Guidelines for performing ultrasound guided vascular cannulation: recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists

Outcomes of POCUS-Guided Peripheral Intravenous Access in Difficult Venous Access Patients: A Systematic Review and Meta-Analysis

Point Of Care Ultrasound (POCUS) guided peripheral intravenous (PIV) access offers a safer and more efficient alternative for patients with difficult venous access. A systematic review of 15 studies with 1485 patients, sourced from five databases, including PubMed, Cochrane Library, MEDLINE, Web of Science, and Google Scholar, showed POCUS significantly improved success rates (OR: 4.25), first-attempt success (OR: 5.31), reduced attempts (MD: -0.83), and decreased procedure time (MD: -9.75 min). Fewer complications (OR: 0.49) observed with POCUS compared to standard techniques. Statistical analyses were conducted using Review Manager, and quality was assessed with Cochrane Risk of Bias and Newcastle Ottawa tools. Findings support POCUS as a safe, time-saving procedure for improving patient outcomes.

Randomized Comparison of Oblique versus Transverse Orientation for Ultrasound-Guided Internal Jugular Venous Cannulation in Pediatric Heart Surgery Patients

BACKGROUND

Ultrasound-guided internal jugular venous access improves the rate of successful cannulation of the internal jugular vein in both adult and pediatric patients. Internal jugular venous cannulation in pediatric patients is anatomically and technically more challenging than in adults. The oblique method is a novel approach for guiding central venous cannulation. There is currently a scarcity of research on central venous cannulation techniques for pediatric patients.

AIM

The purpose of this study was to compare the success rates between the oblique and transverse approach of jugular venous cannulation in pediatric cardiac surgery patients.

METHODS

A prospective randomized clinical trial of pediatric patients who underwent cardiac surgery at Cipto Mangunkusumo Hospital was conducted between February and May 2021. Sixty patients were randomized into two groups: 30 in the oblique group and 30 in the transverse group.

RESULTS

There was no difference in the first needle pass success rate between the oblique and transversal approaches (86.7% vs. 73.3%; P = 0.19). There is no difference in the total number of attempts between the two groups (1.3 vs 1.43; P > 0.05).

CONCLUSION

There was no difference between oblique and transverse orientations for internal jugular venous cannulation in pediatric cardiac surgery patients in terms of successful cannulation on the first needle pass and total number of attempts.

Role of ultrasound-guided brachiocephalic venous cannulation for difficult venous cannulation in pediatric patients: A narrative review

Difficult venous access is characterized by non-visible and non-palpable veins; a highly experienced operator is required with the use of technological aids to insert a vascular device. Patients with difficult venous cannulation undergo multiple, painful attempts to gain peripheral venous access. Compared to adults, inserting a central venous cannulation (CVC) is thought to be a more difficult procedure in children, particularly in neonates and young infants. IJV catheterization is perceived as the gold-standard route for CVC but remains difficult for newborn, premature, and critically ill children. Therefore, in recent years, novel ultrasound-guided brachiocephalic venous (BCV) cannulation in neonates has gained popularity. The aim of this narrative review was to assess the success rate. The primary objective of this review was to determine the first-attempt success rate. The secondary objectives were the total number of attempts, cannulation time, overall success rate, and complications. All articles relevant to BCV cannulation were searched in six major databases (PubMed, Embase, Medline, Ovid, PMC, and Google Scholar). A total of 16 records were included in this narrative review. According to Breschan et al., Merchaoui et al., and Vafek et al., the success rate of BCV cannulation in children was 89.1%, 98.4%, and 50%, respectively. Kumar et al., Erroz et al., and Breschan et al. found that the first-attempt success rate was higher in the in-plane left BCV (74%, 73% and 82.9% respectively). Falay et al. and Erroz et al. found a lower complication and infection with BCV cannulation. There is evidence that during CVC placement, US-guided BCV cannulation has a higher first-attempt success rate, requires less cannulation time, and has a lower complication rate in comparison to other approaches.

Ultrasound-guided vs. Non-ultrasound-guided femoral artery puncture techniques: a comprehensive systematic review and meta-analysis

PURPOSE

To compare the effectiveness of ultrasound-guided (US) versus non-US femoral artery puncture (FAP) methods, including fluoroscopy-guided (FL) and non-guided (NG) techniques.

MATERIALS

This meta-analysis included 11 randomized controlled trials and 1 non-randomized retrospective study, comprising a total of 12 studies involving 5534 patients across diverse clinical settings. Studies varied in operator experience, institutional settings, and procedural protocols. Key outcomes assessed included complication rates, vessel access time, first-pass success rates, number of attempts, and the risk of accidental venipuncture.

RESULTS

Analysis of the heterogeneous dataset showed that guided techniques were associated with reduced complication rates compared to NG methods (pooled odds ratio (OR): 0.45, 95% Confidence Interval (CI) 0.28-0.73). US guidance was associated with decreased vessel access time (mean difference: - 16.30 s, 95% CI - 29.83 to - 2.76), higher first-pass success rates (pooled OR: 3.54, 95% CI 2.36 to 5.30), and required fewer attempts compared to non-US techniques. US guidance also showed lower risk of inadvertent venipuncture (pooled OR: 0.22, 95% CI 0.14 to 0.34).

CONCLUSION

This meta-analysis suggests potential benefits of US femoral artery puncture techniques over non-US methods, while acknowledging significant heterogeneity across studies. The observed advantages in procedural outcomes varied across different clinical settings and operator experience levels. These findings provide setting for institutional decision-making regarding the implementation of guided puncture methods, considering factors such as operator expertise, resource availability, and specific patient populations.

Ultrasound-guided peripheral intravenous access in adults: A randomized crossover controlled trial

BACKGROUND

Peripheral intravenous access is a common invasive clinical procedure, and difficult peripheral intravenous access is a common problem in the care of emergency and critically ill patients. The timeliness of immediate treatment is affected by the difficulty of intravenous access in clinical practice, which endangers patient safety. Repeated injections increase the pressure on nursing staff, consume more nursing hours, and incur higher medical costs.

PURPOSE

This study aimed to develop an evidence-based ultrasound-guided peripheral intravenous access protocol and evaluate the effectiveness of ultrasound guidance on difficult peripheral intravenous access.

