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Imai E, Kataoka Y, Watanabe J, Okano H, Namekawa M, Owada G, Matsui Y, Yokozuka M. Ultrasound-guided central venous catheterization around the neck: Systematic review and network meta-analysis. Am J Emerg Med 2024; 78:206-214. [PMID: 38330835 DOI: 10.1016/j.ajem.2024.01.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 01/25/2024] [Accepted: 01/29/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND Ultrasound-guided central venous catheterization (CVC) has become the standard of care. However, providers use a variety of approaches, encompassing the internal jugular vein (IJV), supraclavicular subclavian vein (SupraSCV), infraclavicular subclavian vein (InfraSCV), proximal axillary vein (ProxiAV), distal axillary vein (DistalAV), and femoral vein. OBJECTIVE This review aimed to compare the first-pass success rate and arterial puncture rate for different approaches to ultrasound-guided CVC above the diaphragm. METHODS In May 2023, Embase, MEDLINE, CENTRAL, ClinicalTrials.gov, and World Health Organization International Clinical Trials Platform were searched for randomized controlled trials (RCTs) comparing the 5 CVC approaches. The Confidence in Network Meta-Analysis tool was used to assess confidence. Thirteen RCTs (4418 participants and 13 comparisons) were included in this review. RESULTS The SupraSCV approach likely increased the proportion of first-attempt successes compared to the other 4 approaches. The SupraSCV first-attempt success demonstrated risk ratios (RRs) > 1.21 with a lower 95% confidence interval (CI) exceeding 1. Compared to the IJV, the SupraSCV approach likely increased the first-attempt success proportion (RR 1.22; 95% confidence interval [CI] 1.06-1.40, moderate confidence), whereas the DistalAV approach reduced it (RR 0.72; 95% CI 0.59-0.87, high confidence). Artery puncture had little to no difference across all approaches (low to high confidence). CONCLUSION Considering first-attempt success and mechanical complications, the SupraSCV may emerge as the preferred approach, while DistalAV might be the least preferable approach. Nevertheless, head-to-head studies comparing the approaches with the greatest first attempt success should be undertaken.
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Affiliation(s)
- Eriya Imai
- Division of Anesthesia, Mitsui Memorial Hospital, Tokyo, Japan; Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan.
| | - Yuki Kataoka
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan; Department of Internal Medicine, Kyoto Min-iren Asukai Hospital, Kyoto, Japan; Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan; Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine/Public Health, Kyoto, Japan
| | - Jun Watanabe
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan; Department of Surgery, Division of Gastroenterological, General, and Transplant Surgery, Jichi Medical University, Tochigi, Japan; Center for Community Medicine, Jichi Medical University, Tochigi, Japan
| | - Hiromu Okano
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan; Department of Emergency and Critical Care Medicine, St. Luke's International Hospital, Tokyo, Japan
| | - Motoki Namekawa
- Division of Anesthesia, Mitsui Memorial Hospital, Tokyo, Japan
| | - Gen Owada
- Department of Intensive Care Medicine, Yokohama Rosai Hospital, Kanagawa, Japan
| | - Yuko Matsui
- Department of Cardiology, National Hospital Organization Yokohama Medical Center, Kanagawa, Japan
| | - Motoi Yokozuka
- Division of Anesthesia, Mitsui Memorial Hospital, Tokyo, Japan
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Brown DC, Gonzalez-Vargas JM, Tzamaras HM, Sinz EH, Ng PK, Yang MX, Adhikary SD, Miller SR, Moore JZ. Evaluating the Impact of Assessment Metrics for Simulated Central Venous Catheterization Training. Simul Healthc 2024; 19:27-34. [PMID: 36378597 PMCID: PMC10185707 DOI: 10.1097/sih.0000000000000704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Performance assessment and feedback are critical factors in successful medical simulation-based training. The Dynamic Haptic Robotic Trainer (DHRT) allows residents to practice ultrasound-guided needle insertions during simulated central venous catheterization (CVC) procedures while providing detailed feedback and assessment. A study was performed to examine the effectiveness of the DHRT in training the important skills of needle tip tracking and aspiration and how these skills impact procedural complications in simulated CVC. METHODS The DHRT data were collected for 163 residents at 2 hospitals for 6 simulated needle insertions. Users were given automated feedback on 5 performance metrics, which measure aspiration rate, arterial punctures, punctures through and through the vein, loss of access to the vein, and successful access to the vein. Aspiration rates and tip tracking rates were analyzed to determine their significance in preventing CVC complications and improving performance. RESULTS Tip tracking rates higher than 40% were 2.3 times more likely to result in successful venous access than rates less than 10%. Similarly, aspiration rates higher than 80% were 2.6 times more likely to result in successful venous access than rates less than 10%. Proper tip tracking and aspiration both reduced mechanical complications. Resident performance improved for all metrics except tip tracking. CONCLUSIONS Proper tip tracking and aspiration both reduced complications and increased the likelihood of success. However, the skill of tip tracking was not effectively learned through practice without feedback. Therefore, ultrasound-guided needle-based procedures, including CVC, can be improved by providing specific feedback to users on their ultrasound usage to track needle insertions.
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Affiliation(s)
- Dailen C Brown
- From the Departments of Mechanical and Nuclear Engineering (D.C.B., J.Z.M.) and Industrial and Manufacturing Engineering (J.M.G.-V., H.M.T.), The Pennsylvania State University; The Pennsylvania State University College of Medicine (E.H.S., S.D.A.), Hershey, PA; Cedars Sinai Medical Procedure Center and Vascular Access Services (P.K.N.); Cedars Sinai Medical Center (M.X.Y.), Los Angeles, CA; and Department of Engineering Design and Industrial Engineering (S.R.M.), The Pennsylvania State University, Hershey, PA
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Lundgreen Mason N, Thomas R, Skidmore C, Loveless B, Muir M, Limov A, Fritsch A, Yancey T, Zapata I, Nigh A. Comparing the Utility of Landmark-Palpation Guided to Ultrasound-Guided Teaching Methodologies for Subclavian Central Venous Access Using a Formalin-Embalmed Cadaver Model. ADVANCES IN MEDICAL EDUCATION AND PRACTICE 2023; 14:1327-1337. [PMID: 38028367 PMCID: PMC10680480 DOI: 10.2147/amep.s439243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 11/16/2023] [Indexed: 12/01/2023]
Abstract
Background Low-risk and realistic simulation strategies are needed to train clinical learners to perform hands-on invasive procedures. This follow-up study compares the utility of landmark-guided palpation-based to ultrasound-guided teaching techniques for subclavian central venous access using formalin-embalmed cadavers. Methods The subclavian veins of 3 cadavers were imaged with ultrasound to evaluate vein patency before palpation-based venous access was attempted. Twenty-three first-year medical students were trained to access the subclavian vein using palpation-based techniques. Training involved ten minutes of didactic orientation and ten minutes of hands-on practical instruction using cadavers. Participant confidence was measured using a 10-point Likert scale on pre- and post-training questionnaires. Objective skills testing for each participant included quantifying the number of skin punctures and recording the time elapsed from first skin puncture to fluid flashback into the syringe. Data was analyzed using a generalized linear model (GLM) approach. Results Participant confidence significantly increased following training in both ultrasound and palpation training groups across all questionnaire items (P<0.001). The ultrasound group had fewer skin punctures (P<0.001) and fewer failures (1) than the palpation group (6). Participants in the ultrasound group were more confident than those in the palpation group in their ability to locate the vein and select the optimal site for needle access (P<0.05). Conclusion Formalin-embalmed cadavers provide a safe, stress-free, and effective means by which to train students in subclavian vein access using both palpation and ultrasound-based techniques. Repeated practice accessing and aspirating fluid from a cadaveric subclavian vein significantly increases trainee confidence, an essential factor in physician performance that may lead to fewer complications. Introducing this type of low-risk and hands-on practice may be beneficial for trainees before they attempt subclavian vein access on live patients.
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Affiliation(s)
| | - Rebecca Thomas
- Rocky Vista University College of Osteopathic Medicine – Southern Utah, Ivins, UT, 84738, USA
| | - Chad Skidmore
- Rocky Vista University College of Osteopathic Medicine – Southern Utah, Ivins, UT, 84738, USA
| | - Bosten Loveless
- Rocky Vista University College of Osteopathic Medicine – Southern Utah, Ivins, UT, 84738, USA
| | - Maxton Muir
- Rocky Vista University College of Osteopathic Medicine – Southern Utah, Ivins, UT, 84738, USA
| | - Abigail Limov
- Rocky Vista University College of Osteopathic Medicine – Southern Utah, Ivins, UT, 84738, USA
| | - Alexa Fritsch
- Rocky Vista University College of Osteopathic Medicine – Southern Utah, Ivins, UT, 84738, USA
| | - Taylor Yancey
- Rocky Vista University College of Osteopathic Medicine – Southern Utah, Ivins, UT, 84738, USA
| | - Isain Zapata
- Rocky Vista University College of Osteopathic Medicine – Colorado, Parker, CO, 80134, USA
| | - Andrew Nigh
- Rocky Vista University College of Osteopathic Medicine – Southern Utah, Ivins, UT, 84738, USA
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Engberg M, Mikkelsen S, Hörer T, Lindgren H, Søvik E, Frendø M, Svendsen MB, Lönn L, Konge L, Russell L, Taudorf M. Learning insertion of a Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) catheter: Is clinical experience necessary? A prospective trial. Injury 2023; 54:1321-1329. [PMID: 36907823 DOI: 10.1016/j.injury.2023.02.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 02/08/2023] [Accepted: 02/22/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emerging and potentially life-saving procedure, necessitating qualified operators in an increasing number of centres. The procedure shares technical elements with other vascular access procedures using the Seldinger technique, which is mastered by doctors not only in endovascular specialties but also in trauma surgery, emergency medicine, and anaesthesiology. We hypothesised that doctors mastering the Seldinger technique (experienced anaesthesiologist) would learn the technical aspects of REBOA with limited training and remain technically superior to doctors unfamiliar with the Seldinger technique (novice residents) given similar training. METHODS This was a prospective trial of an educational intervention. Three groups of doctors were enroled: novice residents, experienced anaesthesiologists, and endovascular experts. The novices and the anaesthesiologists completed 2.5 h of simulation-based REBOA training. Their skills were tested before and 8-12 weeks after training using a standardised simulated scenario. The endovascular experts, constituting a reference group, were equivalently tested. All performances were video recorded and rated by three blinded experts using a validated assessment tool for REBOA (REBOA-RATE). Performances were compared between groups and with a previously published pass/fail cutoff. RESULTS Sixteen novices, 13 board-certified specialists in anaesthesiology, and 13 endovascular experts participated. Before training, the anaesthesiologists outperformed the novices by 30 percentage points of the maximum REBOA-RATE score (56% (SD 14.0) vs 26% (SD 17%), p<0.01). After training, there was no difference in skills between the two groups (78% (SD 11%) vs 78 (SD 14%), p = 0.93). Neither group reached the endovascular experts' skill level (89% (SD 7%), p<0.05). CONCLUSION For doctors mastering the Seldinger technique, there was an initial inter-procedural transfer of skills advantage when performing REBOA. However, after identical simulation-based training, novices performed equally well to anaesthesiologists, indicating that vascular access experience is not a prerequisite to learning the technical aspects of REBOA. Both groups would need more training to reach technical proficiency.
