Evaluating the effects of comprehensive simulation on central venous catheterization training: a comparative observational study.

BACKGROUND: Simulation-based training (SBT) is vital to complex medical procedures such as ultrasound guided central venous catheterization (US-IJCVC), where the experience level of the physician impacts the likelihood of incurring complications. The Dynamic Haptic Robotic Trainer (DHRT) was developed to train residents in CVC as an improvement over manikin trainers, however, the DHRT and manikin trainer both only provide training on one specific portion of CVC, needle insertion. As such, CVC SBT would benefit from more comprehensive training. An extended version of the DHRT was created, the DHRT + , to provide hands-on training and automated feedback on additional steps of CVC. The DHRT + includes a full CVC medical kit, a false vein channel, and a personalized, reactive interface. When used together, the DHRT and DHRT + systems provide comprehensive training on needle insertion and catheter placement for CVC. This study evaluates the impact of the DHRT + on resident self-efficacy and CVC skill gains as compared to training on the DHRT alone. METHODS: Forty-seven medical residents completed training on the DHRT and 59 residents received comprehensive training on the DHRT and the DHRT + . Each resident filled out a central line self-efficacy (CLSE) survey before and after undergoing training on the simulators. After simulation training, each resident did one full CVC on a manikin while being observed by an expert rater and graded on a US-IJCVC checklist. RESULTS: For two items on the US-IJCVC checklist, "verbalizing consent" and "aspirating blood through the catheter", the DHRT + group performed significantly better than the DHRT only group. Both training groups showed significant improvements in self-efficacy from before to after training. However, type of training received was a significant predictor for CLSE items "using the proper equipment in the proper order", and "securing the catheter with suture and applying dressing" with the comprehensive training group that received additional training on the DHRT + showing higher post training self-efficacy. CONCLUSIONS: The integration of comprehensive training into SBT has the potential to improve US-IJCVC education for both learning gains and self-efficacy.

Implementation frameworks, strategies and outcomes in optimizing central venous access device practice in paediatrics: A scoping review.

Paediatric patients with complex or acute conditions may require a central venous access device, however, almost one-third of these devices have associated complications (e.g. infections). Implementation of evidence-based practices regarding central venous access devices can reduce and potentially prevent complications. AIMS: This scoping review aimed to explore recent interventional research in CVAD management through an implementation lens. DESIGN: This scoping review used the Arksey and O'Malley framework. Studies were included if they were written in English, published in 2012 to July 2023, involved children and were relevant to the study aims. Risk of bias was appraised by the Mixed Methods Appraisal Tool. DATA SOURCES: Searches were undertaken in EMBASE, CINAHL (Ebsco), PubMed, Web of Science and Cochrane Library (CENTRAL). RESULTS: Of the 1769 studies identified in a systematic search, 46 studies were included. Studies mostly focused on health professionals and central venous access device maintenance and had quantitative pre-post study designs. Adherence to implementation frameworks was lacking, with many studies employing quality improvement approaches. Implementation strategies were typically multipronged, using health-professional education, bundles and working groups. Bundle compliance and reductions in central line-associated bloodstream infections were the most featured outcomes, with most studies primarily focusing on effectiveness outcomes. CONCLUSION: Translation of evidence-based practices to the clinical setting is difficult and current adoption of implementation frameworks (apart from 'quality improvement') is limited. Implementation strategies are diverse and dependent on the local context, and study outcomes typically focus on the effectiveness of the physical intervention, rather than measuring the implementation effort itself. IMPLICATIONS FOR PATIENTS: Future intervention research requires a more uniform and deliberate application of implementation frameworks and strategies. IMPACT: Greater exploration of relationships between frameworks and strategies and implementation and service outcomes is required to increase understanding of their role in maximizing resources to improve health care. Adhered to best reporting guidelines as per PRISMA-ScR (Tricco et al., 2018). PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

The pediatric DAV-expert algorithm: A GAVeCeLT/GAVePed consensus for the choice of the most appropriate venous access device in children.