METHODS

This was a randomized crossover study. This study enrolled 36 adult volunteers with difficult peripheral intravenous access at a medical center in southern Taiwan via convenience sampling. A randomized block design was used to generate random sequences. Each participant underwent ultrasound-guided and traditionally blind peripheral intravenous access. Ultrasound-guided peripheral intravenous access was performed using a high-frequency 12-MHz-ultrasound probe, and a two-person, dynamic, longitudinal, and transverse scanning method was adopted to help locate the position, direction, and depth of the peripheral veins. In this study, the chi-square test, Fisher's exact test, and independent t-test were used to compare post-test differences between the two groups.

RESULTS

Ultrasound guidance significantly improved the first attempt success rate (odds ratio = 10.97, p < 0.0001) and overall success rate (odds ratio = 49.67, p < 0.0001) and reduced the number of attempts (mean difference = -0.50 attempts, p < 0.0001) in difficult peripheral intravenous access.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

The ultrasound-guided peripheral intravenous access protocol developed in this study can significantly improve injection effectiveness in adults for whom intravenous access is difficult. A two-person, dynamic, longitudinal, and transverse scanning method is recommended in clinical practice to perform intravenous cannulation through rigorous ultrasound operation training to resolve the clinical problem of difficult intravenous access, reduce pressure on nursing staff, and improve the quality of clinical care.

TRIAL REGISTRATION

ISRCTN18025891.

Guidelines for Performing Ultrasound-Guided Vascular Cannulation: Recommendations of the American Society of Echocardiography

Vascular access is a commonly performed procedure to facilitate patient care. This document provides expert consensus from diverse specialists on best practices and techniques for incorporating ultrasound (US) into vascular access procedures. This update replaces the 2011 American Society of Echocardiography guidelines for US-guided vascular cannulation. It includes recommendations for US-guided access to central and peripheral veins and arteries in adult and pediatric patients based on the strength of the scientific evidence present in the literature. The major roles of US during vascular access include (1) precannulation vessel assessment, (2) dynamic US guidance during cannulation, and (3) identification of local complications. This document discusses the general aspects of anatomic and US imaging of vessels, US-guided vascular cannulation techniques, and the identification of local vascular cannulation complications. Proper training should impart the cognitive knowledge and technical skills necessary to perform US-guided cannulation. There is an increasing body of literature indicating that US-guided vascular access improves success rates and reduces complications, although the quality of the evidence to date remains weak. A gap remains between the existing evidence and guidelines for the use of US in clinical practice. The availability of US equipment and clinical proficiency will more likely influence the role of US-guided vascular access as a standard of care than will future research studies.

Differences in coagulation responses to vascular injury between uninterrupted dabigatran and apixaban: A clinical prospective randomized study

BACKGROUND

The coagulation response during vascular injury with uninterrupted administration of direct oral anticoagulants has not been elucidated.

OBJECTIVE

Our aim was to evaluate differences in coagulation responses after vascular injury between uninterrupted direct thrombin inhibitor and direct factor Xa inhibitor recipients.

METHODS

Patients scheduled for catheter ablation for atrial fibrillation were randomly assigned to receive dabigatran or apixaban in this prospective, randomized, comparative, parallel-group study. Venous blood was collected 3 times: 180 minutes after taking the anticoagulant on the day before the procedure, before vascular punctures of the ablation procedure, and 10-15 minutes after the start of vascular punctures.

RESULTS

Forty-two patients were enrolled. The prothrombin fragment 1+2 level, the primary end point, was much larger after vascular puncture in the uninterrupted dabigatran recipients (median, 83 pmol/L; interquartile range, 56-133 pmol/L) than in the uninterrupted apixaban recipients (median, 1 pmol/L; interquartile range, -3 to 19 pmol/L; P < .001). Antithrombin levels decreased after vascular puncture in dabigatran recipients, and both protein C and antithrombin levels decreased after vascular puncture in apixaban recipients.

CONCLUSION

Unlike uninterrupted apixaban, uninterrupted dabigatran does not inhibit thrombin generation in response to vascular injury.

Feasibility and efficacy of real-time ultrasound-guided venous closure with suture-mediated vascular closure device

BACKGROUND

Venous vascular access complications are usually nonfatal but are the most common complications after transvenous catheter intervention. Vascular closure devices (VCDs) have recently become available for venous closure.

OBJECTIVE

This study aimed to evaluate the feasibility and efficacy of real-time ultrasound-guided venous closure with suture-mediated VCDs in patients who underwent catheter ablation.

METHODS

This single-center observational study enrolled 226 consecutive patients who underwent elective catheter ablation with femoral venipuncture. For hemostasis, vessel closure by VCD was performed with real-time ultrasound guidance after 2022 (n = 123) and without ultrasound guidance in 2021 (n = 103). The occurrence of venous access site-related complications (major, minor, or other) was compared.

RESULTS

The rate of device failure was significantly lower in patients with ultrasound guidance than in those without (1.6% vs 6.3%; P = .048). The occurrence of all venous access site-related complications was significantly lower in patients with ultrasound guidance than in those without (4.9% vs 18.4%; P = .001). Time to ambulation was shorter in patients with ultrasound guidance than in those without (2.0 ± 0.1 hours vs 2.2 ± 0.6 hours; P < .001).

CONCLUSION

Real-time ultrasound guidance can reduce device failure, access site-related complications, and time to ambulation in performing venous closure with a VCD.

A Randomized Study Comparing Ultrasound-Guided Internal Jugular Vein Cannulation Using Two Techniques: Short-Axis Out-of-Plane With Dynamic Needle Tip Positioning Versus Long-Axis In-Plane

Introduction Internal jugular vein (IJV) cannulation is a routine procedure in operating rooms, critical care units, and perioperative settings. Ultrasound guidance has notably increased the success rates of IJV cannulation. A modified ultrasound technique known as the short-axis out-of-plane method with dynamic needle tip positioning (DNTP) allows for continuous visualization of the needle tip throughout the procedure. This study aims to compare the first-pass success rate of IJV cannulation using the DNTP and long-axis in-plane (LAIP) approaches. Methods One hundred patients between 18 and 70 years undergoing elective surgery requiring IJV cannulation were recruited. Patients were assigned randomly to the DNTP group (n = 50) or the LAIP group (n = 50). We recorded the first-pass success rate, time to achieve successful cannulation, number of skin punctures, overall success rate within five minutes, and potential complications such as pneumothorax and hematoma. Results The first pass success rate was higher in the DNTP group (48/50, 96%) as compared to the LAIP group (38/50, 76%, relative risk, 1.67; 95% confidence interval, 0.039-0.707; p = 0.008). The cannulation time was shorter in DNTP (116.98 ± 22.90 seconds) versus the LAIP group (213.04 ± 52.08 seconds; p < 0.001). No complications like pneumothorax or hematoma were noted in both groups. Conclusion We conclude that the ultrasound-guided DNTP technique for IJV cannulation, as compared with the LAIP technique, may significantly improve the first attempt cannulation, number of attempts, and cannulation time.

