Ultrasound-Guided Short-Axis Out-of-Plane Approach With or Without Dynamic Needle-Tip Positioning for Peripheral Venous Catheterization in Pediatric Patients: A Systematic Review With Network Meta-Analysis

OBJECTIVES

To compare the efficacy of the ultrasound-guided approach with and without dynamic needle-tip positioning and the palpation technique regarding success for peripheral venous catheterization in children.

DESIGN

A systematic review with network meta-analysis.

SETTING

Databases of MEDLINE (via PubMed) and Cochrane Central Register of Controlled Trials.

PARTICIPANTS

Patients (<18 years) undergoing peripheral venous catheter insertion.

INTERVENTIONS

Randomized clinical trials were included to compare the following techniques: the ultrasound-guided short-axis out-of-plane approach with dynamic needle-tip positioning, the approach without dynamic needle-tip positioning, and the palpation technique.

MEASUREMENTS AND MAIN RESULTS

The outcomes were first-attempt and overall success rates. Eight studies were included in the qualitative analyses. According to the estimate of network comparison, dynamic needle-tip positioning was associated with higher first-attempt (risk ratio [RR] 1.67; 95% CI 1.33-2.09) and overall success rates (RR 1.25; 95% CI 1.08-1.44) than palpation. The approach without dynamic needle-tip positioning was not associated with higher first-attempt (RR 1.17; 95% CI 0.91-1.49) and overall success rates (RR 1.10; 95% CI 0.90-1.33) than palpation. Compared to the approach without dynamic needle-tip positioning, dynamic needle-tip positioning was associated with a higher first-attempt success rate (RR 1.43; 95% CI 1.07-1.92), but not a higher overall success rate (RR 1.14; 95% CI 0.92-1.41).

CONCLUSIONS

Dynamic needle-tip positioning is efficacious for peripheral venous catheterization in children. It would be better to include dynamic needle-tip positioning for the ultrasound-guided short-axis out-of-plane approach.

Ultrasound education improves safety for peripheral intravenous catheter insertion in critically ill children

BACKGROUND

Difficulty in obtaining peripheral vascular access is a common problem in patients admitted to the pediatric intensive care unit (PICU). The use of ultrasound guidance can improve the overall success in obtaining vascular access. This study evaluated the success and longevity of PIV placement by nurses pre- and post-implementation of an USGPIV curriculum.

METHODS

PICU nurses participated in a prospective quality improvement study. Each participating nurse attempted 10 PIVs by using landmark (LM) methods. The same nurses then received individual instruction in an USGPIV placement curriculum. Following the educational intervention, each nurse attempted 10 USGPIVs.

RESULTS

A total of 150 LM PIVs and 143 USGPIVs were attempted. The first stick success in the post-intervention (USGPIV) group was 85.9% compared to 47.3% in the pre-intervention (LM) group (p < 0.001). Overall success was also superior in the USGPIV group (94.3 versus 57.3%, respectively; p < 0.001). PIVs placed by US lasted longer with a median survival time of 4 ± 3.84 days versus 3 ± 3.51 days for LM PIVs (p < 0.050, log-rank test).

CONCLUSIONS

Successful implementation of a standardized curriculum for USGPIV placement for PICU nurses improves first stick, overall success, and longevity of PIV catheter placement.

IMPACT

An ultrasound-guided IV curriculum can be successfully implemented resulting in increased first stick success and increased longevity. Registered nurses can be trained in placement of ultrasound-guided IV placement. This study provides a training curriculum for ultrasound-guided IV placement that can be applied to other settings or institutions.

Ultrasound-Guided Great Saphenous Vein Access: Revisiting an Old Friend in a New Location

BACKGROUND

Early recognition of difficult intravenous (i.v.) access and use of ultrasound-guided techniques prior to multiple attempts are important steps in improving patient care in the emergency department (ED). Success rates for ultrasound-guided peripheral i.v. (PIV) cannulation are affected by depth, size of target vessel, and predictability of anatomy. The great saphenous vein (GSV) in the medial distal thigh may provide an alternative site for ultrasound-guided cannulation in cases of difficult peripheral venous access.

OBJECTIVES

Our objective was to determine the feasibility of ultrasound-guided GSV PIV placement as an alternative site for patients with difficult i.v. access.

METHODS

Participants were prospectively enrolled from a convenience sample of patients presenting to the ED in June and July 2019. Inclusion criteria were age 18 years and older, and a history of difficult i.v. access or two unsuccessful nursing staff attempts. Ultrasound-guided access was conducted with an in-plane or out-of-plane approach on the basis of proceduralist preference.

