European Society of Anaesthesiology guidelines on peri-operative use of ultrasound-guided for vascular access (PERSEUS vascular access):

Trendelenburg position for internal jugular vein catheterization: A systematic review and meta-analysis

To determine the effect of Trendelenburg position on the diameter or cross-section area of the internal jugular vein (IJV) a systematic review and metanalysis was performed. Studies that evaluated the cross-sectional area (CSA) and anteroposterior (AP) diameter of the right internal jugular vein (RIJV) with ultrasonography in supine and any degree of head-down tilt (Trendelenburg position) were analyzed. A total of 22 articles (613 study subjects) were included. A >5° Trendelenburg position statistically increases RIJV CSA and AP diameter. Further inclination from 10° does not statistically benefit IJV size. This position should be recommended for CVC placement, when patient conditions allow it, and US-guided cannulation is not available.

Prevention of device-related infections in patients with cancer: Current practice and future horizons

Over the past several years, multifaceted advances in the management of cancer have led to a significant improvement in survival rates. Throughout patients' oncological journeys, they will likely receive one or more implantable devices for the administration of fluids and medications as well as management of various comorbidities and complications related to cancer therapy. Infections associated with these devices are frequent and complex, often necessitating device removal, increasing health care costs, negatively affecting quality of life, and complicating oncological care, usually leading to delays in further life-saving cancer therapy. Herein, the authors comprehensively review multiple evidence-based recommendations along with best practices, expert opinions, and novel approaches for the prevention of diverse device-related infections. The authors present many general principles for the prevention of these infections followed by specific device-related recommendations in a systematic manner. The continuous involvement and meaningful cooperation between regulatory entities, industry, specialty medical societies, hospitals, and infection control-targeted interventions, along with primary care and consulting health care providers, are all vital for the sustained reduction in the incidence of these preventable infections.

Rapid Assessment of Vascular Exit Site and Tunneling Options (RAVESTO): A new decision tool in the management of the complex vascular access patients

In the last decade, different standardized protocols have been developed for a systematic ultrasound venous assessment before central venous catheterization: RaCeVA (Rapid Central Vein Assessment), RaPeVA (Rapid Peripheral Vein Assessment), and RaFeVA (Rapid Femoral Vein Assessment). Such protocols were designed to locate the ideal puncture site to minimize insertion-related complications. Recently, subcutaneous tunneling of non-cuffed central venous access devices at bedside has also grown in acceptance. The main rationale for tunneling is to relocate the exit site based on patient factors and concerns for dislodgement. The tool we describe (RAVESTO-Rapid Assessment of Vascular Exit Site and Tunneling Options) defines the different options of subcutaneous tunneling and their indications in different clinical situations in patients with complex vascular access.

Arterial cannulation in adult critical care patients: A comparative study between ultrasound guidance and palpation technique

OBJECTIVE

To compare first attempt success rate for ultrasound-guided (USG) versus direct palpation (DP) for radial, femoral, and dorsalis pedis artery cannulations in adult intensive care unit (ICU) patients.

DESIGN

Prospective randomized clinical trial.

SETTING

Mixed adult ICU of a University Hospital.

PARTICIPANTS

Adult patients (≥18 years) admitted to the ICU requiring invasive arterial pressure monitoring were included. Exclusion criteria were patients with a pre-existing arterial line and cannulated with other than a 20-gauge cannula for radial and dorsalis pedis artery.

INTERVENTION

Comparison of arterial cannulation by USG versus palpation technique in radial, femoral and dorsalis pedis arteries.

MAIN VARIABLES OF INTEREST

Primary outcome was first attempt success rate, secondary outcomes were assessing time for cannulations, number of attempts, overall success rate, complications, and comparison of two techniques on patients requiring vasopressor.

RESULTS

201 patients were enrolled in study, with 99 randomized to DP group and 102 to USG group. Arteries (radial, dorsalis pedis, femoral) cannulated in both groups were comparable (P = .193). Arterial line was placed on first attempt in 85 (83.3%) in USG group versus 55 (55.6%) in DP group (P = .02). Cannulation time in USG group was significantly shorter compared to DP group.

CONCLUSIONS

In our study, USG arterial cannulation, compared to palpatory technique, had a higher success rate at first attempt and a shorter cannulation time.

CLINICAL TRIAL REGISTRY OF INDIA NUMBER

CTRI/2020/01/022989.

The SIC protocol: A seven-step strategy to minimize complications potentially related to the insertion of centrally inserted central catheters

Insertion of central venous catheters in the cervico-thoracic area is potentially associated with the risk of immediate/early untoward events, some of them negligible (repeated punctures), some relevant (accidental arterial puncture), and some severe (pneumothorax). Furthermore, different strategies adopted during insertion may reduce or increase the incidence of late catheter-related complications (infection, venous thrombosis, dislodgment). This paper describes a standardized protocol (S.I.C.: Safe Insertion of Centrally Inserted Central Catheters) for the systematic application of seven basic beneficial strategies to be adopted during insertion of central venous catheters in the cervico-thoracic region, aiming to minimize immediate, early, or late insertion-related complications. These strategies include: preprocedural evaluation, appropriate aseptic technique, ultrasound guided insertion, intra-procedural assessment of the tip position, adequate protection of the exit site, proper securement of the catheter, and adequate coverage of the exit site.

Vascular access and clinical competency: Which elements matter? The development of three bottom-up and evidence-grounded self-assessment tools

BACKGROUND

Assessing competency in the speciality of vascular access is still limited, and few valid and reliable tools are available. Therefore, this study aimed to develop and validate three different tools for assessing competency in managing the care of short peripheral cannulas (SPCs), midlines, peripherally inserted central catheters (PICCs), centrally inserted central catheters (CICCs), and arterial catheters (ACs) (tool one), placing SPCs (tool two), placing PICCs and midlines (tool three).

METHODS

A two-phase and multi-method design was adopted. Phase one was implemented to develop the initial pool of items for each tool, starting from a literature overview. Panel discussions were adopted for developing the items. In phase two, the developed items were tested for content and face validity, involving a panel of 10 experts. Once obtained adequate content validity, a cross-sectional data collection was implemented to enroll three samples of healthcare workers who had to assess their competency through the developed tools. Dimensionality was assessed by performing a principal component analysis (PCA) and assessing internal consistency (Cronbach's α).

RESULTS

Tool one had 26 items, and the dimensionality was given by placement, risk assessment, procedure conformity and traceability, and patient education to self-care. Tool two had 35 items; its principal components were: risk evaluation, identification, clinical assessment and orientation to self-care, placement, and procedure registration shaped the competency of placing SPCs. Tool three had 31 items; its principal components were: risk assessment, placement, conformity to standards and procedure traceability, education, and orientation to self-care were the essential elements for adequately placing midlines and PICCs. Cronbach's α values ranged between 0.806 and 0.959.

CONCLUSIONS

The three developed tools reflected the core elements of competency in each application area, representing an initial framework that could be useful in future research and educational projects. Cross-national investigations are required to corroborate the described results.

A new inexpensive ultrasound-guided central venous catheterization simulation model

BACKGROUND

Central venous catheters (CVCs) are life-saving tools for fluid therapy during surgery. Ultrasound-guided CVC placement has been shown to be safe and highly efficient. However, it is difficult for medical workers with less experience in ultrasonography to acquire the necessary skill in a short time. Simulation-based training is a good way to enhance the skill of a beginner. Therefore, in this study, we introduced a new, inexpensive and easily implemented model for ultrasound-guided CVC placement training and assessed the feasibility of this model.

METHODS

This was a quasi-experimental study. Thirty-three anaesthesiology postgraduate year 2 and 3 residents with strong CVC interest were included in a simulator-based training workshop in a department of anaesthesiology. The simulation model consisted of a piece of pork and two latex catheters filled with red and blue ink. The workshop comprised 3 parts: a 10-min introductory lecture, a 15-min orientation on performing ultrasound-guided CVC insertion based on the model, and a 30-min practice session. Participants completed relevant questionnaires before and after the training. Moreover, an examination was held to evaluate their skill with the novel model.

