Access Success Rate Research Articles

Enhanced RACH optimization in IoT networks: A DQN approach for balancing H2H and M2M communications

A novel adaptive Deep Q-Network (DQN)-based algorithm is designed for the dynamic management of the Random Access Channel (RACH) in LTE networks, facilitating the coexistence of Human-to-Human (H2H) and Machine-to-Machine (M2M) communications. This algorithm employs the integration of user priority and block rate-based dynamic adjustment policies within the DQN framework, significantly enhancing service quality across cellular communications. By categorizing devices into three priority tiers based on their Quality of Service (QoS) requirements, the scheme enables dynamic allocation of RACH resources, thus effectively reducing collisions and enhancing network efficiency. Additionally, the implementation of a dual-criteria convergence check within the model ensures the algorithm’s robustness and reliability, offering a significant advancement in managing the intricate dynamics of M2M and H2H communications. This approach not only exhibits effectiveness in access success rates, reductions in access delay, and increased preamble utilization but also underscores the potential for further refinements in learning efficiency and overall performance through dynamic parameter adjustments. This innovative study offers valuable insights into optimizing RACH resources and sets a solid foundation for advancing intelligent network management in increasingly complex communication landscapes.

Factors associated with failure of intraosseous access in prehospital trauma treatment by military medical personnel

IntroductionIntraosseous devices have become an alternative to peripheral intravenous (PIV) access. Despite the established success of intraosseous devices in laboratory and simulator studies, there is a lack of data regarding...

Factors effecting the success of retrograde tibiopedal access and recanalization in infrapopliteal artery occlusions.

Peripheral arterial disease (PAD) is increasingly prevalent, particularly among the aging population. Retrograde tibiopedal access (RTPA) has emerged as a useful endovascular treatment for PAD. However, there is limited research examining factors that influence the efficacy of RTPA. To investigate factors affecting the access, crossing, and recanalization success rates of RTPA for infrapopliteal PAD treatment. A retrospective study was conducted on 720 patients who underwent endovascular treatment for PAD. Of these, 104 patients (mean age: 65.5 ± 16.2; 89 men) with 131 RTPA trials were included in the final evaluation. The disease and its duration, Rutherford score, smoking status, access site, and its occlusion status, access, crossing, and recanalization success were noted. Data were analyzed using Pearson's chi-square and Mann-Whitney U tests and multivariate logistic regression to evaluate the impact of various factors on success rates. The access success rate was 82.6%, the crossing success rate was 95.4%, and the recanalization success rate was 74%. Access success was significantly higher when the dorsal pedal artery (DPA) was the access artery compared with the posterior tibial artery (91.3% vs. 74.2%, P = 0.009). Access success was notably lower in patients with thromboangiitis obliterans compared with patients with diabetes mellitus (DM) and non-DM atherosclerosis (68.6% vs. 90.3% and 80.3%, P = 0.019). Recanalization success was higher when the puncture site was non-occluded (76.7% vs. 53.5%, P = 0.023). The study suggests that RTPA is a generally effective and safe technique for infrapopliteal PAD treatment. The most favorable outcomes are observed in individuals with DM who have a non-occluded DPA at the puncture site. Recanalization success is only affected by the patency of the artery at the puncture site. These findings offer targeted guidance for clinicians and highlight areas requiring further investigation.

The efficacy of technology-based devices on the first-attempt success rate for difficult intravenous access in pediatrics: A systematic review and network meta-analysis.

Previous studies have compared various technology-based devices, such as ultrasonography (USG), near-infrared (NIR), and transilluminator (TI), with standard care (SC) to facilitate peripheral intravenous cannulation (PIVC) in pediatric patients. This study aims to investigate the efficacy of these interventions on the first-attempt success rate (FASR) of PIVC in pediatric patients with difficult intravenous access (DIVA) using network meta-analysis (NMA). We conducted a comprehensive literature search in databases to identify randomized clinical trials comparing the effects of different devices on the FASR of PIVC from inception until August 2023. Pooled relative risks with 95% credible intervals were estimated using pairwise and network meta-analysis with random effects. To rank the efficacy of devices, we calculated the probabilities of the surface under the cumulative ranking curve (SUCRA). A total of 18 studies were included in the final analysis. The results of pairwise meta-analysis showed that the use of devices increased the FASR for PIVC by 13% (RR: 1.13, 95% CI: [0.98, 1.30]) compared to SC. The ranking of interventions based on efficacy from highest to lowest was as follows: USG (SUCRA: 1), NIR (SUCRA: 0.6), SC (SUCRA: 0.3), and TI (SUCRA: 0.1), with a very low confidence estimate. Based on our findings, the prioritization of device usage to increase the FASR of PIVC in pediatric patients with DIVA is as follows: USG, NIR, SC, and TI, respectively. However, due to inconsistencies in the network, existence of an overall high risk of bias in the included studies, and very low confidence estimate, further clinical trials are required.