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Affiliation(s)
- Morten Engberg
- Copenhagen Academy for Medical Education and Simulation (CAMES), Centre for Human Resources and Education, the Capital Region of Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.
| | - Søren Mikkelsen
- The Mobile Emergency Care Unit, Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark; The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark; Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Tal Hörer
- Department of Cardiothoracic and Vascular Surgery and Department of Surgery, Faculty of Life Science, Örebro University Hospital, Örebro, Sweden
| | - Hans Lindgren
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden; Department of Surgery, Section of Interventional Radiology, Helsingborg Hospital, Helsingborg, Sweden
| | - Edmund Søvik
- Department of Radiology and Nuclear Medicine, St. Olavs University Hospital, Trondheim, Norway
| | - Martin Frendø
- Copenhagen Academy for Medical Education and Simulation (CAMES), Centre for Human Resources and Education, the Capital Region of Denmark; Department of Plastic and Reconstructive Surgery, Copenhagen University Hospital Herlev, Denmark
| | - Morten Bo Svendsen
- Copenhagen Academy for Medical Education and Simulation (CAMES), Centre for Human Resources and Education, the Capital Region of Denmark
| | - Lars Lönn
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark; Department of Radiology, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Lars Konge
- Copenhagen Academy for Medical Education and Simulation (CAMES), Centre for Human Resources and Education, the Capital Region of Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Lene Russell
- Copenhagen Academy for Medical Education and Simulation (CAMES), Centre for Human Resources and Education, the Capital Region of Denmark; Department of Anaesthesiology and Intensive Care, Copenhagen University Hospital Gentofte, Denmark
| | - Mikkel Taudorf
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark; Department of Radiology, Copenhagen University Hospital Rigshospitalet, Denmark
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Zante B. Impact of number of critical care procedural skill repetitions on supervision level and teaching style. PLoS One 2023; 18:e0280207. [PMID: 36689411 PMCID: PMC9870148 DOI: 10.1371/journal.pone.0280207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 12/22/2022] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND During critical care procedural skills training (e.g., in intubation and pericardiocentesis) the appropriate supervision level is important to ensure correct use of techniques and guarantee patient safety. The appropriate teaching style should be selected to address residents' learning behavior and foster their competence. The aim of this study was to explore the number of repetitions for given skills needed to achieve a specified supervision level and a specific teaching style. METHODS This cross-sectional multicenter survey obtained data from residents and faculty of three multidisciplinary intensive care units (ICU) in Switzerland. Using a 4-point Likert scale, participants were asked to indicate the number of repetitions required to achieve the specified supervision level and teaching style. RESULTS Among 91 physicians, the response rate was 64% (n = 59). Their median estimations of the numbers of skill repetitions needed to achieve the final fourth level of supervision and final fourth stage of teaching style were as follows: arterial catheter insertion: supervision level 32, teaching style 17.5; peritoneal paracentesis: supervision level 27, teaching style 17; central venous catheter insertion: supervision level 38, teaching style 28; lumbar puncture: supervision level 38, teaching style 21; endotracheal intubation: supervision level 100, teaching style 45; chest drain insertion: supervision level 27, teaching style 21.5; temporary pacemaker placement: supervision level 50, teaching style 19.5; percutaneous tracheostomy: supervision level 50, teaching style 29; pericardiocentesis: supervision level 50, teaching style 35. Comparison of repetitions between supervision level and teaching style revealed no difference at the first and second levels, except for endotracheal intubation at level 2 (p = 0.03). Differences were observed at the third and fourth levels of supervision level and teaching style (p≤0.04). CONCLUSIONS It appears that the supervision level and teaching style applied by faculty should change according to both the number of repetitions and the difficulty of critical care procedural skills.
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Affiliation(s)
- Bjoern Zante
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Sugiki D, Matsushima H, Asao T, Tokumine J, Lefor AK, Kamisasanuki T, Suzuki M, Gomei S. A web-based self-learning system for ultrasound-guided vascular access. Medicine (Baltimore) 2022; 101:e31292. [PMID: 36316890 PMCID: PMC9622633 DOI: 10.1097/md.0000000000031292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Ultrasound-guided vascular access is practiced widely. Optimal educational methods have not yet been established. We hypothesized that a step-by-step web-based learning system is effective for self-learning. In this study, we examined the potential of this system as a self-learning tool. This was an observational study at a single institution. Participants included residents, who were self-educated through the web-based system. Skill proficiency was measured after self-learning. The primary outcome was the extent to which self-learning enabled residents to acquire proficiency in the basic skills of ultrasound-guided vascular access: needle visualization, hand-eye coordination, and avoiding posterior wall penetration. A secondary outcome was the time required to achieve proficiency. Thirty-nine residents were enrolled in this study. Eleven residents (28%) passed the first skill assessment test. There was no significant difference in the number of days that the web-based system was accessed, the total number of screen views, or the total learning time between participants who passed and those who failed the first test. Skill assessment scores between those who passed and those who failed the first test were different, especially the score for hand-eye coordination, and the number of posterior wall penetrations. Self-learning with a web-based system enabled 28% of residents to pass the first skill assessment test. The remaining 72% failed the first skill assessment test but continued to learn using the web-based system and eventually passed the test. Hence, the web-based system needed formative testing to function as a self-learning system. Simulation education for vascular access is expected to increase in educational content and methods. Self-learning through a web-based learning system is a leading candidate for this growth.
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Affiliation(s)
- Daisuke Sugiki
- Emergency and Critical Care Center, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Hisao Matsushima
- Emergency and Critical Care Center, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Takayuki Asao
- Gunma University Center for Mathematics and Data Science, Gunma, Japan
| | - Joho Tokumine
- Department of Anesthesiology, Kyorin University School of Medicine, Tokyo, Japan
- *Correspondence: Joho Tokumine, Department of Anesthesiology, Kyorin University School of Medicine, 6-20-2 Sinkawa, Mitaka, Tokyo, Japan (e-mail: )
| | | | - Toshirou Kamisasanuki
- Emergency and Critical Care Center, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Mitsuhiro Suzuki
- Emergency and Critical Care Center, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Sayaka Gomei
- Emergency and Critical Care Center, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
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Effect of specific training course for competency in professional oral hygiene care in the intensive care unit: a quasi-experimental study for developing a standardized learning curve. BMC Anesthesiol 2022; 22:171. [PMID: 35650528 PMCID: PMC9158265 DOI: 10.1186/s12871-022-01709-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 05/26/2022] [Indexed: 11/20/2022] Open
Abstract
Background The development of evidence-based training standards can help improve the quality of educational programs for novice intensive care unit (ICU) nurses. This study was conducted to assess the application of a training course on competency development of nurses in relation to oral hygiene care in ICU patients and to develop a checklist for evaluating the competence performance. In addition, to achieve a certain level of oral hygiene competence, as well as to assess the relative importance of predicting factors and learning competency patterns in oral hygiene care, we used standard learning curve. Methods This quasi-experimental study with time series design was conducted on newly registered ICU nurses of a teaching hospital affiliated with Tehran University of Medical Sciences, Iran, between 2016 and 2018. In the first phase of this study, we designed a checklist to assess nurses' professional competence in oral hygiene care in three stages: before, during, and after care. Then, in the second phase, the level of competence of nurses in repeated times of oral hygiene care was determined based on checklist items and recorded in the learning curve. Results The greatest increase of oral hygiene care competency due to repetition was observed in the first and fourth times of repetition in comparison to the subsequent and previous steps. In the linear regression model, demographic variables predicted 12–19% of changes related to skill scores in repetitions. Conclusion According to the learning curve, newly registered ICU nurses can reach an acceptable competency after 6 repetitions of oral hygiene care.
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Advancing Point-of-Care Ultrasound Training in Medical Schools: Ultrasound-Guided Subclavian Vein Access Training Using Formalin-Embalmed Cadavers. Crit Care Explor 2022; 4:e0680. [PMID: 35492259 PMCID: PMC9042585 DOI: 10.1097/cce.0000000000000680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Groves L, Li N, Peters TM, Chen ECS. Towards a First-Person Perspective Mixed Reality Guidance System for Needle Interventions. J Imaging 2022; 8:jimaging8010007. [PMID: 35049848 PMCID: PMC8778355 DOI: 10.3390/jimaging8010007] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 12/20/2021] [Accepted: 12/24/2021] [Indexed: 12/23/2022] Open
Abstract
While ultrasound (US) guidance has been used during central venous catheterization to reduce complications, including the puncturing of arteries, the rate of such problems remains non-negligible. To further reduce complication rates, mixed-reality systems have been proposed as part of the user interface for such procedures. We demonstrate the use of a surgical navigation system that renders a calibrated US image, and the needle and its trajectory, in a common frame of reference. We compare the effectiveness of this system, whereby images are rendered on a planar monitor and within a head-mounted display (HMD), to the standard-of-care US-only approach, via a phantom-based user study that recruited 31 expert clinicians and 20 medical students. These users performed needle-insertions into a phantom under the three modes of visualization. The success rates were significantly improved under HMD-guidance as compared to US-guidance, for both expert clinicians (94% vs. 70%) and medical students (70% vs. 25%). Users more consistently positioned their needle closer to the center of the vessel’s lumen under HMD-guidance compared to US-guidance. The performance of the clinicians when interacting with this monitor system was comparable to using US-only guidance, with no significant difference being observed across any metrics. The results suggest that the use of an HMD to align the clinician’s visual and motor fields promotes successful needle guidance, highlighting the importance of continued HMD-guidance research.
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Affiliation(s)
- Leah Groves
- School of Biomedical Engineering, Western University, London, ON N6A 3K7, Canada; (N.L.); (T.M.P.); (E.C.S.C.)
- Correspondence:
| | - Natalie Li
- School of Biomedical Engineering, Western University, London, ON N6A 3K7, Canada; (N.L.); (T.M.P.); (E.C.S.C.)
| | - Terry M. Peters
- School of Biomedical Engineering, Western University, London, ON N6A 3K7, Canada; (N.L.); (T.M.P.); (E.C.S.C.)
- Robarts Research Institute, Western University, London, ON N6A 5K8, Canada
| | - Elvis C. S. Chen
- School of Biomedical Engineering, Western University, London, ON N6A 3K7, Canada; (N.L.); (T.M.P.); (E.C.S.C.)
- Robarts Research Institute, Western University, London, ON N6A 5K8, Canada
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Lazaar S, Mazaud A, Delsuc C, Durand M, Delwarde B, Debord S, Hengy B, Marcotte G, Floccard B, Dailler F, Chirossel P, Bureau-Du-Colombier P, Berthiller J, Rimmelé T. Ultrasound guidance for urgent arterial and venous catheterisation: randomised controlled study. Br J Anaesth 2021; 127:871-878. [PMID: 34503827 DOI: 10.1016/j.bja.2021.07.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 06/02/2021] [Accepted: 07/08/2021] [Indexed: 10/20/2022] Open
Abstract
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.
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Affiliation(s)
- Stephen Lazaar
- Hospices Civils de Lyon, Department of Anesthesiology and Intensive Care Medicine, Edouard Herriot Hospital, Lyon, France.