RESULTS

Twenty patients were enrolled; 1 patient withdrew consent prior to cannulation. GSV cannulation was successful in 14 (73.7%) of the 19 patients. Phlebotomy, blood transfusion, i.v. medications including norepinephrine, and i.v. computed tomography contrast medium were successfully performed via GSV access. No reported infection, thrombosis, or extravasation was identified throughout the cannulation dwell time, hospitalization, or for 72 h after discharge.

CONCLUSION

Ultrasound-guided GSV PIV placement is a feasible alternative in situations of difficult i.v. access. No unforeseen complication or safety issue was identified. Blood products, medications, and contrast medium were successfully administered safely.

Feasibility study of cumulative sum (CUSUM) analysis as a competency assessment tool for ultrasound-guided venous access procedures

PURPOSE

Typically, physician training programs use a self-reported case-log competency assessment that does not measure procedure success or objectively assess competency. Cumulative sum (CUSUM) analysis could provide objective assessments of competency and progress over the training period. Our study objective was to determine the feasibility of CUSUM analysis to assess competency of ultrasound-guided peripheral intravenous (USG-PIV) line placement in pediatric anesthesiology fellows.

METHODS

We applied a CUSUM analysis to assess competency in USG-PIV placement in three consecutive pediatric anesthesia fellowship classes. After a didactic and hands-on training session, fellows placed a USG-PIV line and self-reported the outcomes via a web-based application. Fellows were deemed competent if the CUSUM curve crossed two consecutive boundary lines from above.

RESULTS

Twenty-nine fellows reported 1,388 USG-PIV attempts, with 74% success. Most fellows (26/29; 90%) achieved competency by the end of the fellowship. Two fellows identified in the mid-year CUSUM as not progressing towards competency achieved competency after targeted interventions. Fellows achieving competency (11/29 vs 25/29; odds ratio, 15; 95% confidence interval [CI], 1.98 to 113.56; P = 0.01) and attempts needed to achieve competency (19 vs 11; mean difference, 8.5; 95% CI, 3.3 to 13.7; P = 0.002) were significantly lower in younger patients and significantly higher in older patients.

CONCLUSION

Our study showed that CUSUM can be used to assess competence in USG-PIV procedures performed by pediatric anesthesia fellows and to identify learners not progressing toward competency in procedural skills. Ultrasound-guided venous access required more attempts to achieve competency in younger patients.

Ultrasound-guided peripheral vascular catheterization in pediatric patients: a narrative review

Peripheral vascular catheterization (PVC) in pediatric patients is technically challenging. Ultrasound guidance has gained the most interest in perioperative and intensive care fields because it visualizes the exact location of small target vessels and is less invasive than other techniques. There have been a growing number of studies related to ultrasound guidance for PVC with or without difficult access in pediatric patients, and most findings have demonstrated its superiority to other techniques. There are various ultrasound guidance approaches, and a comprehensive understanding of the basics, operator experience, and selection of appropriate techniques is required for the successful utilization of this technique. This narrative review summarizes the literature regarding ultrasound-guided PVC principles, approaches, and pitfalls to improve its clinical performance in pediatric settings.

Ultrasound-guided techniques for peripheral intravenous placement in children with difficult venous access

Peripheral intravenous placement in children can be challenging. Different techniques have been used to improve first pass success rates in children with known history of difficult venous access including surface landmarking, local warming, transillumination, ultrasonography, epidermal nitroglycerin, central venous access, intraosseous placement, and venous cutdown. Among these, ultrasound guidance has garnered the most interest among anesthesiologists. The cumulative literature surrounding the utility of ultrasound-guided peripheral intravenous placement in children with and without difficult venous access has shown mixed results. Literature on the utility of ultrasound guidance for peripheral intravenous placement in children under deep sedation or anesthesia is limited but encouraging. This review summarizes the overall evidence for ultrasound-guided peripheral intravenous placement in children with difficult venous access under deep sedation or general anesthesia. Furthermore, five subtly varying approaches to ultrasound-guided peripheral intravenous placement with their advantages and disadvantages will be discussed. One of these five approaches is Dynamic Needle Tip Positioning. Utilizing a short axis out of plane ultrasound view, this promising technique allows for accurate needle tip localization and may increase the success rate of peripheral intravenous placement, even in small children, under deep sedation, or general anesthesia.