In pediatric patients, the choice of the venous access device currently relies upon the operator's experience and preference and on the local availability of specific resources and technologies. Though, considering the limited options for venous access in children if compared to adults, such clinical choice has a great critical relevance and should preferably be based on the best available evidence. Though some algorithms have been published over the last 5 years, none of them seems fully satisfactory and useful in clinical practice. Thus, the GAVePed-which is the pediatric interest group of the most important Italian group on venous access, GAVeCeLT-has developed a national consensus about the choice of the venous access device in children. After a systematic review of the available evidence, the panel of the consensus (which included Italian experts with documented competence in this area) has provided structured recommendations answering 10 key questions regarding the choice of venous access both in emergency and in elective situations, both in the hospitalized and in the non-hospitalized child. Only statements reaching a complete agreement were included in the final recommendations. All recommendations were also structured as a simple visual algorithm, so as to be easily translated into clinical practice.

Ultrasound-Guided Centrally Inserted Central Catheter (CICC) Placement in Newborns: A Safe Clinical Training Program in a Neonatal Intensive Care Unit.

BACKGROUND: Centrally inserted central catheters (CICCs) are increasingly used in neonatal care. CICCs have garnered attention and adoption owing to their advantageous features. Therefore, achieving clinical competence in ultrasound-guided CICC insertion in term and preterm infants is of paramount importance for neonatologists. A safe clinical training program should include theoretical teaching and clinical practice, simulation and supervised CICC insertions. METHODS: We planned a training program for neonatologists for ultrasound-guided CICCs placement at our level III neonatal intensive care unit (NICU) in Modena, Italy. In this single-centre prospective observational study, we present the preliminary results of a 12-month training period. Two paediatric anaesthesiologists participated as trainers, and a multidisciplinary team was established for continuing education, consisting of neonatologists, nurses, and anaesthesiologists. We detail the features of our training program and present the modalities of CICC placement in newborns. RESULTS: The success rate of procedures was 100%. In 80.5% of cases, the insertion was obtained at the first ultrasound-guided venipuncture. No procedure-related complications occurred in neonates (median gestational age 36 weeks, IQR 26-40; median birth weight 1200 g, IQR 622-2930). Three of the six neonatologists (50%) who participated in the clinical training program have achieved good clinical competence. One of them has acquired the necessary skills to in turn supervise other colleagues. CONCLUSIONS: Our ongoing clinical training program was safe and effective. Conducting the program within the NICU contributes to the implementation of medical and nursing skills of the entire staff.

Case series of peripherally inserted central catheter insertion in young children: A new approach to the axillary vein.

BACKGROUND: We have developed a new approach for peripherally inserted central catheter (PICC) insertion that we think has several advantages, including ease of insertion, access to a larger vein and patient comfort. METHODS: In this case series report, the first 19 cases were audited. RESULTS: All PICCs were inserted without complications; 17 on the first attempt. CONCLUSION: We conclude that the novel approach to the axillary vein for PICC insertion is feasible and appears to be safe when performed by an experienced operator.

Comparison of the Ultrasound-Guided Supraclavicular and Infraclavicular Approaches for Subclavian Vein Cannulation in Children With Congenital Heart Disease.

OBJECTIVES: Central venous catheterization is used widely in critical pediatric patients. The authors sought to compare the success rate and safety of ultrasound-guided subclavian vein cannulation performed via infraclavicular and supraclavicular approaches. DESIGN: The authors compared the success rate of the first puncture and other information for cannulation in the children with congenital heart disease requiring central venous catheterization who were assigned randomly to the supraclavicular approach group (group A) or infraclavicular approach group (group B). SETTING: Medical university hospital pediatric cardiac intensive care units. PARTICIPANTS: Pediatric patients diagnosed with congenital heart disease in the preoperative period who were admitted to the cardiac intensive care unit and required subclavian vein catheterization. INTERVENTIONS: Ultrasound-guided subclavian vein cannulation. MEASUREMENTS AND MAIN RESULTS: Sixty-seven children were included in the study, with 32 in group A and 35 in group B. Notably, there was a significant difference in the success rate of the first puncture between groups A and B (90.6% v 71.4, %, p = 0.047). Furthermore, the access time in group A was 11.8 seconds (3.2-95), which was significantly shorter than that in group B (16.0 [6.5-227] seconds, p = 0.001). In addition, the catheter malposition rate in group A was significantly lower than that in group B (0% v 11.4%, p = 0.049). Conversely, there were no significant differences in the total access time, overall success rate, and complications (eg, pneumothorax, hemorrhage, puncture artery, and nerve injury) between the 2 groups. CONCLUSIONS: For children with congenital heart disease requiring central venous catheterization during the perioperative period, the subclavian vein is a feasible site for catheterization. The supraclavicular approach, especially the left side, has a higher first-puncture success rate, shorter access time, lower complications, and a trend of lower incidence of catheter malposition. However, a larger sample size of a randomized controlled study is expected to verify the advantages of ultrasound-guided subclavian catheterization in children.