Effectiveness of Radial Artery Positioning Board (RAPB) on Radial Artery Access and Prevention of Access Site Complications among Patients Admitted in Critical Care Units at Tertiary Care Hospital, Puducherry

Background: Radial artery access is a fundamental procedure in critical care settings, yet achieving optimal wrist extension poses challenges. This study investigates the efficacy of a novel intervention, the radial artery positioning board (RAPB), in enhancing radial artery access success rates and preventing access site complications among critically ill patients.  Methods: Employing a randomized controlled trial with a two-group post-tests only control design, 160 patients were enrolled using a block random sampling method. The study, conducted at a tertiary care hospital in Puducherry, utilized both descriptive and inferential statistical analyses to assess the outcomes.  Results: Analysis revealed a significant improvement in the success rates of radial artery access (z = -11.125, p < 0.05) and a notable reduction in access site complications (z = 7.938, p < 0.05) in the RAPB group compared to the control group. Furthermore, a positive correlation was established between successful radial artery access using RAPB and the prevention of access site complications (r = 0.504, p < 0.05).  Conclusion: The findings underscore the effectiveness of RAPB in facilitating early radial artery access with heightened success rates and diminished access site complications among critically ill patients. Additionally, body mass index and comorbidities exhibited statistically significant associations with radial artery access (p < 0.05), emphasizing the need for tailored interventions in this population.

First-Pass Success Rate of Small Vessel Arterial and Venous Access Using an Articulating-Tip Micro Guidewire – Initial International and US Experience

First-Pass Success Rate of Small Vessel Arterial and Venous Access Using an Articulating-Tip Micro Guidewire – Initial International and US Experience

The Outcome of the Miniaturized Percutaneous Nephrolithotomy in Lateral Position with Guidance of Non-Rotational C-Arm.

Evaluation of the outcome of the miniaturized percutaneous nephrolithotomy in the treatment of nephrolithiasis with a lateral position based on the principle of a right triangle under the guidance of a C-Arm without contrast fluid. Sixty-nine cases of Mini-PCNL with the assistance of a vacuum-assisted sheath in the lateral position were performed at Central Hospital from March 2021 to August 2022. Percutaneous renal access was under the guidance of a non-rotational C-arm without contrast medium, and we determined the puncture location and depth of the needle based on the principle of right triangles. The median age was 51.6 ± 12.5 years, and males accounted for 68.1% of the cases. 60.9% of all patients had normal weight. The median stone surface area was 361.1mm2, and 59.4% of all cases were graded as 2 regarding Guy's stone score. The successful renal access rate was 100%. The tunnel access from the middle and lower calyx accounted for 94.2%. The median access duration, fluoroscopy duration, and hospital length of stay were 271.7 seconds, 14.79 seconds, and 6.3 days, respectively. The complete stone clearance rate was 78.3%. Bleeding complications occurred in 2 patients without mortality. Three patients required an additional procedure. The puncture technique into the renal calyxes based on the principle of the right triangle under the guidance of a non-rotational C-Arm without contrast medium in PCNL is a fast, exact, and safe technique.

Percutaneous nephrolithotomy guided by 5G-powered robot-assisted teleultrasound diagnosis system: first clinical experience with a novel tele-assistance approach (IDEAL stage 1)

