AIUM Practice Parameter for the Use of Ultrasound to Guide Vascular Access Procedures

Spatial sensitivity distribution assessment and Monte Carlo simulations for needle-based bioimpedance imaging during venipuncture using the finite element method

Despite being among the most common medical procedures, needle insertions suffer from a high error rate. Impedance measurements using electrode-equipped needles offer promise for improved tissue targeting and reduced errors. Impedance visualization usually requires an extensive pre-measured impedance dataset for tissue differentiation and knowledge of the electric fields contributing to the resulting impedances. This work presents two finite element simulation approaches for both problems. The first approach describes the generation of a multitude of impedances with Monte Carlo simulations for both, homogeneous and inhomogeneous tissue to circumvent the need to rely on previously measured data. These datasets could be used for tissue discrimination. The second method describes the simulation of the spatial sensitivity distribution of an electrode layout. Two singularity analysis methods were employed to determine the bulk of the sensitivity within a finite volume, which in turn enables consistent 3D visualization. The modeled electrode layout consists of 12 electrodes radially placed around a hypodermic needle. Electrical excitation was simulated using two neighboring electrodes for current carriage and voltage pickup, which resulted in 12 distinct bipolar excitation states. Both, the impedance simulations and the respective singularity analysis methods were compared with each other. The results show that the statistical spread of impedances is highly dependent on the tissue type and its inhomogeneities. The bounded bulk of sensitivities of both methods are of similar extent and symmetry. Future models should incorporate more detailed tissue properties such as anisotropy or changing material properties due to tissue deformation to gain more accurate predictions.

Comparing the Utility of Landmark-Palpation Guided to Ultrasound-Guided Teaching Methodologies for Subclavian Central Venous Access Using a Formalin-Embalmed Cadaver Model

Background

Low-risk and realistic simulation strategies are needed to train clinical learners to perform hands-on invasive procedures. This follow-up study compares the utility of landmark-guided palpation-based to ultrasound-guided teaching techniques for subclavian central venous access using formalin-embalmed cadavers.

Methods

The subclavian veins of 3 cadavers were imaged with ultrasound to evaluate vein patency before palpation-based venous access was attempted. Twenty-three first-year medical students were trained to access the subclavian vein using palpation-based techniques. Training involved ten minutes of didactic orientation and ten minutes of hands-on practical instruction using cadavers. Participant confidence was measured using a 10-point Likert scale on pre- and post-training questionnaires. Objective skills testing for each participant included quantifying the number of skin punctures and recording the time elapsed from first skin puncture to fluid flashback into the syringe. Data was analyzed using a generalized linear model (GLM) approach.

Results

Participant confidence significantly increased following training in both ultrasound and palpation training groups across all questionnaire items (P<0.001). The ultrasound group had fewer skin punctures (P<0.001) and fewer failures (1) than the palpation group (6). Participants in the ultrasound group were more confident than those in the palpation group in their ability to locate the vein and select the optimal site for needle access (P<0.05).

Conclusion

Formalin-embalmed cadavers provide a safe, stress-free, and effective means by which to train students in subclavian vein access using both palpation and ultrasound-based techniques. Repeated practice accessing and aspirating fluid from a cadaveric subclavian vein significantly increases trainee confidence, an essential factor in physician performance that may lead to fewer complications. Introducing this type of low-risk and hands-on practice may be beneficial for trainees before they attempt subclavian vein access on live patients.

Evaluation of a Point-of-care ultrasound (POCUS) workshop for peripheral intravenous cannulation

BACKGROUND

Point-of-care ultrasound (POCUS) is increasingly used as a non-invasive vascular access assessment method by clinicians from multiple disciplines worldwide, prior and during vascular access cannulations. While POCUS is a relatively new method to establish a vascular access in patients with complex vascular conditions, it is also essential to train and educate individuals who are novices in the techniques of cannulation so that they become proficient in performing this task subsequently on patients safely and successfully. A simulated environment may be a helpful tool to help healthcare providers establish skills in using POCUS safely and may also help them to successfully establish vascular access in patients. With this project, we sought to determine if participants of a simulated POCUS workshop for vascular access can use this technique successfully in their individual clinical environment after their attendance of a half-day workshop.

