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Ultrasound transducer with dynamic visual aid improves out-of-plane vascular access: a feasibility study

2022; Elsevier BV; Volume: 129; Issue: 3 Linguagem: Inglês

10.1016/j.bja.2022.05.037

1471-6771

Harm J. Scholten, Yomi Hoever, Elke Kanters, Tamara Hoveling, Marco de Wild, Erik H.M. Korsten, R. Arthur Bouwman,

Hemodynamic Monitoring and Therapy

Editor—Out-of-plane ultrasonography-guided vascular access procedures can be challenging. Reported first-pass success rates vary from 81%1van Loon F.H.J. Buise M.P. Claassen J.J.F. Dierick-van Daele A.T.M. Bouwman A.R.A. Comparison of ultrasound guidance with palpation and direct visualisation for peripheral vein cannulation in adult patients: a systematic review and meta-analysis.Br J Anaesth. 2018; 121: 358-366Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar in peripheral cannulation to 51–95% for arterial catheter placement.2Tang L. Wang F. Li Y. et al.Ultrasound guidance for radial artery catheterization: an updated meta-analysis of randomized controlled trials.PLoS One. 2014; 9: e111527Crossref PubMed Scopus (72) Google Scholar Additionally, the complication rate increases with each subsequent attempt.3White L. Halpin A. Turner M. Wallace L. Ultrasound-guided radial artery cannulation in adult and paediatric populations: a systematic review and meta-analysis.Br J Anaesth. 2016; 116: 610Abstract Full Text Full Text PDF PubMed Scopus (83) Google Scholar,4Nuttall G. Burckhardt J. Hadley A. et al.Surgical and patient risk factors for severe arterial line complications in adults.Anesthesiology. 2015; 124: 590-597Crossref Scopus (93) Google Scholar During out-of-plane needling, the target is placed approximately under the midline of the probe, and the required angle is based on a trigonometric interpretation by the operator. As transducer position, entry point, and needle angle are based on estimations, they are prone to error. The needle tip can be advanced beyond the imaging plane inadvertently, as the needle tip and shaft can appear similar by ultrasonography.5Kiberenge R.K. Ueda K. Rosauer B. Ultrasound-guided dynamic needle tip positioning technique versus palpation technique for radial arterial cannulation in adult surgical patients.Anesth Analg. 2018; 126: 120-126Crossref PubMed Scopus (70) Google Scholar If unnoticed, this error can lead to posterior wall puncture (PWP) with subsequent failure of catheter placement.6Berk D. Gurkan Y. Kus A. Ulugol H. Solak M. Toker K. Ultrasound-guided radial arterial cannulation: long axis/in-plane versus short axis/out-of-plane approaches?.J Clin Monit Comput. 2013; 27: 319-324Crossref PubMed Scopus (80) Google Scholar We hypothesised that providing visual clues could optimise the needle entry point and might consequently improve outcomes of out-of-plane procedures. To test this, we equipped a linear L12-4 ultrasound transducer with an organic light-emitting diode (OLED) strip and screen (Fig 1). The OLED strip was connected to an Xperius touchscreen ultrasound machine (B. Braun, Melsungen, Germany and Philips Medical Systems, Eindhoven, the Netherlands) through an Arduino Microcontroller (Arduino, Ivrea, Italy). After touching the target on the ultrasound (US) screen, the OLED strip showed the corresponding horizontal position of the target relative to the transducer. Furthermore, after entering the desired angle of approach, the required distance from the entry point to the transducer to enter the vessel precisely in plane was shown. This suggestion was accompanied by a visual representation of the angle. We tested the device in a vascular phantom with a small vessel at ∼5 mm depth and a large vessel at ∼1.5 cm depth. Participants were either expert ultrasonographers (anaesthesiologists and intensivists, n=37) or ultrasound-naive users (anaesthetic nurses, n=32). Inexperienced users were allowed to perform practice punctures as desired. Participants performed the punctures individually to minimise bias. All participants performed one cannulation with the visual aid and one without the aid in each vessel. Participants were randomised to start with or without the device, and to start with the large or the small vessel. All attempts were performed at an angle of 45°. The study protocol was approved by the Medical Ethics Committee United (nWMO-2019.097). The primary endpoint was first-pass success, defined as a correct intravascular placement of the needle tip in one puncture. A correction of the direction of the needle before the needle tip was visible on the US screen was allowed, so in that case a successful first-pass was counted with a withdrawal. Secondary endpoints were the total number of punctures, procedure time (defined as breaking of the skin until correct placement of the needle tip), needle withdrawals >5 mm, and operator satisfaction. Primary and secondary endpoints were analysed using SPSS (version 27.0, SPSS Inc., Chicago, IL, USA) and included paired t-tests or Wilcoxon signed rank tests depending on data distribution. Proportions were compared using McNemar's test. First-pass success was higher with the dynamic visual aid, with a success rate of 92% (64/69) for the large vessel