BackgroundTo demonstrate the technical feasibility of percutaneous nephrolithotomy (PCNL) guided by 5G-powered robot-assisted teleultrasound diagnosis system (RTDS) in a complex kidney-stone (CKS) cohort and present our preliminary outcomes. PCNL is highly skill-required, which hinders it popularization in primary medical units of remote regions. We designed an innovative tele-assistance approach to make PCNL easy to be operated by inexperienced surgeons.MethodsThis was a prospective proof-of-concept study (IDEAL phase 1) on intraoperative tele-assistance provided by online urological experts via a 5G-powered RTDS. Total 15 CKS patients accepted this technology. Online experts manipulated a simulated probe to assist unskilled local operators by driving a patient-side robot-probe to guide and monitor the steps of access establishment and finding residual stones.ResultsMedian total delay was 177ms despite one-way network-connecting distance > 5,800 km. No perceptible delay of audio-visual communication, driving robot-arm or dynamic ultrasound images was fed back. Successful tele-assistance was obtained in all cases. The first-puncture access-success rate was 78.6% with a one-session SF rate of 71.3% and without complications of grade III-V.ConclusionsThe current technology based on 5G-powered RTDS can provide high-quality intraoperative tele-assistance, which has preliminarily shown satisfactory outcomes and reliable safety. It will break down a personal competence-based barrier to endow PCNL with more popular utilization.Trial registrationThe study was approved by ethics committee of the Xinjiang Kezhou People’s Hospital and ethics committee of the First Affiliated Hospital of Nanjing Medical University and was registered on http://www.chictr.org.cn (ChiCTR2200065849, 16/11/2022).

Utilization of Point-of-Care Ultrasound as an Imaging Modality in the Emergency Department: A Systematic Review and Meta-Analysis.

Point-of-care ultrasound (POCUS) is an imaging modality that has become a fundamental part of clinical care provided in the emergency department (ED). The applications of this tool in the ED have ranged from resuscitation, diagnosis, and therapeutic to procedure guidance. This review aims to summarize the evidence on the use of POCUS for diagnosis and procedure guidance. To achieve this, CrossRef, PubMed, Cochrane Library, Web of Science, and Google Scholar databases were extensively searched for studies published between January 2000 and November 2023. Additionally, the risk of bias assessment was performed using the Quality Assessment of Diagnostic Accuracy Studies 2 (for studies on the diagnostic role of POCUS) and Cochrane Risk of Bias tool (for studies on the use of POCUS for procedure guidance). Furthermore, diagnostic accuracy outcomes were pooled using STATA 16 software (StatCorp., College Station, TX, USA), while outcomes related to procedure guidance were pooled using the Review Manager software. The study included 81 articles (74 evaluating the diagnostic application of POCUS and seven evaluating the use of POCUS in guiding clinical procedures). In our findings sensitivities and specificities for various conditions were as follows: appendicitis, 65% and 89%; hydronephrosis, 82% and 74%; small bowel obstruction, 93% and 82%; cholecystitis, 75% and 96%; retinal detachment, 94% and 91%; abscess, 95% and 85%; foreign bodies, 67% and 97%; clavicle fractures, 93% and 94%; distal forearm fractures, 97% and 94%; metacarpal fractures, 94% and 92%; skull fractures, 91% and 97%; and pleural effusion, 91% and 97%. A subgroup analysis of data from 11 studies also showed that the two-point POCUS has a sensitivity and specificity of 89% and 96%, while the three-point POCUS is 87% sensitive and 92% specific in the diagnosis of deep vein thrombosis. In addition, the analyses showed that ultrasound guidance significantly increases the overall success rate of peripheral venous access (p = 0.02) and significantly reduces the number of skin punctures (p = 0.01) compared to conventional methods. In conclusion,POCUS can be used in the ED to diagnose a wide range of clinical conditions accurately. Furthermore, it can be used to guide peripheral venous access and central venous catheter insertion.

Distal radial access for neuroangiography and neurointerventions: systematic review and meta-analysis

BackgroundMany studies have shown that coronary angiography (CAG) and percutaneous coronary intervention (PCI) via distal radial access (DRA) are safe and effective. Safety and efficacy of neuroangiography and neurointerventions via DRA are unknown.PurposeSearch the literatures on neuroangiography and neurointerventions via DRA and conduct a systematic review and meta-analysis.MethodsPubMed, Embase and Cochrane were searched from inception to November 10, 2022. After literature screening, data extraction and assessment of literature quality, random effects model was used for meta-analysis.ResultsA total of 236 literatures were retrieved, and 17 literatures including 1163 patients were finally included for meta-analysis.The pooled access success rate was 0.96 (95% confidence interval, 0.94–0.98), and the heterogeneity was obvious (I2 = 55.5%). The pooled access-related complications incidence rate was 0.03 (95% confidence interval, 0.02–0.05), and the heterogeneity was not obvious (I2 = 15.8%).ConclusionNeuroangiography and neurointerventions via DRA may be safe and effective. DRA is an alternative access for neuroangiography and neurointerventions.