RESULTS

All participants indicated that the novel model increased their self-perceived confidence in ultrasound-guided catheterization. They also all reported that the model was adequate for training anaesthesiology residents in ultrasound-guided catheterization. A few individuals thought the model did not mimic the progress of CVC insertion (3 of 33). After training, participants did not show a significant difference in the acquisition of central venous catheterization theory. However, their competency with ultrasound-guided CVC placement was enhanced. This was demonstrated not only based on subjective answers to the following questions, namely, "how do you perform central venous catheterization with ultrasound guidance?" (p < 0.001), "can you perform ultrasound-guided central venous catheterization?" (p < 0.001), and "how much self-confidence do you have in performing ultrasound-guided central venous catheterization?" (p < 0.001), but also in objective performance (evaluation of the core step in ultrasound-guided placement (p < 0.001)).

CONCLUSION

The new simulator is a feasible, inexpensive and easily reproducible tool for training anaesthesiologists in ultrasound-guided central venous catheterization. After the simulation-based training workshop, the competency of residents in performing central venous catheterization with ultrasound guidance improved.

Peripheral Nerve Block Practice in Portugal: A National Survey

Regional anesthesia (RA) has several benefits and its use has increased with the advent of ultrasound-guided techniques. Opioid-sparing anesthesia and reduced use of general anesthesia are some of the mainstay advantages of RA. Although anesthetic practices differ deeply between countries, RA has assumed a crucial role in the daily practice of anesthesiologists, particularly during the COVID-19 pandemic period. This cross-sectional study provides an overview of peripheral nerve block (PNB) techniques performed in Portuguese hospitals. An online survey was reviewed by members of Clube de Anestesia Regional (CAR/ESRA Portugal) and then sent to a national mailing list of anesthesiologists. The survey focused on specific topics related to RA techniques such as the importance of training and experience, and the relevance of logistical limitations during the execution of RA. All data were collected anonymously and included in a Microsoft Excel (Microsoft Corp., Redmond, WA, USA) database, for further analysis. A total of 335 valid answers were obtained. All participants considered RA as a key competence in their daily practice. Half of those inquired performed PNB techniques once to twice per week. The main limitations identified for performing RA in Portuguese hospitals were the absence of block rooms and insufficiently trained personnel for the appropriate and safe execution of these techniques. This survey provides a comprehensive overview of RA in the Portuguese setting and could serve as a baseline for further studies.

Ultrasound-Guided Infraclavicular Axillary Vein Versus Internal Jugular Vein Cannulation in Critically Ill Mechanically Ventilated Patients: A Randomized Trial

OBJECTIVES

This clinical trial aimed to compare the ultrasound-guided in-plane infraclavicular cannulation of the axillary vein (AXV) and the ultrasound-guided out-of-plane cannulation of the internal jugular vein (IJV).

DESIGN

A prospective, single-blinded, open label, parallel-group, randomized trial.

SETTING

Two university-affiliated ICUs in Poland (Opole and Lublin).

PATIENTS

Mechanically ventilated intensive care patients with clinical indications for central venous line placement.

INTERVENTIONS

Patients were randomly assigned into two groups: the IJV group ( n = 304) and AXV group ( n = 306). The primary outcome was to compare the IJV group and AXV group through the venipuncture and catheterization success rates. Secondary outcomes were catheter tip malposition and early mechanical complication rates. All catheterizations were performed by advanced residents and consultants in anesthesiology and intensive care.

MEASUREMENTS AND MAIN RESULTS

The IJV puncture rate was 100%, and the AXV was 99.7% (chi-square, p = 0.19). The catheterization success rate in the IJV group was 98.7% and 96.7% in the AXV group (chi-square, p = 0.11). The catheter tip malposition rate was 9.9% in the IJV group and 10.1% in the AXV group (chi-square, p = 0.67). The early mechanical complication rate in the IJV group was 3% (common carotid artery puncture-4 cases, perivascular hematoma-2 cases, vertebral artery puncture-1 case, pneumothorax-1 case) and 2.6% in the AXV group (axillary artery puncture-4 cases, perivascular hematoma-4 cases) (chi-square, p = 0.79).

CONCLUSIONS

No difference was found between the real-time ultrasound-guided out-of-plane cannulation of the IJV and the infraclavicular real-time ultrasound-guided in-plane cannulation of the AXV. Both techniques are equally efficient and safe in mechanically ventilated critically ill patients.

[Anesthesiological and postinterventional management in percutaneous hepatic melphalan perfusion (chemosaturation)]

Percutaneous hepatic melphalan perfusion (PHMP) is a last-line treatment of inoperable primary or secondary liver tumors. Selective perfusion and saturation (chemosaturation) of the liver with the chemotherapeutic agent melphalan is performed via catheterization of the hepatic artery without affecting the rest of the body with its cytotoxic properties. Using an extracorporeal circulation and balloon occlusion of the inferior vena cava, the venous hepatic blood is filtered and returned using a bypass procedure. During the procedure, considerable circulatory depression and coagulopathy are frequent. The purpose of this article is to review the anesthesiological and postprocedural management of patients undergoing PHMP with consideration of the pitfalls and special circumstances.

Ultrasound guidance versus conventional technique for radial artery puncture in septic shock patients: A pilot study

BACKGROUND

Arterial puncture, for obtaining an analysis of blood gas, is an interventional procedure often performed in emergency departments and intensive care units. This study compares the ultrasound (US) guided method with the conventional digital palpation method in radial artery puncture (RAP) for blood gas analysis in septic shock patients.

METHODS

This is a prospective, single-centre study. Septic shock patients over 18 years of age who needed a RAP sample for blood gas analysis were included. Patients with local infection or trauma at the puncture site, arteriovenous fistula, vascular graft, coagulopathy, a positive Allen test, or did not want to participate were excluded. Patients were randomized into two groups and RAP was obtained with either the US-guided method or the conventional method. The main outcomes were success at first entry, the number of attempts before success, and the time to success.

RESULTS

The 50 eligible patients were randomized into two groups. First entry success rate for the US-guided group and the conventional group was 80% and 42%, respectively. The number of attempts before success and time to success was significantly higher in the conventional group.

CONCLUSION

The US-guided method has been found to be more successful in terms of first entry success, the number of attempts before success, and the time to success when compared to the conventional method.

High success rates of ultrasound-guided distal internal jugular vein and axillary vein approaches for central venous catheterization: A randomized controlled open-label pilot trial

BACKGROUND

Ultrasound (US)-guided axillary vein (AV) catheterization has been considered as the preferred site of insertion to minimize catheter-related infections. Given its difficulty of realization, internal jugular vein (IJV) access remains, thus, the first choice of catheter insertion site. This descriptive study was aimed to assess the success and complication rates of in-plane short axis approach of IJV in the lower neck and the AV approach under US-guidance.

METHODS

In a prospective randomized controlled open-label pilot trial, all patients requiring central venous catheterization (CVC) in intensive care unit or operating room were randomly assigned to low IJV or AV groups. The primary objective was to estimate the overall success rate of both approaches. The secondary objectives were immediate complication rates, procedure durations, success rate after the first puncture, late complication rates (i.e., thrombosis, catheter colonization, and catheter-related infections), and nurse satisfaction regarding insertion site dressings.

RESULTS

One hundred and seventy-three out of two hundred and ten included patients were fully analyzed (90 and 83 in the IJV and AV approach groups, respectively). Overall success rates for IJV and AV sites were 96% (95% confidence interval (CI) [90-99]) and 89% (95% CI [81-94]) respectively. First puncture success rates were 90% and 80% respectively. The median overall procedure duration from US pre-procedural screening to guidewire insertion was 8 and 10 min in IJV and AV groups. Overall immediate complications rates for IJV and AV sites were 11.6% and 14.6%, respectively. Incidence of catheter colonization were 7.9% and 6.8% and catheter-related infection rate were 2.6% and 0%, respectively.