Superiority of Dynamic Needle Tip Positioning for Ultrasound-Guided Peripheral Venous Catheterization in Patients Younger Than 2 Years Old: A Randomized Controlled Trial

OBJECTIVES

This study evaluated whether the dynamic needle tip positioning technique increased the success rate of ultrasound-guided peripheral venous catheterization in pediatric patients with a small-diameter vein compared with the static ultrasound-guided technique.

DESIGN

Randomized controlled study.

SETTING

Single institution, Osaka Women's and Children's Hospital.

PATIENTS

The study population included 60 pediatric patients less than 2 years old who required peripheral venous catheterization in the PICU.

INTERVENTIONS

Patients were randomly divided into the dynamic needle tip positioning (n = 30) or static group (n = 30). Each group received ultrasound-guided peripheral venous catheterization with or without dynamic needle tip positioning, respectively. The Fisher exact test, Kaplan-Meier curve plots, log-rank tests, and Mann-Whitney U test were used in the statistical analysis.

MEASUREMENTS AND MAIN RESULTS

The first-attempt success rate was higher in the dynamic needle tip positioning group than in the static group (86.7% vs 60%; p = 0.039; relative risk = 1.44; 95% CI, 1.05-2.0). The overall success rate within 10 minutes was higher in the dynamic needle tip positioning group than in the static group (90% vs 63.3%; p = 0.03; relative risk = 1.42; 95% CI, 1.06-1.91). Significantly fewer attempts were made in the dynamic needle tip positioning group than in the static group (median [interquartile range, range] = 1 [1-1, 1-2] vs 1 [1-2, 1-3]; p = 0.013]). The median (interquartile range) catheterization times were 51.5 seconds (43-63 s) and 71.5 seconds (45-600 s) in the dynamic needle tip positioning and static groups, respectively (p = 0.01).

CONCLUSIONS

Dynamic needle tip positioning increased the first-attempt and overall success rates of ultrasound-guided peripheral venous catheterization in pediatric patients less than 2 years old.

Point of care ultrasonography in the pediatric emergency department

IMPORTANCE

Point-of-care ultrasonography (POCUS) allows to obtain real-time images to correlate with the patient's presenting signs and symptoms. It can be used by various specialties and may be broadly divided into diagnostic and procedural applications.

OBJECTIVE

We aimed at reviewing current knowledge on the use of POCUS in Pediatric Emergency Departments (PEDs).

FINDINGS

US diagnostic capacity in paediatric patients with suspected pneumonia has been studied and debated whereas literature regarding the usefulness of point-of-care echocardiography in the pediatric setting is still limited. Similarly, Focused Assessment with Sonography for Trauma (FAST) has become a standard procedure in adult emergency medicine but it is still not well codified in the pediatric practice. Concerning procedural applications of POCUS we identified 4 main groups: peripheral vascular access, bladder catheterizations, identification and drainage of abnormal fluid collections and foreign body identification.

CONCLUSIONS AND RELEVANCE

Bedside emergency ultrasound is routinely used by adult emergency physicians and in the last 10 years its application is recognized and applied in PED. Pediatric emergency physicians are encouraged to familiarize with POCUS as it is a safe technology and can be extremely helpful in performing diagnosis, managing critical situations and guiding procedures, which results in globally improving pediatric patients care.

Choosing Wisely in pediatric anesthesia: An interpretation from the German Scientific Working Group of Paediatric Anaesthesia (WAKKA)

Inspired by the Choosing Wisely initiative, a group of pediatric anesthesiologists representing the German Working Group on Paediatric Anaesthesia (WAKKA) coined and agreed upon 10 concise positive ("dos") or negative ("don'ts") evidence-based recommendations. (i) In infants and children with robust indications for surgical, interventional, or diagnostic procedures, anesthesia or sedation should not be avoided or delayed due to the potential neurotoxicity associated with the exposure to anesthetics. (ii) In children without relevant preexisting illnesses (ie, ASA status I/II) who are scheduled for elective minor or medium-risk surgical procedures, no routine blood tests should be performed. (iii) Parental presence during the induction of anesthesia should be an option for children whenever possible. (iv) Perioperative fasting should be safe and child-friendly with shorter real fasting times and more liberal postoperative drinking and enteral feeding. (v) Perioperative fluid therapy should be safe and effective with physiologically composed balanced electrolyte solutions to maintain a normal extracellular fluid volume; addition of 1%-2.5% glucose to avoid lipolysis, hypoglycemia, and hyperglycemia, and colloids as needed to maintain a normal blood volume. (vi) To achieve safe and successful airway management, the locally accepted airway algorithm and continued teaching and training of basic and alternative techniques of ventilation and endotracheal intubation are required. (vii) Ultrasound and imaging systems (eg, transillumination) should be available for achieving central venous access and challenging peripheral venous and arterial access. (viii) Perioperative disturbances of the patient's homeostasis, such as hypotension, hypocapnia, hypothermia, hypoglycemia, hyponatremia, and severe anemia, should not be ignored and should be prevented or treated immediately. (ix) Pediatric patients with an elevated perioperative risk, eg, preterm and term neonates, infants, and critically ill children, should be treated at institutions where all caregivers have sufficient expertise and continuous clinical exposure to such patients. (x) A strategy for preventing postoperative vomiting, emergence delirium, and acute pain should be a part of every anesthetic procedure.