Toward Fast and Energy-Efficient Access to Cloudlets in Hostile Environments

Cloudlets, which refer to the edge computing services deployed at the proximity of end devices, are key providers of connectivity, storage, and computation resources to many applications. While access to cloudlets is pervasive in typical settings, it can be difficult in challenging, even hostile environments, such as military or post-disaster scenarios, featuring multi-hop communication and energy-constrained end devices. In these cases, cloudlets may have become the only equipment powerful enough to execute life-critical applications, such as battle-field situation awareness, tactic cooperation, and search-and-rescue missions. Quality of these services is greatly influenced by the minimum time that a packet can be delivered, <italic xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">i.e</i> ., the <italic xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">cloudlet access delay</i> (CAD), whose characteristics remain unknown. To address the open question of fast and efficient cloudlet access, we establish a <italic xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">packet mobility</i> model that allows CAD and energy consumption to be analyzed as a function of the initial device-cloudlet distance. We find that the expected CAD scales either linearly or quadratically under distinct types of packet mobility, and the <italic xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">successful access rate</i> (SAR) can be bounded by functions of the delay constraint. Based on these findings, we develop a packet shedding algorithm that saves 24% transmission power, and reduces the average CAD by 2%, while maintaining a similar SAR in simulated cloudlet access environments.

Ultrasound Guidance for Vascular Access for Coronary Angiogram: A Meta-Analysis of Randomized Controlled Trials

Obtaining vascular access during percutaneous coronary intervention is necessary to facilitate the procedure but carries procedural risks that impact patient outcomes. Historically, vascular access has been accomplished using anatomic landmarks, pulsation, and/or fluoroscopic guidance. Ultrasound (US) guidance has emerged as a modality for achieving vascular access in a multitude of interventional procedures including those in the cardiac catheterization laboratory. US use has been demonstrated in randomized controlled trials and meta-analyses to be associated with an increased success rate for vascular access with fewer complications, although the data are mixed. We aimed to re-evaluate the totality of evidence in an updated meta-analysis to compare the ease of access and complications rates between US-guided and manual vascular access. A meta-analysis of 8 randomized controlled trials including 5,170 patients was performed. The primary outcome evaluated was the rate of access failure, and the secondary outcomes included hematomas and access site bleeding. US-guided arterial access was associated with a significantly higher rate of first-attempt success and a decreased risk of venipuncture. US use had a trend toward a lower total number of attempts, but the results were not significant. This updated meta-analysis further supports the use of US for vascular access for coronary angiography because of higher rates of first-attempt success and reduced venipuncture. However, there was no significant difference in vascular complications such as hematoma, pseudoaneurysm, and bleeding complications. Because of the high morbidity of bleeding complications associated with coronary angiography, further research should be done to reduce these complications.

The Efficacy of Preoperative Tamsulosin on Ureteroscopy Access in Pediatrics: A Systematic Review and Meta-Analysis

Objective: The incidence of urolithiasis in pediatrics increases to 4-10% annually. One of the methods for treating urolithiasis is ureteroscopy (URS). The small anatomy in pediatrics often makes the initial URS unsuccessful. Alpha blockers, a drug that can relax the ureteral muscles, is a therapy that can be considered before URS is carried out. The objective of this study is to evaluate the efficacy of preoperative tamsulosin for URS access in pediatrics. Materials and Methods: We conducted a search using four databases, including PubMed, EBSCO, Cochrane Library, and ProQuest. This study includes randomized controlled trials (RCTs), retrospective and prospective studies, which compared the efficacy of preoperative alpha blockers and placebo or non-placebo controls in pediatrics undergoing ureteroscopy. The outcome of interest was the success rate of URS access and the duration of surgery. Results: A total of 120 studies were identified from a database search. There were 3 studies included in this review involving 235 patients. The meta-analysis was conducted using a random-effects model. The results of the meta-analysis showed that alpha blockers provided a successful rate of ureteroscopy access in pediatric patients (Odds ratio (OR) 2.73; 95% confidence interval (CI) 1.52 up to 4.91; p=0.0008). Duration of surgery did not show significant results (Mean difference (MD) 3.46; 95% CI -3.59 up to 10.50; p=0.34).

Superficial venous morphometry in the antecubital fossa: An autonomous robotic ultrasound-based analysis.