compared with 78% (54/60) without the visual aid (95% confidence intervals 87.0–98.6 vs 68.1–88.4, P=0.021). When targeting the small vessel, the difference was even greater: with visual assistance 70% (48/69) of the punctures were successful vs 42% (29/69) without assistance (95% confidence intervals 59.4–81 vs 30.4–53.6, P<0.001). Regarding the secondary endpoints, the number of punctures with the visual aid was lower for the small vessel but not for the large vessel. Fewer needle withdrawals were counted with the aid when targeting the large vessel (0.17 vs 0.55) and the small vessel (0.78 vs 1.93) (Supplementary Table S1). Operator satisfaction was higher with the aid, regardless of previous experience. Supplementary Tables S2 and S3 show the results for the inexperienced and experienced groups. Our results suggest that a dynamic visual aid improves first-pass success for ultrasound-guided out-of-plane vascular access, probably by optimising the needle entry point. The effect of the visual aid was greatest among inexperienced users, but experienced users still benefited from the aid when targeting the small vessel. Previous studies have shown that success rates can also be improved by other techniques, such as dynamic needle tip positioning, but those techniques require extensive practice.5Kiberenge R.K. Ueda K. Rosauer B. Ultrasound-guided dynamic needle tip positioning technique versus palpation technique for radial arterial cannulation in adult surgical patients.Anesth Analg. 2018; 126: 120-126Crossref PubMed Scopus (70) Google Scholar Technological innovations such as magnetism7Auyong D.B. Yuan S.C. Rymer A.N. Green C.L. Hanson N.A. A randomized crossover study comparing a novel needle guidance technology for simulated internal jugular vein cannulation.Anesthesiology. 2015; 123: 535-541Crossref PubMed Scopus (21) Google Scholar or specialised needle tips8Kåsine T. Romundstad L. Rosseland L.A. et al.The effect of needle tip tracking on procedural time of ultrasound-guided lumbar plexus block: a randomised controlled trial.Anaesthesia. 2020; 75: 72-79Crossref PubMed Scopus (8) Google Scholar have not consistently shown improvement in patient outcomes.9Scholten H.J. Pourtaherian A. Mihajlovic N. Korsten H.H.M. Bouwman R A. Improving needle tip identification during ultrasound-guided procedures in anaesthetic practice.Anaesthesia. 2017; 72: 889-904Crossref PubMed Scopus (61) Google Scholar The OLED screen on the transducer facilitates correct needle tip placement without the need for specialised needles or expensive hardware, even when used by inexperienced users. Moreover, by increasing the chance that the needle tip enters the vessel exactly below the transducer, the risk of posterior wall puncture is possibly reduced. Since the use of the visual aid benefitted both inexperienced and experienced users and both groups reported greater satisfaction, the present study suggests that the aid can improve workflow and facilitate obtaining competency in ultrasound-guided peripheral vascular access. A phantom study has its limitations. However, we show proof-of-principle that providing visual clues can improve out-of-plane ultrasound-guided procedures. Although we did not evaluate catheter placement, we did evaluate needle tip placement, which is the major determinant for failed catheter placement.5Kiberenge R.K. Ueda K. Rosauer B. Ultrasound-guided dynamic needle tip positioning technique versus palpation technique for radial arterial cannulation in adult surgical patients.Anesth Analg. 2018; 126: 120-126Crossref PubMed Scopus (70) Google Scholar A disadvantage of the aid was that unintentional movements of the probe were not followed by a subsequent correction of the marker. This would have required not only a real-time tracked probe, but also extensive software programming to establish communication between the tracked probe, the ultrasound machine, and the OLED marker, which was not within the scope of our resources. In summary, use of the visual aid led to significant improvement in first-pass success in out-of-plane procedures. Clinical studies should follow to determine whether vascular access accuracy can be improved or the incidence of posterior wall puncture reduced by integrating visual aids in ultrasonography, possibly in combination with a real-time tracked probe or 3D imaging. Conceptualised and designed the study: RAB, HHMK, HJS Developed the OLED enhanced probe: RAB, HHMK, TH, EK, MdW Collected data: YH Performed statistical analyses and drafted the manuscript: HJS Revised the manuscript for important intellectual content: RAB, HHMK, TH, EK, MdW, YH All authors take full responsibility for data integrity. S. Houterman provided assistance with the statistical analysis. L. van Hulst provided language help. RAB and HHMK have acted as clinical consultants for Philips Medical Research (Eindhoven, the Netherlands) since January 2016. All other authors declare no competing interests. The following are the Supplementary data to this article: Download .docx (.02 MB) Help with docx files Multimedia component 1 Download .docx (.02 MB) Help with docx files Multimedia component 2 Download .docx (.02 MB) Help with docx files Multimedia component 3