Complications in pediatric enteral and vascular access

Obtaining reliable enteral and vascular access constitutes a significant fraction of a pediatric surgeon׳s job. Multiple approaches are available. Given the complicated nature of this patient population multiple complications can also occur. This article discusses the various techniques and potential complications associated with short- and long-term enteral and vascular access.

Ultrasound evaluation of saphenous vein for peripheral intravenous cannulation in adults

OBJECTIVES

The objective of this study was to investigate variables that may affect sonographic cannulation of great saphenous vein and determine the ideal location for ultrasound-guided saphenous vein cannulation in adult emergency department (ED) patients.

METHODS

A prospective observational study at an academic ED. The great saphenous vein was identified in adult subjects at three distinct sites after placing the tourniquet proximal to the vein: the ankle, mid-calf, and below the knee using a 10-5 MHz linear transducer. The depth of the saphenous vein from the skin surface and its diameter were measured in supine and reverse trendelenburg positions in both extremities.

RESULTS

A total of 60 subjects (male 30, female 30) were enrolled in the study. The median age of the patients was 50.5 years [interquartile range (IQR) 34.5-67.5]. The median body mass index (BMI) was 27.3 (IQR, 24.2-31.8). The great saphenous vein was significantly superficial in location at the ankle level compared with the calf (p&lt;0.001), knee (p&lt;0.001), and left side compared with the right (p&lt;0.001). The subject position was not significantly related to saphenous vein depth (p = 0.68). The saphenous vein diameter was significantly larger in the left lower extremity than the right side (p = 0.007), and at the ankle level compared with the calf (p&lt;0.001) and knee (p&lt;0.001). The diameter of the vein increased significantly when patient's position changed from supine to reverse Trendelenburg (p&lt;0.001).

CONCLUSIONS

Our results support ultrasound evaluation of the course of great saphenous vein from the ankle to the knee for the selection of appropriate venipuncture site and cannulation.

Optimal site for ultrasound-guided venous catheterisation in paediatric patients: an observational study to investigate predictors for catheterisation success and a randomised controlled study to determine the most successful site

Introduction

Venous catheterisation in paediatric patients can be technically challenging. We examined factors affecting catheterisation of invisible and impalpable peripheral veins in children and evaluated the best site for ultrasound-guided catheterisation.

Methods

Systolic pressure, age, sex, and American Society of Anaesthesiologists (ASA) physical status were determined in 96 children weighing less than 20 kg. Vein diameter and subcutaneous depth were measured with ultrasound. Logistic regression was used to evaluate the contribution of these factors to cannulation success with (n = 65) or without (n = 31) ultrasound guidance. Thereafter, we randomly assigned 196 patients for venous catheter insertion in the dorsal veins of the hand, the cephalic vein in the forearm, or the great saphenous vein. Success rates and vein diameters were evaluated by using Dunn tests; insertion time was evaluated by using Kaplan-Meier cumulative incidence analysis.

Results

Independent predictors of catheterisation were ultrasound guidance (odds ratio (OR) = 7.3, 95% confidence interval (CI) 2.0 to 26.0, P = 0.002), vein diameter (OR = 1.5 per 0.1 mm increase in diameter, 95% CI 1.1 to 2.0, P = 0.007), and ASA physical status (OR = 0.4 per status 1 increase, 95% CI 0.2 to 0.9, P = 0.03). Cephalic veins were significantly larger (cephalic diameter 1.8 mm, P = 0.001 versus saphenous 1.5 mm, P <0.001 versus dorsal 1.5 mm). Catheterisation success rates were significantly better at the cephalic vein than either the dorsal hand or saphenous vein (cephalic 95%, 95% CI 89% to 100%, P <0.001 versus dorsal 69%, 95% CI 56% to 82%, P = 0.03 versus saphenous 75%, 95% CI 64% to 86%).