Global use of ultrasound in newborn vascular access: RA. CE. VA: implantation and management of complications

The use of ultrasound is advantageous in many respects: pre-procedural vein selection, real-time venipuncture, tip navigation (to verify guidewire or catheter progression) and post-procedural tip location, detection of early (hematoma, pneumothorax, hemothorax) and late complications (cardiac tamponade, fibroblastic sleeve, thrombosis).Such assessment is best performed using a systematic and standardized approach, as the Rapid Central Vein Assessment, described in this study for neonates too.

Are routine chest radiographs still indicated after central line insertion? A scoping review

Introduction

Central venous catheters are increasingly inserted using point-of-care ultrasound (POCUS) guidance. Following insertion, it is still common to request a confirmatory chest radiograph for subclavian and internal jugular lines, at least outside of the operating theater. This scoping review addresses: (i) the justification for routine post-insertion radiographs, (ii) whether it would better to use post-insertion POCUS instead, and (iii) the perceived barriers to change.

Methods

We searched the electronic databases, Ovid MEDLINE (1946-) and Ovid EMBASE (1974-), using the MESH terms ("Echography" OR "Ultrasonography" OR "Ultrasound") AND "Central Venous Catheter" up until February 2023. We also searched clinical practice guidelines, and targeted literature, including cited and citing articles. We included adults (⩾18 years) and English and French language publications. We included randomized control trials, prospective and retrospective cohort studies, systematic reviews, and surveys.

Results

Four thousand seventy-one articles were screened, 117 full-text articles accessed, and 41 retained. Thirteen examined cardiac/vascular methods; 5 examined isolated contrast-enhanced ultrasonography; 7 examined isolated rapid atrial swirl sign; and 13 examined combined/integrated methods. In addition, three systematic reviews/meta-analyses and one survey addressed barriers to POCUS adoption.

Discussion

We believe that the literature supports retiring the routine post-central line chest radiograph. This is not only because POCUS has made line insertion safer, but because POCUS performs at least as well, and is associated with less radiation, lower cost, time savings, and greater accuracy. There has been less written about perceived barriers to change, but the literature shows that these concerns- which include upfront costs, time-to-train, medicolegal concerns and habit- can be challenged and hence overcome.

Surgical removal of an ectopic haemodialysis catheter in the brachiocephalic artery: a case report

Percutaneous central vein catheterization is commonly performed to access venous circulation for various clinical indications. However, unintentional arterial puncture may occur which can result in catastrophic complications. We report a case of an inadvertent right brachiocephalic artery cannulation in a 77-year-old lady planned for haemodialysis via a percutaneous internal jugular vein vascular access performed under ultrasound guidance. As an intravascular stent is not favourable in view of the close proximity of the right common carotid artery to the site of puncture as well as the risk of massive bleeding upon simple removal of the catheter, an open surgical removal via a median sternotomy was performed. Acquiring the competency in procedural skills, an understanding of the surgical anatomy and anticipating impending complications are of paramount importance in preventing as well as in mitigating the above complication.

Well-palpable pulse over an occluded radial artery: A case series reporting ultrasound outcomes

We report a case series of four patients with radial artery occlusion complicating vascular access who were scheduled for coronary angiography. We describe the challenges in selecting adequate vascular access in patients with a history of coronary angiography and percutaneous coronary intervention, as well as the benefits of using preprocedural ultrasound examination of forearm arteries to detect radial artery occlusion. Our case series suggests that if the anterior interosseous artery provides partial blood supply to the hand as a collateral circulation of the occluded radial artery, the transulnar approach may be an alternative safe option for coronary angiography and percutaneous coronary intervention in this population.

[Practice Guidelines for Central Venous Access 2020 - Time for German Guidelines]

The American Society of Anesthesiologists released practice guidelines for central venous access in 2020, and the entire world literature was examined for evidence on how to perform the entire process with best practice and minimal risk and harm to the patient. These guidelines may serve as a gold standard for individual procedural steps, allowing practitioners and hospital departments to critically question the own standard and improve upon them.We interpreted the guidelines for individual procedural steps on how to improve success of catheterization, minimize risks or adverse effects, enhance the management of accidental arterial punctures, adhere to evidence-based practices, and generally reduce the trauma of puncturing. In our opinion, the most needed recommendation for central venous access is to utilize ultrasound guidance, a practice that many international societies have already incorporated into their published national guidelines.In our view, it is time to implement a national guideline for central venous access using ultrasound in Germany. Doing so may improve success rates in the first attempt, reduce procedural time, decrease the number of needle insertions per patient, and lower the rate of arterial punctures. This approach represents best practice from ethical, insurance, civil rights, and patient security perspectives, and is supported by relevant societies.

Below-the-Knee Endovascular Revascularization: A Position Statement

Patients with chronic limb-threatening ischemia, the terminal stage of peripheral artery disease, are frequently afflicted by below-the-knee disease. Although all patients should receive guideline-directed medical therapy, restoration of inline flow is oftentimes necessary to avoid limb loss. Proper patient selection and proficiency in endovascular techniques for below-the-knee revascularization are intended to prevent major amputation and promote wound healing. This review, a consensus among an international panel of experienced operators, provides guidance on these challenges from an endovascular perspective and offers techniques to navigate this complex disease process.

Pain and Satisfaction Perceptions of Ultrasound-Guided Versus Conventional Peripheral Intravenous Catheterization: A Randomized Controlled Trial

BACKGROUND

While many emergency department (ED) patients need peripheral vascular catheterization, diagnosis and treatment are often delayed by difficult intravenous access (DIVA).