CONCLUSION

In this pilot study, US-guided low IJV and AV approaches are safe and efficient techniques for CVC insertion associated with high success and low complications rates. Duration for guidewire insertion seemed to be shorter in the short axis in-plane IJV approach. It provides the basis for a future randomized trial comparing these two approaches.

Chest-to-arm tunneling: A novel technique for medium/long term venous access devices

BACKGROUND

Chest-to-arm (CTA) tunneling has been described recently as a technique that allows an optimal exit site at mid-arm even in chronically ill patients with complex clinical issues and challenging problems of vascular access.

METHOD

We adopted CTA tunneling in oncologic and in non-oncologic patients, in totally implanted and in external devices, for both medium and long-term intravenous treatments. We report our experience with 60 cases of CTA tunneling: 19 patients requiring a totally implantable device, who had bilateral contraindication to venous access at the arm and bilateral contraindication to placement of the pocket in the infra-clavicular area; 41 patients requiring an external central venous catheter, who had bilateral contraindication to insertion of peripherally inserted central catheters or femoral catheters, as well as contraindication to an exit site in the infraclavicular area. All venous access devices were inserted with ultrasound guidance and tip location by intracavitary electrocardiography, under local anesthesia.

RESULTS

There were no immediate or early complications. Patients with CTA-ports had no late complications. In patients with CTA-tunneled external catheters, there were two dislodgments, four episodes of central line associated blood stream infections, and one local infection. There were no episodes of venous thrombosis or catheter malfunction.

CONCLUSION

Our experience suggests that CTA tunneling is a safe maneuver, with very low risk of complications, and should be considered as an option in patients with complex venous access.

ECHOTIP-Ped: A structured protocol for ultrasound-based tip navigation and tip location during placement of central venous access devices in pediatric patients

Central venous access devices are routinely used in pediatric care for administration of fluids and medications and for drawing blood samples. The adoption of ultrasound guided venipuncture, the availability of bedside ultrasound devices and the use of intraprocedural methods for tip location have been shown to reduce procedure-related complications, as documented by the recommendations of most recent guidelines. In pediatric patients, bedside ultrasound is a promising tool not only for optimizing the choice of the vein and guiding the venipuncture, but also for ensuring an accurate and intraprocedural method of tip navigation and tip location. The aim of this paper is to review all the evidence about the accuracy of ultrasound methods for tip navigation and tip location in pediatric patients, and to suggest a structured protocol for clinical practice.

Arterial cannulation with ultrasound: clinical trial protocol for a randomised controlled trial comparing handheld ultrasound versus palpation technique for radial artery cannulation

Background

Early intraoperative hypotension is associated with acute kidney and myocardial injury in patients undergoing noncardiac surgery. Precise arterial blood pressure measurement before and during the induction of general anaesthesia may avert early intraoperative hypotension. However, rapid arterial cannulation in anxious, conscious patients can be challenging. We describe the protocol for a randomised controlled trial designed to test the hypothesis that readily available, handheld ultrasound-guided arterial cannulation is the optimal method in conscious patients undergoing noncardiac surgery.

Methods

Participants >45 yr undergoing noncardiac surgery expected to last >120 min and requiring an overnight hospital stay will be eligible. We will randomly allocate participants to undergo cannulation of the radial artery in the non-dominant arm before the induction of general or regional anaesthesia using either handheld ultrasound-guided dynamic needle position technique or palpation. The primary outcome is first-pass successful arterial cannulation, analysed by intention-to-treat. Secondary outcomes include adequacy/characteristics of the arterial waveform and complications within 24 h of cannulation. We will require 118 patients to demonstrate a doubling of successful first-pass arterial cannulation, from ∼30% using the palpation approach (α=0.05; 1-β=0.1).

Results

This study has been approved by the NHS Health Research Authority and Health Care Research Wales (21/WA/0403) and commenced recruitment in May 2022.

Conclusions

This study will establish whether handheld ultrasound-guided arterial cannulation before the induction of anaesthesia should be the standard of care in patients at risk of developing perioperative organ injury after noncardiac surgery.

Clinical trial registration

NCT05249036.

Central Venous Catheter Cannulation in Pediatric Anesthesia and Intensive Care: A Prospective Observational Trial

Currently, ultrasound-guided central venous catheter (CVC) insertion is recommended in pediatric patients. However, the clinical practice may vary. The primary aim of this study was the overall success rate and the first attempt success rate in ultrasound-guided CVC insertion versus anatomic-based CVC insertion in pediatric patients. The secondary aim was the incidence of associated complications and the procedural time. The physician could freely choose the cannulation method and venous approach. Data were collected for 10 months. Overall, 179 patients were assessed for eligibility and 107 patients were included. In almost half of the patients (48.6%), the percutaneous puncture was performed by real-time ultrasound navigation. In 51.4% of the patients, the puncture was performed by the landmark method. The overall success rate was 100% (n = 52) in the real-time ultrasound navigation group, 96.4% (n = 53) in the landmark insertion group, (p = 0.496). The first percutaneous puncture success rate was 57.7% (n = 30) in the real-time ultrasound navigation group and 45.5% (n = 25) in the landmark insertion group, (p = 0.460). The data show a higher overall success rate and the first success rate in the US-guided CVC insertion group, but the difference was not statistically significant.

Head to toe ultrasound: a narrative review of experts' recommendations of methodological approaches

Critical care ultrasonography (US) is widely used by intensivists managing critically ill patients to accurately and rapidly assess different clinical scenarios, which include pneumothorax, pleural effusion, pulmonary edema, hydronephrosis, hemoperitoneum, and deep vein thrombosis. Basic and advanced critical care ultrasonographic skills are routinely used to supplement physical examination of critically ill patients, to determine the etiology of critical illness and to guide subsequent therapy. European guidelines now recommend the use of US for a number of practical procedures commonly performed in critical care. Full training and competence acquisition are essential before significant therapeutic decisions are made based on the US assessment. However, there are no universally accepted learning pathways and methodological standards for the acquisition of these skills.Therefore, in this review, we aim to provide a methodological approach of the head to toe ultrasonographic evaluation of critically ill patients considering different districts and clinical applications.

Comparison of out-of-plane short axis with in-plane long axis for ultrasound-guided radial arterial cannulation: A systematic review with trial sequential analysis of randomised controlled trials

Background

It is controversial whether the short-axis out-of-plane or long-axis in-plane approach is a better needling technique for ultrasound-guidance radial artery cannulation. We aimed to compare the efficacy and safety of the two approaches for ultrasound-guided radial artery cannulation.

Methods

A systematic search of Medline, Embase, the Cochrane Library, and Web of Science for relevant articles published until 1 May 2021 was conducted. Randomised controlled trials comparing the long-axis in-plane with short-axis out-of-plane approaches were included. Review Manager software version 5.4, STATA version 14.2, and trial sequential analysis (TSA) version 0.9.5.10 Beta were used for statistical analysis. Risk of bias and methodological quality of all studies included in this review were assessed according to the Cochrane Collaboration tool for the risk of bias. Subgroup analyses and meta-regression were performed to explore sources of heterogeneity.

Results

The rate of cannula insertion success on the first attempt was similar between the short-axis out-of-plane and long-axis in-plane approaches (RR = 1.03; 95% CI: 0.83 to 1.28; P = 0.79; I ² = 83.0%). No significant differences were observed in total time to successful cannulation between the two approaches (MD = -3.9; 95% CI:-18.30 to 10.49; P = 0.6; I ² = 97%). However, the required information size for the success rate of the first attempt and total time to successful cannulation was not reached.

Conclusion

It remains inconclusive whether short-axis out-of-plane is a better choice for radial arterial cannulation than the long-axis in-plane approach. Inexperienced operators may need more attempts and longer ultrasound location time with the short-axis out-of-plane technique.