PICC insertion and veins of the arm size variation during dialysis treatment: A prospective observational study.

BACKGROUND: Peripherally Inserted Central Catheters play an increasingly important role in Central Venous Access Devices. However, the use of these devices should be carefully considered in specific situations such as central catheterisation in patients with chronic kidney disease. When evaluating the feasibility of placement for a patient undergoing dialysis, the relationship between changes in circulating volume before and after dialysis treatment, and potential variations in the size of deep veins in the upper limbs, should be considered. MATERIALS: Upper limb veins, specifically the basilic or brachial veins, were identified and measured before and after dialysis treatment. Patient data and weight loss data during dialysis treatment were also collected. Linear regression analysis was performed to assess the correlation between the variables. RESULTS: The average variation in vein size for the entire sample was +0.17 ± 0.43 mm. The mean volume removed was 2.2 ± 0.8 l. In subgroup 1 (fluid volume loss <2000 ml), the population experienced a decrease in the measured vein size after dialysis. In subgroup 2 (fluid volume loss ⩾2000 ml), the population experienced an increase in the measured vein size after dialysis. CONCLUSIONS: Upper arm vascular access placement in dialysed patients with fluid removal of less than 2000 ml should be performed after the dialysis session. Conversely, in dialysed patients with fluid removal of more than 2000 ml, where a significant increase in vein size was observed, vascular access placement should be performed before the dialysis session when the veins are smaller. Additionally, it should be noted that in patients with chronic kidney disease, the venous system of the upper limbs should be preserved as much as possible to prevent thrombosis and stenosis in potential arteriovenous fistula creation.

Bacteremia associated with non-tunneled central venous catheters in children undergoing chronic hemodialysis. / Bacteriemia asociada a catéteres venosos centrales no tunelizados en niños en hemodiálisis crónica.

Introduction. Central venous catheter (CVC)-related infection is the main complication observed in patients undergoing hemodialysis with this type of venous access. Objective. To estimate the incidence of non-tunneled CVC-related bacteremia, analyze the frequency of causative agents, and explore associated risk factors in children undergoing hemodialysis. Population and methods. Retrospective study in children receiving hemodialysis via a non-tunneled CVC between June 1st, 2015 and June 30th, 2019. A logistic regression was carried out to assess risk factors that were predictors of CVC-related bacteremia. Independent risk factors were described as odds ratios with their corresponding 95% confidence interval (CI). A value of p < 0.05 was considered statistically significant. Results. A total of 121 non-tunneled CVCs were included in this study. The incidence of bacteremia was 3.15 per 1000 catheter-days. The most commonly isolated microorganism was Staphylococcus epidermidis (16 cases, 51.5%). Prior catheter infection was the only independent risk factor for the development of bacteremia associated with non-tunneled CVC (OR: 2.84, 95% CI: 1.01-7.96, p = 0.04). Conclusions. Prolonged use of non-tunneled CVCs for chronic hemodialysis was associated with a low incidence of bacteremia. Gram-positive microorganisms prevailed among causative agents. A prior CVC infection almost trebled the risk for CVC-related bacteremia in our pediatric population receiving hemodialysis.

Introducción. La infección asociada a catéter venoso central (CVC) es la principal complicación que presentan los pacientes en hemodiálisis en los que se usa este tipo de acceso. Objetivo. Estimar la incidencia de bacteriemia asociada a CVC no tunelizado, analizar la frecuencia de agentes causales y explorar factores de riesgo asociados en niños en hemodiálisis. Población y métodos. Estudio retrospectivo realizado en niños en hemodiálisis por CVC no tunelizado entre el 1 junio de 2015 y el 30 de junio de 2019. Para evaluar factores de riesgo predictores de bacteriemia asociada a CVC, se realizó regresión logística. Los factores de riesgo independiente se expresaron con odds ratio con sus respectivos intervalos de confianza del 95 %. Se consideró estadísticamente significativo un valor de p <0,05. Resultados. En este estudio se incluyeron 121 CVC no tunelizados. La incidencia de bacteriemia fue de 3,15 por 1000 días de catéter. El microorganismo aislado con mayor frecuencia fue Staphylococcus epidermidis (16 casos, 51,5 %). La infección previa del catéter fue el único factor de riesgo independiente encontrado para el desarrollo de bacteriemia asociada a CVC no tunelizado (OR: 2,84; IC95%: 1,017,96; p =0,04). Conclusiones. El uso prolongado de los CVC no tunelizados para hemodiálisis crónica se asoció con una incidencia baja de bacteriemia. Los gérmenes grampositivos predominaron como agentes causales. La presencia de infección previa del CVC aumentó en casi 3 veces el riesgo de bacteriemia asociada a CVC en nuestra población pediátrica en hemodiálisis.

