A novel method for ultrasound-guided radial artery cannulation in neonates by trainee anaesthesiologists: A randomised controlled trial

A novel track guidance ultrasound facilitates radial arterial cannulation: A prospective randomized controlled trial

BACKGROUND

Ultrasound guidance for radial arterial cannulation is currently considered a best practice approach despite its clear advantages over the blind and palpation technique, the success rate is related to several factors, including clinician's experience and technical ability. The study aimed to explore the use of a novel track guidance ultrasound that may increase the success rate of radial arterial cannulation.

METHODS

A randomized controlled trial was conducted, in which 80 adults scheduled for elective surgery requiring radial arterial cannulation were recruited and randomly assigned to either the experimental group, which utilized novel track ultrasound guidance (group T, n = 40), or the control group, which utilized traditional ultrasound guidance (group U, n = 40). The novel track guidance ultrasound comprises a positioning track and a guided track. The radial artery could be positioned at the center of the positional track on the ultrasound image, and the direction and angle of needle are fixed and toward the center of the positioning track. The primary endpoint of the study was the first-pass cannulation success rate, while the secondary endpoints included the failure rate of cannulation, the number of radial artery punctures, the time of cannulation, and the incidence of hematoma.

RESULTS

The success rate of cannulation at the first attempt in group T (35 of 40 (87.5%)) was significantly higher than that in group U (23 of 40 (57.5%); p = 0.003). Although seven patients in Group U (7 of 40 (17.5%)) experienced failed cannulation compared to one in Group T (1 of 40 (2.5%)), the difference in failure rate between the two groups did not reach statistical significance (p = 0.06).

CONCLUSIONS

The implementation of novel track ultrasound guidance has demonstrated a notable improvement in the success rates at the first attempt while reducing the frequency of punctures and cannulation times.

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 ).

Long-axis in-plane combined with short-axis out-of-plane technique in ultrasound-guided arterial catheterization in infants: A randomized controlled trial

STUDY OBJECTIVE

To determine whether the long-axis in-plane (LAX-IP) combined with short-axis out-of-plane (SAX-OOP) technique is more suitable than modified dynamic needle tip positioning (MDNTP) technique for ultrasound-guided radial artery catheterization in infants.

DESIGN

A randomized controlled trial.

SETTING

Department of Anesthesiology, Children's Hospital of Chongqing Medical University.

PATIENTS

Overall, 72 patients, aged 1-12 months old, who were primarily undergoing thoracic or cardiac surgery in the Children's Hospital of Chongqing Medical University between July 1, 2021, and March 31, 2022, were selected. These patients were randomly divided into two groups: i) the MDNTP group and ii) the LAX-IP combined with SAX-OOP group.

INTERVENTIONS

Radial artery cannulation in the two groups was performed using ultrasound-guided MDNTP or LAX-IP combined with SAX-OOP technique.

MEASUREMENTS

The primary outcome was first-time success rate, and the secondary outcomes included total success rate, cannulation time, and incidence of complications.

MAIN RESULTS

In the LAX-IP combined with SAX-OOP group, the first-time success rate was 75.0% (n = 27), total success rate was 97.2% (n = 35), cannulation time was 91.39 ± 102.60 s, puncture attempts was 1.5 ± 1.3 times, and local hematoma was formed on the first day in one (2.8%) infant. In the MDNTP group, the first-time success rate was 36.1% (n = 13) (P = 0.001; RR, 2.08; 95% confidence interval, 1.29-3.34), total success rate was 91.7% (n = 33) (P = 0.303; RR, 1.06; 95% confidence interval, 0.95-1.19), cannulation time was 181.00 ± 146.72 s(P = 0.047; Median difference,-89.61; 95% confidence interval, -149.12 to -30.10), puncture attempts was 2.3 ± 1.6 times (P = 0.133; Median difference,-0.81), and local hematoma was formed on the first day in nine (25%) infants (P = 0.006; RR, 0.11; 95% confidence interval, 0.01-0.83). No thrombosis occurred in any group.

CONCLUSIONS

The ultrasound-guided LAX-IP combined with SAX-OOP technique for radial arterial catheterization in infants, which was performed by anesthesia residents, exhibited an increased first-time success rate, reduced cannulation time, and lower incidence of complications than the MDNTP technique.

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.