| | - Amélie Mazaud
- Hospices Civils de Lyon, Department of Anesthesiology and Intensive Care Medicine, Edouard Herriot Hospital, Lyon, France
| | - Claire Delsuc
- Hospices Civils de Lyon, Department of Anesthesiology and Intensive Care Medicine, Edouard Herriot Hospital, Lyon, France
| | - Maeva Durand
- Hospices Civils de Lyon, Department of Anesthesiology and Intensive Care Medicine, Edouard Herriot Hospital, Lyon, France
| | - Benjamin Delwarde
- Hospices Civils de Lyon, Department of Anesthesiology and Intensive Care Medicine, Edouard Herriot Hospital, Lyon, France
| | - Sophie Debord
- Hospices Civils de Lyon, Department of Anesthesiology and Intensive Care Medicine, Edouard Herriot Hospital, Lyon, France
| | - Baptiste Hengy
- Hospices Civils de Lyon, Department of Anesthesiology and Intensive Care Medicine, Edouard Herriot Hospital, Lyon, France
| | - Guillaume Marcotte
- Hospices Civils de Lyon, Department of Anesthesiology and Intensive Care Medicine, Edouard Herriot Hospital, Lyon, France
| | - Bernard Floccard
- Hospices Civils de Lyon, Department of Anesthesiology and Intensive Care Medicine, Edouard Herriot Hospital, Lyon, France
| | - Frédéric Dailler
- Hospices Civils de Lyon, Department of Anesthesiology and Intensive Care Medicine, Pierre Wertheimer Hospital, Lyon, France
| | - Pierre Chirossel
- Hospices Civils de Lyon, Department of Vascular Explorations, Louis Pradel Hospital, Lyon, France
| | | | - Julien Berthiller
- Hospices Civils de Lyon, Epidemiology, Pharmacology and Clinical Investigations, Lyon, France
| | - Thomas Rimmelé
- Hospices Civils de Lyon, Department of Anesthesiology and Intensive Care Medicine, Edouard Herriot Hospital, Lyon, France; EA7426 Pathophysiology of Injury-Induced Immunosuppression, PI3, Hospices Civils de Lyon-Biomérieux-University Claude Bernard Lyon 1, Lyon, France
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Zante B, Klasen JM. Learner-centered education: ICU residents' expectations of teaching style and supervision level. BMC MEDICAL EDUCATION 2021; 21:411. [PMID: 34330260 PMCID: PMC8325219 DOI: 10.1186/s12909-021-02844-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 07/12/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND If the education of intensive care unit (ICU) residents focuses on individual learning behavior, the faculty's style of teaching and level of supervision need to be adapted accordingly. The aim of this study was to delineate the associations between residents' perceived learning behavior, experience, and demographics and their expectations with regard to teaching style and supervision levels. METHODS This multicenter survey obtained data on ICU residents' base specialty, duration of ICU training, individual postgraduate year, gender, and number of repetitions of ICU skills. Using 4-point Likert scales, residents assessed perceived learning behavior, expected teaching style, and supervision level for respective skills. Multivariate regression analysis was used to evaluate associations between assessed variables. RESULTS Among 109 residents of four interdisciplinary ICUs, 63 (58%) participated in the survey and 95% (60/63) questionnaires were completed. The residents' perceived learning behavior was associated with number of skill repetitions (p < 0.0001), internal medicine as base specialty (p = 0.02), and skill type (p < 0.0001). Their expected teaching style was associated with learning behavior (p < 0.0001) and skill type (p < 0.0001). Their expected supervision level was associated with skill repetitions (p < 0.0001) and skill type (p < 0.0001). CONCLUSION For effective learner-centered education, it appears useful to recognize how the residents' learning behavior is affected by the number of skill repetitions and the skill type. Hence, faculty may wish to take into account the residents' learning behavior, driven mainly by skill complexity and the number of skill repetitions, to deliver the appropriate teaching style and supervision level.
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Affiliation(s)
- Bjoern Zante
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 10, 3010, Bern, Switzerland.
| | - Jennifer M Klasen
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, University Hospital Basel, Basel, Switzerland
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On the Challenges of Anesthesia and Surgery during Interplanetary Spaceflight. Anesthesiology 2021; 135:155-163. [PMID: 33940633 DOI: 10.1097/aln.0000000000003789] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Confirmatory radiographs have limited utility following ultrasound-guided tunneled femoral central venous catheter placements by interventional radiology. Pediatr Radiol 2021; 51:1253-1258. [PMID: 33544192 DOI: 10.1007/s00247-020-04957-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 11/23/2020] [Accepted: 12/20/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Ultrasonography may reliably visualize both appropriately positioned and malpositioned femoral-approach catheter tips. Radiography may be used to confirm catheter tip position after placement, but its utility following intraprocedural ultrasound (US) catheter tip verification is unclear. OBJECTIVES To report the utility of confirmatory radiographs after US-guided tunneled femoral central venous catheter (CVC) placements by interventional radiology in pediatric patients. MATERIALS AND METHODS A total of 484 pediatric patients underwent bedside US-guided tunneled femoral CVC placements in an intensive care setting at a single tertiary children's hospital between Jan. 1, 2016, and April 20, 2020. Technical success, adverse events, post-procedure radiographic practices and inter-modality catheter tip concordance were recorded. All radiographs were performed within 12 h of catheter placement. RESULTS The mean patient age was 175±508 days (range: 1 day to 19 years), including 257 (53.1%) males and 227 (46.9%) females. Of the 484 attempted placements, 472 (97.5%) were primary placements. Four hundred eighty-one (99.4%) placements were technically successful. There were three (0.6%) technical failures due to previously undiagnosed iliofemoral venous occlusive disease. Five (1.0%) adverse events occurred. Radiographs were obtained within 12 h of CVC placement in 171 (35.3%) patients, in 120 (70.2%) of whom the indication was recent catheter placement. All 171 (100%) post-placement radiographs showed catheter tip location concordance with the intra-procedural US. In one (0.2%) patient, in whom there was nonvisualization of a guidewire and clinical concern for malposition during US-guided placement, post-procedure radiographs, coupled with multiplanar venography, demonstrated inadvertent paravertebral venous plexus catheter placement. CONCLUSION The concordance between intra-procedural US and confirmatory post-procedure radiographs of CVC placements by interventional radiology obviates the need for routine radiographs. Radiographs may be obtained in instances of proceduralist uncertainty or clinical concern.
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Impact of Videolaryngoscopy Expertise on First-Attempt Intubation Success in Critically Ill Patients. Crit Care Med 2021; 48:e889-e896. [PMID: 32769622 DOI: 10.1097/ccm.0000000000004497] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVES The use of a videolaryngoscope in the ICU on the first endotracheal intubation attempt and intubation-related complications is controversial. The objective of this study was to evaluate the first intubation attempt success rate in the ICU with the McGrath MAC videolaryngoscope (Medtronic, Minneapolis, MN) according to the operators' videolaryngoscope expertise and to describe its association with the occurrence of intubation-related complications. DESIGN Observational study. SETTING Medical ICU. SUBJECTS Consecutive endotracheal intubations in critically ill patients. INTERVENTIONS Systematic use of the videolaryngoscope. MEASUREMENTS AND MAIN OUTCOMES We enrolled 202 consecutive endotracheal intubations. Overall first-attempt success rate was 126 of 202 (62%). Comorbidities, junior operator, cardiac arrest upon admission, and coma were associated with a lower first-attempt success rate. The first-attempt success rate was less than 50% in novice operators (1-5 previous experiences with videolaryngoscope, independently of airway expertise with direct laryngoscopies) and 87% in expert operators (> 15 previous experiences with videolaryngoscope). Multivariate analysis confirmed the association between specific skill training with videolaryngoscope and the first-attempt success rate. Severe hypoxemia and overall immediate intubation-related complications occurred more frequently in first-attempt failure intubations (24/76, 32%) than in first-attempt success intubations (14/126, 11%) (p < 0.001). CONCLUSIONS We report for the first time in the critically ill that specific videolaryngoscopy skill training, assessed by the number of previous videolaryngoscopies performed, is an independent factor of first-attempt intubation success. Furthermore, we observed that specific skill training with the McGrath MAC videolaryngoscope was fast. Therefore, future trials evaluating videolaryngoscopy in ICUs should consider the specific skill training of operators in videolaryngoscopy.
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Yoon HK, Hur M, Cho H, Jeong YH, Lee HJ, Yang SM, Kim WH. Effects of practitioner's experience on the clinical performance of ultrasound-guided central venous catheterization: a randomized trial. Sci Rep 2021; 11:6726. [PMID: 33762662 PMCID: PMC7991409 DOI: 10.1038/s41598-021-86322-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 03/12/2021] [Indexed: 11/09/2022] Open
Abstract
We investigated whether two needle insertion techniques for ultrasound-guided internal jugular vein (IJV) catheterization differ in the number of needling attempts and complication rate between inexperienced and experienced practitioners. A total of 308 patients requiring IJV catheterization were randomly assigned into one of four groups: IJV catheterization performed by inexperienced practitioners using either Seldinger (IE-S; n = 78) or modified Seldinger technique (IE-MS; n = 76) or IJV catheterization performed by experienced practitioners using either Seldinger (E-S; n = 78) or modified Seldinger technique (E-MS; n = 76). All catheterizations were performed under the real-time ultrasound guidance. The number of needling attempts was not significantly different between the two techniques within each experience group (between IE-S vs. IE-MS P = 0.550, between E-S and E-MS P = 0.834). Time to successful catheterization was significantly shorter in the E-S group compared to E-MS group (P < 0.001) while no significant difference between IE-S and IE-MS groups (P = 0.226). Complication rate was not significantly different between the two techniques within each experience group. Practitioner's experience did not significantly affect the clinical performance of needle insertion techniques during ultrasound-guided IJV catheterization except the time to successful catheterization. Regarding the number of needling attempts and complication rate, both techniques could be equally recommended regardless of practitioner's experience.Trial registration: clinicaltrials.gov (https://clinicaltrials.gov/ct2/show/NCT03077802).
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Affiliation(s)
- Hyun-Kyu Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Min Hur
- Department of Anesthesiology and Pain Medicine, School of Medicine, Ajou University, Suwon, Republic of Korea
| | - Hyeyeon Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Young Hyun Jeong
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Ho-Jin Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Seong-Mi Yang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Won Ho Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
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Vinayagamurugan A, Badhe AS, Jha AK. Comparison of external jugular vein-based surface landmark approach and ultrasound-guided approach for internal jugular venous cannulation: A randomised crossover clinical trial. Int J Clin Pract 2021; 75:e13783. [PMID: 33095965 DOI: 10.1111/ijcp.13783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 10/19/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Historically, landmark techniques for central venous access through the internal jugular vein (IJV) have yielded a lesser success rate and higher complication rate than the ultrasound (US)-guided approach. The purpose of this study is to assess the success and safety of a novel external jugular vein (EJV)-based landmark (EJV-LM) approach compared with the real-time US-guided approach for central venous access through the IJV. METHODS This was a prospective, randomised, crossover trial performed in patients during elective cardiac and non-cardiac surgery. Each resident randomly inserted a central venous catheter using EJV-LM approach and real-time US-guided approach. The primary outcome was first-attempt success. Secondary outcomes included overall success rate, number of puncture attempts, cannulation time, haematoma and mechanical complications. RESULTS A total of 188 patients were randomly assigned to the EJV-LM and US groups. The demographic characteristics of the groups were comparable. The first-attempt success was not different between EJV-LM and US-guided techniques (79.8%; [95% CI: 70.2-87.4] vs 89.4% [95% CI 81.3-94.8]; P = .06). The overall success rate was 100% with both techniques. There were no differences in the number of puncture attempts with introducer needle (1[1-3] vs 1[1-2]; P = .07). Cannulation time was longer in the EJV-LM group compared with the US group (58.11 ± 6.6 vs 44.27 ± 5.28 seconds; P = .0001). EJV-LM technique was associated with a higher occurrence of overall complications compared with the US technique (12.8% [95% CI: 6.7- 21.2] vs 4.2% [95% CI: 1.1-10.5]; P = .03). No major mechanical complications were observed with either techniques. CONCLUSIONS In patients with non-distorted neck anatomy and a visible EJV, IJV catheterisation using the EJV-based LM approach and standard US-guided technique yielded similar first-attempt and overall success rates. Cannulation time was longer and complications occurred more frequently in the EJV-based LM compared with the standard US-guided technique.
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Affiliation(s)
- Arunagiri Vinayagamurugan
- Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Ashok Shankar Badhe
- Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Ajay Kumar Jha
- Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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Effect of the Specific Training Course for Competency in Doing Arterial Blood Gas Sampling in the Intensive Care Unit: Developing a Standardized Learning Curve according to the Procedure's Time and Socioprofessional Predictors. BIOMED RESEARCH INTERNATIONAL 2021; 2021:2989213. [PMID: 33628776 PMCID: PMC7899780 DOI: 10.1155/2021/2989213] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 01/13/2021] [Accepted: 01/27/2021] [Indexed: 11/18/2022]
Abstract
Background Standardization of clinical practices is an essential part of continuing education of newly registered nurses in the intensive care unit (ICU). The development of educational standards based on evidence can help improve the quality of educational programs and ultimately clinical skills and practices. Objectives The objectives of the study were to develop a standardized learning curve of arterial blood gas (ABG) sampling competency, to design a checklist for the assessment of competency, to assess the relative importance of predictors and learning patterns of competency, and to determine how many times it is essential to reach a specific level of ABG sampling competency according to the learning curve. Design A quasi-experimental, nonrandomized, single-group trial with time series design. Participants. All newly registered nurses in the ICU of a teaching hospital of Tehran University of Medical Sciences were selected from July 2016 to April 2018. Altogether, 65 nurses participated in the study; however, at the end, only nine nurses had dropped out due to shift displacement. Methods At first, the primary checklist was prepared to assess the nurses' ABG sampling practices and it was finalized after three sessions of the expert panel. The checklist had three domains, including presampling, during sampling, and postsampling of ABG competency. Then, 56 nurses practiced ABG sampling step by step under the supervision of three observers who controlled the processes and they filled the checklists. The endpoint was considered reaching a 95 score on the learning curve. The Poisson regression model was used in order to verify the effective factors of ABG sampling competency. The importance of variables in the prediction of practice scores had been calculated in a linear regression of R software by using the relaimpo package. Results According to the results, in order to reach a skill level of 55, 65, 75, 85, and 95, nurses, respectively, would need average ABG practice times of 6, 6, 7, 7, and 7. In the linear regression model, demographic variables predict 47.65 percent of changes related to scores in practices but the extent of prediction of these variables totally decreased till 7 practice times, and in each practice, nurses who had the higher primary skill levels gained 1 to 2 skill scores more than those with low primary skills. Conclusions Utilization of the learning curve could be helpful in the standardization of clinical practices in nursing training and optimization of the frequency of skills training, thus improving the training quality in this field. This trial is registered with NCT02830971.