AIMS

This study of ED patients with DIVA was designed to evaluate ultrasound (US)-guided peripheral intravenous (IV) catheterization, compare it with conventional catheterization, and analyse patient pain and satisfaction regarding catheterization.

DESIGN

Randomized controlled clinical trial.

METHODS

Adult patients treated in the ED who scored >3 on the Adult-Difficult Venous Catheterization scale were randomly assigned to either US-guided or conventional peripheral IV catheterization. Data were collected from April to December 2016. Study variables were catheter insertion success, number of catheterization attempts, time required to perform the procedure, catheter length and calibre, puncture site, complications, and catheter functioning. Pain and patient satisfaction were also analysed for each group and the full sample.

RESULTS

120 and 138 patients were recruited for the US-guided and conventional peripheral IV catheterization groups, respectively. For the US-guided compared to the conventional procedure, insertion success was greater (91.75% versus 89.9%; p=0.04), the mean (SD) number of attempts was lower (1.29 (0.59) versus 1.81 (1.28); p<0.001), mean (SD) satisfaction was greater (7.59 (2.04) versus 6.69 (2.28); p=0.03), and the mean (SD) required time in minutes was greater (7.89 (7.13) versus 5.1 (3.69); p=0.045). Mean (SD) pain was moderate in both groups (4.6 (2.75) versus 4.33 (2.91) (p=0.32). Logistic regression for the full sample indicated that more attempts and greater pain were both associated with reduced satisfaction, while use of higher-calibre catheters was associated with greater satisfaction.

CONCLUSION

US-guided compared to conventional peripheral IV catheterization in patients with DIVA was more successful, required fewer attempts, enabled use of longer and higher-calibre catheters, and led to greater patient satisfaction. Patients who underwent US-guided intravenous catheterization reported moderate pain, similar to that reported for the conventional procedure.

CLINICAL IMPLICATIONS

US-guided peripheral intravenous catheterization improves ED patient care, as it requires fewer catheterization attempts. It is especially recommended for patients with DIVA.

Radial Arterial Cannulation by Ultrasound-Guided Dynamic Needle-Tip Positioning Using the Short-Axis Out-of-Plane Approach Versus the Long-Axis In-Plane Approach: A Randomized Controlled Study

Introduction Radial artery cannulation is a commonly performed invasive procedure for assessing a patient's hemodynamic status and collecting blood samples. Ultrasound guidance has shown benefits in improving the success rate of first-attempt cannulation. Two main approaches, short-axis out-of-plane (SAOOP) and long-axis in-plane (LAIP), are commonly used. A modified technique called dynamic needle-tip positioning (DNTP) using the short-axis out-of-plane approach has been reported to enhance arterial catheterization. This study aims to compare the first-attempt success rates of radial artery cannulation using the two techniques, DNTP versus LAIP, along with overall success rates, cannulation time, and number of attempts. Methods This prospective, randomized, controlled, clinical study was conducted after obtaining clearance from the Institute Ethics Committee of AIIMS, Raipur. Ninety-six patients between the ages of 18 and 50 years, undergoing elective surgery under general anesthesia, and required radial arterial cannulation were randomized and equally allocated into two groups as the LAIP and DNTP approaches. The first-pass success rate, time to achieve successful cannulation, number of attempts needed, overall success rate within five minutes, and potential complications, such as thrombosis, vasospasm, and hematoma, were recorded. Results A total of 96 patients were included, with 48 in the LAIP group and 48 in the DNTP group. The DNTP group showed statistically significant advantages over the LAIP group, with a higher first-pass success rate (97.9% vs. 83.3%; p = 0.014) and shorter time to achieve successful cannulation (9.29±3.79 vs. 26.16±20.22 seconds; p = 0.001). Conclusion The ultrasound-guided short-axis DNTP technique for radial artery cannulation demonstrated a significant advantage as compared to the LAIP technique. The DNTP technique resulted in higher first-attempt cannulation success and shorter cannulation time.

Guidance for clinical practice using emergency and point-of-care ultrasonography

Owing to the miniaturization of diagnostic ultrasound scanners and their spread of their bedside use, ultrasonography has been actively utilized in emergency situations. Ultrasonography performed by medical personnel with focused approaches at the bedside for clinical decision-making and improving the quality of invasive procedures is now called point-of-care ultrasonography (POCUS). The concept of POCUS has spread worldwide; however, in Japan, formal clinical guidance concerning POCUS is lacking, except for the application of focused assessment with sonography for trauma (FAST) and ultrasound-guided central venous cannulation. The Committee for the Promotion of POCUS in the Japanese Association for Acute Medicine (JAAM) has often discussed improving the quality of acute care using POCUS, and the "Clinical Guidance for Emergency and Point-of-Care Ultrasonography" was finally established with the endorsement of JAAM. The background, targets for acute care physicians, rationale based on published articles, and integrated application were mentioned in this guidance. The core points include the fundamental principles of ultrasound, airway, chest, cardiac, abdominal, and deep venous ultrasound, ultrasound-guided procedures, and the usage of ultrasound based on symptoms. Additional points, which are currently being considered as potential core points in the future, have also been widely mentioned. This guidance describes the overview and future direction of ultrasonography for acute care physicians and can be utilized for emergency ultrasound education. We hope this guidance will contribute to the effective use of ultrasonography in acute care settings in Japan.

Short-axis versus long-axis approach for ultrasound-guided vascular access: An updated systematic review and meta-analysis of randomised controlled trials

Background and Aims

There are two approaches for ultrasound (US)-guided vessel cannulation: the short axis (SA) approach and the long axis (LA) approach. However, it remains to be seen which approach is better. Therefore, we performed the present updated systematic review and meta-analysis to assess the effectiveness and safety of US-guided vascular cannulation between the SA and LA techniques.

Methods

We performed a comprehensive electronic database search in PubMed, Embase, Cochrane Library and Web of Science for the relevant studies from inception to June 2022. Randomised controlled trials comparing the SA approach and the LA approach for US-guided vascular access were incorporated in this updated meta-analysis. The first-attempt success rate was the primary outcome. The secondary outcomes were the overall success rate, cannulation time, number of attempts and the incidence of complications. The statistical analysis was conducted using RevMan software (version 5.4; the Nordic Cochrane Centre, the Cochrane Collaboration, Copenhagen, Denmark). The Cochrane risk of bias tool was used to evaluate each study's potential risk for bias.