METHODS

A mixed-methods longitudinal study design was chosen to evaluate a point-of-care ultrasound workshop for peripheral intravenous cannula insertion. The workshops used simulation models for cannulation in combination with multiple ultrasound devices from various manufacturers to expose participants to a broader variety of POCUS devices as they may also vary in different clinical areas. Participants self-assessed their cannulation skills using questionnaires on a 10-point rating scale prior to and directly after the workshop.

RESULTS

A total of 85 Individuals participated in eleven half-day workshops through 2021 and 2022. Workshop participants claimed that attending the workshop had significantly enhanced their clinical skill of using ultrasound for the purpose of cannulating a venous vessel. The level of confidence in using this technique had increased in all participants directly after conclusion of the workshop.

CONCLUSIONS

Globally, clinicians are increasingly using POCUS to establish vascular access in patients, and it is necessary that they receive sufficient and adequately structured and formal training to successfully apply this technique in their clinical practice. Offering a workshop which uses simulation models in combination with various POCUS devices to demonstrate this technique in a hands-on approach has proven to be useful to establish this newly learned skill in clinicians.

Educating health professionals in ultrasound guided peripheral intravenous cannulation: A systematic review of teaching methods, competence assessment, and patient outcomes

BACKGROUND

Peripheral intravenous cannula insertion is the most common invasive healthcare procedure, however failure rates remain unacceptably high, particularly in patients with difficult intravascular access. This leads to treatment delays and increased complication risk, causing poorer outcomes among this patient subset. Ultrasonographic guidance reduces these risks and is therefore becoming a competency required of health professionals. However, there is no consensus on how to design teaching sessions to achieve this competency.

METHODS

Systematic review was conducted to identify characteristics of effective teaching sessions for current and training health professions to achieve ultrasound guided peripheral intravenous cannulation competency. Secondary outcomes included defining competency and to assess benefits to patients and healthcare systems. Eligibility for inclusion required description of teaching of ultrasound guided peripheral intravenous cannulation to qualified or training health professionals who went on to perform it in human patients or volunteers with reported outcomes or success rates. Studies were excluded if not accessible in full, not peer-reviewed or presented research that had been presented elsewhere previously. Of the 1085 records identified on review of 6 databases, 35 were included for final review based on eligibility criteria.

RESULTS

Almost all (97.1%) used mixed modality teaching comprising of didactic and simulation portions, although time allocated varied widely. A median of 5 proctored procedures was required for competency. Competency was independent of previous experience or staff seniority. Mean reported insertion attempts was 1.7, success rate was 82.5% and first-time success rate was 75.5%. All included studies described improvement in their participants or healthcare system including significantly reduced midline insertion rates, central venous catheter insertion rates and associated bacteremia and sepsis, self-reported cannulation difficulty, specialist input, therapy delays and premature catheter failure rates. Further, there was significantly improved procedural confidence, knowledge and competence.

CONCLUSION

Simple teaching interventions can lead to competent ultrasound guided peripheral intravenous cannula insertion by novices, resulting in numerous positive outcomes for patients and healthcare systems.

Comparison between the long-axis in-plane and short-axis out-of-plane approaches for ultrasound-guided arterial cannulation: a meta-analysis and systematic review

BACKGROUND

The two most common methods for ultrasound-guided arterial cannulation are the long-axis in-plane (LA-IP) and short-axis out-of-plane (SA-OOP) approaches. However, it is uncertain which method is more advantageous. We conducted a meta-analysis of reported randomized clinical trials (RCTs) comparing the two techniques in terms of success rate, cannulation time, and complications.

METHODS

We systematically searched PubMed, Embase, and the Cochrane Library database for RCTs comparing the LA-IP and SA-OOP techniques for ultrasound-guided arterial cannulation published from inception through April 31, 2022. The Cochrane Collaboration's Risk of Bias Tool was used to evaluate the methodological quality of each RCT. Review Manager 5.4 and Stata/SE 17.0 were used to analyze the two primary outcome measures (first-attempt success rate and total success rate) and two secondary outcome measures (cannulation time and complications).

RESULTS

A total of 13 RCTs with 1,377 patients were included. There were no significant differences in first-attempt success rate (risk ratio [RR], 0.93; 95% confidence interval [CI], 0.78-1.12; P = 0.45; I² = 84%) and overall success rate (RR, 0.99; 95% CI, 0.95-1.02; P = 0.48; I² = 57%). When compared with the LA-IP technique, the SA-OOP technique was associated with an increased incidence of posterior wall puncture (RR, 3.01; 95% CI, 1.27-7.14; P = 0.01; I² = 79%) and hematoma (RR, 2.15; 95% CI, 1.05-4.37; P = 0.04; I² = 63%). There was no significant difference in the incidence of vasospasm between techniques (RR, 1.26; 95% CI, 0.37-4.23; P = 0.07; I² = 53%).