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Woerner A, Wenger JL, Monroe EJ. Single-access ultrasound-guided tunneled femoral lines in critically ill pediatric patients. J Vasc Access 2020; 21:1034-1041. [PMID: 32538296 DOI: 10.1177/1129729820933527] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Central venous access is an essential aspect of critical care for pediatric patients. In the critically ill pediatric population, image-guided procedures performed at the bedside expedite care and may reduce risks and logistical challenges associated with patient transport to a remote procedure suite such as interventional radiology. We describe our institutional technique for ultrasound-guided tunneled femoral venous access in neonates and infants and provide technical pearls from our experience, with an intended audience including specialists performing point-of-care ultrasound-guided procedures as well as interventional radiologist making their services available in the intensive care unit.
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Affiliation(s)
- Andrew Woerner
- Division of Interventional Radiology, Seattle Children's Hospital and University of Washington, Seattle, WA, USA
| | - Jesse L Wenger
- Division of Pediatric Critical Care Medicine, Seattle Children's Hospital and University of Washington, Seattle, WA, USA
| | - Eric J Monroe
- Division of Interventional Radiology, Seattle Children's Hospital and University of Washington, Seattle, WA, USA
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de la Fuente R, Fuentes R, Munoz-Gama J, Dagnino J, Sepúlveda M. Delphi Method to Achieve Clinical Consensus for a BPMN Representation of the Central Venous Access Placement for Training Purposes. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17113889. [PMID: 32486300 PMCID: PMC7312914 DOI: 10.3390/ijerph17113889] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/25/2020] [Accepted: 05/26/2020] [Indexed: 12/31/2022]
Abstract
Proper teaching of the technical skills necessary to perform a medical procedure begins with its breakdown into its constituent steps. Currently available methodologies require substantial resources and their results may be biased. Therefore, it is difficult to generate the necessary breakdown capable of supporting a procedural curriculum. The aim of our work was to breakdown the steps required for ultrasound guided Central Venous Catheter (CVC) placement and represent this procedure graphically using the standard BPMN notation. Methods: We performed the first breakdown based on the activities defined in validated evaluation checklists, which were then graphically represented in BPMN. In order to establish clinical consensus, we used the Delphi method by conducting an online survey in which experts were asked to score the suitability of the proposed activities and eventually propose new activities. Results: Surveys were answered by 13 experts from three medical specialties and eight different institutions in two rounds. The final model included 28 activities proposed in the initial model and four new activities proposed by the experts; seven activities from the initial model were excluded. Conclusions: The proposed methodology proved to be simple and effective, generating a graphic representation to represent activities, decision points, and alternative paths. This approach is complementary to more classical representations for the development of a solid knowledge base that allows the standardization of medical procedures for teaching purposes.
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Affiliation(s)
- Rene de la Fuente
- Department of Anesthesiology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago 8331150, Chile; (R.d.l.F.); (J.D.)
| | - Ricardo Fuentes
- Department of Anesthesiology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago 8331150, Chile; (R.d.l.F.); (J.D.)
- Correspondence:
| | - Jorge Munoz-Gama
- Department of Computer Science, School of Engineering, Pontificia Universidad Católica de Chile, Santiago 7820436, Chile; (J.M.-G.); (M.S.)
| | - Jorge Dagnino
- Department of Anesthesiology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago 8331150, Chile; (R.d.l.F.); (J.D.)
| | - Marcos Sepúlveda
- Department of Computer Science, School of Engineering, Pontificia Universidad Católica de Chile, Santiago 7820436, Chile; (J.M.-G.); (M.S.)
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Hamaba H, Miyata Y, Wada T, Hayasaka T, Hayashi Y. An analysis of prior experience influencing quality of pulmonary artery catheter placement in residents. Ann Card Anaesth 2020; 23:161-164. [PMID: 32275029 PMCID: PMC7336959 DOI: 10.4103/aca.aca_220_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: Prior experience may be important for successful placement of a pulmonary artery catheter (PAC). However, there is no report about the minimum number of the placement to reach acceptable technique for the catheter placement during residency. Aims: This study was designed to examine quality of the catheter placement and to assess the effect of prior experience. Setting and Design: Prospective, observational, cohort study. Methods: This study included eight residents and one experienced staff in our hospital. We prospectively examined the performance of placement of a PAC in eight residents for the first 2 months of their training period and one staff for previous 2 years. We examined the time required for the catheter placement and probability of ventricular arrhythmias during the placement. Each resident and the staff reported approximate number of past experience of the catheter placement according to the self-statement. In addition, we continued to examine the placement of a PAC in one resident with zero experience to show his improvement. Statistical Analysis: Statistical analysis was performed by Kruskal–Wallis test, Mann–Whitney test, or Fisher's exact test as appropriate and Benjamini and Hochberg method was used for multiple comparisons. Results: The catheter placement time and probability of the ventricular arrhythmias of two residents with zero experience of the placement were significantly larger than those of the staff. On the other hand, the placement quality of the other residents who experienced at least 20 PAC placements was not significantly different from that of the staff. The placement quality of one resident with zero experience became comparable with that of the staff after 20 placements. Conclusion: Our data suggested that about 20 catheter placements may be required to reach acceptable technical level for the PAC placement.
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Affiliation(s)
- Hirofumi Hamaba
- Department of Anesthesia and Intensive Care, Sakurabashi-Watanabe Hospital, 2-4-32 Umeda, Kita-ku,Osaka, Japan
| | - Yuka Miyata
- Department of Anesthesia and Intensive Care, Sakurabashi-Watanabe Hospital, 2-4-32 Umeda, Kita-ku,Osaka, Japan
| | - Tsutomu Wada
- Department of Anesthesia and Intensive Care, Sakurabashi-Watanabe Hospital, 2-4-32 Umeda, Kita-ku,Osaka, Japan
| | - Tomohiko Hayasaka
- Department of Anesthesia and Intensive Care, Sakurabashi-Watanabe Hospital, 2-4-32 Umeda, Kita-ku,Osaka, Japan
| | - Yukio Hayashi
- Department of Anesthesia and Intensive Care, Sakurabashi-Watanabe Hospital, 2-4-32 Umeda, Kita-ku,Osaka, Japan
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Kaae R, Kyng KJ, Frederiksen CA, Sloth E, Rosthøj S, Kerrn-Jespersen S, Eika B, Sørensen JL, Henriksen TB. Learning Curves for Training in Ultrasonography-Based Examination of Umbilical Catheter Placement: A Piglet Study. Neonatology 2020; 117:144-150. [PMID: 31661695 DOI: 10.1159/000503176] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 09/05/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND The training required for accurate assessment of umbilical catheter placement by ultrasonography (US) is unknown. OBJECTIVE To describe the learning curve and provide an estimate of the accuracy of physicians' US examinations (US skills) and self-confidence when examining umbilical catheter tip placement. METHODS Twenty-one physicians with minimal experience in US completed a 1.5-hour eLearning module. Ten piglets with catheters inserted in the umbilical vessels were used as training objects. Following eLearning each physician performed up to twelve 10-min US examinations of the piglets. Expert examinations were reference standards. Sensitivity and specificity of physicians' skills in detecting catheter tip placement by US was used to describe the learning curve. Self-confidence was reported by Likert scale after each examination. RESULTS Physicians' detection of a correctly placed and misplaced umbilical artery catheter tip increased by an odds ratio of 1.6 (95% CI: 1.1, 2.3) and 3.6 (95% CI: 1.7, 7.8) per examination performed. A sensitivity of 0.97 (95% CI: 0.80, 0.99) and specificity of 0.95 (95% CI: 0.84, 0.99) was reached after 6 examinations. For the venous catheter, US skills in detecting a misplaced catheter tip increased with an odds ratio of 2.4 (95% CI: 1.2, 4.8) per US examination. Overall, performance and self-confidence plateaus were reached after 6 examinations. CONCLUSION We found steep learning curves for targeted US examination of umbilical catheter placement. eLearning followed by 6 examinations was found to be adequate training to perform with a sufficiently high accuracy and self-confidence to allow for point-of-care use.
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Affiliation(s)
- Rikke Kaae
- Division of Neonatology, Department of Child and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark,
| | - Kasper Jacobsen Kyng
- Division of Neonatology, Department of Child and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | | | - Susanne Rosthøj
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Sigrid Kerrn-Jespersen
- Division of Neonatology, Department of Child and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Berit Eika
- Rector's Office, Aarhus University, Aarhus, Denmark
| | - Jette Led Sørensen
- Juliane Marie Centre for Children, Women and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Tine Brink Henriksen
- Division of Neonatology, Department of Child and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
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Imataki O, Shimatani M, Ohue Y, Uemura M. Effect of ultrasound-guided central venous catheter insertion on the incidence of catheter-related bloodstream infections and mechanical complications. BMC Infect Dis 2019; 19:857. [PMID: 31619174 PMCID: PMC6796423 DOI: 10.1186/s12879-019-4487-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 09/20/2019] [Indexed: 01/06/2023] Open
Abstract
Background Central venous catheters (CVCs) are necessary for critically ill patients, including those with hematological malignancies. However, CVC insertion is associated with inevitable risks for various adverse events. Whether ultrasound guidance decreases the risk of catheter-related infection remains unclear. Methods We observed 395 consecutive CVC insertions between April 2009 and January 2013 in our hematological oncology unit. Because the routine use of ultrasound guidance upon CVC insertion was adopted based on our hospital guidelines implemented after 2012, the research period was divided into before December 2011 (early term) and after January 2012 (late term). Results Underlying diseases included hematological malignancies and immunological disorders. In total, 235 and 160 cases were included in the early- and late term groups, respectively. The median insertion duration was 26 days (range, 2–126 days) and 18 days (range, 2–104 days) in the early- and late term groups, respectively. The internal jugular, subclavian, and femoral veins were the sites of 22.6, 40.2, and 25.7% of the insertions in the early term group and 32.3, 16.9, and 25.4% of the insertions in the late term group, respectively. The frequency of catheter-related bloodstream infection (CRBSI) was 1.98/1000 catheter days and 2.17/1000 catheter days in the early- and late term groups, respectively. In the subgroup analysis, the detected causative pathogens of CRBSI did not differ between the two term groups; gram-positive cocci, gram-positive bacilli, and gram-negative bacilli were the causative pathogens in 68.9, 11.5, and 14.8% of the cases in the early term group and in 68.2, 11.4, and 18.2% of the cases in the late term group, respectively. In the multivariate analysis to determine the risk of CRBSI, only age was detected as an independent contributing factor; the indwelling catheter duration was detected as a marginal factor. A significant reduction in mechanical complications was associated with the use of ultrasound guidance. Conclusions Ultrasound-guided CVC insertion did not decrease the incidence of CRBSI. The only identified risk factor for CRBSI was age in our cohort. However, we found that the introduction of ultrasound-guided insertion triggered an overall change in safety management with or without the physicians’ intent.