Systematic application of SICA-PED protocol for central venous catheterization in neonates: A prospective clinical study on 104 cases.

BACKGROUND: Catheterization of central vessels can be associated with early and late, potentially fatal complications. A proactive approach is imperative to reduce the frequency and magnitude of adverse events. Recently, the GAVeCeLT has proposed a protocol called SICA-PED (i.e. Safe Insertion of Central Access in Pediatric patients) and includes seven evidence-based strategies. METHODS: Through a single-center prospective observational study, the authors wanted to consolidate the efficacy and safety of these protocol in newborns. In a series of 104 newborns, the seven steps of the protocol were applied (1) pre-procedural ultrasound study of the RaCeVA veins, (2) correct aseptic technique, (3) ultrasound-guided venipuncture, (4) intraprocedural localization of the tip of the catheter with TTE (ECHO TIP) and (iECG) intracavitary electrocardiogram, (5) reasoned choice of the implant exit site with the RAVESTO Tunneling technique, (6) anchoring without stitches, and (7) exit point protection with the use of glue and transparent semipermeable membrane. The authors have included a further precaution in point (6) the subcutaneous anchoring system has added the counter-fixation of the catheter wings that we will call 6Plus Point. RESULTS: All infants requiring implantation of elective us-guided central venous access were enrolled in the study. None of the 104 implanted central venous catheters experienced early complications (accidental arterial puncture, PNX, primary malposition); rare late complications such as ecchymosis, CRBSI, exit site infection or dislodgement were observed, No catheter-related thrombotic phenomena were observed. The CRBSI catheter-related infection rate was 2.47 × 1000 days catheter cases. CONCLUSION: The results of this prospective study strengthen the feasibility and efficacy of the SICA-Ped Protocol. Demonstrating that the systematic application of the evidence-based seven-step implantation strategy increases the success rate, minimizes early and late complications, which result in increased patient safety.

Ultrasound-guided central venous catheterization around the neck: Systematic review and network meta-analysis.

BACKGROUND: Ultrasound-guided central venous catheterization (CVC) has become the standard of care. However, providers use a variety of approaches, encompassing the internal jugular vein (IJV), supraclavicular subclavian vein (SupraSCV), infraclavicular subclavian vein (InfraSCV), proximal axillary vein (ProxiAV), distal axillary vein (DistalAV), and femoral vein. OBJECTIVE: This review aimed to compare the first-pass success rate and arterial puncture rate for different approaches to ultrasound-guided CVC above the diaphragm. METHODS: In May 2023, Embase, MEDLINE, CENTRAL, ClinicalTrials.gov, and World Health Organization International Clinical Trials Platform were searched for randomized controlled trials (RCTs) comparing the 5 CVC approaches. The Confidence in Network Meta-Analysis tool was used to assess confidence. Thirteen RCTs (4418 participants and 13 comparisons) were included in this review. RESULTS: The SupraSCV approach likely increased the proportion of first-attempt successes compared to the other 4 approaches. The SupraSCV first-attempt success demonstrated risk ratios (RRs) > 1.21 with a lower 95% confidence interval (CI) exceeding 1. Compared to the IJV, the SupraSCV approach likely increased the first-attempt success proportion (RR 1.22; 95% confidence interval [CI] 1.06-1.40, moderate confidence), whereas the DistalAV approach reduced it (RR 0.72; 95% CI 0.59-0.87, high confidence). Artery puncture had little to no difference across all approaches (low to high confidence). CONCLUSION: Considering first-attempt success and mechanical complications, the SupraSCV may emerge as the preferred approach, while DistalAV might be the least preferable approach. Nevertheless, head-to-head studies comparing the approaches with the greatest first attempt success should be undertaken.