CONCLUSIONS

The present results suggest that the SA-OOP technique is associated with a higher incidence of posterior wall puncture and hematoma than the LA-IP technique, whereas success rates are similar for the two ultrasound-guided arterial cannulation techniques. These findings should be experimentally evaluated in a more rigorous manner due to high inter-RCT heterogeneity.

The Adult Difficult Intravenous Access (DIVA) Cognitive Aid: An Evidence-Based Cognitive Aid Prototype for Difficult Peripheral Venous Access

Difficult intravenous access (DIVA) is common, with imperfect solutions. Cognitive aids are widespread in anaesthesia; however, a standard DIVA cognitive aid is lacking. This article describes a cognitive aid for DIVA. It has been developed using evidence-based techniques for DIVA. The effects of heuristics, biases, and automatic thinking on procedural decision-making are briefly discussed. While often useful, shortcut decision-making can impair the performance of apparently simple tasks. Cognitive aids may lead to better outcomes by providing choice architecture. This resource is intended as a cognitive aid prototype for difficult peripheral venous access, incorporating both modern behavioural psychology principles and evidence-based medicine. It may be used as both an educational tool, or as a cognitive aid to assist in situations where DIVA is encountered or expected. The adult DIVA cognitive aid is intended for use in both elective and emergency scenarios by practitioners adequately trained in ultrasound-guided or ultrasound-assisted vascular access and Seldinger-based techniques. Clinical implementation and audit of the adult DIVA cognitive aid, or similar locally developed cognitive aids based on this prototype are recommended.

Effectiveness of ultrasound-guided cannulation of AVF on infiltration rates: A single center quality improvement study

Though ultrasonography is increasingly used throughout the spectrum of hemodialysis access, its role in outpatient dialysis units in the United States has been limited so far. This may, in part, be due to limited ultrasound exposure, knowledge and training of dialysis staff. We implemented a quality improvement initiative in our dialysis units to expand the use of ultrasound by our frontline dialysis staff to prospectively evaluate newly placed AVF and guide cannulation. This manuscript describes our experience and the impact of our protocol on infiltration rates in our outpatient HD units.

Management of Vascular Access in the Setting of Percutaneous Mechanical Circulatory Support (pMCS): Sheaths, Vascular Access and Closure Systems

The use of percutaneous mechanical circulatory support (pMCS), such as intra-aortic balloon pump, Impella, TandemHeart and VA-ECMO, in the setting of cardiogenic shock or in protect percutaneous coronary intervention (protect-PCI) is rapidly increasing in clinical practice. The major problem related to the use of pMCS is the management of all the device-related complications and of any vascular injury. MCS often requires large-bore access, if compared with common PCI, and for this reason the correct management of vascular access is a crucial point. The correct use of these devices in catheterization laboratories requires specific knowledge such as the correct evaluation of the vascular access performed, when possible, with advance imaging techniques in order to choose a percutaneous or a surgical approach. In addition to conventional transfemoral access, other types of access, such as transaxillary/subclavial access and the transcaval approach, have emerged over the years. These other approaches require advanced skills of the operators and a multidisciplinary team with dedicated physicians. Another important part of the management of vascular access is the closure systems used for hemostasis. Currently, two types of devices are typically used in the lab: suture-based or plug-based ones. In this review we want to describe all these aspects related to the management of vascular access in pMCS and describe, finally, a case report from our center's experience.

Incorporating Evidence-based Ultrasound-guided Vascular Access (USGVA) Standards Into the Nurse Anesthetist Armamentarium: A Quality Improvement Project

PURPOSE

This quality improvement (QI) project developed and implemented a hybrid training program, that included online modules and hands-on training for experienced certified registered nurse anesthetists (CRNAs) to increase confidence, knowledge, and competency with ultrasound-guided vascular access (USGVA).

DESIGN

This QI project used a pre-post design. Seventeen volunteer CRNAs participated in USGVA training and education, and a 90-day follow-up assessment was performed.