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Affiliation(s)
- Osamu Imataki
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-town, Kita-county, Kagawa, 761-0793, Japan.
| | - Mami Shimatani
- Nursing Division, Kagawa University Hospital, Kagawa, Japan
| | - Yukiko Ohue
- Nursing Division, Kagawa University Hospital, Kagawa, Japan
| | - Makiko Uemura
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-town, Kita-county, Kagawa, 761-0793, Japan
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Leibowitz A, Oren-Grinberg A, Matyal R. Ultrasound Guidance for Central Venous Access: Current Evidence and Clinical Recommendations. J Intensive Care Med 2019; 35:303-321. [PMID: 31387439 DOI: 10.1177/0885066619868164] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Ultrasound-guided central line placement has been shown to decrease the number of needle puncture attempts, complication, and failure rates. In order to obtain successful central access, it is important to have adequate cognitive knowledge, workflow understanding, and manual dexterity to safely execute this invasive procedure. The operator should also be familiar with the anatomical variations, equipment operations, and potential complications and their prevention. In this article, we present a detailed review of ultrasound-guided central venous access. It includes a description of anatomy, operative technique, equipment operation, and techniques for specific situations. We describe the use of ultrasound guidance to avoid and identify various complications associated with this procedure. We have also reviewed recent recommendations and guidelines for the use of ultrasound for central venous access and the current evidence pertaining to the recommendations for the expected level of training, methodology, and metrics for establishing competency.
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Affiliation(s)
- Akiva Leibowitz
- Department of Anesthesia and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Achikam Oren-Grinberg
- Department of Anesthesia and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Robina Matyal
- Department of Anesthesia and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Chew SC, Beh ZY, Hakumat Rai VR, Jamaluddin MF, Ng CC, Chinna K, Hasan MS. Ultrasound-guided central venous vascular access-novel needle navigation technology compared with conventional method: A randomized study. J Vasc Access 2019; 21:26-32. [PMID: 31148509 DOI: 10.1177/1129729819852057] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Central venous catheter insertion is a common procedure in the intensive care setting. However, complications persist despite real-time ultrasound guidance. Recent innovation in needle navigation technology using guided positioning system enables the clinician to visualize the needle's real-time position and trajectory as it approaches the target. We hypothesized that the guided positioning system would improve performance time in central venous catheter insertion. METHODS A prospective randomized study was conducted in a single-center adult intensive care unit. In total, 100 patients were randomized into two groups. These patients underwent internal jugular vein central venous catheter cannulation with ultrasound guidance (short-axis scan, out-of-plane needling approach) in which one group adopted conventional method, while the other group was aided with the guided positioning system. Outcomes were measured by procedural efficacy (success rate, number of attempts, time to successful cannulation), complications, level of operators' experience, and their satisfaction. RESULTS All patients had successful cannulation on the first attempt except for one case in the conventional group. The median performance time for the guided positioning system method was longer (25.5 vs 15.5 s; p = 0.01). And 86% of the operators had more than 3-year experience in anesthesia. One post-insertion hematoma occurred in the conventional group. Only 88% of the operators using the guided positioning system method were satisfied compared to 100% in the conventional group. CONCLUSION Ultrasound-guided central venous catheter insertion via internal jugular vein was a safe procedure in both conventional and guided positioning system methods. The guided positioning system did not confer additional benefit but was associated with slower performance time and lower satisfaction level among the experienced operators.
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Affiliation(s)
- Sou Chen Chew
- Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Zhi Yuen Beh
- Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Vineya Rai Hakumat Rai
- Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Ching Choe Ng
- Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Karuthan Chinna
- Department of Social and Preventive Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - M Shahnaz Hasan
- Department of Anesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Can Haptic Simulators Distinguish Expert Performance? A Case Study in Central Venous Catheterization in Surgical Education. Simul Healthc 2019; 14:35-42. [PMID: 30601466 DOI: 10.1097/sih.0000000000000352] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION High-tech simulators are gaining popularity in surgical training programs because of their potential for improving clinical outcomes. However, most simulators are static in nature and only represent a single anatomical patient configuration. The Dynamic Haptic Robotic Training (DHRT) system was developed to simulate these diverse patient anatomies during Central Venous Catheterization (CVC) training. This article explores the use of the DHRT system to evaluate objective metrics for CVC insertion by comparing the performance of experts and novices. METHODS Eleven expert surgeons and 13 first-year surgical residents (novices) performed multiple needle insertion trials on the DHRT system. Differences between expert and novice performance on the following five metrics were assessed using a multivariate analysis of variance: path length, standard deviation of deviations (SDoD), average velocity, distance to the center of the vessel, and time to complete (TtC) the needle insertion. A regression analysis was performed to identify if expertise could be predicted using these metrics. Then, a curve fit was conducted to identify whether learning curves were present for experts or novices on any of these five metrics. RESULTS Time to complete the insertion and SDoD of the needle tip from an ideal path were significantly different between experts and novices. Learning curves were not present for experts but indicated a significant decrease in path length and TtC for novices. CONCLUSIONS The DHRT system was able to identify significant differences in TtC and SDoD between experts and novices during CVC needle insertion procedures. In addition, novices were shown to improve their skills through DHRT training.
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Mullaney P. Qualitative ultrasound training: defining the learning curve. Clin Radiol 2019; 74:327.e7-327.e19. [DOI: 10.1016/j.crad.2018.12.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 12/24/2018] [Indexed: 12/01/2022]
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Ultrasound-guided vascular access in critical illness. Intensive Care Med 2019; 45:434-446. [PMID: 30778648 DOI: 10.1007/s00134-019-05564-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 02/04/2019] [Indexed: 10/27/2022]
Abstract
Over the past two decades, ultrasound (US) has become widely accepted to guide safe and accurate insertion of vascular devices in critically ill patients. We emphasize central venous catheter insertion, given its broad application in critically ill patients, but also review the use of US for accessing peripheral veins, arteries, the medullary canal, and vessels for institution of extracorporeal life support. To ensure procedural safety and high cannulation success rates we recommend using a systematic protocolized approach for US-guided vascular access in elective clinical situations. A standardized approach minimizes variability in clinical practice, provides a framework for education and training, facilitates implementation, and enables quality analysis. This review will address the state of US-guided vascular access, including current practice and future directions.
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Sun C, Lv B, Zheng W, Hu L, Ouyang X, Hu B, Zhang Y, Wang H, Ye H, Zhang X, Lan H, Chen L, Chen C. The learning curve in blind bedside postpyloric placement of spiral tubes: data from a multicentre, prospective observational study. J Int Med Res 2019; 47:1884-1896. [PMID: 30747017 PMCID: PMC6567746 DOI: 10.1177/0300060519826830] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Objective This study sought to quantify the learning curve for the blind bedside postpyloric placement of a spiral tube in critically ill patients. Methods We retrospectively analysed 127 consecutive experiences of three intensivists who performed comparable procedures of blind bedside postpyloric placement of a spiral tube subsequent to failed self-propelled transpyloric migration in a multicentre study. Each intensivist’s cases were divided chronologically into two groups for analysis. The assessment of the learning curve was based on efficiency and safety outcomes. Results All intensivists achieved postpyloric placement for over 80% of their patients. The junior intensivist showed major improvement in both efficiency and safety outcomes, and the learning curve for both outcomes was approximately 20 cases. The junior intensivist showed a significant increase in the success rate of proximal jejunum placement and demonstrated a substantial decrease in the major adverse tube-associated events rate. The time to insertion significantly decreased in each intensivist as case experience accumulated. Conclusions Blind bedside postpyloric placement of a spiral tube involves a significant learning curve, indicating that this technique could be readily acquired by intensivists with no previous experience using an adequate professional training programme.
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Affiliation(s)
- Cheng Sun
- 1 Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China
| | - Bo Lv
- 1 Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China
| | - Wei Zheng
- 3 Department of Emergency, Longgang District Central Hospital, Shenzhen, Guangdong Province, China
| | - Linhui Hu
- 4 Department of Critical Care Medicine, The People's Hospital of Gaozhou, Gaozhou, Guangdong Province, China.,5 School of Medicine, South China University of Technology, Guangzhou Higher Education Mega Center, Guangzhou, Guangdong Province, China
| | - Xin Ouyang
- 2 Department of Intensive Care Unit of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China.,5 School of Medicine, South China University of Technology, Guangzhou Higher Education Mega Center, Guangzhou, Guangdong Province, China
| | - Bei Hu
- 1 Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China
| | - Yanlin Zhang
- 6 Department of Critical Care Medicine, Xinjiang Kashgar Region's First People's Hospital, Kashgar Region, Xinjiang Uygur Autonomous Region, China
| | - Hao Wang
- 6 Department of Critical Care Medicine, Xinjiang Kashgar Region's First People's Hospital, Kashgar Region, Xinjiang Uygur Autonomous Region, China
| | - Heng Ye
- 7 Department of Critical Care Medicine, Guangzhou Nansha Central Hospital, Guangzhou, Guangdong Province, China
| | - Xiunong Zhang
- 1 Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China
| | - Huilan Lan
- 1 Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China
| | - Lifang Chen
- 1 Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China
| | - Chunbo Chen
- 1 Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China.,2 Department of Intensive Care Unit of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong Province, China
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Pazeli JM, Vieira ALS, Vicentino RS, Pazeli LJ, Lemos BC, Saliba MMR, Mello PA, Costa MD. Point-of-care ultrasound evaluation and puncture simulation of the internal jugular vein by medical students. Crit Ultrasound J 2018; 10:34. [PMID: 30564947 PMCID: PMC6298909 DOI: 10.1186/s13089-018-0115-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 11/22/2018] [Indexed: 12/12/2022] Open
Abstract
Objectives To show that medical students can evaluate the internal jugular vein (IJV) and its anatomical variations after rapid and focused training. We also aimed to evaluate the success rate of IJV puncture in simulation following traditional techniques (TTs) and monitored via ultrasound (US). Materials and methods Six medical students without experience with US were given 4 h of theoretical–practical training in US, and then evaluated the IJV and common carotid artery (CCA) of 105 patients. They also simulated a puncture of the IJV at a demarcated point, where a TT was theoretically performed. Results Adequate images were obtained from 95% of the patients; the IJV, on the right side, was more commonly found in the anterolateral position in relation to the CCA (38%). On the left side, the most commonly position observed was the anterior (36%). The caliber of the IJV relative to the CCA greatly varied. The success rate in the IJV puncture simulation, observed with US, by the TTs was 55%. Conclusion The training of medical students to recognize large neck vessels is a simple, quick, and feasible task and that can be integrated into the undergraduate medical curriculum.
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Affiliation(s)
- José Muniz Pazeli
- FAME - Barbacena's School of Medicina, Barbacena, Brazil. .,Federal University of Juiz de Fora, Juiz de Fora, Brazil.
| | - Ana Luisa Silveira Vieira
- FAME - Barbacena's School of Medicina, Barbacena, Brazil.,Federal University of Juiz de Fora, Juiz de Fora, Brazil
| | | | - Luisa Jabour Pazeli
- SUPREMA - School of Medical Sciences and Health of Juiz de Fora, Juiz de Fora, Brazil
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Hundley DM, Brooks AC, Thomovsky EJ, Johnson PA, Freeman LJ, Schafbuch RM, Heng HG, Moore GE. Comparison of ultrasound-guided and landmark-based techniques for central venous catheterization via the external jugular vein in healthy anesthetized dogs. Am J Vet Res 2018; 79:628-636. [PMID: 30085854 DOI: 10.2460/ajvr.79.6.628] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To compare time to achieve vascular access (TTVA) between an ultrasound-guided technique (UST) and landmark-based technique (LMT) for central venous catheter (CVC) placement in healthy anesthetized dogs. ANIMALS 39 purpose-bred hounds. PROCEDURES Anesthetized dogs that were hemodynamically stable following completion of a terminal surgical exercise were enrolled in the study during 2 phases, with a 45-day intermission between phases. For each dog, a UST and LMT were used for CVC placement via each external jugular vein by 2 operators (criticalist and resident). The TTVA and number of venipuncture attempts and catheter redirections were recorded for each catheterization. Placement of the CVC was confirmed by contrast fluoroscopy. After euthanasia, a gross dissection was performed during which a hematoma score was assigned to the catheter insertion site. For each phase, nonlinear least squares estimation was used for learning curve analysis of the UST. RESULTS Median TTVA, number of venipuncture attempts and catheter redirections, and hematoma score did not differ significantly between the 2 operators for either technique. Median TTVA for the UST (45 seconds) was significantly longer than that for the LMT (7 seconds). Learning curve analysis indicated that 8 and 7 UST catheterizations were required to achieve performance stability in phases 1 and 2, respectively. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated that the UST was comparable to the LMT for CVC placement in healthy dogs. The extra time required to perform the UST was not clinically relevant. Additional studies evaluating the UST for CVC placement in clinically ill dogs are warranted.
