Accesos Vasculares por Ultrasonografia

Notas del editor

• #3: Ultrasound-guided procedures are performed by visualizing the target structure with ultrasound before beginning the procedure, followed by real-time ultrasound visualiza- tion of the needle during the procedure (dynamic guidance). Ultrasound-assisted pro- cedures are performed by visualizing the target structure with ultrasound before the procedure, and marking the site where the needle will be inserted (static guidance). The procedure is then performed without direct ultrasound visualization.1 Visualuzar la aguja como una linea o punto ecogenico brillante con ventana acustica y artefacto en anillo
• #5: Multiple studies have shown that the use of ultrasound increases success rates and improves patient safety during central venous access attempts. Ultrasound can be used to help guide cannulation of the internal jugular (IJ) vein, femoral veins, and subclavian veins.1,12,13 When performing a central venous cannulation, ultrasound guidance with direct visualization of the needle in the vein is recommended rather than ultrasound assis- tance
• #6: 3SITES study
• #7: . Complications of central venous cannulation include hematoma formation, air embolism, thoracic duct fistula, pneumothorax or hemothorax, venous thrombosis, infection, catheter embolism, myocardial puncture, hydromediastinum, and hydrotho- rax. Performing the procedure under dynamic guidance greatly reduces some of these complication rates.1,12–15 Despite advances with ultrasound guidance, accidental arterial puncture can still occur. Performing the procedure in a dynamic fashion in the long-axis approach can help reduce the chances of accidental arterial puncture.
• #8: success significantly depends on patient anatomy, comorbid conditions and operator skill
• #9: Potential benefits and possible risks associated with ultrasound guidance compared with traditional palpation for radial artery catheterization are not fully understood. METHODS: We searched PubMed, Embase, and the Cochrane Library through July 2015 to identify randomized controlled trials that evaluated ultrasound guidance compared with traditional palpation for radial artery catheterization. Primary outcome was first-attempt failure. Secondary outcomes included mean attempts to success, mean time to success, and hematoma complications. A random-effects model was used to estimate relative risks (RRs) with 95% CIs. RESULTS: Twelve trials used dynamic two-dimensional (2-D) ultrasound guidance (N = 1,992) and two used Doppler ultrasound guidance (N = 666). Compared with traditional palpation, dynamic 2-D ultrasound guidance was associated with a reduced first-attempt failure (RR, 0.68; 95% CI, 0.52-0.87). Trial sequential analysis showed that the cumulative z curve crossed the trial sequential monitoring boundary for benefit establishing
• #10: Primary Outcome: First-Attempt Failure: Twelve trials totaling 1,992 patients provided data on first-attempt failure.9,11-17,21-24 Compared with traditional palpation, dynamic 2-D ultrasound significantly reduced first-attempt failure (RR, 0.68; 95% CI, 0.52-0.87; P ¼ .003) (Fig 2), with significant heterogeneity (I 2 ¼ 72%). TSA showed that the cumulative z curve crossed both the conventional boundary for benefit and the
• #11: Secondary Outcomes: Compared with traditional palpation, dynamic 2-D ultrasound guidance for radial artery catheterization further reduced mean attempts to success (MD, –1.26 times; 95% CI, –1.58 to –0.94 times; P < .00001) (Fig 4), mean time to success (MD, –43.18 s; 95% CI, –80.22 to –6.13 s; P ¼ .02) (Fig 5), and hematoma complications (RR, 0.39; 95% CI, 0.16-0.95; P ¼ .04) (Fig 6).
• #12: ), mean time to success (MD, –43.18 s; 95% CI, –80.22 to –6.13 s; P ¼ .02) (Fig 5), and hematoma complications (RR, 0.39; 95% CI, 0.16-0.95; P ¼ .04) (Fig 6).
• #14: trials were identified (289 participants). Ultrasound guidance increases the likelihood of successful cannulation (pooled OR 2.42; 95% CI 1.26 to 4.68; p1⁄40.008). There were no differences in time to successful cannulation, or number of percutaneous skin punctures.
• #15: Primary outcome: successful cannulation Six out of the seven studies3 22e26 reported on cannulation success using Ultrasound guidance versus the standard tech- nique. Ultrasound-guidance was found to increase the likelihood of successful cannulation (107/136 Ultrasound group vs 84/136 ST group; pooled OR 2.42; 95% CI 1.26 to 4.68; p1⁄40.008). There was no evidence of heterogeneity (Cochran’s Q 1.79, 5 df, p1⁄40.144) or bias (Egger test 1⁄4 0.25 p1⁄40.69). The funnel plot was symmetrical overall (figures 1e4)
• #29: Average access time and number of attempts were both significantly reduced using ultrasound compared with the landmark technique (p < 0.001) It is of note that the number of CVC-BSIs was positively correlated to the number of needle passes in the total study population (r = 0.65, p < 0.001).