METHODS

The Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) guidelines were used as a framework to assess confidence, knowledge, and hands-on competency of 17 CRNAs who regularly place vascular access devices using USGVA in patients with difficult vascular access at a single facility. These assessments were measured at: (1) baseline, (2) immediately after attending a hybrid training educational program, and (3) 90 days after implementation into clinical practice. Additionally, the number of vascular access attempts required for successful placement of peripheral intravenous (PIV) catheters, arterial catheters, and central venous catheters (CVC) with ultrasound assistance over a 90-day period was reviewed.

FINDINGS

Certified registered nurse anesthetists' median confidence score increased significantly from pre- to post-education (P = .009). The confidence reported from post- to 90 days post-education improved, however it did not reach statistical significance (P = .812). The knowledge scores from pre- to post-education indicated significant improvement (P <. 001), as well as from pre- to 90 days post-education (P = .03). However, knowledge scores from post- to 90 days post-education revealed a statistically significant decline (P = .004). The overall median score for hands-on USGVA competency declined from post- to 90 days post-education (P = .109). The number of successful USGVA placements increased from 50% to 80% within a 90-day period.

CONCLUSIONS

The implementation of a USGVA hybrid training and education program improved overall provider confidence, knowledge, and competency. While confidence remained high in the 90-day follow-up, knowledge retention declined. Despite a decline in knowledge retention over time, results showed a significant improvement when compared to baseline scores. Although a decline in hands-on USGVA competency was seen at 90 days posteducation, it was not statistically significant. The percentage of overall successful USGVA placements in clinical practice increased following implementation.

Comparison of ultrasound-guided peripheral intravenous catheter insertion with landmark technique in paediatric patients: A systematic review and meta-analysis

BACKGROUND

Paediatric peripheral intravenous catheter (PIVC) insertion using traditional landmark insertion technique can be difficult.

AIM

To systematically review the evidence comparing landmark to ultrasound guidance for PIVC insertion in general paediatric patients.

STUDY DESIGN

Cochrane methodology to systematically search for randomised controlled trials comparing landmark to ultrasound-guided PIVC insertion.

DATA SOURCES

Cochrane Central Register of Controlled Trials, US National Library of Medicine, Cumulative Index to Nursing and Allied Health, Embase.

DATA EXTRACTION

English-language, paediatric trials published after 2000, reporting first-attempt insertion success, overall PIVC insertion success, and/or time to insert were included. Central venous, non-venous and trials including only difficult intravenous access were excluded. Data were independently extracted and critiqued for quality using GRADE by three authors, and analysed using random effects, with results expressed as risk ratios (RR), mean differences (MD) and 95% confidence intervals (CI). Registration (CRD42020175314).

RESULTS

Of 70 titles identified, 5 studies (995 patients; 949 PIVCs) were included. There was no evidence of an effect of ultrasound guidance, compared to landmark, for first-attempt insertion success (RR 1.27; 95% CI 0.90-1.78; I2  = 88%; moderate quality evidence), overall insertion success (RR 1.14; 95% CI 0.90-1.44; I2  = 82%; low quality evidence), or time to insertion (mean difference -3.03 min; 95% CI -12.73 to 6.67; I2  = 92%; low quality evidence).

LIMITATIONS

Small sample sizes, inconsistent outcomes and definitions in primary studies precluded definitive conclusions.

CONCLUSIONS

Large clinical trials are needed to explore the effectiveness of ultrasound guidance for PIVC insertion in paediatrics. Specifically, children with difficult intravenous access might benefit most from this technology.

Ultrasound-Guided Peripheral Intravenous Catheter Insertion Training Reduces Use of Midline Catheters in Hospitalized Patients With Difficult Intravenous Access

OBJECTIVES

Difficult intravenous (IV) access (DIVA) is a prevalent condition in the hospital setting and increases utilization of midline catheters (MCs) and peripherally inserted central catheters (PICCs). Ultrasound-guided peripheral intravenous (USGPIV) insertion is effective at establishing intravenous access in DIVA but remains understudied in the inpatient setting. We evaluated the effect of an USGPIV simulation-based mastery learning (SBML) curriculum for nurses on MC and PICC utilization for hospitalized patients.

METHODS

We performed a quasi-experimental observational study. We trained nurses across all inpatient units at a large tertiary care hospital. We queried the electronic medical record to compare PICC and MC utilization for patients with DIVA during 3 periods: before USGPIV SBML training (control), during pilot testing of the intervention, and during the SBML intervention. To account for variations in insertion practices over time, we performed an interrupted time series (ITS) analysis between 2 periods, the combined control and pilot periods and the intervention period.

