Trendelenburg position does not increase cross-Sectional area of the internal jugular vein predictably. (Kamat)

Chest. 2013 Feb 7. doi: 10.1378/chest.11-2462. [Epub ahead of print] PMID: 23392444

BACKGROUND: The Trendelenburg position is used to distend the central veins, improving both success and safety of vascular cannulation. The purpose of this study was to measure the cross-sectional area (CSA) of the internal jugular vein (IJV) in three different positions using surface ultrasound.

METHODS: Fifty one subjects were enrolled. A Sonosite Titan 180 or M-Turbo portable ultrasound machine with a 10.5 mHz broadband linear surface probe was used. We measured the CSA of the IJV (at end-expiration at the level of the cricoid cartilage) in three positions: 15 degrees reverse Trendelenburg, supine, and 15 degrees Trendelenburg.

RESULTS: The mean CSA at 15 degrees reverse Trendelenburg was 0.83 cm2 (Std Dev 0.86), in the supine position it was 1.25 cm2 (Std Dev 0.98) and at minus 15 degrees Trendelenburg it was 1.47 cm2 (Std Dev 1.03). Moving from reverse Trendelenburg to supine, CSA increased 50 percent. In contrast, lowering the head to a Trendelenburg position increased mean CSA only 17 percent. Surprisingly, Trendelenburg positioning reduced CSA in 9 of 51 subjects.

CONCLUSIONS: Trendelenburg positioning augments CSA only modestly, on average, compared with the supine position, and in some patients reduces the CSA. TRIAL REGISTRATION: Identifier: NCT01099254.

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Supraclavicular ultrasound-guided catheterization of the subclavian vein in pediatric and neonatal ICUs: a feasibility study. (Ruth)

Pediatr Crit Care Med. 2013 May;14(4):351-5. PMID: 23392376

OBJECTIVES: To assess the feasibility of ultrasound-guided supraclavicular catheterization of the subclavian vein in pediatric and neonatal ICU.

DESIGN: Retrospective cohort.

SETTING: Ten-bed pediatric medicosurgical ICU and 15-bed neonatal ICU.

PATIENTS: Children and newborns undergoing supraclavicular ultrasound-guided subclavian vein catheterization from March 2010 to September 2010.

MEASUREMENTS: The placement of central venous catheter in ICU was carried out either by one of the experts in ultrasound-guided puncture of the unit or by a novice completely supervised by the expert. The success and the early complications were recorded. A comparison between novice and expert operators was also made.

RESULTS: Forty-two catheters were placed in 40 children. The median age and median weight were, respectively, 6.5 months and 6.5 kg. The success rate was 97.6% (one failure) and the early complication rate was 4.7% (one pneumothorax and one arterial puncture); 61% of children breathed spontaneously during the catheter placement. No significant difference was found between expert and novice operators.

CONCLUSIONS: Supraclavicular ultrasound-guided catheterization of the subclavian vein in pediatric and neonatal ICU seems to be a promising technique in the context of emergency. It is safe, reliable, with few early complications. Furthermore, it does not compromise the airways of the patient owing to the low level of sedation needed for its placement.

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Ultrasound-guided radial artery catheterization in infants and small children. (Ruth)

Pediatr Crit Care Med. 2013 Apr 26. [Epub ahead of print] PMID: 23628835

OBJECTIVE: To determine whether ultrasound guidance increases the success rates, decreases the complication rates, and shortens the time to successful radial artery catheterization in infants and small children.

DESIGN: Randomized study.

SETTING: Single university-affiliated hospital.

PATIENTS: Infants and childrenweighing 3-20 kg, undergoing cardiac surgery for congenital heart disease.

INTERVENTION: We randomly assigned the right and left radial arteries of patients undergoing arterial catheterization to ultrasound-guidedtechnique versus the usual palpation technique.

MEASUREMENTS: The primary study endpoints were the rates of successful cannulation at first and within three attempts. The secondary endpoints were time to radial arteryidentification, number of attempts for successful cannulation, and rate of complications. MAIN

RESULTS: Compared with palpation, ultrasound-guided radial artery catheterization was successful in 76.3% versus 35.6% of first attempts and in 94.9% versus 50.8% of arteries after three attempts (both comparisons, p < 0.01). The median time [interquartile range] to identification of the arteries (18.5 seconds [11.25-27.25] vs 30 seconds [17.75-39.5]) was significantly shorter (p < 0.01), the number of attempts [interquartile range] at successful cannulation (1 [1-1] vs 2 [1-2]) was significantly fewer (p < 0.01), and the proportion of hematomas (5.1% vs 25.4%) was significantly lower (p < 0.01) in the ultrasound group than those in the palpation group.

CONCLUSIONS: In infants and small children, ultrasound-guided radial artery catheterization was more successful and expeditious than the usual palpation technique.

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A general Critical Care Ultrasonography workshop: results of a novel Web-based learning program combined with simulation-based hands-on training. (Chandler)

J Crit Care. 2013 Apr;28(2):217.e7-12. PMID: 22762931

PURPOSE: The aim of this study was to facilitate attainment of Critical Care Ultrasonography (CCUS) competence.

MATERIALS AND METHODS: We developed a Web-based learning program followed by simulation-based hands-on training in noncardiac CCUS for novice learners. We administered knowledge and skills tests before and after the workshop and conducted surveys on confidence levels using a 10-point Likert scale. Knowledge tests were conducted online, and skills tests were video-captured for evaluation.

RESULTS: Sixteen physicians participated in a 4-hour combined vascular and thoracic CCUS workshop, and 23 in a 2-hour abdominal CCUS workshop. In the combined vascular and thoracic workshop, the mean (SD) pre-workshop and post-workshop knowledge scores were 24 (4) and 33 (5), respectively, out of 43 (P < .001). The pre-workshop and post-workshop skill scores were 15 (5) and 23 (2), out of 28 (P < .001). In the abdominal workshop, the pre-workshop and post-workshop knowledge scores were 11 (3) and 18 (2), out of 20 (P < .001). The pre-workshop and post-workshop skill scores were 6 (3) and 15 (2), out of 16 (P < .001). Learners’ confidence increased significantly in both workshops (P < .001).

CONCLUSIONS: Our novel hybrid educational workshop on general CCUS significantly improved knowledge, skills, and confidence levels. Our flexibly scheduled module can be a practical option for the busy intensivist.

Copyright © 2013 Elsevier Inc. All rights reserved.

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