Results

In total, 16 studies consisting of 1885 participants were incorporated in this updated meta-analysis. No statistically significant difference was found between the SA and LA vascular access techniques for first-pass success rate (risk ratio = 1.07, 95% confidence interval: 0.94-1.22). The overall cannulation success rate, complication rate, average cannulation time and average number of attempts were not significantly different between the SA and LA groups.

Conclusion

This updated meta-analysis demonstrated that the SA and LA approaches of US-guided vessel cannulation are similar regarding first-pass success, overall cannulation success rate, total complication rate, cannulation time and the number of attempts.

Internal jugular access using pocket ultrasound in a simulated model: comparison between biplane and monoplane visualization techniques

INTRODUCTION

Ultrasound is the current standard for central venous access due to its advantages in efficiency and safety. In-plane and out-of-plane visualization techniques are commonly used, but there is no clear evidence showing an advantage of one technique over the other. The objective of this study was to compare the success and time required for biplane visualization vs. in-plane and out-of-plane techniques in simulated models.

METHODOLOGY

Ten emergency medicine specialists participated in 60 simulated events, with randomization of the visualization technique for each event. Each event required intravenous cannulation of a simulated model for jugular venous access, with a maximum of three attempts allowed. The number of attempts required for each event, success of puncture and venous cannulation, frequency of redirection and puncture of the posterior wall, time required to obtain an optimal window, visualize the needle inside the vessel, and passage of the guidewire were recorded. The success ratios and times required for each visualization technique (biplane, in-plane, and out-of-plane) were compared.

RESULTS

Cannulation success rate was 100% for all three techniques. Success on the first attempt was 95% for biplane visualization vs. 100% for in-plane and out-of-plane. The median total time for the procedure was higher for biplane visualization (29.9 s) compared to in-plane (25.2 s) and out-of-plane (29 s), but this difference was not statistically significant (p = 0.999). There were no significant differences in cannulation success, needle redirection, or posterior wall puncture frequency between biplane visualization and in-plane and out-of-plane techniques.

CONCLUSIONS

This study suggests that biplane visualization with the use of pocket ultrasound for internal jugular cannulation in simulated models did not demonstrate significant differences when compared with in-plane and out-of-plane visualization techniques. Further research with larger sample sizes may be needed to confirm these results.

Ultrasound-Guided Radial Arterial Catheterization in Patients With Regurgitant and Stenotic Left-Sided Cardiac Valvular Lesions

Background. The pulse characteristics of arterial circulation might affect radial artery catheterization's success rate. Therefore, we hypothesized that the success rate of radial artery catheterization would be lower in the left-sided severe stenotic valvular lesion group than severe regurgitant valvular lesion group. Methods. This prospective study was conducted among patients with left-sided cardiac valvular lesions undergoing cardiac and non-cardiac surgery. The patients with left-sided severe valvular stenosis and left-sided severe valvular regurgitation were included in the study. Radial artery cannulation was performed using an ultrasound-guided out-of-plane short-axis approach. The outcome measures were success rate, number of attempts, and cannulation time. Result. One hundred fifty-two patients were recruited for the study, and all were eligible for final analysis. The first attempt success rate was non-significantly higher in the stenotic valvular lesion group than the regurgitant group (69.7% vs 56.6%; P = .09). Furthermore, the number of attempts (median; 95% CI) was significantly higher in the regurgitant group (1; 1.2-1.43 vs 1; 1.38-1.67; P = .04). However, it may not be of clinical relevance. Moreover, the cannulation time and the number of redirections of the cannula were comparable. Heart rate was significantly higher in the regurgitant group (91.8 ± 13.9 vs 82.26 ± 15.92 beats/min; P = .00), while the incidence of atrial fibrillation was significantly higher in the stenotic lesion (P = .00). No failure was reported, and the incidence of periarterial hematoma was comparable. Conclusion. The success rate of ultrasound-guided radial arterial catheterization is comparable in left-sided stenotic valvular and regurgitant lesion groups.

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

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

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

OBJECTIVES

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

DESIGN

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

SETTING

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

PATIENTS

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

INTERVENTIONS

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

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSIONS

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

Arterial Cannulation Near-Miss During Jugular Venous Catheterization With Carotid Artery Aneurysm: A Case Report

Central venous catheterization is a common procedure that may lead to inadvertent arterial cannulation, potentially causing bleeding, hematoma, stroke or rarely, death. In this near-miss case presentation, an aneurysmal carotid artery was misidentified with ultrasound by a junior resident, nearly leading to placement of a sheath into the artery. This case highlights arterial punctures that still occur even with ultrasound guidance. Further, training inadequacies as well as anatomic, cultural, and production pressure factors led to this potentially highly morbid near-miss. Physician teachers should critically evaluate teaching methods to confirm that trainees are learning skills as intended. (A&A Practice. 2023;17:e01661.).

Incorporating Evidence-based Ultrasound-guided Vascular Access (USGVA) Standards Into the Nurse Anesthetist Armamentarium: A Quality Improvement Project

PURPOSE

This quality improvement (QI) project developed and implemented a hybrid training program, that included online modules and hands-on training for experienced certified registered nurse anesthetists (CRNAs) to increase confidence, knowledge, and competency with ultrasound-guided vascular access (USGVA).

DESIGN

This QI project used a pre-post design. Seventeen volunteer CRNAs participated in USGVA training and education, and a 90-day follow-up assessment was performed.

METHODS

The Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) guidelines were used as a framework to assess confidence, knowledge, and hands-on competency of 17 CRNAs who regularly place vascular access devices using USGVA in patients with difficult vascular access at a single facility. These assessments were measured at: (1) baseline, (2) immediately after attending a hybrid training educational program, and (3) 90 days after implementation into clinical practice. Additionally, the number of vascular access attempts required for successful placement of peripheral intravenous (PIV) catheters, arterial catheters, and central venous catheters (CVC) with ultrasound assistance over a 90-day period was reviewed.

FINDINGS

Certified registered nurse anesthetists' median confidence score increased significantly from pre- to post-education (P = .009). The confidence reported from post- to 90 days post-education improved, however it did not reach statistical significance (P = .812). The knowledge scores from pre- to post-education indicated significant improvement (P <. 001), as well as from pre- to 90 days post-education (P = .03). However, knowledge scores from post- to 90 days post-education revealed a statistically significant decline (P = .004). The overall median score for hands-on USGVA competency declined from post- to 90 days post-education (P = .109). The number of successful USGVA placements increased from 50% to 80% within a 90-day period.