RESULTS

One hundred forty-eight nurses completed USGPIV SBML training. Midline catheters inserted monthly per 1000 patient-days for DIVA decreased significantly from 1.86 ± 0.51 (control) to 2.31 ± 0.28 (pilot) to 1.33 ± 0.51 (intervention; P = 0.001). The ITS analysis indicated a significant intervention effect (P < 0.001). Peripherally inserted central catheters inserted monthly per 1000 patient-days for DIVA also significantly decreased over the study periods; however, the ITS failed to show an intervention effect as PICC insertions were already decreasing during the control period.

CONCLUSIONS

A hospital-wide USGPIV SBML curriculum for inpatient nurses was associated with a significant reduction in MCs inserted for DIVA.

Success of implementation of a systemwide point-of-care ultrasound privileging program for emergency medicine faculty

OBJECTIVES

Point-of-care ultrasound (POCUS) is widely used in the emergency department (ED). Not all practicing emergency physicians received POCUS training during residency, leaving a training gap that is reflected in POCUS privileging. The purpose of this study was to evaluate the success of meeting privileging criteria as well as associated factors, following implementation of a basic POCUS training and privileging program within a large emergency medicine department.

METHODS

We implemented a POCUS training and privileging program, based on national guidelines, for faculty physicians who worked at one of the following EDs staffed by the same emergency medicine department: a pediatric tertiary site, two tertiary academic sites, and seven community sites. POCUS examinations included aorta, cardiac, first-trimester obstetrics (OB), and extended focused assessment with sonography in trauma. Pediatric emergency medicine faculty were taught soft tissue and thoracic US instead of aorta and OB. Completion of the program required 16 h of didactics, ≥25 quality-assured US examinations by examination type, and passing a series of knowledge-based examinations. Descriptive statistics were calculated. Associations between physician characteristics and successfully becoming privileged in POCUS were modeled using Firth's logistic regression.

RESULTS

A total of 176 faculty physicians were eligible. A total of 145 (82.4%) achieved basic POCUS privileging during the study period. Different pathways were used including 86 (48.9%) practice-based, nine (5.1%) fellowship-based, and 82 (46.9%) residency-based. POCUS privileging was lower for those working in a community versus academic setting (odds ratio 0.3, 95% confidence interval 0.1-0.9). A greater number of scans completed prior to the privileging program was associated with greater success.

CONCLUSIONS

Implementation of a POCUS training and privileging program can be successful in a large emergency medicine department that staffs hospitals in a large-scale health care system composed of both academic and community sites. Faculty physicians with at least some prior exposure to POCUS were more successful.

Simulation-Based Mastery Learning Improves Ultrasound-Guided Peripheral Intravenous Catheter Insertion Skills of Practicing Nurses

INTRODUCTION

Difficult intravenous (IV) access (DIVA) is frequently encountered in the hospital setting. Ultrasound-guided peripheral IV catheter (USGPIV) insertion has emerged as an effective procedure to establish access in patients with DIVA. Despite the increased use of USGPIV, little is known about the optimal training paradigms for bedside nurses. Therefore, we developed and evaluated a novel, sustainable, USGPIV simulation-based mastery learning (SBML) curriculum for nurses.

METHODS

This is a prospective cohort study of an USGPIV SBML training program for bedside nurses over a 12-month period. We evaluated skills and self-confidence before and after training and measured the proportion of the nurses achieving independent, proctor, and instructor status. Procedure logs and surveys were used to explore the nurse experience and utilization of USGPIV on real patients with DIVA 3 months after the intervention.

RESULTS

Two hundred thirty-eight nurses enrolled in the study. The USGPIV skill checklist scores increased from median of 6.0 [interquartile range = 4.0-9.0 (pretest) to 29.0, interquartile range = 28-30 (posttest), P < 0.001]. The USGPIV confidence improved from before (mean = 2.32, SD = 1.17) to after (mean = 3.85, SD = 0.73, P < 0.001) training (5-point Likert scale). Sixty-two percent of the nurses enrolled achieved independent status, 47.5% became proctors, and 11.3% course trainers. At 3-month posttraining, the nurses had attempted a mean of 35.6 USGPIV insertions with an 89.5% success rate.

CONCLUSIONS

This novel USGPIV SBML curriculum improves nurses' insertion skills, self-confidence, and progresses patient care through USGPIV insertions on hospitalized patients with DIVA.