The antecubital fossa is an important site for venepuncture and intravenous procedures. The size and location of a vein can affect the success of venepuncture and intravenous access. Several studies have investigated the superficial vein morphometry, but they had small sample sizes or focused on specific populations or groups. Therefore, we conducted a prospective study with large participants in general population to analyse the morphology of the antecubital superficial vein and identify the association of sex, age and body mass index (BMI) with the size and location of the vein. This study collected images of superficial veins prospectively using autonomous robotic ultrasound on the antecubital area between October and November 2020. We measured the superficial vein depth, vertical diameter and horizontal diameter at the antecubital area, extracted population characteristics (sex, age and BMI), and analysed a relationship between the vein dimensions and the characteristics. In this study, data from 461 participants (201 males and 260 females) with mean age of 41.1 years were produced. The mean vein depth, mean vertical diameter and mean horizontal diameter (±standard deviation) were 4.81 (±2.17), 3.01 (±1.10) and 4.46 (±1.60) mm, respectively. We found significant differences in vein dimensions between males and females, with males having larger vertical and horizontal diameters than females (p < 0.001). The study also revealed significant differences in vein depth and dimensions among age groups and BMI subgroups (p < 0.001). These findings revealed that the superficial vein in the antecubital area was oval, with a larger horizontal diameter than vertical diameter. Morphometry revealed differences in sex, age and BMI. Understanding variations in vein dimensions among different subgroups can help medical professionals improve success rate of venous access and patient safety.

Randomized trial of an oblique versus standard fluoroscopic-guided micropuncture technique for femoral arterial access: The Micropuncture-CFA trial

BackgroundThe anterior-posterior fluoroscopic guidance (the AP technique) is a standard method for common femoral artery (CFA) access, but the rate of CFA access with ultrasound vs. the AP technique was not significantly different. We have shown an oblique fluoroscopic guidance (the oblique technique) with a micropuncture needle (MPN) resulted in CFA access in 100 % of patients. The outcome of the oblique vs. AP technique is unknown. We compared the utilities of the oblique vs. AP technique for CFA access with a MPN in patients undergoing coronary procedures. MethodsA total of 200 patients were randomized to the oblique vs. AP technique. Using the oblique technique, a MPN was advanced to the mid pubis in the 20° ipsilateral right-or left anterior oblique view with fluoroscopic guidance and the CFA was punctured. In the AP technique, a MPN was advanced to the mid femoral head in the AP view with fluoroscopic guidance and the CFA was punctured. The primary endpoint was the rate of successful access to the CFA. ResultsThe rates of first pass and CFA access were higher with the oblique vs. AP technique (82 % vs. 61 %, and 94 % vs. 81 %, respectively; P < 0.01). The number of needle punctures was lower with the oblique vs. AP technique (1.1 ± 0.39 vs. 1.4 ± 0.78, respectively; P < 0.01). In high CFA bifurcations, the rate of CFA access was higher with the oblique vs. AP technique (76 % vs. 52 %, respectively; P < 0.01). Vascular complications were lower with the oblique vs. AP technique (1 % vs. 7 %, respectively; P < 0.05). ConclusionsOur data suggest that the oblique technique, compared with the AP technique, significantly increased the rates of first pass and access to the CFA, and decreased the number of punctures and vascular complication. Trial registrationClinicalTrials.gov Identifier: NCT 03955653.

Medication acquisition program: Successful access to innovative treatment options.

e18521 Background: Targeted treatments are often not available due to clinical, financial, and administrative barriers. Our medication acquisition program (MAP) serves our national network of cancer centers, helping patients gain access to off-label and scientifically appropriate targeted therapy and immunotherapy when access was unavailable due to the following barriers: clinical trial not available, patients with government insurance unable to afford copay, or insurance policy exclusion or denial for an off-label or on-label indication. The use of genomic testing is used increasingly to identify candidates for clinical trials. While our patients are always offered a clinical trial when available, they don’t always qualify. The goal of this study was to examine our success rate in acquiring medications and the clinical outcomes of those therapies. Methods: An IRB approved retrospective review was completed on patients who accessed targeted treatments that had an existing standard of care (SOC) indication in another tumor type or were being denied access for their on-label indication. For purposes of this study, we defined clinical benefit as treatment duration of 4 months or greater. Results: 1,041 referrals were received by our program between 10/1/2015 and 12/31/2021. While not all therapies referred and accessed were started, we have maintained a 99% success rate for access to these therapies with one dedicated oncology nurse. All therapies started were accessed through appeals to payers or through patient assistance programs. Of the 769 patients who started treatment, 507 (66%) were on therapy for 3 months or less, 120 (16%) were on therapy for 4 to 6 months, 64 (8%) were on therapy for 7 to 10 months, and 78 (10%) were on therapy for 11 months or more. 342 of patients starting therapy through MAP went on to progress and of those, 231 (68%) were able to receive another treatment for their cancer and continue treating at our center. Overall, this process has demonstrated a clinical benefit for 262 (34%) patients who were able to stay on therapy for four months or longer. Conclusions: A process for medication access overseen by one oncology certified nurse highly skilled and knowledgeable of access process as well as a lean methodology for execution has made innovative options for precision care accessible to 769 patients with advanced cancer. The number of patients who access and start treatment combined with the overall clinical benefit for these patients demonstrate how this efficient process, facilitated by nominal FTEs, can enable successful alternate access for patients seeking options. Our medication acquisition program has provided our patients access to targeted treatments that would have otherwise not been available while enhancing our center’s ability to offer innovative options to patients who have exhausted SOC options.