Systematic review registration

[https://www.crd.york.ac.uk/prospero/], identifier [CRD42021236098].

Incidence of catheter-related bloodstream infections following ultrasound-guided central venous catheterization: a systematic review and meta-analysis

Background

Ultrasonographic guidance is widely used for central venous catheterization. Several studies have revealed that ultrasound-guided central venous catheterization increases the rate of success during the first attempt and reduces the procedural duration when compared to the anatomical landmark-guided insertion technique, which could result in protection from infectious complications. However, the effect of ultrasound-guided central venous catheterization on catheter-related bloodstream infections remains unclear. We aimed to conduct a systematic review and meta-analysis to evaluate the value of ultrasound guidance in preventing catheter-related bloodstream infections and catheter colonization associated with central venous catheterization.

Methods

The Cochrane Central Register of Controlled Trials (CENTRAL) and MEDLINE (via PubMed) were searched up to May 9, 2022 for randomized controlled trials (RCTs) comparing ultrasound-guided and anatomical landmark-guided insertion techniques for central venous catheterization. Risk of bias was assessed using the Cochrane Risk of Bias 2 (RoB 2) tool for RCTs. A meta-analysis was performed for catheter-related bloodstream infections and catheter colonization, as primary and secondary outcomes, respectively.

Results

Four RCTs involving 1268 patients met the inclusion criteria and were analyzed. Ultrasound-guided central venous catheterization was associated with a slightly lower incidence of catheter-related bloodstream infections (risk ratio, 0.46; 95% confidence interval [CI], 0.16–1.32) and was not associated with a lower incidence of catheter colonization (risk ratio, 1.36; 95% CI, 0.57–3.26).

Conclusion

Ultrasound-guided central venous catheterization might reduce the incidence of catheter-related bloodstream infections. Additional RCTs are necessary to further evaluate the value of ultrasound guidance in preventing catheter-related bloodstream infections with central venous catheterization.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07760-1.

Classification of Central Venous Catheter Tip Position on Chest X-ray Using Artificial Intelligence

Recent studies utilizing deep convolutional neural networks (CNN) have described the central venous catheter (CVC) on chest radiography images. However, there have been no studies for the classification of the CVC tip position with a definite criterion on the chest radiograph. This study aimed to develop an algorithm for the automatic classification of proper depth with the application of automatic segmentation of the trachea and the CVC on chest radiographs using a deep CNN. This was a retrospective study that used plain chest supine anteroposterior radiographs. The trachea and CVC were segmented on images and three labels (shallow, proper, and deep position) were assigned based on the vertical distance between the tracheal carina and CVC tip. We used a two-stage approach model for the automatic segmentation of the trachea and CVC with U-net⁺⁺ and automatic classification of CVC placement with EfficientNet B4. The primary outcome was a successful three-label classification through five-fold validations with segmented images and a test with segmentation-free images. Of a total of 808 images, 207 images were manually segmented and the overall accuracy of the five-fold validation for the classification of three-class labels (mean (SD)) of five-fold validation was 0.76 (0.03). In the test for classification with 601 segmentation-free images, the average accuracy, precision, recall, and F1-score were 0.82, 0.73, 0.73, and 0.73, respectively. We achieved the highest accuracy value of 0.91 in the shallow position label, while the highest F1-score was 0.82 in the deep position label. A deep CNN can achieve a comparative performance in the classification of the CVC position based on the distance from the carina to the CVC tip as well as automatic segmentation of the trachea and CVC on plain chest radiographs.

Combined short-axis out-of-plane and long-axis in-plane approach versus long-axis in-plane approach for ultrasound-guided central venous catheterization in infants and small children: A randomized controlled trial

The ultrasound-guided long-axis in-plane approach for central venous catheterization in infants and small children can prevent posterior wall penetration. The combined short-axis out-of-plane and long-axis in-plane approach reportedly prevents such penetration in adults. To test the hypothesis of non-inferiority of the combined approach to the long-axis in-plane approach, we compared the two approaches in infants and small children. Patients were randomized based on whether they underwent ultrasound-guided internal jugular vein catheterization using the combined or long-axis in-plane approach. Posterior wall penetration rates, first-attempt success rates, overall success rates within 20 min; scanning, puncture, and procedure durations; and number of attempts were compared between the groups. In the combined and long-axis in-plane groups (n = 55 per group), the posterior wall penetration rates were 5.5% (3/55) and 3.6% (2/55) (P = 0.65), the first-attempt success rates were 94.5% (52/55) and 92.7% (51/55) (P = 0.70), and the overall success rates within 20 min were 100% (55/55) and 98.2% (54/55) (P = 0.32), respectively. In the combined and long-axis in-plane groups, the median (interquartile range) scanning durations were 21 (16.5–34.8) s and 47 (29.3–65) s (P<0.0001), the puncture durations were 114 (83–170) s and 74 (52.3–117.3) s (P = 0.0002), and the procedure durations were 141 (99–97.8) s and 118 (88.5–195.5) s (P = 0.14), respectively. The median number of attempts was 1 (interquartile range: 1–1, range: 1–3) in both groups (P = 0.72). Similar to the long-axis in-plane approach, the combined approach for internal jugular vein catheterization prevented posterior wall penetration in infants and small children.

Trial registration: This trial was registered before patient enrollment in the University Hospital Medical Information Network Clinical Trials Registry, registration number UMIN000039387 (https://upload.umin.ac.jp/cgi-bin/ctr/ctr_view_reg.cgi?recptno=R000044907).

Point-of-care ultrasound training for residents in anaesthesia and critical care: results of a national survey comparing residents and training program directors' perspectives

BACKGROUND

Point-of-care ultrasound (POCUS) has become an essential tool for anaesthesia and critical care physicians and dedicated training is mandatory. This survey describes the current state of Italian residency training programs through the comparison of residents' and directors' perspective.

METHODS

Observational prospective cross-sectional study: 12-question national e-survey sent to Italian directors of anaesthesia and critical care residency programs (N = 40) and residents (N = 3000). Questions focused on POCUS teaching (vascular access, transthoracic echocardiography, focused assessment for trauma, transcranial Doppler, regional anaesthesia, lung and diaphragm ultrasound), organization (dedicated hours, teaching tools, mentors), perceived adequacy/importance of the training and limiting factors.

RESULTS

Five hundred seventy-one residents and 22 directors completed the survey. Bedside teaching (59.4-93.2%) and classroom lessons (29.7-54.4%) were the most frequent teaching tools. Directors reported higher participation in research projects (p < 0.05 for all techniques but focused assessment for trauma) and simulation (p < 0.05 for all techniques but transthoracic echocardiography). Use of online teaching was limited (< 10%); however, 87.4% of residents used additional web-based tools. Consultants were the most frequent mentors, with different perspectives between residents (72.0%) and directors (95.5%; p = 0.013). Residents reported self-training more frequently (48.5 vs. 9.1%; p < 0.001). Evaluation was mainly performed at the bedside; a certification was not available in most cases (< 10%). Most residents perceived POCUS techniques as extremely important. Residents underestimated the relevance given by directors to ultrasound skills in their evaluation and the minimal number of exams required to achieve basic competency. Overall, the training was considered adequate for vascular access only (62.2%). Directors mainly agreed on the need of ultrasound teaching improvement in all fields. Main limitations were the absence of a standardized curriculum for residents and limited mentors' time/expertise for directors.

CONCLUSION

POCUS education is present in Italian anaesthesia and critical care residency programs, although with potential for improvement. Significant discrepancies between residents' and directors' perspectives were identified.

Factors affecting mechanical complications of central venous access devices in children

PURPOSE

Factors leading to mechanical complications following insertion of central venous access devices (CVADs) in children are poorly understood. We aimed to quantify the rates and elucidate the mechanisms of these complications.

METHODS

Retrospective (2016-2021) review of children (< 18 years old) receiving a CVAD. Data, reported as number of cases (%) and median (IQR), were analysed by Fisher's exact test, chi-squared test and logistic regression analysis.