CONCLUSIONS

The implementation of a USGVA hybrid training and education program improved overall provider confidence, knowledge, and competency. While confidence remained high in the 90-day follow-up, knowledge retention declined. Despite a decline in knowledge retention over time, results showed a significant improvement when compared to baseline scores. Although a decline in hands-on USGVA competency was seen at 90 days posteducation, it was not statistically significant. The percentage of overall successful USGVA placements in clinical practice increased following implementation.

Comparison of ultrasound-guided femoral artery cannulation versus palpation technique in neonates undergoing cardiac surgery

OBJECTIVES

Palpation technique for femoral artery cannulation can be very difficult, especially in neonates. In this study, we evaluated whether ultrasound-guided cannulation of the femoral artery is superior to palpation technique in neonates undergoing cardiac surgery.

METHODS

Forty neonates undergoing cardiac surgery were prospectively randomized into two groups (Ultrasound group and Palpation group). Access time, number of attempts, number of successful cannulations on first attempt, success rate, number of cannulas used, inadvertent access, and complications were compared between the two groups. Cost analyses of the cannulation were performed in two groups.

RESULTS

In the ultrasound group, access time for femoral artery cannulation was shorter (6.4 ± 3.0 and 10.2 ± 4.4, p = 0.003) and the number of attempts (1.4 ± 0.6 and 2.3 ± 0.8, p < 0.001) was lower compared to the palpation group. The number of successful cannulations on first-attempt (15 (75%) and 5 (25%), p = 0.002) and the success rate (95% (19) and 60% (12), p = 0.008) were higher in the ultrasound group. The number of cannulas used in the ultrasound group was less than the palpation group (p = 0.001). The cost of intervention was higher in the palpation group compared to the ultrasound group (p = 0.048).

CONCLUSIONS

The ultrasound-guided cannulation of the femoral artery in neonates is superior to the palpation technique based on the increased of the number of successful first-attempt cannulation and success rate, and the reducing of the access time, number of attempts, number of cannulas used, and cost of cannulation.

Neonatologist-Performed Ultrasound-Guided Internal Jugular Vein Cannulation

We retrieved data of ultrasound-guided neonatal internal jugular vein (IJV) cannulations done between November, 2020 and March, 2021. Of the 33 ultrasound-guided IJV cannulation in neonates, 32 were successful with overall success rate of 97%. Median (IQR) number of attempts per insertion was 2 (1,3.5). There were no major complications observed during the insertion of the catheter. In one instance, inadvertent carotid artery puncture was encountered, without significant bleeding.

Neonatologist-Performed Ultrasound-Guided Internal Jugular Vein Cannulation

We retrieved data of ultrasound-guided neonatal internal jugular vein (IJV) cannulations done between November, 2020 and March, 2021. Of the 33 ultrasound-guided IJV cannulation in neonates, 32 were successful with overall success rate of 97%. Median (IQR) number of attempts per insertion was 2 (1,3.5). There were no major complications observed during the insertion of the catheter. In one instance, inadvertent carotid artery puncture was encountered, without significant bleeding.

Point‑of‑Care Ultrasound - accuracy, education

A review article discussing the reliability of Point-of-Care ultrasound and education in this method in various fields of medicine.

Ultrasound-Guided Access Reduces Vascular Complications in Patients Undergoing Catheter Ablation for Cardiac Arrhythmias

Background: Femoral vascular access using the standard anatomic landmark-guided method is often limited by peripheral artery disease and obesity. We investigated the effect of ultrasound-guided vascular puncture (UGVP) on the rate of vascular complications in patients undergoing catheter ablation for atrial or ventricular arrhythmias. Methods: The data of 479 patients (59% male, mean age 68 years ± 11 years) undergoing catheter ablation for left atrial (n = 426; 89%), right atrial (n = 28; 6%) or ventricular arrhythmias (n = 28; 6%) were analyzed. All patients were on uninterrupted oral anticoagulants and heparin was administered intravenously during the procedure. Femoral access complications were compared between patients undergoing UGVP (n = 320; 67%) and patients undergoing a conventional approach (n = 159; 33%). Complication rates were also compared between patients with a BMI of >30 kg/m2 (n = 136) and patients with a BMI < 30 kg/m2 (n = 343). Results: Total vascular access complications including mild hematomas were n = 37 (7.7%). In the conventional group n = 17 (10.7%) and in the ultrasound (US) group n = 20 (6.3%) total vascular access complications occurred (OR 0.557, 95% CI 0.283−1.096). UGVP significantly reduced the risk of hematoma > 5 cm (OR 0.382, 95% CI 0.148, 0.988) or pseudoaneurysm (OR 0.160, 95% CI 0.032, 0.804). There was no significant difference between the groups regarding retroperitoneal hematomas or AV fistulas (p > 0.05). In patients with BMI > 30 kg/m2, UGVP led to a highly relevant reduction in the risk of total vascular access complications (OR 0.138, 95% CI 0.027, 0.659), hematomas > 5 cm (OR 0.051, 95% CI 0.000, 0.466) and pseudoaneurysms (OR 0.051, 95% CI 0.000, 0.466). Conclusion: UGVP significantly reduces vascular access complications. Patients with a BMI > 30 kg/m2 seem to particularly profit from a UGVP approach.

Ultrasound-Guided Dynamic Needle-Tip Positioning Method Is Superior to Conventional Palpation and Ultrasound Method in Arterial Catheterization

Background: Dynamic needle-tip positioning (DNTP) was shown to improve arterial cannulation efficiency with fewer complications than conventional palpation and ultrasound methods by some studies. However, this is still controversial, and we performed this meta-analysis to comprehensively assess its value in arterial cannulation. Methods: A literature search of randomized controlled trials was conducted, and 11 studies were finally included. Efficiency outcomes (first-attempt success, overall success, and total cannulation time) and complications (hematoma, thrombosis, posterior wall puncture, and vasospasm) were separately analyzed. Subgroup analyses in different populations under cannulation were also performed. Results: DNTP was associated with increased first-attempt success (pooled RR = 1.792, p < 0.001), overall success (pooled RR = 1.368, p = 0.001), and decreased cannulation time (pooled SMD = −1.758, p = 0.001) than palpation. DNTP gained even more advantage in small children and infants. No significant difference in these outcomes between DNTP and conventional ultrasound method was detected. Fewer hematoma occurred in DNTP than palpation (pooled RR = 0.265, p < 0.001) or traditional ultrasound (pooled RR = 0.348, p < 0.001). DNPT was also associated with fewer posterior wall punctures (pooled RR = 0.495, p = 0.001) and vasospasm (pooled RR = 0.267, p = 0.007) than traditional ultrasound. Conclusions: DNTP was a better choice in artery cannulation than conventional palpation and ultrasound method, especially in small children and infants.

