).

Conclusions

Acoustic shadowing via the use of double developing lines significantly improved the success rate of radial artery puncture in young children, compared with that achieved with the use of traditional ultrasound guidance.

Application of Optimized Ultrasonic Localization System for Radial Artery Puncture by Intern Doctors: A Randomized Trial

BACKGROUND Ultrasound with developing line may by suitable for medical personnel who are inexperienced in the use of ultrasound-guided radial artery puncture. In this trial, we assessed whether this technology could increase the success rate of radial artery puncture performed by interns. MATERIAL AND METHODS Seventy-seven patients undergoing general anesthesia were enrolled and randomly divided into 2 groups: an ultrasound with developing line group and a traditional ultrasound group. All radial artery punctures were performed by interns who received theoretical explanation (including video demonstration of puncture) and on-site guidance puncture once. The primary end-point was the success rate of cannulation at the first attempt and the secondary end-point was cannulation failure rate. RESULTS The success rate of cannulation at the first attempt in ultrasound in the developing line group was significantly higher than that in the traditional ultrasound group (proportion difference: 34.21%, 95% confidence interval [CI], -0.5483 to -0.1334; P=0.0025). However, no significant between-group difference was observed with respect to failure rate (mean difference 95% CI, (-0.0084 to 0.2743; P=0.0866). The ultrasonic location time in the ultrasound with developing line group was significantly lower than that in the traditional ultrasound group (mean difference -12.4 seconds, 95% CI, 10.64 to 13.98 s; P<0.0000). CONCLUSIONS Use of ultrasound with developing line significantly improved the success rate of radial artery puncture performed by interns as compared to that with use of traditional dynamic ultrasound guidance technology.

Ultrasound-guided versus palpation-guided radial artery catheterization in adult population: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The radial artery (RA) is routinely used for both hemodynamic monitoring and for cardiac catheterization. Although cannulation of the RA is usually undertaken through manual palpation, ultrasound (US)-guided access has been advocated as a mean to increase cannulation success rates and to lower RA complications; however, the published data are mixed. We sought to evaluate the impact of US-guided RA access compared with palpation alone on first-pass success to access RA.

METHODS AND RESULTS

Meta-analysis of 12 randomized controlled trials comparing US-guided with palpation-guided radial access in 2,432 adult participants was done. Hemodynamic monitoring was the most common reason for RA catheterization. Only 2 randomized controlled trials evaluated patients undergoing cardiac catheterization. Ultrasound-guided radial access was associated with increased first-attempt success rate (risk ratio [RR] 1.35, 95% CI 1.16-1.57]) and decreased failure rate (RR 0.52, 95% CI 0.32-0.87). There were no significant differences in the risk of hematoma (RR 0.43, 95% CI 0.27-1.06), the mean time to first successful attempt (mean difference 25.13 seconds, 95% CI -1.06 to 51.34) or to any successful attempt (mean difference -4.74 seconds; 95% CI -22.67 to 13.18) between both groups.

CONCLUSIONS

Ultrasound-guided technique for RA access has higher first-attempt success and lower failure rate compared with palpation alone, with no significant differences in access site hematoma or time to a successful attempt. These findings support the routine use of US guidance for RA access.