Ultrasound-Guided Peripherally Inserted Central Catheter Placement in Extremely Low Birth Weight Neonates

Extremely low birth weight (ELBW), <1,000 g, neonates require central venous access for their growth, development, and survival. Peripherally inserted central catheters (PICCs) provide such access and reduce the risks associated with other types of central venous catheters. While the use of ultrasound (US) to guide PICC placement further reduces these risks, this technology has not been integrated into neonatal practice. The purpose of this case study is to describe US-guided PICC placement in 2 ELBW neonates. PICCs were placed in 2 patients weighing 505 g and 800 g, respectively, utilizing US guidance where the practitioner was unable to identify veins using traditional methods (e.g., palpation, landmarks, transillumination, or infrared device). PICC placement utilizing US guidance in ELBW neonates is a safe and effective technique that improves outcomes, prevents complications, and promotes vessel preservation in this vulnerable population. It is essential that this technique is integrated into neonatal practice.

Real time wire localization by ultrasound during central line insertion improves accurate positioning in all upper torso sites

PURPOSE

To investigate whether point of care ultrasound can improve central venous catheter tip positioning.

MATERIAL AND METHODS

A single center retrospective case control study. We compared the precision of central venous catheter tip positioning between two intensive care units while in only one of the units, we used point of care ultrasound for guidewire identification.

RESULTS

207 cases in which central venous catheter was inserted using point of care ultrasound guided method, compared to 192 controls. The primary outcome of correct placement of the central venous catheter tip was significantly higher in the point of care ultrasound guided group (97.6% vs 88.0% p = 0.001). Central venous catheter tip was located too low among 12% of patients in the control group while in only 2.4% of patients in the point of care ultrasound group (p = 0.001). Logistics regression analysis revealed that the correct placement of central venous catheter tip in the point of care ultrasound group versus the control group had an odds ratio of 4.9 (CI 1.6-14.5 P = 0.004).

CONCLUSION

Point of care ultrasound for guidewire identification and localization, while inserting central venous catheter from all upper torso sites, improves precision positioning.

Ultrasound guided cannulation of dialysis access

Vascular access is the key part of haemodialysis (HD) treatment, as this is not possible without a functioning access. The use of the arteriovenous fistula (AVF) has fewer complications, lower mortality and fewer hospital admissions compared to central venous catheter (CVC). However, although guidelines recommend AVF as the access of choice, access-related cannulation complications may lead to greater morbidity. Most guidelines recommend using Doppler ultrasound (DU) to surveil the AVF for HD, but its use must not only be limited to surveillance as it can also be used for needling. Therefore, among those techniques at our disposal today, one of the best tools for AVF needling is Doppler ultrasound (DU). Despite the lack of evidence regarding ultrasound-guided needling of AVF, it is becoming part of our usual practice arsenal in many HD centres. Its use has allowed needling results to improve and the number of complications to be reduced versus traditional ‘blind’ needling. It should be remembered that even though it is very useful for the daily work of dialysis nurses, as in the case of other techniques, it requires adequate, specialised and long-term training to acquire competence in using it. For example, it is important to learn some concepts and terminology that should be known and, at the same time, be highly familiar with different techniques available. Two types of needling techniques are described using US assistance: US-guided needling, where DU is used to make a map of the vessels which can be utilised and to mark the best site to insert the needles once the mapping is done; and real-time US-guided needling, the simultaneous manipulation of the probe and the insertion of the puncture needle through the slice plane of the ultrasound device. Regarding the real-time technique, there are two approaches: out of plane (the probe takes a transversal image of the needle) and in plane (vessel axis aligned with the probe and the needle in the same plane) To ensure successful needling and to maximise reproducibility, especially with tight deadlines and staff resources, nursing staff need to follow some important recommendations that include safety and the use of the method, both for them and the patient. In this way, ultrasound-guided needling becomes a tool with enormous potential utility, but practical training is as important as knowing the technique.

Ultrasound in central venous access for hemodialysis

Central venous cannulation is a frequent need for urgent or scheduled hemodialysis. Many studies confirmed the pivotal role of ultrasound in this procedure. Vascular access guidelines strongly recommend ultrasound guidance. Its usefulness has been demonstrated not only in reducing complications of venipuncture but more recently for the evaluation of central venous catheter (CVC) placement and real-time check for possible complications. The use of ultrasound requires a precise technique for the correct handling of the probe and the needle movement. Different approaches as the out-of-plane, in-plane, and oblique methods are available, enabling the most appropriate for the individual case. Although the learning curve for CVC ultrasound placement is usually fast, formal training and certification for beginners are strongly recommended.