Optimal Insertion Depth of Central Venous Catheter through the Right Internal Jugular Vein, Verified by Transesophageal Echocardiography: A Prospective Observational Study.

This prospective observational study investigated the optimal insertion depth of the central venous catheter through the right internal jugular vein using transesophageal echocardiography. After tracheal intubation, the anesthesiologist inserted a probe for esophageal echocardiography into the patient's esophagus. The investigators placed the catheter tip 2 cm above the superior edge of the crista terminalis with echocardiography, which was defined as the optimal point. We measured the inserted length of the catheter. Pearson correlation tests were performed with the measured optimal depth and some patient parameters. We made a new formula for placing the catheter at the optimal position. A total of 89 subjects were enrolled in this trial. The correlation coefficient between the measured optimal depth and the patient's parameters was the highest for patient height (0.703, p < 0.001). We made a new formula of 'height (cm)/10 - 1.5 cm'. The accuracy rate of this formula for the optimal zone was 71.9% (95% confidence interval; 62.4 - 81.4%), which was the highest among the previous formulas or guidelines when we compared. In conclusion, the central venous catheter tip was evaluated with transesophageal echocardiography, and we could make a new formula of 'height (cm)/10 - 1.5', which seemed to be better than other previous guidelines.

Clinical Outcomes of Standardized Central Venous Catheterization Simulation Training: A Comparative Analysis.

OBJECTIVE: A standardized ultrasound-guided Internal Jugular Central Venous Catheterization (US-IJCVC) using online- and simulation-based training was first designed and then large-scale deployed at a teaching hospital institution to improve CVC surgical education. To understand the impact that the standardized training might have on patient complications, this study focuses on identifying the impact of the integration of an iteratively designed US-IJCVC training on clinical complications at a teaching hospital. DESIGN AND PARTICIPANTS: A comparative study was conducted using TriNetX, a global health research network. Using Current Procedural Terminology (CPT) codes and the International Statistical Classification of Diseases and Related Health Problems (ICD-10) codes, we identified the total number of patients with a CVC and mechanical, infectious, and thrombosis complications with and without billable ultrasound between July 1 to June 30 in 2016, 2017, and 2022. SETTING: A teaching hospital institution in Pennsylvania. RESULTS: Results showed a correlation between years and complications indicating, (1) mechanical complications billable ultrasound, (2) infectious complications billable ultrasound, and (3) thrombosis complications billable ultrasound were significantly lower with the large-scale deployment. Results also showed that (4) mechanical, infectious, and thrombosis complications with and without billable ultrasound are within the range that prior work has reported. CONCLUSION: These results indicate that there has been a decrease in mechanical, infectious, and thrombosis complications, which correlates with the US-IJCVC training large-scale deployment.

Macro- and microscopic changes in veins with short-term central venous catheters: an observational autopsy study.

BACKGROUND: Centrally inserted central catheters (CICCs) are indispensable in modern healthcare, but unfortunately, come with complications. Catheter-related thrombosis is a well-known complication reported to occur in 5-30% of patients with CICC. There is a paucity of studies that report the incidence of catheter-related thrombosis after the introduction of real-time ultrasound insertion guidance as clinical practice. This study aimed to demonstrate any pathological macro- or microscopic changes in the vein wall associated with CICCs. METHODS: The study was approved by the Swedish Ethical Review Authority and was conducted at a large university hospital. The study included 12 patients with a short-term CICC who were subject to autopsies. Vessels with inserted catheters were macroscopically and microscopically examined. RESULTS: In total, seven female and five male patients with a median age of 70 (interquartile range 63-76) were included. With one exception, all patients received routine thromboprophylaxis throughout the period with CICC. Most inserted CICCs were 9.5 French (54%) and were inserted in the internal jugular vein (92%). The median time with CICC was seven days (interquartile range 1.8-20). At autopsy, thrombi were observed in all cases (100%), macroscopically and microscopically, attached to the distal portion of the CICC and/or the adjacent vessel wall. Inflammatory changes in the vessel walls were seen in all cases, and varying degrees of fibrosis were demonstrated in eight cases (67%). CONCLUSIONS: This autopsy study demonstrated that catheter-related thrombus formation with adjacent inflammatory and fibrotic vessel wall thickening was very common, despite a limited period of catheter use. The consequences of these findings are important, as thrombi may cause pulmonary embolism and possibly lead to catheter-related infections, and since inflammatory and fibrotic vessel wall thickening may evolve into chronic venous stenosis. Furthermore, the findings are a cause of concern, as CICCs are indispensable in modern healthcare and complications may be masked by the general disease that was the indication for CICC insertion.