Conclusions

The cephalic vein in the proximal forearm appears to be the most appropriate initial site for ultrasound-guided catheterisation in invisible and impalpable veins of paediatric patients.

Trial registry number

UMIN Clinical Trials Registry as UMIN000010961. Registered on 14 June 2013.

Ultrasound first, second, and last for vascular access

Vascular access is the most commonly performed invasive procedure in medicine. For more than 20 years, ultrasound has been shown to improve the success and decrease complications of central venous access; however, it is still not universally used for this procedure. Ultrasound may also be used to facilitate difficult peripheral vascular access, potentially avoiding other more invasive procedures such as central or intraosseus vascular access. This article reviews some of the indications and evidence for ultrasound-guided vascular access, provides tips for successful ultrasound guidance, and discusses barriers to adoption.

Ultrasound-guided infraclavicular axillary vein cannulation: a useful alternative to the internal jugular vein

BACKGROUND

Ultrasound (US) guidance reduces complications and increases accuracy during internal jugular vein (IJV) cannulation. The subclavian vein (SCV) is popular but is less amenable to US guidance. The axillary vein (AxV), a direct continuation of the SCV, is an alternative, but to date, experience with US is limited to small case series.

METHODS

Retrospective procedural data were collected on 2586 sequential patients referred for insertion of tunnelled central venous access at a UK tertiary centre from 2004 to 2011.

RESULTS

A total of 99.8% of patients tolerated the procedure with local anaesthesia ± sedation; six patients had general anaesthesia. Twenty-six (1%) patients had uncorrected coagulopathy or thrombocytopenia. A total of 2572 (99.5%) of patients were cannulated successfully: right AxV 1644 cases, left AxV 279, right IJV 547, left IJV 89, other techniques 13, and 14 (0.5%) cases failed. The initial site chosen was successful in 96%. In patients who previously underwent long-term cannulation, 93.3% of lines were sited easily. Forty-eight (1.9%) procedural complications occurred.

CONCLUSIONS

In this large analysis of US-guided central venous access in a complex patient group, the majority of patients were cannulated successfully and safely. The subset of patients undergoing AxV cannulation demonstrated a low rate of complications. The AxV route of access appears to be a safe and effective alternative to the IJV.

Regional anesthesia in children: the future

Pediatric regional anesthesia continues to evolve. Education and attention to anatomical detail remain key elements to successful outcomes. New techniques, some adapted from adult practice, provide analgesia for pediatric surgical procedures such cleft palate or congenital hip dysplasia. Despite technological advances a number of controversial issues remain unresolved.

Ultrasound guidance allows faster peripheral IV cannulation in children under 3 years of age with difficult venous access: a prospective randomized study

OBJECTIVES

Ultrasound-guided peripheral venous access (USG-PIVA) presents many advantages over the reference 'blind' technique in both adults and children in emergency situations.

AIM

To compare USG-PIVA with the blind technique in children <3 years undergoing general anesthesia.

METHODS

After obtaining the approval of the ethics committee and informed consent from the parents, we included all children <3 years scheduled to undergo general anesthesia [surgery, magnetic resonance imaging (MRI)], who presented difficult venous access. The children were randomized into two groups: the US group (USG-PIVA) and the B group (blind). The primary endpoint was time to cannulation (from tourniquet placement to successful IV cannulation), compared between USG-PIVA group and B group by intention-to-treat analysis. Secondary outcomes were success rate at the first puncture, number of punctures, and diameter of the catheters. Cannulations requiring >15 min were considered as failures. In case of failure in group B, USG-PIVA was attempted for a further 15 min.

RESULTS

Twenty children were included in each group. Groups were comparable for sex, age, and BMI. Significant differences were observed in median time to cannulation (63.5 s vs 420.5 s, USG-PIVA vs B respectively, P < 0.001); median number of punctures (1 vs 2.5, USG-PIVA vs B, P = 0.004); and success rate at first cannulation (85% vs 35%, USG-PIVA vs B, P = 0.0012). In contrast, overall success rate did not differ significantly between groups (90% vs 85%, USG-PIVA vs B, P = 0.63).

CONCLUSIONS

Ultrasound-guided peripheral venous access leads to faster peripheral IV access and should therefore be recommended in children presenting with difficult venous access.