• #30: Use of two-dimensional ultrasound reduced the rate of total complications overall by 71% (14 trials, 2406 participants, risk ratio (RR) 0.29, 95% confidence interval (CI) 0.17 to 0.52; P value < 0.0001, I² = 57%), and the number of participants with an inadvertent arterial puncture by 72% (22 trials, 4388 participants, RR 0.28, 95% CI 0.18 to 0.44; P value < 0.00001, I² = 35%). Overall success rates were modestly increased in all groups combined at 12% (23 trials, 4340 participants, RR 1.12, 95% CI 1.08 to 1.17; P value < 0.00001, I² = 85%), and similar benefit was noted across all subgroups. The number of attempts needed for successful cannulation was decreased overall (16 trials, 3302 participants, mean difference (MD) -1.19 attempts, 95% CI -1.45 to -0.92; P value < 0.00001, I² = 96%) and in all subgroups. Use of two-dimensional ultrasound increased the chance of success at the first attempt by 57% (18 trials, 2681 participants, RR 1.57, 95% CI 1.36 to 1.82; P value < 0.00001, I² = 82%) and reduced the chance of haematoma formation (overall reduction 73%, 13 trials, 3233 participants, RR 0.27, 95% CI 0.13 to 0.55; P value 0.0004, I² = 54%). Use of two-dimensional ultrasound decreased the time to successful cannulation by 30.52 seconds (MD -30.52 seconds, 95% CI -55.21 to -5.82; P value 0.02, I² = 97%). Additional data are available to support use of ultrasound during, not simply before, line insertion.
• #32: and reduced the chance of haematoma formation (overall reduction 73%, 13 trials, 3233 participants, RR 0.27, 95% CI 0.13 to 0.55; P value 0.0004, I² = 54%). Use of two-dimensional ultrasound decreased the time to successful cannulation by 30.52 seconds (MD -30.52 seconds, 95% CI -55.21 to -5.82; P value 0.02, I² = 97%). Additional data are available to support use of ultrasound during, not simply before, line insertion.
• #33: Overall success rates were modestly increased in all groups combined at 12% (23 trials, 4340 participants, RR 1.12, 95% CI 1.08 to 1.17; P value < 0.00001, I² = 85%), and similar benefit was noted across all subgroups. The number of attempts needed for successful cannulation was decreased overall (16 trials, 3302 participants, mean difference (MD) -1.19 attempts, 95% CI -1.45 to -0.92; P value < 0.00001, I² = 96%) and in all subgroups. Use of two-dimensional ultrasound increased the chance of success at the first attempt by 57% (18 trials, 2681 participants, RR 1.57, 95% CI 1.36 to 1.82; P value < 0.00001, I² = 82%) and reduced the chance of haematoma formation (overall reduction 73%, 13 trials, 3233 participants, RR 0.27, 95% CI 0.13 to 0.55; P value 0.0004, I² = 54%). Use of two-dimensional ultrasound decreased the time to successful cannulation by 30.52 seconds (MD -30.52 seconds, 95% CI -55.21 to -5.82; P value 0.02, I² = 97%). Additional data are available to support use of ultrasound during, not simply before, line insertion.
• #34: Use of two-dimensional ultrasound increased the chance of success at the first attempt by 57% (18 trials, 2681 participants, RR 1.57, 95% CI 1.36 to 1.82; P value < 0.00001, I² = 82%) The number of attempts needed for successful cannulation was decreased overall (16 trials, 3302 participants, mean difference (MD) -1.19 attempts, 95% CI -1.45 to -0.92; P value < 0.00001, I² = 96%) and in all subgroups. Use of two-dimensional ultrasound increased the chance of success at the first attempt by 57% (18 trials, 2681 participants, RR 1.57, 95% CI 1.36 to 1.82; P value < 0.00001, I² = 82%) and reduced the chance of haematoma formation (overall reduction 73%, 13 trials, 3233 participants, RR 0.27, 95% CI 0.13 to 0.55; P value 0.0004, I² = 54%). Use of two-dimensional ultrasound decreased the time to successful cannulation by 30.52 seconds (MD -30.52 seconds, 95% CI -55.21 to -5.82; P value 0.02, I² = 97%). Additional data are available to support use of ultrasound during, not simply before, line insertion.
• #35: Use of two-dimensional ultrasound decreased the time to successful cannulation by 30.52 seconds (MD -30.52 seconds, 95% CI -55.21 to -5.82; P value 0.02, I² = 97%). Additional data are available to support use of ultrasound during, not simply before, line insertion.