Point-of-care ultrasound for vascular access in neonates and children.

Ultrasound plays a major role in neonatal/pediatric vascular access, both for venous access and for arterial access, not only just for the insertion of intravascular catheters, but also for many other issues related to this type of maneuver. This "global use of ultrasound" includes a systematic and consistent adoption of this technology for several steps of vascular access: (a) the pre-procedural assessment/evaluation of the vessels, (b) the ultrasound-guided puncture and cannulation of arteries and veins, (c) the real-time diagnosis of immediate, puncture-related complications, (d) the so-called "tip navigation" (i.e., real-time intra-procedural assessment of the direction and trajectory of the guidewire and/or of the catheter inside the vasculature), (e) the so-called "tip location" (i.e., intra-procedural or post-procedural assessment of the proper position of the tip of the catheter), and (f) the early diagnosis and/or management of most non-infective late complications. CONCLUSION: Therefore, any vascular access expert (nurse or physicians) should have documented competency in the use of ultrasound. This knowledge should include the use of ultrasound for assessment of vessels, for catheter insertion, for proper placement of the tip, and for real-time detection of complications. WHAT IS KNOWN: • Ultrasound is obviously useful for vascular access procedures in neonates and children. WHAT IS NEW: • Recent evidence suggests that ultrasound is useful for many purposes in the field of vascular access (preprocedural scan, ultrasound-guided puncture, tip navigation, tip location, diagnosis of most non-infective complications). • Recent evidence also suggests that radiological methods no longer play any role in the insertion of vascular accesses in neonates and children.

Case review and imaging: Treatment of central venous catheter associated fibrin sheath and chronic thrombus with the ClotTriever system.

Fibrin sheath formation is a leading culprit of central venous catheter malfunction. The complete removal of fibrin sheaths is an essential component of maintaining catheter patency, preventing future restenosis, and decreasing the risk of bloodborne infections. Treatment of fibrin sheaths includes pharmacologic therapy, balloon angioplasty, catheter exchange, and mechanical stripping. In this article 3 cases are reviewed, 2 patients had long-term hemodialysis catheter malfunction and 1 had complications related to a chest port. On imaging, superior vena cava stenosis, occlusion, and/or filling defect were identified for all patients, as well as findings suggesting the presence of fibrin sheath. Description of these cases detail a new technique for fibrin sheath removal utilizing the ClotTriever System (Inari Medical, Irvine, CA), which is a mechanical thrombectomy device used for the treatment of deep vein thrombosis. This technique allowed for complete removal of the fibrin sheath via a minimally invasive interventional procedure which did not require access through the central venous catheter lumen.

Ultrasound-guided selective supraclavicular nerve block for postoperative pain control in children receiving Hickman catheter or chemoport insertion: A randomized controlled trial.

BACKGROUND: Optimal pain management after insertion of a central venous catheter in children remains unclear. AIM: This study aimed to evaluate the effects of a selective supraclavicular nerve block on postoperative analgesia in pediatric patients undergoing hickman catheter or chemoport insertion. METHODS: Fifty patients aged 3-18 years scheduled for elective Hickman or chemoport insertion were randomized into two groups of 25 each: one group received an ultrasound-guided selective supraclavicular nerve block with 0.1 mL/kg of 0.5% ropivacaine (SSCNB group), and the other group did not receive a nerve block (control group). The primary outcome was the postoperative Wong-Baker Faces Pain Rating Scale score measured between 10 and 30 min after surgery. Secondary outcomes included pain scores at 1, 3, and 24 h after the surgery, block-related complications, length of stay in the postanesthesia care unit, postoperative analgesic consumption, and time to first analgesic use 24 h after surgery. RESULTS: The worst pain score within 30 min in the recovery room was significantly lower in the SSCNB group compared to the control group (6 [5-7] vs. 3 [2-4]; median difference, -3; 95% CI, -4 to -1; p < .001). Pain scores at 1, 3, and 24 h after surgery were also significantly lower in the SSCNB group. The need for both opioid and non-opioid analgesics in the postoperative period was significantly lower in the SSCNB group (36.0% vs. 0%; p = .002 and 44.0% vs. 16.0%; mean difference, -28%; 95% CI, -56 to 0.19; p = .033, respectively), while other secondary outcomes were not significantly different between the two groups. CONCLUSIONS: Ultrasound-guided SSCNB is an effective method for managing postoperative pain in children undergoing Hickman catheter or chemoport insertion, reducing the need for analgesics within 24 h after surgery.