RESULTS

In total, 317 CVADs (245 children) were inserted. Median age was 5.0 (8.9) years, with 116 (47%) females. There were 226 (71%) implantable port devices and 91 (29%) Hickman lines. Overall, 54 (17%) lines had a mechanical complication after 0.4 (0.83) years from insertion: fracture 19 (6%), CVAD migration 14 (4.4%), occlusion 14 (4.4%), port displacement 6 (1.9%), and skin tethering to port device 1 (0.3%). Younger age and lower weight were associated with higher risk of complications (p < 0.0001). Hickman lines had a higher incidence of complications compared to implantable port devices [24/91 (26.3%) vs 30/226 (13.3%); p = 0.008].

CONCLUSION

Mechanical complications occur in 17% of CVADs at a median of < 6 months after insertion. Risk factors include younger age and lower weight. Implantable port devices have a lower complications rate.

LEVEL OF EVIDENCE

Level 4: case-series with no comparison group.

[Developments in the Diagnosis and Therapeutic Strategy of the Apert Hand]

The necessity for early surgical correction of Apert hands for the overall child development has been highlighted repeatedly in older literature. Nevertheless, uncertainties regarding the time and the scale of the initial surgical treatment still remain. While in former times there were no regular follow-ups after the syndactyly release, we now know that during growth bony changes will develop in the Apert hand requiring regular check-ups and, in some cases, revision surgeries. Affected parents need comprehensive clarification about a clear and time-efficient therapeutic concept. This review article describes our actual concept treating Apert hands.

Preventing radial arterial catheter failure in critical care - Factoring updated clinical strategies and techniques

Radial artery catheterization is a frequently performed procedure for critically ill patients. The correct function of arterial catheters is essential to provide accurate and continuous hemodynamic monitoring, facilitating intermittent blood sampling and helping to optimize the workload for critical care nurses and physicians. However, they are not without their own problems. This narrative practice review discusses several clinical aspects that are not frequently considered but may contribute to enhanced catheter functionality, less device-related failure and more acceptable dwell times. Ultrasound has demonstrated unequivocal efficacies and safety with the procedure, improving first attempt success rates with children, the obese or patients with unstable clinical vital signs and shock. Moreover, anatomic variations of the radial artery are not rare, and ultrasound-guided catheterization reduces the incidence of insertion-related complications such as hematoma, posterior wall puncture, intimal dissection, and radial nerve injury. Ultrasound guidance offers several immediate benefits by enhancing the most appropriate insertion techniques, allows for the correct catheter to vessel ratio measurements to be performed and reduces the angle of insertion, which may affect catheter failure due to inappropriate catheter length. A deeper and more proximal cannulation site at least 4 cm from wrist joint, avoiding the area of wrist flexion, reduces mechanical complications related to patient movements and may improve catheter functionality and dwell along with a better area for stabilization and securement.

Ultrasound localization of central vein catheter tip by contrast-enhanced transthoracic ultrasonography: a comparison study with trans-esophageal echocardiography

BACKGROUND

To assess the usefulness of pre-operative contrast-enhanced transthoracic echocardiography (CE-TTE) and post-operative chest-x-ray (CXR) for evaluating central venous catheter (CVC) tip placements, with trans-esophageal echocardiography (TEE) as gold standard.

METHODS

A prospective single-center, observational study was performed in 111 patients requiring CVC positioning into the internal jugular vein for elective cardiac surgery. At the end of CVC insertion by landmark technique, a contrast-enhanced TTE was performed by both the apical four-chambers and epigastric bicaval acoustic view to assess catheter tip position; then, a TEE was performed and considered as a reference technique. A postoperative CXR was obtained for all patients.

RESULTS

As per TEE, 74 (67%) catheter tips were correctly placed and 37 (33%) misplaced. Considering intravascular and intracardiac misplacements together, they were detected in 8 patients by CE-TTE via apical four-chamber view, 36 patients by CE-TTE via epigastric bicaval acoustic view, and 12 patients by CXR. For the detection of catheter tip misplacement, CE-TTE via epigastric bicaval acoustic view was the most accurate method providing 97% sensitivity, 90% specificity, and 92% diagnostic accuracy if compared with either CE-TTE via apical four-chamber view or CXR. Concordance with TEE was 79% (p < 0.001) for CE-TTE via epigastric bicaval acoustic view.

CONCLUSIONS

The concordance between CE-TTE via epigastric bicaval acoustic view and TEE suggests the use of the former as a standard technique to ensure the correct positioning of catheter tip after central venous cannulation to optimize the use of hospital resources and minimize radiation exposure.

Trendelenburg (Head-Down Tilt) and Head Rotation: Ultrasonographic effects on the internal jugular vein for catheterization safety

Most guidelines fail to specify patient positioning during central venous catheterization. The objective was to determine the effects of head-down tilt (Trendelenburg position) and head rotation on the internal jugular vein (IJV). A prospective, observational, longitudinal, and descriptive study using healthy adult volunteers, of both sexes, was performed. The change in position and cross-sectional areas (CSA) of the right IJV and common carotid artery (CA) were measured by ultrasonography during Trendelenburg position (TP) (0°, 5°, 10°, and 15°) and contralateral head-rotation (HR) (0°, 45°, and 90°) for a total of 12 positions. The neutral supine position was first, randomizing the other 11 positions, with 5-minute rest intervals in between. Vital signs and symptoms were recorded. A total of 54 volunteers were recruited between the ages of 21 and 32, of which 30 were men. Any degree of TP or HR significantly increased the CSA. The largest area obtained was 1.78cm² with a TP15HR90 which did not have a statistical difference with TP10HR45 1.59cm² . A HR90 tended to displace the IJV medially, overlaying the CA. Any degree of TP or HR will significantly increase CSA or the right IJV. A 5° to 10° TP is recommended when the patient's condition allows it, with a 45° HR, without significantly displacing the IJV anterior to the CCA. This article is protected by copyright. All rights reserved.

A comparison of first-attempt cannulation success of peripheral venous catheter systems with and without wings and injection ports in surgical patients-a randomized trial

BACKGROUND

A peripheral venous catheter (PVC) is the most widely used device for obtaining vascular access, allowing the administration of fluids and medication. Up to 25% of adult patients, and 50% of pediatric patients experience a first-attempt cannulation failure. In addition to patient and clinician characteristics, device features might affect the handling and success rates. The objective of the study was to compare the first-attempt cannulation success rate between PVCs with wings and a port access (Vasofix® Safety, B. Braun, abbreviated hereon in as VS) with those without (Introcan® Safety, B. Braun, abbreviated hereon in as IS) in an anesthesiological cohort.

METHODS

An open label, multi-center, randomized trial was performed. First-attempt cannulation success rates were examined, along with relevant patient, clinician, and device characteristics with univariate and multivariate analyses. Information on handling and adherence to use instructions was gathered, and available catheters were assessed for damage.

RESULTS

Two thousand three hundred four patients were included in the intention to treat analysis. First-attempt success rate was significantly higher with winged and ported catheters (VS) than with the non-winged, non-ported design (IS) (87.5% with VS vs. 78.2% with IS; P_Chi < .001). Operators rated the handling of VS as superior (rating of "good" or "very good: 86.1% VS vs. 20.8% IS, P_Chi < .001). Reinsertion of the needle into the catheter after partial withdrawal-prior or during the catheterization attempt-was associated with an increased risk of cannulation failure (7.909, CI 5.989-10.443, P < .001 and 23.023, CI 10.372-51.105, P < .001, respectively) and a twofold risk of catheter damage (OR 1.999, CI 1.347-2.967, P = .001).

CONCLUSIONS

First-attempt cannulation success of peripheral, ported, winged catheters was higher compared to non-ported, non-winged devices. The handling of the winged and ported design was better rated by the clinicians. Needle reinsertions are related to an increase in rates of catheter damage and cannulation failure.