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Wagner M, Hauser K, Cardona F, Schmölzer GM, Berger A, Olischar M, Werther T. Implementation and Evaluation of Training for Ultrasound-Guided Vascular Access to Small Vessels Using a Low-Cost Cadaver Model. Pediatr Crit Care Med 2018; 19:e611-e617. [PMID: 30234738 DOI: 10.1097/pcc.0000000000001721] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Critically ill neonatal and pediatric patients often require central vascular access. Real-time ultrasound guidance for central venous catheterization is beneficial. Because the diameter of central veins is much smaller in neonates than in adults, extensive training is needed to master the visualization and catheterization of central veins in neonates. This study assessed the learning effect of a standardized simulation-based teaching program on ultrasound-guided cannulation in a low-cost cadaver tissue model. DESIGN This simulation-based prospective study assessed physician competence in the ultrasound-guided central venous catheterization procedure. Analyses were conducted before and after the teaching course. SETTING Pediatric simulation center at a tertiary care center. SUBJECTS Staff physicians from the Neonatal ICU and PICUs at the Medical University of Vienna. INTERVENTIONS Two latex tubes, with internal diameters of 2 and 4 mm, were inserted in parallel into cadaver tissue to mimic vessels and create a model for central venous catheterization. MEASUREMENTS AND MAIN RESULTS Under ultrasound guidance, each participant attempted to puncture and insert a guide-wire into each of the latex tubes using in-plane and out-of-plane techniques, both before and after the teaching course. The training program was assessed using a questionnaire and a performance checklist. Thirty-nine physicians participated in this study. The rates of failure of guide-wire insertion into 2-mm tubes were significantly lower after than before the teaching course, using both in-plane (p = 0.001) and out-of-plane (p = 0.004) techniques. Teaching, however, did not significantly reduce the insertion failure rate into 4-mm tubes, either in-plane (p = 0.148) or out-of-plane (p = 0.069). The numbers of successful cannulations on the first attempt increased after the teaching in all methods (p = 0.001). CONCLUSIONS Implementation of a skills training program for ultrasound-guided central venous catheterization in a cadaver tissue model was feasible and cost- and time-effective. The number of attempts until successful cannulation of small vessels (2-mm tube) was significantly lower after than before the standardized teaching program.
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Affiliation(s)
- Michael Wagner
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Medical University of Vienna, Vienna, Austria.,Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada
| | - Kirstin Hauser
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Francesco Cardona
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Neonatal Research Unit, Royal Alexandra Hospital, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Angelika Berger
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Monika Olischar
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Tobias Werther
- Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Department of Pediatrics, Medical University of Vienna, Vienna, Austria
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Passos RDH, Ribeiro M, da Conceição LFMR, Ramos JGR, Ribeiro JC, Batista PBP, Dutra MMD, Rouby JJ. Agitated saline bubble-enhanced ultrasound for the positioning of cuffed, tunneled dialysis catheters in patients with end-stage renal disease. J Vasc Access 2018; 20:362-367. [PMID: 30354909 DOI: 10.1177/1129729818806121] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In patients with end-stage renal disease, the use of cuffed, tunneled dialysis catheters for hemodialysis has become integral to treatment plans. Fluoroscopy is a widely accepted method for the insertion and positioning of cuffed dialysis catheters, because it is easy to use, accurate and reliable, and has a relatively low incidence of complications. The purpose of our study was to evaluate the feasibility of tunneled hemodialysis catheter placement without the use of fluoroscopy but with a dynamic ultrasound-imaging-based guided technique. METHODS From January 2015 to December 2017, we performed an observational prospective cohort study of 56 patients with end-stage renal disease who required tunneled dialysis catheter placement. RESULTS The overall success rate for ultrasound-guided central access was 100%, with a mean number of 1.16 (±0.4) attempts per patient. There were no incidences of guide wire coiling/kinking, carotid puncture, pneumothorax, or catheter malfunction. Catheter flow during dialysis was 286 (±38) mL/min. The total number of catheter days was 7451, with a mean of 133 days and a range of 46-322 days. Life table analysis revealed primary patency rates of 100%, 96%, and 53% at 30, 60, and 120 days, respectively. CONCLUSION Dynamic ultrasound-based visualization of microbubbles in the right atrium is a highly accurate method to detect percutaneous implantation of large-lumen, tunneled, central venous catheters without the need for fluoroscopic guidance technology. Future research should further develop and confirm these initial findings.
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Affiliation(s)
- Rogerio da Hora Passos
- 1 Nephrology and Critical Care Department, Hospital Portugues, Salvador, Brazil.,2 Critical Care Department, Hospital São Rafael, Salvador, Brazil
| | - Michel Ribeiro
- 2 Critical Care Department, Hospital São Rafael, Salvador, Brazil.,3 Critical Care Department, Hospital Portugues, Salvador, Brazil
| | | | | | | | | | | | - Jean Jacques Rouby
- 5 Multidisciplinary Intensive Care Unit, Department of Anesthesia and Critical Care Medicine, Pitie-Salpetriere Hospital, Assistance Publique Hopitaux de Paris, School of Medicine, University Pierre and Marie Curie (UPMC), Paris, France
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Anaesthesia in austere environments: literature review and considerations for future space exploration missions. NPJ Microgravity 2018; 4:5. [PMID: 29507873 PMCID: PMC5824960 DOI: 10.1038/s41526-018-0039-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 01/30/2018] [Accepted: 01/31/2018] [Indexed: 01/28/2023] Open
Abstract
Future space exploration missions will take humans far beyond low Earth orbit and require complete crew autonomy. The ability to provide anaesthesia will be important given the expected risk of severe medical events requiring surgery. Knowledge and experience of such procedures during space missions is currently extremely limited. Austere and isolated environments (such as polar bases or submarines) have been used extensively as test beds for spaceflight to probe hazards, train crews, develop clinical protocols and countermeasures for prospective space missions. We have conducted a literature review on anaesthesia in austere environments relevant to distant space missions. In each setting, we assessed how the problems related to the provision of anaesthesia (e.g., medical kit and skills) are dealt with or prepared for. We analysed how these factors could be applied to the unique environment of a space exploration mission. The delivery of anaesthesia will be complicated by many factors including space-induced physiological changes and limitations in skills and equipment. The basic principles of a safe anaesthesia in an austere environment (appropriate training, presence of minimal safety and monitoring equipment, etc.) can be extended to the context of a space exploration mission. Skills redundancy is an important safety factor, and basic competency in anaesthesia should be part of the skillset of several crewmembers. The literature suggests that safe and effective anaesthesia could be achieved by a physician during future space exploration missions. In a life-or-limb situation, non-physicians may be able to conduct anaesthetic procedures, including simplified general anaesthesia.
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Kim JH, Park JH, Cho J, Kong TY, Lee JH, Beom JH, Joo YS, Ko DR, Chung HS. Simulated internal jugular vein cannulation using a needle-guiding device. Am J Emerg Med 2018; 36:1931-1936. [PMID: 29467087 DOI: 10.1016/j.ajem.2018.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 02/10/2018] [Accepted: 02/11/2018] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Using a two-dimensional ultrasound-guided approach does not guarantee success during the first attempt at internal jugular vein cannulation. Our randomized, parallel simulation study examined whether a new disposable device could improve the success rate of the first attempt at ultrasound-guided internal jugular vein cannulation of a simulated internal jugular vein. METHODS Eighty-eight participants were randomized to perform needle insertion for internal jugular vein cannulation of a phantom using the ultrasound-guided approach with (case group) or without (control group) this new device. The primary outcome was the success rate of the first attempt. The secondary outcome was the frequency of mechanical complications such as arterial puncture and posterior wall puncture, procedure time, and level of difficulty. RESULTS Among 44 participants using the device, 33 (75.0%) achieved successful cannulation on the first attempt. However, only 12 (27.3%) of the 44 participants not using the device recorded success during the first attempt (risk difference, 0.477; 95% confidence interval [CI] 0.294-0.661; P<0.001). The number of attempts was significantly lower (risk difference, -3.955; 95% CI, -5.014 to -3.712; P<0.001) when participants performed cannulation with the device (1.63±1.71) than without the device (5.59±5.78). Our study also showed that participants were comfortable when performing the ultrasound-guided approach with the new device (risk difference, -1.955; 95% CI, -2.016 to -1.493; P<0.0001). CONCLUSIONS The new disposable device was effective for successful first attempts at needle insertion during ultrasound-guided internal jugular vein cannulation. Future clinical trials are needed to assess the effectiveness of this device.
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Affiliation(s)
- Ji Hoon Kim
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Jin Ha Park
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemoon-gu, Seoul 03722, Republic of Korea
| | - Junho Cho
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Tae Young Kong
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Ji Hwan Lee
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Jin Ho Beom
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Young Seon Joo
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Dong Ryul Ko
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | - Hyun Soo Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea.
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Waheed S, Maursetter L, Yevzlin A. Dialysis access procedure training for the nephrologist. Semin Dial 2018; 31:149-153. [PMID: 29314241 DOI: 10.1111/sdi.12670] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Historically, the placement and maintenance of dialysis access has been an integral part of nephrology training. However, in recent years, a big debate has ensued regarding whether this should be limited to trainees' understanding and counseling the patients regarding indications, alternatives, risks and possible complications of these procedures or should it actually involve more of a hands-on experience for the trainees. Some of the barriers in making these procedures a requirement across the board are the lack of standardization of procedural training across various training programs and the absence of consensus on what achieving competency in these procedures looks like. However, in the era of declining interest in nephrology, giving up "ownership" of nephrology procedures and increasing reliance on other sub specialties might be a deterrent in attracting residents to this field; we have to make a concerted effort to increase the exposure and opportunities for the trainees to perform these procedures. Moreover, we need to emphasize the implementation of a curriculum for nephrology fellows to evaluate access properly in order to decrease the burden of access related complications. Lastly, we need to continue working towards a more structured curriculum for a dedicated interventional nephrology fellowship for trainees who want to focus on procedures for their long-term career goals.
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Affiliation(s)
- Sana Waheed
- Division of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Laura Maursetter
- Division of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Alexander Yevzlin
- Division of Nephrology, University of Michigan School of Medicine, Ann Arbor, MI, USA
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Anantasit N, Cheeptinnakorntaworn P, Khositseth A, Lertbunrian R, Chantra M. Ultrasound Versus Traditional Palpation to Guide Radial Artery Cannulation in Critically Ill Children: A Randomized Trial. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2017; 36:2495-2501. [PMID: 28688136 DOI: 10.1002/jum.14291] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 03/07/2017] [Accepted: 03/09/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To identify success rates for radial artery cannulation in a pediatric critical care unit using either palpation or ultrasound guidance to cannulate the radial artery. METHODS A prospective randomized comparative study of critically ill children who required invasive monitoring in a tertiary referral center was conducted. All patients were randomized by a stratified block of 4 to either ultrasound-guided or traditional palpation radial artery cannulation. The primary outcomes were the first attempt and total success rates. RESULTS Eighty-four children were enrolled, with 43 randomized to the palpation technique and 41 to the ultrasound-guided technique. Demographic data between the groups were not significantly different. The total success and first attempt rates for the ultrasound-guided group were significantly higher than those for the palpation group (success ratio, 2.03; 95% confidence interval, 1.13-3.64; P = .018; and success ratio, 4.18; 95% confidence interval, 1.57-11.14; P = .004, respectively). The median time to success for the ultrasound-guided group was significantly shorter than that for the palpation group (3.3 versus 10.4 minutes; P < .001). Cannulation complications were lower in the ultrasound-guided group than the palpation group (12.5% versus 53.3%; P < .001). CONCLUSIONS The ultrasound-guided technique could improve the success rate and allow for faster cannulation of radial artery catheterization in critically ill children.
