The impact of ultrasound-guided vascular access for catheter ablation of left atrial arrhythmias in a high-volume centre

BACKGROUND

Vascular complications are a common occurrence during atrial fibrillation ablation. Observational studies indicate that the utilization of ultrasound (US)-guided puncture may decrease the incidence of vascular complications; however, its routine use is not established in many centres.

METHODS

Patients undergoing catheter ablation for atrial fibrillation were included sequentially. All patients receiving US-guided punctures were prospectively enrolled (US group), while patients who underwent the procedure with standard puncture technique served as control group (No-US group). Periprocedural vascular complications requiring intervention within 30 days of the procedure were defined as the primary endpoint.

RESULTS

A total of 599 patients (average age: 69 ± 11 years, 62.9% male) were analysed. The incidence of vascular complications was lower with the US-guided puncture than with the anatomic landmark-guided puncture (14/299 [4.7%] vs. 27/300 [9%], p = 0.036). The US-guided vascular access significantly reduced the rate of false aneurysms (3/299 [1%] vs. 12/300 [4%], p = 0.019). In addition, the occurrence of arteriovenous fistula (2/299 [0.7%] vs. 4/300 [1.3%], p = 0.686) and haematoma requiring treatment (9/299 [3%] vs. 11/300 [3.7%], p = 0.655) were also lower in the US group. US-guided puncture did not prolong the procedure time (mean procedure time: 57.48 ± 24.47 min vs. 56.09 ± 23.36 min, p = 0.478). Multivariate regression analysis identified female gender (OR 2.079, CI 95% 1.096-3.945, p = 0.025) and conventional vascular access (OR 2.079, CI 95% 1.025-3.908, p = 0.042) as predictors of vascular complications.

CONCLUSIONS

The implementation of US-guided vascular access for left atrial catheter ablation resulted in a significant decrease of the overall vascular complication rate.

Comparison of ultrasound-guided and palpation-inserted peripheral venous cannula in -patients before primary hip or knee arthroplasty: study protocol for a randomized controlled trial

BACKGROUND

More than 2 billion peripheral vascular cannulas are introduced globally each year. It is the most frequently performed invasive procedure in medicine worldwide. There is a group of patients with difficult intravenous access (DIVA). In experts' hands, ultrasound-guided vascular access appears to be a significantly better method. Investigators hypothesize that UGVA is superior also in short-term patency of cannula and even for blood draw through cannula. Repeated cannula pricks in the operating room setting not only puts a lot of stress on the patient and medical staff, but they also waste OR time.

METHODS

This investigator-initiated prospective randomized monocentric controlled trial is designed to randomly allocate 200 patients undergoing elective primary total joint arthroplasty of hip or knee to one of two groups as follows: Group C (control group) - peripheral venous cannula insertion by palpation or Group USG (intervention) - cannula insertion by ultrasound-guided vascular access. Our primary endpoint is to compare the number of attempts for ultrasound-guided insertion of the peripheral venous cannula with common palpation insertion of the peripheral venous cannula in overweight/obese patients (BMI ≥ 25). The secondary endpoint is a failure rate of the peripheral venous cannula to administer intravenous therapy up to 5 days postoperatively. Tertiary endpoints include a portion of long PVCs that are able to ensure blood draw up to 5 days postoperatively, time needed to insert PVC in each group, number of needle tip redirections in both groups, and reinsertion of PVC needed in both groups for any reason.

DISCUSSION

This study is pragmatic and is looking for clinically relevant data. After completion, it will answer the question of whether it is clinically relevant to use ultrasound-guided vascular access in the context of not only short-term benefit of insertion, but also up to 5 days after insertion. Also, if this method can ensure blood draw through a peripheral vein cannula, it can save resources in the perioperative period - valuable especially considering the ongoing shortage of medical staff worldwide. If this hypothesis is confirmed, this finding could contribute to more widespread implementation of ultrasound-guided peripheral vascular access in the perioperative period.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05156008. Registered on 13.12.2021.

Ultrasound-guided vascular access in the neonatal intensive care unit: a nationwide survey

Ultrasound-guided vascular access (USG-VA) is recommended by international practice guidelines but information regarding its use in the neonatal intensive care unit (NICU) is lacking. Our objective was to assess neonatologist's perceptions and current implementation of USG-VA in Spain. This was a nationwide online survey. The survey was composed of 37 questions divided in 4 domains: (1) neonatologist's background, (2) NICU characteristics, (3) personal perspectives about USG-VA, and (4) clinical experience in USG-VA. One-hundred and eighty survey responses from 59 NICUs (62% of Spanish NICUs) were analyzed. Most neonatologists (81%) perceive that competence in USG-VA is indispensable or very useful in clinical practice. However, 64 (35.5%) have never used USG-VA in real patients. Among neonatologists with some experience in USG-VA most perform less than 5 procedures per year (59% in venous access and 80% in arterial access) and a 38% and 60% have never used USG for venous and arterial access, respectively, in very low birth weight infants (VLBWI). More than a half of neonatologists (55.5%) use US to check catheter tip location but a 46.6% always perform a radiography for confirmation. Spanish neonatologists report that resident/fellow training in USG-VA is absent (52.2%) or unstructured (32%) in their units. The lack of adequate training is identified by a 60% of neonatologists as the most important barrier for implementation of USG-VA and 87% would recommend that future neonatologists receive formal training.

CONCLUSION

Spanish neonatologists perceive that USG-VA is important in clinical practice but currently, these techniques are largely underused. Our results indicate that specific training in USG-VA should be implemented in the NICU.

WHAT IS KNOWN

• Ultrasound-guided vascular access is recommended as the preferred method for central venous access and arterial line placement in children and adults. • The degree of current implementation of ultrasound for vascular access in the NICU and the perceptions of neonatologist about its use are largely unknown.

WHAT IS NEW

• Most neonatologists consider that competence in ultrasound-guided vascular access is an indispensable aid for clinical practice. • However, most neonatologists are not adequately trained in ultrasound-guided vascular access and the technique is largely underused.

Targeting zero catheter-related bloodstream infections in pediatric intensive care unit: a retrospective matched case-control study

INTRODUCTION

The aim of this study was to evaluate the effectiveness and safety of a new three-component 'bundle' for insertion and management of centrally inserted central catheters (CICCs), designed to minimize catheter-related bloodstream infections (CRBSIs) in critically ill children.

METHODS

Our 'bundle' has three components: insertion, management, and education. Insertion and management recommendations include: skin antisepsis with 2% chlorhexidine; maximal barrier precautions; ultrasound-guided venipuncture; tunneling of the catheter when a long indwelling time is expected; glue on the exit site; sutureless securement; use of transparent dressing; chlorhexidine sponge dressing on the 7^th day; neutral displacement needle-free connectors. All CICCs were inserted by appropriately trained physicians proficient in a standardized simulation training program.

RESULTS

We compared CRBSI rate per 1000 catheters-days of CICCs inserted before adoption of our new bundle with that of CICCs inserted after implementation of the bundle. CICCs inserted after adoption of the bundle remained in place for a mean of 2.2 days longer than those inserted before. We found a drop in CRBSI rate to 10%, from 15 per 1000 catheters-days to 1.5.

CONCLUSIONS

Our data suggest that a bundle aimed at minimizing CR-BSI in critically ill children should incorporate four practices: (1) ultrasound guidance, which minimizes contamination by reducing the number of attempts and possible break-down of aseptic technique; (2) tunneling the catheter to obtain exit site in the infra-clavicular area with reduced bacterial colonization; (3) glue, which seals and protects the exit site; (4) simulation-based education of the staff.