TRIAL REGISTRATION

ClinicalTrials.gov, Identifier: NCT02213965 , Date: 12/08/2014.

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.

The right supraclavicular fossa ultrasound view for correct catheter tip positioning in right subclavian vein catheterisation: a prospective observational study

Central venous catheter misplacement is common (approximately 7%) after right subclavian vein catheterisation. To avoid it, ultrasound-guided tip navigation may be used during the catheterisation procedure to help direct the guidewire towards the lower superior vena cava. We aimed to determine the number of central venous catheter misplacements when using the right supraclavicular fossa ultrasound view to aid guidewire positioning in right infraclavicular subclavian vein catheterisation. We hypothesised that the incidence of catheter misplacements could be reduced to 1% when using this ultrasound technique. One -hundred and three adult patients were prospectively included. After vein puncture and guidewire insertion, we used the right supraclavicular fossa ultrasound view to confirm correct guidewire J-tip position in the lower superior vena cava and corrected the position of misplaced guidewires using real-time ultrasound guidance. Successful catheterisation of the right subclavian vein was achieved in all patients. The guidewire J-tip was initially misplaced in 15 patients, either in the ipsilateral internal jugular vein (n = 8) or in the left brachiocephalic vein (n = 7). In 12 patients it was possible to adjust the guidewire J-tip to a correct position in the lower superior vena cava. All ultrasound-determined final guidewire J-tip positions were consistent with the central venous catheter tip positions on chest X-ray. Three out of 103 catheters were misplaced, corresponding to an incidence (95%CI) of 2.9 (0.6-8.3) %. Although the hypothesis could not be confirmed, this study demonstrated the usefulness of the right supraclavicular fossa ultrasound view for real-time confirmation and correction of the guidewire position in right infraclavicular subclavian vein catheterisation.

The state of vascular access teams: Results of a European survey

BACKGROUND

Many European health institutions have appointed multidisciplinary teams for the general management of vascular access to help improve efficiency, patient safety and reduce costs. Vascular access teams (VATs), or infusion teams, are specifically trained groups of healthcare professionals who assess, place, manage and monitor various outcomes and aspects of vascular access care.

OBJECTIVE

To assess the current landscape of vascular access management as a discipline across Europe.

METHODS

A Faculty of European VAT leads and experts developed a survey of 20 questions which was disseminated across several European countries. Questions focused on respondent and institution profile, vascular access device selection and placement, monitoring and reporting of complications, and access to training and education. The 1449 respondents included physicians, nurses, anaesthetists, radiologists and surgeons from public and private institutions ranging in size.

RESULTS

Availability of dedicated VATs vary by country, institution size, and institution type. Institutions with a VAT are more likely to utilise a tool (eg, algorithm or guideline) to determine the appropriate vascular access device (55% vs 38%, P < .0002) and to have feedback on systematic monitoring of complications (40% vs 28%, P = .015). Respondents from institutions with a VAT are more likely to have received training on vascular access management (79% vs 53%, P < .0001) and indicated that the VAT was a source of support when difficulties arise.

CONCLUSION

The survey results highlight some of the potential benefits of implementing a dedicated VAT including the use of a broader range of vascular access devices, increased awareness of the presence of vascular access policies, increased the likelihood of recent vascular access training, and increased rates of systematic monitoring of associated complications. The study reveals potential areas for further focus in the field of vascular access care, specifically examining the direct impact of vascular access teams.

Ultrasound-guided transjugular embolization of ruptured huge venous ectasia of a Cognard IV tentorial dural arteriovenous fistula as a first-stage lifesaving procedure: Review of the literature

Tentorium is a rare location of the brain dural arteriovenous fistulae (DAVF) consisting <4% of cases. Hemorrhagic clinical presentation is common, as cortical venous reflux consists a usual characteristic of tentorial DAVF’s angioarchitecture. We present a case of transvenous, transjugular embolization of a ruptured huge venous ectasia of a Cognard IV tentorial middle-line DAVF, as a first step life-saving procedure. Initially, a transarterial antegrade embolization attempt was performed but failed due to the tortuous course of arterial feeders. Subsequently, the internal jugular vein (IJV) was directly catheterized under ultrasound (U/S) guidance and a 6F guiding catheter was placed at the ipsilateral transverse sinus. A microcatheter was navigated inside the venous ectasia and eventually, coils were deployed inside causing complete occlusion of the huge venous ectatic aneurysm. In this way, initial occlusion of the venous ectatic ruptured point has been achieved as a first-stage lifesaving treatment. Subsequently, the patient underwent stereotactic radiosurgery for the DAVF 4 months after embolization. Angiographic control with digital subtraction angiography 2 years after embolization and additional stereotactic radiosurgery revealed complete occlusion of the tentorial DAVF. The patient experienced complete neurological recovery. Direct puncture of the IJV under U/S guidance may assist transvenous embolization of ruptured venous ectasia in case of complex tentorial middle-line DAVFs type IV when the ecstatic venous aneurysm is recognized as the bleeding source.

Ultrasound guidance for urgent arterial and venous catheterisation: randomised controlled study

BACKGROUND

Haemodynamically unstable patients often require arterial and venous catheter insertion urgently. We hypothesised that ultrasound-guided arterial and venous catheterisation would reduce mechanical complications.

METHODS

We performed a prospective RCT, where patients requiring both urgent arterial and venous femoral catheterisation were randomised to either ultrasound-guided or landmark-guided catheterisation. Complications and characteristics of catheter insertion (procedure duration, number of punctures, and procedure success) were recorded at the time of insertion (immediate complications). Late complications were investigated by ultrasound examination performed between the third and seventh days after randomisation. Primary outcome was the proportion of patients with at least one mechanical complication (immediate or late), by intention-to-treat analysis. Secondary outcomes included success rate, procedure time, and number of punctures.

RESULTS

We analysed 136 subjects (102 [75%] male; age range: 27-62 yr) by intention to treat. The proportion of subjects with one or more complications was lower in 22/67 (33%) subjects undergoing ultrasound-guided catheterisation compared with landmark-guided catheterisation (40/69 [58%]; odds ratio: 0.35 [95% confidence interval: 0.18-0.71]; P=0.003). Ultrasound-guided catheterisation reduced both immediate (27%, compared with 51% in the landmark approach group; P=0.004) and late (10%, compared with 23% in the landmark approach group; P=0.047) complications. Ultrasound guidance also reduced the proportion of patients who developed deep vein thrombosis (4%, compared with 22% following landmark approach; P=0.012), and achieved a higher procedural success rate (96% vs 78%; P=0.004).

CONCLUSIONS

An ultrasound-guided approach reduced mechanical complications after urgent femoral arterial and venous catheterisation, while increasing procedural success.

CLINICAL TRIAL REGISTRATION

NCT02820909.

Smart Glasses for Radial Arterial Catheterization in Pediatric Patients: A Randomized Clinical Trial

BACKGROUND

Hand-eye coordination and ergonomics are important for the success of delicate ultrasound-guided medical procedures. These can be improved using smart glasses (head-mounted display) by decreasing the head movement on the ultrasound screen. The hypothesis was that the smart glasses could improve the success rate of ultrasound-guided pediatric radial arterial catheterization.

METHODS

This prospective, single-blinded, randomized controlled, single-center study enrolled pediatric patients (n = 116, age less than 2 yr) requiring radial artery cannulation during general anesthesia. The participants were randomized into the ultrasound screen group (control) or the smart glasses group. After inducing general anesthesia, ultrasound-guided radial artery catheterization was performed. The primary outcome was the first-attempt success rate. The secondary outcomes included the first-attempt procedure time, the overall complication rate, and operators' ergonomic satisfaction (5-point scale).