Ultrasound-guided dynamic needle tip positioning technique for radial artery cannulation in elderly patients: A prospective randomized controlled study

Background

Radial artery cannulation, which is a useful procedure for anesthetic management, is often challenging in elderly patients. Recently, the dynamic needle tip positioning (DNTP) technique was introduced to facilitate ultrasound-guided vascular catheterization. Therefore, we performed this prospective, parallel group, randomized, controlled trial to compare the ultrasound-guided DNTP technique with the palpation method in elderly patients.

Methods

For this study, 256 patients aged 65 years or older were randomly allocated to the ultrasound-guided DNTP technique group (DNTP group) or the palpation method group (palpation group). The primary outcome was first-attempt success rate. The secondary outcomes were overall success rate, numbers of attempts and redirections, cannulation time, and incidence of complications.

Results

The first-attempt success rate (85.9% vs. 72.3%; relative risk [RR], 1.47; 95% CI 1.25–1.72; P<0.001) and the overall success rate (99.2% vs. 93.0%; RR, 1.07; 95% CI 1.02–1.12; P = 0.01) were significantly higher in the DNTP group compared to the palpation group. The numbers of attempts [1 (1,1) vs. 1 (1,3), P<0.001] and redirections [0 (0,1) vs. 2 (0,4), P<0.001] were significantly lower in the DNTP group. The cannulation time for successful attempts was 42 (32,55) seconds in the DNTP group and 53 (36,78) seconds in the palpation group (P<0.001). The incidence of hematoma was significantly lower in the DNTP group (7% vs. 24.2%; RR, 0.29; 95% CI, 0.14–0.59; P<0.001).

Conclusions

Ultrasound-guided radial artery cannulation with the DNTP technique improved the efficiency of radial artery cannulation in elderly patients by increasing the success rate while minimizing complications.

Survey of ultrasound-guided peripheral intravenous practices: a report of supply usage and variability between clinical roles and departments

BACKGROUND

The purpose of this study was to investigate ultrasound-guided peripheral intravenous (UGPIV) supply usage practices by clinicians working in vascular access, in emergency departments (EDs), or in other roles.

METHODOLOGY

In 2019, a voluntary cross-sectional descriptive survey was conducted via SurveyMonkey. Data collected included demographics, practice-oriented information, procedural activities, and supplies used for UGPIV insertions. Frequency distributions and results of Fisher's exact test and one-way analysis of variance were reported using R v.3.5.2.

RESULTS

A total of 26,649 surveys were distributed with a response rate of 5.5% (n = 1475). Forty-eight percent of respondents (n = 709) indicated that they worked in a vascular access role, 310 (21%) worked in an ED, and 455 (31%) categorized their role as other. Clinically meaningful differences existed in all variables for UGPIV procedures and supplies between departments (P < 0.0001) and in all care settings. Using an investigatorconstructed overall metric of supplies used, important differences were demonstrated between personnel supply use in vascular access roles and other roles (P < 0.0001) and personnel in EDs and other roles (P < 0.0001).

CONCLUSIONS

Use of supplies for UGPIV insertions varies by department. The variability in supply usage for UGPIV insertions revealed by this survey suggests a need for clinical education on guideline application and evaluation of compliance with policies to promote standardization of supplies for UGPIV insertion.

Regional Variation in Usage of Ultrasound-Guided Femoral Access in the Vascular Quality Initiative

BACKGROUND

Access site complications are among the most common complications following peripheral vascular interventions. Previous studies have demonstrated a reduced rate of complications with ultrasound-guided vascular access (UGVA). The objective of this study is to evaluate the regional use of UGVA within the Vascular Quality Initiative (VQI).

METHODS

The VQI peripheral intervention module between 2010 and 2018 was evaluated. Regional ID was used to compare distribution of ultrasound usage. Regions were grouped into terciles based on the rate of ultrasound use. Patients were categorized based on type of access. Primary outcome was use of ultrasound across regions. Secondary outcomes were access site complications.