A web-based self-learning system for ultrasound-guided vascular access

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.

Professional Standards in Medical Ultrasound - EFSUMB Position Paper (Short Version) - General Aspects

This first position paper of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) on professional standards presents a common position across the different medical professions within EFSUMB regarding optimal standards for the performing and reporting of ultrasound examinations by any professional ultrasound operator. It describes general aspects of professionality that ensure procedure quality, effectiveness, efficiency, and sustainability in virtually all application fields of medical ultrasound. Recommendations are given related to safety and indication of ultrasound examinations, requirements for examination rooms, structured examination, systematic reporting of results, and management, communication and archiving of ultrasound data. The print version of this article is a short version. The long version is published online.

Professional Standards in Medical Ultrasound - EFSUMB Position Paper (Long Version) - General Aspects

This first position paper of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) on professional standards presents a common position across the different medical professions within EFSUMB regarding optimal standards for the performing and reporting of ultrasound examinations by any professional ultrasound operator. It describes general aspects of professionality that ensure procedure quality, effectiveness, efficiency, and sustainability in virtually all application fields of medical ultrasound. Recommendations are given related to safety and indication of ultrasound examinations, requirements for examination rooms, structured examination, systematic reporting of results, and management, communication and archiving of ultrasound data. The print version of this article is a short version. The long version is published online.

Fabrication and Characterization of Tissue-Mimicking Phantoms for Ultrasound-Guided Cannulation Training

Tissue-mimicking materials (TMMs) have been investigated and used for decades as imaging phantoms in various medical applications. They are designed and fabricated to replicate certain biological tissue characteristics, a process often dictated by the target application. Moreover, TMMs have been utilized in some medical procedural training requiring the use of imaging modalities. One potential application for TMMs is ultrasound-guided cannulation training. Cannulation is a procedure that requires a level of dexterity to gain vascular access using ultrasound guidance while avoiding complications like vessel laceration and bleeding. However, an ideal phantom for this application is yet to be developed. This work investigates the development and characterization of high-fidelity phantoms for cannulation training. The mechanical (shore hardness, elastic modulus, and needle-interaction forces) and acoustic (B-mode ultrasound scans) properties of candidate materials were quantitatively compared with biological tissue. The evaluated materials included ballistic gel, plasticized polyvinyl chloride (PVC), silicone, gelatin, agar, and polyvinyl alcohol (PVA)- cryogel. Mechanical testing demonstrated that each material could replicate the Shore hardness and elasticity characteristics of different biological tissues (skin, fat, and muscle), with PVA and PVC showing tunability by varying composition or fabrication processes. Shore hardness (OO-range) for PVA ranged between 6.3 ± 1.0 to 59.3 ± 2.6 and PVC from 4.8 ± 0.7 to 14.6 ± 0.8. Ultrasound scans of PVA were the closest to human scans, both qualitatively (based on experts' opinion) and quantitatively (based on pixel intensity measurements). Modified mixtures of PVA are found to best serve as high-fidelity cannulation phantoms. Alternatively, PVC can be used to avoid troublesome fabrication processes of PVA.

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

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

CONCLUSION

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

WHAT IS KNOWN

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

WHAT IS NEW

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

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

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

Success of implementation of a systemwide point-of-care ultrasound privileging program for emergency medicine faculty

OBJECTIVES

Point-of-care ultrasound (POCUS) is widely used in the emergency department (ED). Not all practicing emergency physicians received POCUS training during residency, leaving a training gap that is reflected in POCUS privileging. The purpose of this study was to evaluate the success of meeting privileging criteria as well as associated factors, following implementation of a basic POCUS training and privileging program within a large emergency medicine department.

METHODS

We implemented a POCUS training and privileging program, based on national guidelines, for faculty physicians who worked at one of the following EDs staffed by the same emergency medicine department: a pediatric tertiary site, two tertiary academic sites, and seven community sites. POCUS examinations included aorta, cardiac, first-trimester obstetrics (OB), and extended focused assessment with sonography in trauma. Pediatric emergency medicine faculty were taught soft tissue and thoracic US instead of aorta and OB. Completion of the program required 16 h of didactics, ≥25 quality-assured US examinations by examination type, and passing a series of knowledge-based examinations. Descriptive statistics were calculated. Associations between physician characteristics and successfully becoming privileged in POCUS were modeled using Firth's logistic regression.

RESULTS

A total of 176 faculty physicians were eligible. A total of 145 (82.4%) achieved basic POCUS privileging during the study period. Different pathways were used including 86 (48.9%) practice-based, nine (5.1%) fellowship-based, and 82 (46.9%) residency-based. POCUS privileging was lower for those working in a community versus academic setting (odds ratio 0.3, 95% confidence interval 0.1-0.9). A greater number of scans completed prior to the privileging program was associated with greater success.

CONCLUSIONS

Implementation of a POCUS training and privileging program can be successful in a large emergency medicine department that staffs hospitals in a large-scale health care system composed of both academic and community sites. Faculty physicians with at least some prior exposure to POCUS were more successful.

Comparison of comfort and complications of Implantable Venous Access Port (IVAP) with ultrasound guided Internal Jugular Vein (IJV) and Axillary Vein/Subclavian Vein (AxV/SCV) puncture in breast cancer patients: a randomized controlled study

Background

Axillary vein/subclavian vein (AxV/SCV) and Internal jugular vein (IJV) are commonly used for implantable venous access port (IVAP) implantation in breast cancer patients for chemotherapy. Previous research focused on comparison of complications while patient comfort was ignored. This study aims to compare patient comfort, surgery duration and complications of IVAP implantation between IJV and AxV/SCV approaches.