RESULTS

In total, 116 children were included in the analysis. The smart glasses group had a higher first-attempt success rate than the control group (87.9% [51/58] vs. 72.4% [42/58]; P = 0.036; odds ratio, 2.78; 95% CI, 1.04 to 7.4; absolute risk reduction, -15.5%; 95% CI, -29.8 to -12.8%). The smart glasses group had a shorter first-attempt procedure time (median, 33 s; interquartile range, 23 to 47 s; range, 10 to 141 s) than the control group (median, 43 s; interquartile range, 31 to 67 s; range, 17 to 248 s; P = 0.007). The overall complication rate was lower in the smart glasses group than in the control group (5.2% [3/58] vs. 29.3% [17/58]; P = 0.001; odds ratio, 0.132; 95% CI, 0.036 to 0.48; absolute risk reduction, 24.1%; 95% CI, 11.1 to 37.2%). The proportion of positive ergonomic satisfaction (4 = good or 5 = best) was higher in the smart glasses group than in the control group (65.5% [38/58] vs. 20.7% [12/58]; P <0.001; odds ratio, 7.3; 95% CI, 3.16 to 16.8; absolute risk reduction, -44.8%; 95% CI, -60.9% to -28.8%).

CONCLUSIONS

Smart glasses-assisted ultrasound-guided radial artery catheterization improved the first-attempt success rate and ergonomic satisfaction while reducing the first-attempt procedure time and overall complication rates in small pediatric patients.

EDITOR’S PERSPECTIVE

Levels of Evidence Supporting the North American and European Perioperative Care Guidelines for Anesthesiologists between 2010 and 2020: A Systematic Review

BACKGROUND

Although there are thousands of published recommendations in anesthesiology clinical practice guidelines, the extent to which these are supported by high levels of evidence is not known. This study hypothesized that most recommendations in clinical practice guidelines are supported by a low level of evidence.

METHODS

A registered (Prospero CRD42020202932) systematic review was conducted of anesthesia evidence-based recommendations from the major North American and European anesthesiology societies between January 2010 and September 2020 in PubMed and EMBASE. The level of evidence A, B, or C and the strength of recommendation (strong or weak) for each recommendation was mapped using the American College of Cardiology/American Heart Association classification system or the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The outcome of interest was the proportion of recommendations supported by levels of evidence A, B, and C. Changes in the level of evidence over time were examined. Risk of bias was assessed using Appraisal of Guidelines for Research and Evaluation (AGREE) II.

RESULTS

In total, 60 guidelines comprising 2,280 recommendations were reviewed. Level of evidence A supported 16% (363 of 2,280) of total recommendations and 19% (288 of 1,506) of strong recommendations. Level of evidence C supported 51% (1,160 of 2,280) of all recommendations and 50% (756 of 1,506) of strong recommendations. Of all the guidelines, 73% (44 of 60) had a low risk of bias. The proportion of recommendations supported by level of evidence A versus level of evidence C (relative risk ratio, 0.93; 95% CI, 0.18 to 4.74; P = 0.933) or level of evidence B versus level of evidence C (relative risk ratio, 1.63; 95% CI, 0.72 to 3.72; P = 0.243) did not increase in guidelines that were revised. Year of publication was also not associated with increases in the proportion of recommendations supported by level of evidence A (relative risk ratio, 1.07; 95% CI, 0.93 to 1.23; P = 0.340) or level of evidence B (relative risk ratio, 1.05; 95% CI, 0.96 to 1.15; P = 0.283) compared to level of evidence C.

CONCLUSIONS

Half of the recommendations in anesthesiology clinical practice guidelines are based on a low level of evidence, and this did not change over time. These findings highlight the need for additional efforts to increase the quality of evidence used to guide decision-making in anesthesiology.

EDITOR’S PERSPECTIVE

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.

A randomized controlled trial of ultrasound-assisted technique versus conventional puncture method for saphenous venous cannulations in children with congenital heart disease

Background

The study investigated the success rate of the great saphenous venous catheter placement performed by ultrasound-assisted technique compared with the conventional puncture method in infants and toddlers with congenital heart disease and aimed to assess the efficiency and feasibility of this method within the context of pediatric peripheral venous access.

Methods

We selected infants and toddlers who underwent congenital cardiac surgery in our medical center from June 1, 2020, to September 7, 2020, by convenience sampling. Children were stratified by the presence of the manifesting cardiac types (cyanotic or acyanotic heart disease). They were assigned to the conventional puncture method group or the ultrasound-assisted group through randomly blocked randomization. The primary outcome was the success rate of the first attempt. The second outcomes included the time to cannulation at the first attempt, the redirections of the first attempt, overall puncture time, and overall redirections of efforts. Besides, a binary logistic regression model was implemented to identify the possible variables related to the success rate of the first attempt.

Results

A total of 144 children in our medical center were recruited in the study. The success rate of the first attempt in the ultrasound-assisted group was higher than that of the conventional puncture method group in the stratification of cyanotic children (66.7% vs. 33.3%, P = 0.035). Among children of acyanotic kind, the difference in the success rate of the first attempt between the two groups was not significant (57.6% vs. 42.4%, P = 0.194). Overall puncture time (45.5 s vs. 94 s, P = 0.00) and the time to cannulation at the first attempt (41.0 s vs. 60 s, P = 0.00) in the ultrasound-assisted group was less than the conventional puncture method group. The ultrasound-assisted group also required fewer redirections of the first attempt (three attempts vs. seven attempts, P = 0.002) and fewer total redirections of efforts (two attempts vs. three attempts, P = 0.027) than the conventional puncture method group. The result of binary Logistic regression showed that the success rate of the first attempt was related to age (OR:1.141; 95% CI = 1.010–1.290, P = 0.034), the redirections of the first attempt (OR:0.698; 95% CI = 0.528–0.923, P = 0.012) and the saphenous venous width (OR:1.181; 95% CI = 1.023–1.364, P = 0.023).

Conclusions

The ultrasound-assisted technique improves the saphenous venous cannulation sufficiently in children with difficult peripheral veins. The younger age is associated with a higher likelihood of peripheral venous difficulty. The ultrasound-assisted methods can effectively screen peripheral veins, e.g., selecting thicker diameter peripheral veins, making puncture less uncomfortable, and improving success rates. This method can be used as one of the effective and practical ways of peripheral venipuncture in children, especially in difficult situations. It should be widely applied as one of the alternative ultrasound techniques in the operating room.

Trial registration

ChiCTR.org.cn (ChiCTR-2,000,033,368). Prospectively registered May 29, 2020.

Ultrasound-guided arterial catheterization

Ultrasonography facilitates arterial catheterization compared to traditional palpation techniques, especially in small arteries. For successful catheterization without complications, practitioners should be familiar with the anatomic characteristics of the artery and ultrasound-guided techniques. There are two approaches for ultrasound-guided arterial catheterization: the short-axis view out-of-plane approach and the long-axis view in-plane approach. There are several modified techniques and tips to facilitate ultrasound-guided arterial catheterization. This review deals with the anatomy relevant to arterial catheterization, several methods to improve success rates, and decrease complications associated with arterial catheterization.

Ultrasound-guided peripheral intravenous catheters insertion in patient with difficult vascular access: Short axis/out-of-plane versus long axis/in-plane, a randomized controlled trial

PURPOSE

The aim of this study was to evaluate the rate of successful peripheral cannulation between short-axis and long-axis ultrasound guided techniques.

METHODS

A single-center, two-arm randomized controlled, intention-to-treat, open-label study was conducted at the Emergency Department, between August and November 2020. Patients requiring a peripheral intravenous catheter insertion and identified as having a difficult intravascular access, were enrolled and followed for up to 96 h.The primary endpoint was the correct placement of the peripheral intravenous catheter. The secondary endpoints were number of venipunctures, intra-procedural pain, local complications, and positive blood return during the follow up.

RESULTS

A total of 283 patients were enrolled: 141 subjects were randomized to the short-axis and 142 to the long-axis group. Success rate was 96.45% (135/141; 95% CI, 91.92%-98.84%) in the short-axis group compared with 92.25% (132/142; 95% CI, 86.56%-96.07%) in the long-axis group (p = 0.126). No significant differences were found in terms of intraprocedural pain and local complications. Higher rate of positive blood return at 72 h [3/17 long-axis, 14/17 short-axis (p = 0.005)] and 96 h [1/10 long-axis, 9/10 short-axis 96 h, (p = 0.022)] was found for the short-axis group.