The value of transthoracic echocardiography and chest X-ray in locating the tip of central venous catheter in dialysis patients: a comparative study with computed tomography imaging.

To determine the tip position of the central venous catheter (CVC) in patients with dialysis, the guidelines recommend that it be determined using chest radiography (CXR) after catheterization, without fluoroscopy. However, some researchers have proposed that transthoracic echocardiography (TTE) can replace CXR, but this has not been widely adopted. This study aimed to determine which of the two aforementioned methods is more suitable for locating the tip position of the CVC. This prospective study included 160 patients who underwent hemodialysis at our hospital from March 2021 to December 2022. After inserting the CVC through the internal jugular vein, we used transthoracic echocardiography and CXR to determine the tip of the CVC and compared the results with those of computed tomography (CT). In the comparison between TTE and CXR for locating the CVC tip, we obtained three main findings. (1) TTE was associated with fewer misdiagnosed cases than CXR. (2) TTE provided higher sensitivity (similar sensitivity in position 2), specificity, positive/negative predictive values, and accuracy than CXR. (3) When comparing the receiver operating characteristic curves of TTE and CXR, the area under the curve (95% confidence interval) for the former was larger. Additionally, we made anatomical discoveries: the "hyperechoic triangle" recognized by TTE was equivalent to the entrance of the superior vena cava into the right atrium shown by transesophageal transthoracic echocardiography. TTE is more suitable than CXR as the first examination for CVC tip localization, as it improves diagnostic accuracy and reduces X-ray radiation damage.

Single-plane versus real-time biplane approaches for ultrasound-guided central venous catheterization in critical care patients: a randomized controlled trial.

BACKGROUND: Critical care patients often require central venous cannulation (CVC). We hypothesized that real-time biplane ultrasound-guided CVC would improve first-puncture success rate and reduce mechanical complications. The purpose of this study was to compare the success rate and safety of single-plane and real-time biplane approaches for ultrasound-guided CVC. METHODS: From October 2022 to March 2023, 256 participants with critical illness requiring CVC were randomized to either the single-plane (n = 128) or biplane (n = 128) ultrasound-guided cannulation groups. The success rate, number of punctures, procedure duration, incidence of catheterization-related complications, and confidence score of operators were documented. RESULTS: The central vein was successfully cannulated in all 256 participants (163 [64%] man and 93 [36%] women; mean age 69 ± 19 [range 13-104 years]), including 182 and 74 who underwent internal jugular vein cannulation (IJVC) and femoral vein cannulation (FVC), respectively. The incidence of successful puncture on the first attempt was higher in the biplane group than that in the single-plane group (91.6% vs. 74.7%; relative risk (RR), 1.226; 95% confidence interval (CI), 1.069-1.405; P = 0.002 for the IJVC and 90.9% vs. 68.3%; RR, 1.331; 95% CI, 1.053-1.684; P = 0.019 for the FVC). The biplane group was also associated with a higher first-puncture single-pass catheterization success rate (87.4% vs. 69.0% and 90.9% vs. 68.3%), fewer undesired punctures (1[1-1(1-2)] vs. 1[1-2(1-4)] and 1[1-1(1-3)] vs. 1[1-2(1-4)]), shorter cannulation time (205 s [162-283 (66-1,526)] vs. 311 s [243-401 (136-1,223)] and 228 s [193-306 (66-1,669)] vs. 340 s [246-499 (130-944)]), and fewer immediate complications (10.5% vs. 28.7% and 9.1% vs. 34.1%) for both IJVC and FVC (all P < 0.05). CONCLUSION: Real-time biplane imaging of ultrasound-guided CVCs offers advantages over the single-plane approach for critically ill patients. TRIAL REGISTRATION: This prospective RCT was registered at Chinese Clinical Trial Registry (ChiCTR2200064843). Registered 19 October 2022.