The Improved Catheterization Is Associated With the Deeper Radial Arteries in Ultrasound-Guided Dynamic Needle Tip Positioning Technique

Objective

This study aimed to determine the associations between the first-attempt success and arterial depth in ultrasound-guided radial artery catheterization (RAC) with dynamic needle tip positioning (DNTP) technique. This study also aimed to further explore the cut-off depth correlated to improved first-attempt success catheterization in less time.

Methods

The cases undertaken by RAC within the DNTP technique between March 2019 and July 2020 were extracted from our institutional cohort database. Relevant variables were collected, including patients' demographics and catheterized information. Univariable and multivariable logistic regression analyses were performed to determine the association. The receiver operating characteristic (ROC) curve and the Youden index were used to explore the cut-off values of the arterial depth. Categorized cases according to the cut-off values, the Kaplan-Meier analysis, and the log-rank test were used to determine the difference of first-attempt success with limited catheterized time between groups.

Results

In this study, 119 patients were enrolled and 98 achieved first-attempt success. The first-attempt success catheterization was observed to be correlated to arterial depth (p < 0.01, odds ratio 6.47). An optimal cut-off depth of 2.25 mm was found using the Youden index (0.53) by ROC curve (area under curve 0.77). Arterial depth of more than 2.25 mm was correlated to improved first-attempt success catheterization in less time (log-rank p < 0.01).

Conclusion

To achieve first-attempt success catheterization using the DNTP technique, an arterial depth of more than 2.25 mm was associated with less catheterized time.

Modified Long-Axis In-Plane Ultrasound-guided Radial Artery Cannulation In Adult Patients: A Randomized Controlled Trial

INTRODUCTION

For adults with small radial arteries, ultrasound-guided radial artery cannulation remains challenging and the relevant data is currently lacking. The study aimed to test the hypothesis that modified long-axis in-plane ultrasound guidance (M-LAIP) would improve success rates of radial artery cannulation in this population.

PATIENTS AND METHODS

This was a prospective, randomised, and controlled clinical study that enrolled 201 adult patients with diameters of the radial artery less than 2.2 mm. Patients were randomised to M-LAIP, short-axis out-of-plane (SAOP), or conventional palpation (C-P) group according to different approaches of radial artery cannulation (M-LAIP, SAOP, and C-P). Outcome measurements included the success rate, cannulation time, and cannulation-related adverse events.

RESULTS

The cannulation success rate was significantly higher in the M-LAIP group than in the SAOP or C-P groups (first success rate: 80.3% vs. 53.8% or 33.8%; P < 0.001; total success rate: 93.9% vs. 78.5% or 50.8%; P < 0.001). Total cannulation time in the M-LAIP group was shorter than that in the SAOP group (P =  0.002) or the C-P group (P < 0.001). The rates of posterior wall puncture and haematoma in the M-LAIP group were lower than that in the SAOP group or C-P group (P <  0.008).

CONCLUSION

The use of the M-LAIP approach significantly improved the success rate of radial artery cannulation, shortened procedure time, and lowered the rates of posterior wall puncture and haematoma in adults with radial artery diameters less than 2.2 mm, compared with that achieved by the SAOP or C-P approach.

To Explore the Haemostatic Effect of Compression Haemostasis Using an Ultrasonic Probe under the Guidance of Ultrasound after Radial Artery Puncture

OBJECTIVE

To evaluate a new haemostasis method using an ultrasound probe to compress the radial artery and haemostasis under direct vision to replace traditional manual compression of the radial artery.

METHODS

According to a random number table, 240 patients with gastrointestinal tumours who had undergone arterial puncture were divided into Group A (120 cases) and Group B (120 cases). In Group A, patients were under the guidance of ultrasound to confirm the vascular port, determine the compression position of the ultrasound probe, observe the degree of vascular deformation, and press the radial artery puncture port with pressure to stop bleeding under direct vision. In Group B, traditional manual compression was used. All patients received 5 min of compression for haemostasis, and haemostasis conditions were recorded after compression and 24 hours postoperatively.

RESULTS

The incidence of bleeding, haematoma, and skin ecchymosis at the puncture site after 5 minutes of compression in Group A was lower than that in Group B (P < 0.05). No significant difference was found between the two groups at 24 hours after the operation (P > 0.05).