CONCLUSIONS

No differences were found between short-axis and long-axis techniques in terms of success rate, intraprocedural pain, and local complications. Despite this, a slightly higher success rate, a lower number of venipunctures, and a higher rate of positive blood return at 72 and 96 h together with an easier ultrasound technique could suggest a short-axis approach.

Syringe-Free, Long-Axis in-Plane Versus Short-Axis Classic out-of-Plane Approach for Ultrasound-Guided Internal Jugular Vein Catheter Placement in Critically Ill Children: A Prospective Randomized Study

OBJECTIVE

Although pediatric central venous catheterization is performed using ultrasound guidance, it is still a challenge. This study aimed to investigate the efficacy of the syringe-free, long-axis in-plane approach and compared the short-axis classic out-of-plane approach for ultrasound-guided central venous catheter placement in critically ill pediatric patients.

DESIGN

Prospective randomized study.

SETTING

Single institution, tertiary university hospital, pediatric care unit.

PARTICIPANTS

The study comprised 60 patients ages three months to 15 years.

INTERVENTIONS

Participants were randomly divided into two equal groups. Group I (n = 30) incorporated patients who underwent the long-axis, syringe-free in-plane approach, and group II (n = 30) incorporated patients who underwent the short-axis out-of-plane approach.

MEASUREMENTS AND MAIN RESULTS

Performing time, number of needle passes, number of skin punctures, first-pass success rate, and related complications were evaluated. There were no differences between the two groups in terms of demographics and vein-related measurements (p > 0.05). Performing time was statistically shorter in group I compared with group II (32 [25-38] v 58 [42-70] s; p < 0.001). There was no statistical difference between first-pass success rates between groups (group I 86.6% v group II 80%; p = 0.731). There were no significant differences between the groups in the number of needle passes and skin punctures (p = 0.219 and 0.508, respectively). Complications occurred in both groups, but there was no significant difference (4/30 v 7/30; p = 0.317).

CONCLUSIONS

The syringe-free, long-axis in-plane approach can be a safe and fast alternative for pediatric catheterization.

Ultrasound-guided cannulation of the superficial femoral vein for central venous access

BACKGROUND

In some clinical conditions, central venous access is preferably or necessarily achieved by threading the catheter into the inferior vena cava. This can be obtained not only by puncture of the common femoral vein at the groin, but also-as suggested by few recent studies-by puncture of the superficial femoral vein at mid-thigh.

METHODS

We have retrospectively reviewed our experience with central catheters inserted by ultrasound-guided puncture and cannulation of the superficial femoral vein, focusing mainly on indications, technique of venipuncture, and incidence of immediate/early complications.

RESULTS

From June 2020 to December 2020, we have inserted 98 non-tunneled central venous catheters (tip in inferior vena cava or right atrium) by ultrasound-guided puncture of the superficial femoral vein at mid-thigh or in the lower third of the thigh, all of them secured by subcutaneous anchorage. The success of the maneuver was 100% and immediate/early complications were negligible. Follow-up of hospitalized patients (72.5% of all cases) showed only one episode of catheter dislodgment, no episode of infection and no episode of catheter related thrombosis.

CONCLUSIONS

The ultrasound approach to the superficial femoral vein is an absolutely safe technique of central venous access. In our experience, it was not associated with any risk of severe insertion-related complications, even in patients with low platelet count or coagulation disorders. Also, the exit site of the catheter at mid-thigh may have advantages if compare to the exit site in the inguinal area.

European Society of Anaesthesiology and Intensive Care Guidelines on peri-operative use of ultrasound for regional anaesthesia (PERSEUS regional anesthesia): Peripheral nerves blocks and neuraxial anaesthesia

Nowadays, ultrasound-guidance is commonly used in regional anaesthesia (USGRA) and to locate the spinal anatomy in neuraxial analgesia. The aim of this second guideline on the PERi-operative uSE of UltraSound (PERSEUS-RA) is to provide evidence as to which areas of regional anaesthesia the use of ultrasound guidance should be considered a gold standard or beneficial to the patient. The PERSEUS Taskforce members were asked to define relevant outcomes and rank the relative importance of outcomes following the GRADE process. Whenever the literature was not able to provide enough evidence, we decided to use the RAND method with a modified Delphi process. Whenever compared with alternative techniques, the use of USGRA is considered well tolerated and effective for some nerve blocks but there are certain areas, such as truncal blocks, where a lack of robust data precludes useful comparison. The new frontiers for further research are represented by the application of USG during epidural analgesia or spinal anaesthesia as, in these cases, the evidence for the value of the use of ultrasound is limited to the preprocedure identification of the anatomy, providing the operator with a better idea of the depth and angle of the epidural or spinal space. USGRA can be considered an essential part of the curriculum of the anaesthesiologist with a defined training and certification path. Our recommendations will require considerable changes to some training programmes, and it will be necessary for these to be phased in before compliance becomes mandatory.

The value of real-time ultrasound-guidance for definite placement of a right supraclavicular subclavian central venous catheter

Central venous catheters (CVC) are widely used in critically ill patients and in those undergoing major surgery. Significant adverse events, such as pneumothorax and hemothorax, can be caused by needle insertion during CVC insertion. CVC misplacement is less often described, yet equally important, as it can lead to deleterious complications.Here, we describe a case in which misplacement of a guidewire following infraclavicular puncture of the right axillary vein was detected by continuous ultrasound employing the right supraclavicular fossa view. Utilizing this ultrasound view, the insertion approach to the vessel was changed and correct CVC placement could be achieved.While ultrasound guidance is widely accepted for vessel puncture, this case demonstrates the value of continuous ultrasound guidance for the entire process of CVC insertion: vessel puncture, correct guidewire advancement, catheter placement, and exclusion of complications such as pneumothorax. It also shows that there should be a high index of suspicion for guidewire misplacement, even after successful venipuncture.In conclusion, ultrasound protocols covering the complete CVC insertion process should be implemented into current clinical practice.

Minimal guidewire length for central venous catheterization of the right subclavian vein: A CT-based consecutive case series

Background:

Central venous catheter (CVC) misplacement occurs frequently after right subclavian vein catheterization. It can be avoided by using ultrasound to confirm correct guidewire tip position in the lower superior vena cava prior to CVC insertion. However, retraction of the guidewire during the CVC insertion may dislocate the guidewire tip from its desired and confirmed position, thereby resulting in CVC misplacement. The aim of this study was to determine the minimal guidewire length required to maintain correct guidewire tip position in the lower superior vena cava throughout an ultrasound-guided CVC placement in the right subclavian vein.

Methods:

One hundred adult patients with a computed tomography scan of the chest were included. By using multiplanar reconstructions from thin-sliced images, the distance from the most plausible distal puncture site of the right subclavian vein to the optimal guidewire tip position in the lower superior vena cava was measured (vessel length). In addition, measurements of equipment in common commercial over-the-wire percutaneous 15–16 cm CVC kits were performed. The 95th percentile of the vessel length was used to calculate the required minimal guidewire length for each CVC kit.

Results:

The 95th percentile of the vessel length was 153 mm. When compared to the calculated minimal guidewire length, the guidewires were up to 108 mm too short in eight of eleven CVC kits.

Conclusion:

After confirmation of a correct guidewire position, retraction of the guidewire tip above the junction of the brachiocephalic veins should be avoided prior to CVC insertion in order to preclude dislocation of the catheter tip towards the right internal jugular vein or the left subclavian vein. This study shows that many commercial over-the-wire percutaneous 15–16 cm CVC kits contain guidewires that are too short for right subclavian vein catheterization, i.e., guidewire retraction is needed prior to CVC insertion.