• #36: . Based on available data, we conclude that two-dimensional ultrasound offers gains in safety and quality when compared with an anatomical landmark technique. Because of missing data, we did not compare effects with experienced versus inexperienced operators for all outcomes (arterial puncture, haematoma formation, other complications, success with attempt number one), and so the relative utility of ultrasound in these groups remains unclear and no data are available on use of this technique in patients at high risk of complications. The results for Doppler ultrasound techniques versus anatomical landmark techniques are also uncerta
• #41: Altogether 13 studies enrolling 2341 participants (and involving 2360 procedures) fulfilled the inclusion criteria. The quality of evidence was very low (subclavian vein N = 3) or low (subclavian vein N = 4, femoral vein N = 2) for most outcomes, moderate for one outcome (femoral vein) and high at best for two outcomes (subclavian vein N = 1, femoral vein N = 1). Most of the trials had unclear risk of bias across the six domains, and heterogeneity among the studies was significant.For the subclavian vein (nine studies, 2030 participants, 2049 procedures), two-dimensional ultrasound reduced the risk of inadvertent arterial puncture (three trials, 498 participants, risk ratio (RR) 0.21, 95% confidence interval (CI) 0.06 to 0.82; P value 0.02, I² = 0%) and haematoma formation (three trials, 498 participants, RR 0.26, 95% CI 0.09 to 0.76; P value 0.01, I² = 0%). No evidence was found of a difference in total or other complications (together, US, USD), overall (together, US, USD), number of attempts until success (US) or first-time (US) success rates or time taken to insert the catheter (US).For the femoral vein, fewer data were available for analysis (four studies, 311 participants, 311 procedures). No evidence was found of a difference in inadvertent arterial puncture or other complications. However, success on the first attempt was more likely with ultrasound (three trials, 224 participants, RR 1.73, 95% CI 1.34 to 2.22; P value < 0.0001, I² = 31%), and a small increase in the overall success rate was noted (RR 1.11, 95% CI 1.00 to 1.23; P value 0.06, I² = 50%). No data on mortality or participant-reported outcomes were provided.
• #42: Most of the trials had unclear risk of bias across the six domains, and heterogeneity among the studies was significant.For the subclavian vein (nine studies, 2030 participants, 2049 procedures), two-dimensional ultrasound reduced the risk of inadvertent arterial puncture (three trials, 498 participants, risk ratio (RR) 0.21, 95% confidence interval (CI) 0.06 to 0.82; P value 0.02, I² = 0%) and haematoma formation (three trials, 498 participants, RR 0.26, 95% CI 0.09 to 0.76; P value 0.01, I² = 0%). No evidence was found of a difference in total or other complications (together, US, USD), overall (together, US, USD), number of attempts until success (US) or first-time (US) success rates or time taken to insert the catheter (US).For the femoral vein, fewer data were available for analysis (four studies, 311 participants, 311 procedures). No evidence was found of a difference in inadvertent arterial puncture or other complications. However, success on the first attempt was more likely with ultrasound (three trials, 224 participants, RR 1.73, 95% CI 1.34 to 2.22; P value < 0.0001, I² = 31%), and a small increase in the overall success rate was noted (RR 1.11, 95% CI 1.00 to 1.23; P value 0.06, I² = 50%). No data on mortality or participant-reported outcomes were provided.
• #43: For the femoral vein, fewer data were available for analysis (four studies, 311 participants, 311 procedures). No evidence was found of a difference in inadvertent arterial puncture or other complications. However, success on the first attempt was more likely with ultrasound (three trials, 224 participants, RR 1.73, 95% CI 1.34 to 2.22; P value < 0.0001, I² = 31%), and a small increase in the overall success rate was noted (RR 1.11, 95% CI 1.00 to 1.23; P value 0.06, I² = 50%). No data on mortality or participant-reported outcomes were provided.
• #47: rates of arterial puncture (Category A1 evidence). Randomized controlled trials report fewer number of insertion attempts with real-time ultrasound guided venipuncture of the internal jugular vein (Category A2 evidence).97,99,103,104 For the subclavian vein, randomized controlled trials report fewer insertion attempts with real-time ultrasound guided venipuncture (Category A2 evidence),105,106 and one randomized clinical trial indicates a higher success rate and reduced access time, with fewer arterial punctures and hematomas compared with the anatomic landmark approach (Category A3 evidence).106 For the femoral vein, a randomized controlled trial reports a higher first-attempt success rate and fewer needle passes with real-time ultrasound guided venipuncture compared with the anatomic landmark approach in pediatric patients (Category A3 evidence).107