Methods

Two hundred forty-eight breast cancer patients were enrolled in this randomized controlled study from August 2020 to June 2021. Patients scheduled to undergo IVAP implantation were randomly and equally assigned to receive central venous catheters with either AxV /SCV or IJV approaches. All patients received comfort assessment using a comfort scale table at day 1, day 2 and day 7 after implantation. Patient comfort, procedure time of operation as well as early complications were compared.

Results

Patient comfort was significantly better in the AxV/SCV group than that of IJV group in day 1 (P < 0.001), day 2 (P < 0.001) and day 7(P = 0.023). Procedure duration in AxV/SCV group was slightly but significantly shorter than IJV group (27.14 ± 3.29 mins vs 28.92 ± 2.54 mins, P < 0.001). More early complications occurred in AxV/SCV group than IJV group (11/124 vs 2/124, P = 0.019). No difference of complications of artery puncture, pneumothorax or subcutaneous hematoma between these two groups but significantly more catheter misplacement in AxV/SCV group than IJV group (6/124 vs 0/124, P = 0.029). Absolutely total risk of complications was rather low in both groups (8.87% in AxV/SCV group and 1.61% in IJV group).

Conclusions

Our study indicates that patients with AxV/SCV puncture have higher comfort levels than IJV puncture. AxV/SCV puncture has shorter procedure duration but higher risk of early complications, especially catheter misplacement. Both these two approaches have rather low risk of complications. Consequently, our study provides an alternative choice for breast cancer patients to reach better comfort.

Current practice, education, and recommendations for training of central line insertion for trainees and fellows in adult ICUs across Australia and New Zealand

BACKGROUND

The objective of this study was to explore variability in existing training and accreditation processes for Central venous access device (CVAD) insertion among different ICUs, current practices of CVAD insertion among fellows of the College of Intensive Care Medicine (CICM) working in Australia and New Zealand (ANZ) and their recommendations for improvement.

METHODS

A prospective cross-sectional web-based survey was sent via email and CICM e-Newsletter to intensivists and directors of intensive care units (ICUs) across ANZ. All responses were tabulated, post-hoc exploratory analysis using multivariable ordinal logistic regression was used and free texts were analysed thematically and summarized.

RESULTS

115 responses were received from various public and private ICUs from all states of ANZ. 32% of the participants did not have any accreditation process for CVAD insertion skill in their ICUs, whereas 91% of respondents revealed there were no processes to assess deskilling. Most intensivists recommended supervision, simulation, various education tools, and ultrasound training to improve training and assessment. 35% of the participants inserted 0 to 5 CVADs and more than half of the intensivists had inserted <10 CVADs in one-year period. Two-thirds of the respondents recommended inserting between 6 to 20 CVADs each year to maintain competence.

CONCLUSION

The study identified wide variability in current practice, training methods and accreditation process for CVAD insertion amongst intensivists and ICU trainees in ANZ. Policy makers should consider revising the current clinical practice and training policies to new policies for accreditation and ongoing assessment for CVAD insertions across ANZ ICUs. This article is protected by copyright. All rights reserved.

Point-of-Care Ultrasound for Central Venous Assessment in the Emergency Department: A Prospective Study Comparing the Femoral and Internal Jugular Veins

OBJECTIVES

The objective of this study was to estimate the width, height, and depth of the femoral vein (FV) and internal jugular vein (IJV), both sites of potential central line placement in children, using point-of-care ultrasound.

METHODS

This was a prospective observational study. Point-of-care ultrasound was used to measure the width, height, and depth of the right FV and IJV in 100 children. The primary outcome was a comparison of the widths of the FV and the IJV in the same child. Our primary hypothesis was that the IJV would be wider than the FV. Secondary outcome measures included comparison of the heights and depths the FV and IJV and description of vessel overlap frequency between the 2 sites.

RESULTS

A total of 106 children were enrolled, with 6 subjects excluded, and equally divided into 5 age groups (0-30 days, 1-24 months, 2-5 years, 6-11 years, and 12-17 years). The FV/IJV width ratios (95% confidence interval) by age were 0.58 (0.49-0.68), 0.53 (0.43-0.66), 0.57 (0.49-0.67), 0.68 (0.55-0.85), and 0.73 (0.62-0.85), all P < 0.002. The FV/IJV height ratios were <1 in all age groups, with P < 0.003 in the 4 youngest age groups. The FV/IJV depth ratios were >1 in 6 to 11 years (P = 0.018) and 12 to 17 years (P < 0.001).

CONCLUSIONS

The IJV was significantly wider and taller than the FV in the same child in all age groups. The FV was significantly deeper than the IJV in children 6 years and older. This supports the use of the IJV as a potential site when placing ultrasound-guided central lines in children.

Comparative evaluation of ultrasound guided supraclavicular and infraclavicular subclavian venous catheterizations in adult patients

Background and Aims

Ultrasound-guided subclavian vein cannulation has two approaches: supraclavicular and infraclavicular. The aim of this study was to compare the ease of cannulation by recording the puncture time of the subclavian vein with the two approaches in adult patients.

Material and Methods

This study was approved by our institutional ethics committee, and a written informed consent was obtained from the patients. This prospective randomized trial recruited patients aged 18 to 80 years with definite indications of subclavian vein cannulation. Real-time in-plane ultrasound-guided technique was used, and the subclavian vein was punctured at the junction of the brachiocephalic and IJV in supraclavicular approach (SC) and in oblique axis below the border of the clavicle in infraclavicular approach (IC).

Results

A total of 96 patients were randomly allocated equally into two groups of 48 each, but only 45 patients in each group could be successfully cannulated. Median puncture times were comparable; 15 (9-39) s in SC and 21 (5-80) s in IC group. The first attempt success rate was 82.2% and 62.2%, and the mean total access time was 99.11 ± 34.66 s and 103.44 ± 50.27 s in SC and IC approaches, respectively and were comparable. The attempts of needle puncture were significantly higher in IC approach (1.40 ± 0.54 vs 1.20 ± 0.46 in SC approach; P = 0.04). The complication rates were comparable and less than 5%.

Conclusion

Ease of cannulation of the subclavian vein using ultrasound-guided supraclavicular and infraclavicular approach is comparable as no statistically significant difference is noted in the puncture time and first-attempt success rate. The increased number of needle punctures reported in our study with the IC approach did not translate to an increased complication rate.