Ultrasound guidance in difficult radial artery puncture for blood gas analysis: A prospective, randomized controlled trial

Background

Ultrasound (US) guidance has yet to prove its applicability in radial arterial blood gas analysis (ABGA) punctures. The main objective of our study was to compare the number of first-attempt successes (NFAS) for radial arterial puncture in difficult patients with or without US guidance. The Secondary aims were to compare the number of punctures (NOP), puncture time, and patient pain.

Methods

In this single-center, randomized controlled trial, patients who required a radial ABGA and in whom the arterial puncture was assessed as difficult (because of non-palpable radial arteries or two previous puncture failures by a nurse) were assigned to the US group or no-US (NUS) group (procedure performed by a trained physician).

Results

Thirty-six patients were included in the US group and 37 in the NUS groups. The NFAS was 7 (19%) in the NUS group and 19 (53%) in the US group. The relative risk of success in the US group was 2.79 (95% CI,1.34 to 5.82), p = 0.01. In the NUS and US groups, respectively, the median NOP was 3 [2; 6] vs. 1 [1; 2], estimated difference −2.0 (95%CI, −3.4 to −0.6), p < 0.01; the respective puncture time was 3.1 [1.6; 5.4] vs. 1.4 [0.6; 3.1] min, estimated difference −1.45 (95%CI, −2.57 to −0.39), p = 0.01; the respective median patient pain was 6 [4; 8] vs. 2 [1; 4], estimated difference −4.0 (95%CI, −5.8 to −2.3); p < 0.01.

Conclusion

US guidance by a trained physician significantly improves the rate of success in difficult radial ABGA patients.

The impact of emergency department segmentation and nursing staffing increase on inpatient mortality and management times

Background

The aim of our study was to investigate the impact of a new organization of our emergency department (ED) on patients’ mortality and management delays.

Methods

The ED segmentation consisted of the development of a new patient care geographical layout on a pre-existing site and changing the organization of patient flow. It took place on May 10, 2012. We did a before-after study in the ED of a university hospital, “before” (winter 2012) and “after” (summer 2012) reorganization by segmentation into sectors. All ED patients were included.

Results

Eighty-three thousand three hundred twenty-two patient visits were analyzed, 61,118 in phase “before”, 22,204 during the phase “after”. The overall inpatient mortality was 1.5 % during summer 2011 (“before” period), 1.8 % during winter 2012 (“before” period), 1.3 % during summer 2012 (“after” period) period (summer 2012 vs. winter 2012, OR = 0.72; 95 % CIs [0.61, 0.85], and summer 2012 vs. summer 2011, OR = 0.85; 95 % CIs [0.72, 0.99]). The mean (SD) time to first medical contact was 129 min (±133) during winter 2012 and 104 min (± 95) during summer 2012 (p < .05).

Conclusions

Our study showed a decrease in mortality and improvement in time to first medical contact after the segmentation of our ED and nursing staffing increase, without an increase in medical personnel. Improving patient care through optimizing ED segmentation may be an effective strategy.

[Inadequacy of general practitioner training in emergency resuscitation procedures: study in 4 districts of southern France]

OBJECTIVE

To evaluate the knowledge of emergency resuscitation procedures of general practitioners in Bouches-du-Rhône, the Gard, Hérault and Vaucluse.

METHODS

We sent 7239 self-assessment mail questionnaires to general practitioners. The responses were analyzed to determine the factors associated with lack of mastery of emergency resuscitation procedures; physicians who reported they could not perform these procedures were compared with the others.

RESULTS

In all, 1561 responses were analyzed (response rate=22%); 52% reported they had to perform emergency resuscitation procedures at least once a year, but 30% stated they had not mastered them. After multivariate analysis with logistic regression, the factors associated with lack of mastery of these procedures (or with mastery, for the variables with odds ratios <1) were age (reference 25-35 years, 36-45 years: odds ratio [OR]=1.94, 95% confidence interval (95% CI) [1.11-3.40]; 46-55 years, OR=2.93 [1.70-5.05]; age>55 years, OR=3.71 [2.07-6.62]), women (OR=1.39 [1.05-1.82]), clerkship or course in resuscitation and emergency medicine (second cycle clerkships, OR=0.75 [0.57-0.97]; third cycle internship, OR=0.30 [0.22-0.42]; course at another time, OR=0.43 [0.28-0.66]), performance of emergency resuscitation procedures in daily practice (reference: no procedure performed; at least one a year: OR=0.37 [0.29-0.49]; at least one every three months, OR=0.15 [0.08-0.25]), failure to use health records (reference: does not use records; users OR=0.70 [0.54-0.90]).

CONCLUSION

More consistent continuing medical education up seems necessary to meet the need for continuity of care, especially in the greatest emergencies.

Comparison of the parasacral approach and the posterior approach, with single- and double-injection techniques, to block the sciatic nerve

BACKGROUND

The purpose of this study was to compare parasacral and Winnie's single- or double-injection approaches for sciatic nerve block.

METHODS

One hundred fifty adults scheduled to undergo lower limb surgery were randomized to receive on the sciatic nerve 20 ml ropivacaine, 0.75%: single bolus for parasacral and Winnie's single injection. For Winnie's double injection, the peroneal and tibial nerves received separately 10 ml plus 10 ml. Blocks were performed with the use of nerve stimulator (intensity < 0.5 mA, 1 Hz). For the parasacral method, a line was drawn between the posterior superior iliac spine and the ischial tuberosity; needle entry was at 6 cm inferior to the posterior superior iliac spine.

RESULTS

The groups were similar. Time to perform the block was 2 (1-5) min for the parasacral method, with no difference from Winnie's single injection (3 [1-10] min), but was shorter with double injection (5.5 [2-15] min) (P = 0.0001). Onset of sensory block was similar in the parasacral (25 [7.5-50] min) and Winnie single-injection groups (25 [5-50] min) but significantly longer in the double-injection group (15 [5-50] min). Success rates for complete block were similar in the parasacral (66%) and Winnie's double-injection groups (68%) after 30 min but higher in the Winnie's single-injection group for tibial sensory and motor block (48%) (P < 0.017).

CONCLUSION

Time to perform a parasacral block was short, and the parasacral approach had a high success rate and a short onset time. Therefore, this block might be a useful alternative to Winnie's modification for sciatic nerve block.