RESULTS

Over 43,000 cases across the 18 VQI regions were evaluated. The average rate of ultrasound usage was 71% across the regions with a wide variation (range 38-97%). There is a significant difference in utilization among the top third (87%), middle third (79%), and bottom third (58%) (P < 0.001). Average sheath size was similar across all 3 groups. A higher use of ultrasound-guided access was associated with significantly fewer access site complications (top third 1.96% vs. bottom third 3.04%, P < 0.001), the most significant of which was a decreased rate of access site hematoma (top third 1.37% vs. bottom third 2.35%, P < 0.001).

CONCLUSIONS

This is the first study to evaluate ultrasound-guided access across VQI regions. Our results demonstrate that despite strong evidence supporting the utilization of UGVA, there remains a wide variation in ultrasound usage across VQI regions. This is also the first study to show that the prevalence of ultrasound use in peripheral vascular interventions (PVI) is inversely related to access site complications. Given all of the data supporting the usage of UGVA across numerous specialties, our findings encourage the consideration of an ultrasound-first approach for vascular access in PVI and the implementation of targeted strategies and evidence-based guidelines to enhance UGVA utilization in PVI.

The Nephrologist as an Ultrasonographer

Ultrasonography is increasingly being used in the practice of nephrology, whether it is for diagnosis or management of acute or chronic kidney dysfunction, until progression to end-stage kidney disease, including preoperative assessment, access placement, and diagnosis and management of dysfunctional hemodialysis access. Point-of-care ultrasounds are also being used by nephrologists to help manage volume status, especially in patients admitted to the intensive care units, and more recently, for guiding fluid removal in the outpatient dialysis units. Fundamental knowledge of sonography has become invaluable to the nephrologist, and performance and interpretation of ultrasound has now become an essential tool for practicing nephrologists to provide patient-centered care, maximize efficiency, and minimize fragmentation of care. This review will address the growing role of ultrasonography in the management of a patient with CKD from the point of initial contact with the nephrologist throughout the spectrum of kidney disease and its consequences.

Derivation of a procedural performance checklist for ultrasound-guided femoral arterial line placement using the modified Delphi method

BACKGROUND

Many specialties utilize procedural performance checklists as an aid to teach residents and other learners. Procedural checklists ensure that the critical steps of the desired procedure are performed in a specified manner every time. Valid measures of competency are needed to evaluate learners and ensure a standard quality of care. The objective of this study was to employ the modified Delphi method to derive a procedural checklist for use during placement of ultrasound-guided femoral arterial access.

METHODS

A 27-item procedural checklist was provided to 14 experts from three acute care specialties. Using the modified Delphi method, the checklist was serially modified based on expert feedback.

RESULTS

Three rounds of the study were performed resulting in a final 23-item checklist. Each item on the checklist received at least 70% expert agreement on its inclusion in the final checklist.

CONCLUSION

A procedural performance checklist was created for ultrasound-guided femoral arterial access using the modified Delphi method. This is an objective tool to assist procedural training and competency assessment in a variety of clinical and educational settings.

Ultrasound-based simulation for cannulation in outpatient hemodialysis units: An educational protocol

Portable ultrasounds are often referred to as the “new stethoscope.” Their portability and affordability have led to improved diagnostic capabilities at the point of care in virtually every field of medicine, and hemodialysis access is no exception. However, though ultrasonography is increasingly used throughout the spectrum of hemodialysis access, its role in outpatient dialysis units in the United States has been limited so far. This may, in part, be due to limited ultrasound exposure, knowledge, and training of dialysis staff. This article details an educational protocol including hands-on simulation for training dialysis technicians and nurses in ultrasound-guided cannulation techniques.

Ultrasound Guidance for Central Venous Access: Current Evidence and Clinical Recommendations

Ultrasound-guided central line placement has been shown to decrease the number of needle puncture attempts, complication, and failure rates. In order to obtain successful central access, it is important to have adequate cognitive knowledge, workflow understanding, and manual dexterity to safely execute this invasive procedure. The operator should also be familiar with the anatomical variations, equipment operations, and potential complications and their prevention. In this article, we present a detailed review of ultrasound-guided central venous access. It includes a description of anatomy, operative technique, equipment operation, and techniques for specific situations. We describe the use of ultrasound guidance to avoid and identify various complications associated with this procedure. We have also reviewed recent recommendations and guidelines for the use of ultrasound for central venous access and the current evidence pertaining to the recommendations for the expected level of training, methodology, and metrics for establishing competency.