CONCLUSION

The method using an ultrasound probe to guide radial artery compression to haemostasis is better than traditional manual compression when applied for compression haemostasis after removing the radial artery catheter.

Distal superficial femoral vein versus axillary vein central catheter placement under ultrasound guidance for neonates with difficult access: A randomized clinical trial

BACKGROUND

Epicutaneo-caval catheters (ECCs) are extensively used in premature and ill neonates. This prospective, randomized, observational study aimed to compare the outcomes of ECC placement in the distal superficial femoral and axillary veins in neonates with difficult ECC access.

METHODS

In a neonatal intensive care unit at a tertiary referral center, 60 neonates with difficult ECC access were randomized into two groups with catheters placed using the ultrasound-guided modified dynamic needle tip positioning (MDNTP) technique: distal superficial femoral vein (DSFV) and axillary vein (AV) groups.

RESULTS

The first attempt success rate was significantly higher in the DSFV group than in the AV group [23/30 (76.7%) vs 11/30 (36.7%), p = 0.001; odds ratio (OR), 0.176; 95% confidence interval (CI) 0.057-0.543]. The mean procedural duration was significantly shorter in the DSFV group than in the AV group [mean: 308.5 (standard deviation: 81.1) s vs 522.74 (134.8) s, t = -7.17, p < 0.001]. The incidence of complications was significantly lower in the DSFV group than in the AV group [4/30 (13.3%) vs 12/30 (40.0%), p = 0.019; OR, 4.333; 95% CI 1.203-15.604]. The number of attempts was significantly fewer in the DSFV group than in the AV group (p = 0.012).

CONCLUSIONS

The distal superficial femoral and axillary veins are two alternative and safe access points for ECC placement in premature neonates (weight < 2.5 kg) with difficult access. However, access through the distal superficial femoral vein was quicker, easier, and had fewer complications than through the axillary vein.

Ultrasound-guided peripheral vascular catheterization in pediatric patients: a narrative review

Peripheral vascular catheterization (PVC) in pediatric patients is technically challenging. Ultrasound guidance has gained the most interest in perioperative and intensive care fields because it visualizes the exact location of small target vessels and is less invasive than other techniques. There have been a growing number of studies related to ultrasound guidance for PVC with or without difficult access in pediatric patients, and most findings have demonstrated its superiority to other techniques. There are various ultrasound guidance approaches, and a comprehensive understanding of the basics, operator experience, and selection of appropriate techniques is required for the successful utilization of this technique. This narrative review summarizes the literature regarding ultrasound-guided PVC principles, approaches, and pitfalls to improve its clinical performance in pediatric settings.

Dynamic needle tip positioning versus the angle-distance technique for ultrasound-guided radial artery cannulation in adults: a randomized controlled trial

Background

Ultrasound guidance can increase the success rate and reduce the incidence of complications of arterial cannulation. There are few studies on the utility of the dynamic needle tip positioning (DNTP) technique versus the angle-distance (AD) technique for ultrasound-guided radial arterial cannulation in adult surgical patients. We assessed and compared the success rates and incidences of complications of these two short-axis out-of-plane techniques.

Methods

A total of 131 adult surgical patients were randomized into DNTP and AD groups to undergo ultrasound-guided radial artery cannulation. The primary outcome was first-pass success without posterior wall puncture. The secondary outcomes included the first-pass success rate, 10-min overall success rate, cannulation time, posterior wall puncture, and the number of skin punctures.

Results

The first-pass success rates without posterior wall puncture were 53.8% in the DNTP group and 44.6% in the AD group (RR = 1.22, 95% CI: 0.86–1.72; P = 0.26). The cannulation time was significantly longer (P = 0.01) in the DNTP group [79.65 (54.3–109.4) seconds] than in the AD group [47.6 (24.9–103.8) seconds]. The posterior wall puncture rate was significantly lower (P = 0.002) in the DNTP group (29.2%) than in the AD group (56.1%; RR = 0.56, 95% CI: 0.42–0.82).

Conclusions

There were no significant differences in the first-pass success rate, with or without arterial posterior wall puncture, or in the 10-min overall success rate between the DNTP and AD groups. However, the cannulation time was longer and the posterior wall puncture rate was lower in the DNTP group.

Trial registration

The trial was registered at www.clinicaltrials.gov (No: NCT03656978). Registered 4 September 2018.