Ultrasound Guidance Improves Success Rate for Arterial Catheterisation in Critically Ill Hypotensive Patients: Presented at ISICEM

By Chris Berrie

BRUSSELS, Belgium -- March 23, 2018 -- Real-time ultrasound (US) guidance provides significant clinical benefits compared with standard palpation for radial artery catheterisation in critically ill patients with hypotension or those requiring vasopressins, according to a study presented here at the 38th International Symposium on Intensive Care and Emergency Medicine (ISICEM).

US guidance has been reported to improve the success rate of arterial catheterisation, based on greater success with the first attempt and reduced cannulation time.

“These have been done largely in preoperative and surgical patients, in children, and in the emergency department,” noted Jigeeshu Divatia, MD, Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Mumbai, India, on March 20.

Data remain scarce regarding ultrasound guidance for arterial cannulation in critically ill patients with hypotension or those requiring vasopressin infusion. Indeed, in this study, the patients presented in shock, were receiving resuscitation, and were mildly hypotensive at the time of cannulation.

In all, 100 patients were randomised to standard palpation (n = 51; mean age, 47.7 years; male, 56.9%) or real-time US guidance (n = 49; mean age, 52.3 years; male, 50.0%).

The mean patient baseline clinical characteristics were generally similar in the groups, with platelet counts of ~210 × 109, International normalised ratio for prothrombin of 1.3, arterial pressure of 66 mmHg, Acute Physiology and Chronic Health Evaluation II score of 20, and heart rate of 116 beats/min. However, the US-guidance group had significantly greater comorbidities (33.3% vs 62.5%; P = .005).

The primary outcome measure for first-pass success rate for palpitation versus US guidance demonstrated significant benefit for US guidance (41.1% vs 83.3%; P< .0001).

In regard to secondary outcomes, cannulation time was measured from first skin contact of either palpating fingers or US probe to successful cannulation, which was defined as complete placement of an arterial catheter with good pulsatile backflow. A single attempt was defined as 1 skin puncture, whereas a single pass was defined as a single passage of the needle after puncturing the skin without taking back the needle.

Although the final success rate was not significantly different between the techniques (84.3% vs 91.8%), US guidance was superior in significantly reducing mean time for successful catheterisation (cannulation time, 88.7 vs 72.9 s; P = .005) and showed a trend for fewer cannulation attempts (1.19 vs 1.07; P = .08).

The early-complication rate, including haematoma, haemorrhage, and spasm, was also significantly in favour of US guidance (27.5% vs 10.4%; P = .04).

“Although they need to get trained, and initially it is a struggle, most of our people are using ultrasound guidance for arterial cannulation now,” stated Dr. Divatia.

[Presentation title: Comparison of Real Time Ultrasound Guidance Versus Palpation Technique in Radial Artery Catheterization in Critically Ill Patients With Hypotension: A Randomized Controlled Trial. Abstract P267]

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