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Affiliation(s)
- Nattachai Anantasit
- Division of Pediatric Critical Care, Department of Pediatrics, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pimporn Cheeptinnakorntaworn
- Division of Pediatric Critical Care, Department of Pediatrics, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Anant Khositseth
- Division of Pediatric Critical Care, Department of Pediatrics, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Rojjanee Lertbunrian
- Division of Pediatric Critical Care, Department of Pediatrics, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Marut Chantra
- Division of Pediatric Critical Care, Department of Pediatrics, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Learning curve for real-time ultrasound-guided percutaneous tracheostomy. Anaesth Crit Care Pain Med 2017; 36:279-283. [DOI: 10.1016/j.accpm.2016.07.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 05/10/2016] [Accepted: 07/14/2016] [Indexed: 11/21/2022]
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Corvetto MA, Pedemonte JC, Varas D, Fuentes C, Altermatt FR. Simulation-based training program with deliberate practice for ultrasound-guided jugular central venous catheter placement. Acta Anaesthesiol Scand 2017; 61:1184-1191. [PMID: 28685812 DOI: 10.1111/aas.12937] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 06/06/2017] [Accepted: 06/17/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Current evidence supports the utility of simulation training for bedside procedures such as ultrasound-guided jugular central venous catheter (CVC) insertion. However, a standardized methodology to teach procedural skills has not been determined yet. The aim of this study was to evaluate the effectiveness of a simulation-based training program for improving novice technical performance during ultrasound-guided internal jugular CVC placement. METHODS Postgraduate year 1 (PGY-1) residents from anesthesiology, emergency medicine, cardiology, ICU, and nephrology specialties were trained in four deliberate practice sessions. Learning objectives included principles of ultrasound (US), preparation (gown, glove, draping), procedural skills I (US scanning and puncture), and procedural skills II (catheter insertion). CVC technical proficiency was tested pre- and post-training using hand-motion analysis with the Imperial College Surgical Assessment Device (ICSAD) and a global rating scale (GRS). RESULTS Thirty-five PGY-1 residents successfully completed the program. These novices' GRS scores improved significantly after the training (P < 0.001). Total path length measured with the ICSAD decreased significantly after the training (P = 0.008). Procedural time decreased significantly after training from 387 (310-501) seconds to 200 (157-261) seconds (median and interquartile range) (P = 0.029). CONCLUSION This simulation-training program based on deliberate practice significantly increased the technical skills of residents in US-guided short-axis, out-of-plane internal jugular CVC placement. Data also confirm the validity of the ICSAD as an assessment tool for ultrasound-guided internal jugular CVC placement learning.
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Affiliation(s)
- M. A. Corvetto
- Department of Anesthesiology; School of Medicine; Pontificia Universidad Catolica de Chile; Santiago Chile
| | - J. C. Pedemonte
- Department of Anesthesiology; School of Medicine; Pontificia Universidad Catolica de Chile; Santiago Chile
| | - D. Varas
- Department of Anesthesiology; School of Medicine; Pontificia Universidad Catolica de Chile; Santiago Chile
| | - C. Fuentes
- Department of Anesthesiology; School of Medicine; Pontificia Universidad Catolica de Chile; Santiago Chile
| | - F. R. Altermatt
- Department of Anesthesiology; School of Medicine; Pontificia Universidad Catolica de Chile; Santiago Chile
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Lv B, Hu L, Chen L, Hu B, Zhang Y, Ye H, Sun C, Zhang X, Lan H, Chen C. Blind bedside postpyloric placement of spiral tube as rescue therapy in critically ill patients: a prospective, tricentric, observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:248. [PMID: 28950897 PMCID: PMC5615440 DOI: 10.1186/s13054-017-1839-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 09/08/2017] [Indexed: 02/07/2023]
Abstract
Background Various special techniques for blind bedside transpyloric tube placement have been introduced into clinical practice. However, transpyloric spiral tube placement facilitated by a blind bedside method has not yet been reported. The objective of this prospective study was to evaluate the safety and efficiency of blind bedside postpyloric placement of a spiral tube as a rescue therapy subsequent to failed spontaneous transpyloric migration in critically ill patients. Methods This prospective, tricentric, observational study was conducted in the intensive care units (ICUs) of three tertiary hospitals. A total of 127 consecutive patients with failed spontaneous transpyloric spiral tube migration despite using prokinetic agents and still required enteral nutrition for more than 3 days were included. The spiral tube was inserted postpylorically using the blind bedside technique. All patients received metoclopramide intravenously prior to tube insertion. The exact tube tip position was determined by radiography. The primary efficacy endpoint was the success rate of postpyloric spiral tube placement. Secondary efficacy endpoints were success rate of a spiral tube placed in the third portion of the duodenum (D3) or beyond, success rate of placement in the proximal jejunum, time to insertion, length of insertion, and number of attempts. Safety endpoints were metoclopramide-related and major adverse tube-associated events. Results In 81.9% of patients, the spiral feeding tubes were placed postpylorically; of these, 55.1% were placed in D3 or beyond and 33.9% were placed in the proximal jejunum, with a median time to insertion of 14 min and an average number of attempts of 1.4. The mean length of insertion was 95.6 cm. The adverse event incidence was 26.0%, and no serious adverse event was observed. Conclusions Blind bedside postpyloric placement of a spiral tube, as a rescue therapy subsequent to failed spontaneous transpyloric migration in critically ill patients, is safe and effective. This technique may facilitate the early initiation of postpyloric feeding in the ICU. Trial registration Chinese Clinical Trial Registry, ChiCTR-OPN-16008206. Registered on 1 April 2016.
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Affiliation(s)
- Bo Lv
- Department of Critical Care Medicine, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, Guangdong Province, People's Republic of China
| | - Linhui Hu
- Department of Critical Care Medicine, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, Guangdong Province, People's Republic of China.,School of Medicine, South China University of Technology, Guangzhou Higher Education Mega Center, Guangzhou, 510006, Guangdong Province, People's Republic of China
| | - Lifang Chen
- Department of Critical Care Medicine, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, Guangdong Province, People's Republic of China
| | - Bei Hu
- Department of Critical Care Medicine, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, Guangdong Province, People's Republic of China
| | - Yanlin Zhang
- Department of Critical Care Medicine, Xinjiang Kashgar Region's First People's Hospital, 66 Airport Road, Kashgar Region, 844099, Xinjiang Uygur Autonomous Region, People's Republic of China
| | - Heng Ye
- Department of Critical Care Medicine, Guangzhou Nansha Central Hospital, 105 Fengzhedong Road, Guangzhou, 511457, Guangdong Province, People's Republic of China
| | - Cheng Sun
- Department of Critical Care Medicine, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, Guangdong Province, People's Republic of China
| | - Xiunong Zhang
- Department of Critical Care Medicine, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, Guangdong Province, People's Republic of China
| | - Huilan Lan
- Department of Critical Care Medicine, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, Guangdong Province, People's Republic of China
| | - Chunbo Chen
- Department of Critical Care Medicine, Guangdong General Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080, Guangdong Province, People's Republic of China.
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Crocoli A, Sidro L, Zanaboni C, Rossetti F, Pittiruti M. Letter to the Editor. J Pediatr Surg 2017; 52:1535-1536. [PMID: 28526227 DOI: 10.1016/j.jpedsurg.2017.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 04/24/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Alessandro Crocoli
- General and Thoracic Surgery Unit, Bambino Gesù Children Hospital IRCCS, Rome, Italy.
| | - Luca Sidro
- Department of Anesthesiology, Santobono-Pausilipon Children's Hospital of Naples, Italy.
| | - Clelia Zanaboni
- Department of Anesthesiology, Giannina Gaslini Institute, Genoa, Italy.
| | | | - Mauro Pittiruti
- Department of Surgery, "A. Gemelli" Teaching Hospital, Catholic University of the Sacred Heart, Rome, Italy.
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Boet S, Thompson C, Woo MY, Pugh D, Patel R, Pasupathy P, Siddiqui A, Pigford AA, Naik VN. Interactive Online Learning for Attending Physicians in Ultrasound-guided Central Venous Catheter Insertion. Cureus 2017; 9:e1592. [PMID: 29062624 PMCID: PMC5650262 DOI: 10.7759/cureus.1592] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Evidence has demonstrated that the use of dynamic ultrasound guidance (USG) for central venous catheter (CVC) significantly decreases attempts, failures, and complication rates. Despite national organizations recommending the use of USG and its increasing availability, USG is used inconsistently and non-uniformly. We sought to determine if an online training module for CVC insertion with ultrasound guidance will improve acquisition and long-term retention of knowledge and skills for attending physicians. Participants were tested for declarative knowledge and skills on a simulator (pre-test) for ultrasound-guided CVC insertion at baseline. They then completed an online learning module followed by an immediate post-test and a six-month retention test. There were 16 attending physicians who participated in the study. The CVC training module increased declarative knowledge acquisition and retention. No significant difference in simulated CVC performance was found over the three time points.
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Affiliation(s)
- Sylvain Boet
- Anesthesiology and Pain Medicine, The Ottawa Hospital, The University of Ottawa
| | | | - Michael Y Woo
- Ottawa Hospital Research Institute, The Ottawa Hospital
| | | | - Rakesh Patel
- Ottawa Hospital Research Institute, The Ottawa Hospital
| | | | | | | | - Viren N Naik
- Royal College of Physicians / University of Ottawa, The Ottawa Hospital / University of Ottawa
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Jutric Z, Grendar J, Brown WL, Cassera MA, Wolf RF, Hansen PD, Hammill CW. Novel Simulation Device for Targeting Tumors in Laparoscopic Ablation: A Learning Curve Study. Surg Innov 2017. [DOI: 10.1177/1553350617715833] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction. A novel 3-dimensional (3D) guidance system was developed to aid accurate needle placement during ablation. Methods. Five novices and 5 experienced hepatobiliary surgeons were recruited. Using an agar block with analog tumor, participants targeted under 4 conditions: in-line with the ultrasound plane using ultrasound, in-line using 3D guidance, 45° off-axis using ultrasound, and off-axis using 3D guidance. Time to target the tumor, number of withdrawals, and the National Aeronautics and Space Administration Task Load Index were collected. Initial and final parameters for each of the conditions were compared using a within-subjects paired t test. Results. A significant reduction was seen in the number of required withdrawals in all situations when using the 3D guidance (0.75 vs 3.65 in-line and 0.25 vs 3.6 for off-axis). Mental workload was significantly lower when using 3D guidance compared with ultrasound both for novices (29.85 vs 41.03) and experts (31.98 vs 44.57), P < .001 for both. The only difference in targeting time between first and last attempt was in the novice group during off-axis targeting using 3D guidance (115 vs 32.6 seconds, P = .03). Conclusion. Though 3D guidance appeared to decrease time to target, this was not statistically significant likely as a result of lack of power in our trial. Three-dimensional guidance did reduce the number of required withdrawals, potentially decreasing complications, as well as mental workload after proficiency was achieved. Furthermore, novices without experience in ultrasound were able to learn targeting with the 3D guidance system at a faster pace than targeting with ultrasound alone.
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Affiliation(s)
- Zeljka Jutric
- Portland Providence Cancer Institute, Portland, OR, USA
| | - Jan Grendar
- Portland Providence Cancer Institute, Portland, OR, USA
| | - William L. Brown
- The Oregon Clinic, Portland, OR, USA
- Meharry Medical College, Nashville, TN, USA
| | | | - Ronald F. Wolf
- Portland Providence Cancer Institute, Portland, OR, USA
- The Oregon Clinic, Portland, OR, USA
| | - Paul D. Hansen
- Portland Providence Cancer Institute, Portland, OR, USA
- The Oregon Clinic, Portland, OR, USA
| | - Chet W. Hammill
- Washington University School of Medicine in St Louis, St Louis, MO, USA
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A novel technique for ultrasound-guided central venous catheterization under short-axis out-of-plane approach: "stepwise flashing with triangulation". J Anesth 2017. [PMID: 28634641 DOI: 10.1007/s00540-017-2381-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
In ultrasound-guided central venous catheterization, there is no standard technique either for the needle tip visualization or for the adequate needle angle and entry to the skin with short-axis view under out-of-plane technique. In the present study, we propose a novel technique named "stepwise flashing with triangulation", and the efficacy of this technique is assessed. Before and after a didactic session in which the technique was explained, 12 novice residents were asked to position the needle tip on or into the imitation vessels and to avoid deeper penetration by using an agar tissue phantom with ultrasound guidance. "Stepwise flashing" technique was for stepwise visualization of the needle tip, and "triangulation" technique was for adequate needle angle and entry to the skin. After the session, the success rate was increased and a deeper penetration rate was decreased. This technique will help us to facilitate vascular access and to avoid complications in clinical settings.
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Development and Evaluation of a Simulation-based Curriculum for Ultrasound-guided Central Venous Catheterization. CAN J EMERG MED 2016; 18:405-413. [PMID: 27180948 DOI: 10.1017/cem.2016.329] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To develop a simulation-based curriculum for residents to learn ultrasound-guided (USG) central venous catheter (CVC) insertion, and to study the volume and type of practice that leads to technical proficiency. METHODS Ten post-graduate year two residents from the Departments of Emergency Medicine and Anesthesiology completed four training sessions of two hours each, at two week intervals, where they engaged in a structured program of deliberate practice of the fundamental skills of USG CVC insertion on a simulator. Progress during training was monitored using regular hand motion analysis (HMA) and performance benchmarks were determined by HMA of local experts. Blinded assessment of video recordings was done at the end of training to assess technical competence using a global rating scale. RESULTS None of the residents met any of the expert benchmarks at baseline. Over the course of training, the HMA metrics of the residents revealed steady and significant improvement in technical proficiency. By the end of the fourth session six of 10 residents had faster procedure times than the mean expert benchmark, and nine of 10 residents had more efficient left and right hand motions than the mean expert benchmarks. Nine residents achieved mean GRS scores rating them competent to perform independently. CONCLUSION We successfully developed a simulation-based curriculum for residents learning the skills of USG CVC insertion. Our results suggest that engaging residents in three to four distributed sessions of deliberate practice of the fundamental skills of USG CVC insertion leads to steady and marked improvement in technical proficiency with individuals approaching or exceeding expert level benchmarks.
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Czarnik T, Gawda R, Nowotarski J. Real-time ultrasound-guided infraclavicular axillary vein cannulation: A prospective study in mechanically ventilated critically ill patients. J Crit Care 2016; 33:32-7. [PMID: 26993368 DOI: 10.1016/j.jcrc.2016.02.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 01/16/2016] [Accepted: 02/22/2016] [Indexed: 11/27/2022]
Abstract
PURPOSE The main purpose of this study was to define the venipuncture and catheterization success rates and early mechanical complication rates of ultrasound-guided infraclavicular axillary vein cannulation. MATERIALS AND METHODS We performed in-plane, real-time, ultrasound-guided infraclavicular axillary vein catheterizations under emergency and nonemergency conditions in mechanically ventilated, critically ill patients. RESULTS We performed 202 cannulation attempts. One hundred and twenty-six procedures (62.4%) were performed under emergency conditions. The puncture of the axillary vein was successful in 98.5% of patients, and the entire procedure success rate was 95.1% (95% confidence interval, 91.1%-97.6%). For the majority of patients (84.1%; P<.001, exact test), the venipuncture occurred during the first attempt. We noted a 22.4% overall complication rate, and most of the complications were malpositions (13.4%). We observed 8.5% of cases with potentially serious complications (puncture of the axillary artery and needle contact with the brachial plexus) and 1 case (0.5%) of pneumothorax. The puncture of the axillary artery occurred in 5 (2.5%) patients. CONCLUSIONS In-plane, real-time, ultrasound-guided, infraclavicular axillary vein cannulation in mechanically ventilated, critically ill patients is a safe and reliable method of central venous cannulation and can be considered to be a reasonable alternative to other central venous catheterization techniques.
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Affiliation(s)
- Tomasz Czarnik
- Department of Anesthesiology and Critical Care, PS ZOZ Wojewodzkie Centrum Medyczne w Opolu, Aleja Witosa 26, 45-418, Opole, Poland.
| | - Ryszard Gawda
- Department of Anesthesiology and Critical Care, PS ZOZ Wojewodzkie Centrum Medyczne w Opolu, Aleja Witosa 26, 45-418, Opole, Poland
| | - Jakub Nowotarski
- Department of Operations Research, Wroclaw University of Technology, Wybrzeze Wyspianskiego 27, 50-370 Wroclaw, Poland
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A randomized crossover study comparing a novel needle guidance technology for simulated internal jugular vein cannulation. Anesthesiology 2015; 123:535-41. [PMID: 26154184 DOI: 10.1097/aln.0000000000000759] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite ultrasound guidance for central line placement, complications persist, as exact needle location is often difficult to confirm with standard two-dimension ultrasound. A novel real-time needle guidance technology has recently become available (eZono, Germany) that tracks the needle during insertion. This randomized, blinded, crossover study examined whether this needle guidance technology improved cannulation of a simulated internal jugular (IJ) vein in an ultrasound phantom. METHODS One hundred physicians were randomized to place a standard needle in an ultrasound neck phantom with or without the needle guidance system. Video cameras were placed externally and within the lumens of the vessels to record needle location in real time. The primary outcome measured was the rate of posterior wall puncture. Secondary outcomes included number of carotid artery punctures, number of needle passes, final needle position, time to cannulation, and comfort level with this new technology. RESULTS The incidence of posterior vessel wall puncture without and with needle guidance was 49 and 13%, respectively (P < 0.001, odds ratio [OR] = 7.33 [3.44 to 15.61]). The rate of carotid artery puncture was higher without needle navigation technology than with needle navigation 21 versus 2%, respectively (P = 0.001, OR = 12.97 [2.89 to 58.18]). Final needle tip position being located within the lumen of the IJ was 97% accurate with the navigation technology and 76% accurate with standard ultrasound (P < 0.001, OR = 10.42 [2.76 to 40.0]). Average time for successful vessel cannulation was 1.37 times longer without guidance technology. CONCLUSION This real-time needle guidance technology (eZono) shows significant improvement in needle accuracy and cannulation time during simulated IJ vein puncture.
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Sander D, Schick V, Ecker H, Lindacher F, Felsch M, Spelten O, Schier R, Hinkelbein J, Padosch SA. Novel Navigated Ultrasound Compared With Conventional Ultrasound for Vascular Access—a Prospective Study in a Gel Phantom Model. J Cardiothorac Vasc Anesth 2015; 29:1261-5. [DOI: 10.1053/j.jvca.2015.03.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Indexed: 11/11/2022]
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Jaffer U, Normahani P, Singh P, Aslam M, Standfield NJ. Randomized study of teaching ultrasound-guided vascular cannulation using a phantom and the freehand versus needle guide-assisted puncture techniques. JOURNAL OF CLINICAL ULTRASOUND : JCU 2015; 43:469-477. [PMID: 25704049 DOI: 10.1002/jcu.22263] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2013] [Revised: 09/15/2014] [Accepted: 11/16/2014] [Indexed: 06/04/2023]
Abstract
PURPOSE The task of ultrasound-guided vessel cannulation can be technically difficult. Needle guides have been designed to facilitate vessel puncture. We aimed to identify and compare the learning curves of participants performing vessel puncture with conventional freehand (FH) and needle guide-assisted (NG) techniques. METHODS Thirty-six participants were randomly allocated to either the FH or the NG group. They were asked to consecutively perform as many as 30 vessel punctures on a simulated phantom model. Quantitative metrics (time taken and number of skin and posterior-wall punctures) were recorded and compared between the two groups. The cumulative sum and moving F-test statistical methods were used to delineate the learning curves. RESULTS There was a significantly lower rate of posterior-wall punctures in the NG group than in the FH group (15% versus 26%; p < 0.0001). Participants in the NG group also performed significantly fewer skin punctures than did those in the FH group (mean, 405 versus 515; p < 0.0001). Cumulative sum statistical method analysis showed that participants in the NG group surmounted the learning curve earlier (13 attempts; interquartile range, 10.3-17.0) than did those in the FH group (19 attempts; interquartile range, 15.0-27.5). The number of attempts to surmount the learning curve was significantly less for the FH group (7.2 versus 16 attempts; p = 0.007) when using the moving F-test. CONCLUSIONS The NG puncture allows a greater number of trainees to cross the learning threshold and offers the advantages of fewer posterior-wall punctures and skin punctures. The use of NG puncture may result in a shorter path to proficiency, allowing trainees to attempt needle puncture earlier and with a greater degree of safety.
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Affiliation(s)
- Usman Jaffer
- Department of Vascular Surgery, Imperial College School of Medicine, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Pasha Normahani
- Department of Vascular Surgery, Imperial College School of Medicine, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Prashant Singh
- Department of Vascular Surgery, Imperial College School of Medicine, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Mohammed Aslam
- Department of Vascular Surgery, Imperial College School of Medicine, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
| | - Nigel J Standfield
- Department of Vascular Surgery, Imperial College School of Medicine, Hammersmith Hospital, Du Cane Road, London, W12 0HS, UK
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Omid M, Rafiei MH, Hosseinpour M, Memarzade M, Riahinejad M. Ultrasound-guided percutaneous central venous catheterization in infants: Learning curve and related complications. Adv Biomed Res 2015; 4:199. [PMID: 26601087 PMCID: PMC4620612 DOI: 10.4103/2277-9175.166135] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2015] [Accepted: 07/11/2015] [Indexed: 11/10/2022] Open
Abstract
Background: This study was performed to evaluate the learning curve and related complications of ultrasound (US) guided central venous catheter (CVC) insertion in infants. Materials and Methods: This study was performed in Imam Hosein Hospital of Isfahan from September 2014 to March 2015. Participants were infants consecutively candidate for CVC insertion. Three steps were designed to complement the learning. For each step of learning, 20 patients were considered and for every patient one CVC was inserted: (1) In the first step, venous puncture and guide wire passage was performed by an experienced radiologist and the surgeon was taught how to do it, then CVC was placed by the surgeon. (2) In the second step, venous puncture and guide-wire passage was performed by the surgeon under the supervision of the same radiologist, and then CVC was placed by the surgeon. (3) In the third step, US-guided CVC insertion was performed by the surgeon completely, and the radiologist came to the operating room only if it was necessary. In each of these steps, the time spent of the US probe on the skin until the guide wire passage into the vein was recorded for every patient. All perioperative complications were recorded. Results: The mean point for the time spent of the US probe on the skin until the guide wire passage into the vein was 84.9 ± 13.6, 119.1 ± 15.2, and 90.3 ± 11.2 s in the step 1, 2 and 3, respectively (P = 0.04). There was no significant difference between the frequencies of complications among tree steps. Conclusion: US-guided percutaneous CVC insertion is a safe and reliable method which can be easily and rapidly learned.
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Affiliation(s)
- Mohammad Omid
- Department of Pediatric Surgery, Imam Hosein Pediatric Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Hadi Rafiei
- Department of Pediatric Surgery, Imam Hosein Pediatric Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehrdad Hosseinpour
- Department of Pediatric Surgery, Imam Hosein Pediatric Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehrdad Memarzade
- Department of Pediatric Surgery, Imam Hosein Pediatric Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Maryam Riahinejad
- Department of Radiology, Imam Hosein Pediatric Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
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Year in review in Intensive Care Medicine 2014: I. Cardiac dysfunction and cardiac arrest, ultrasound, neurocritical care, ICU-acquired weakness, nutrition, acute kidney injury, and miscellaneous. Intensive Care Med 2015. [PMCID: PMC4315874 DOI: 10.1007/s00134-015-3665-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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