Fortune favors the experienced: entrepreneurs’ Internet-Era Imprint, digital entrepreneurship and venture capital

This study focuses on entrepreneurs’ Internet-era imprint and its effect on the level of digital entrepreneurship and entrepreneurial firms’ venture capital. From the perspective of imprinting theory and signaling theory, we find that entrepreneurs with Internet-era imprint are more willing to use digital technologies in their entrepreneurial process, which raises the level of digital entrepreneurship within a firm. Imprint-driven digital entrepreneurship acts as a quality signal to increase the success rate of access to venture capital from financial institutions. In addition, venture capital providers do not value the entrepreneurs’ personal socioeconomic status for easier access to external resources, but rather their Internet-era imprint, which is more relevant to the success of digital entrepreneurship. Our hypotheses are supported using data from the Chinese private entrepreneurial firms in 2016. Overall, our efforts to extend imprinting theory to digital entrepreneurship literature suggest that the Internet-era imprint persists in the digital entrepreneurial process. Moreover, this study enriches the signaling mechanisms in entrepreneurial venture capital research by conceptualizing digital entrepreneurship as a signal.

Preamble slice orderly queue access scheme in cell-free dense communication systems

High reliability applications in dense access scenarios have become one of the main goals of 6G environments. To solve the access collision of dense Machine Type Communication (MTC) devices in cell-free communication systems, an intelligent cooperative secure access scheme based on multi-agent reinforcement learning and federated learning is proposed, that is, the Preamble Slice Orderly Queue Access (PSOQA) scheme. In this scheme, the preamble arrangement is combined with the access control. The preamble arrangement is realized by preamble slices which is from the virtual preamble pool. The access devices learn to queue orderly by deep reinforcement learning. The orderly queue weakens the random and avoids collision. A preamble slice is assigned to an orderly access queue at each access time. The orderly queue is determined by interaction information among multiple agents. With the federated reinforcement learning framework, the PSOQA scheme is implemented to guarantee the privacy and security of agents. Finally, the access performance of PSOQA is compared with other random contention schemes in different load scenarios. Simulation results show that PSOQA can not only improve the access success rate but also guarantee low-latency tolerant performances.

Association Between Profound Shock Signs and Peripheral Intravenous Access Success Rates in Trauma Patients in the Prehospital Scenario: A Retrospective Study.

Hemorrhage is the leading cause of preventable death in trauma patients, and establishment of intravenous (IV) access is essential for volume resuscitation, a key component in the treatment of hemorrhagic shock. IV access among patients in shock is generally considered more challenging, although data to support this notion are lacking. In this retrospective registry-based study, data were collected from the Israeli Defense Forces Trauma Registry (IDF-TR) regarding all prehospital trauma patients treated by IDF medical forces between January 2020 and April 2022, for whom IV access was attempted. Patients younger than 16 years, nonurgent patients, and patients with no detectable heart rate or blood pressure were excluded. Profound shock was defined as a heart rate >130 or a systolic blood pressure <90 mm Hg, and comparisons were made between patients with profound shock and those not exhibiting such signs. The primary outcome was the number of attempts required for first IV access success, which was regarded as an ordinal categorical variable: 1, 2, 3 and higher and ultimate failure. A multivariable ordinal logistic regression was performed to adjust for potential confounders. Patients' sex, age, mechanism of injury and best consciousness level, as well as type of event (military/nonmilitary), and the presence of multiple patients were included in the ordinal logistic regression multivariable analysis model based on previous publications. Five hundred thirty-seven patients were included, 15.7% of whom were recorded as having signs of profound shock. Peripheral IV access establishment first attempt success rates were higher in the nonshock group, and there was a lower rate of unsuccessful attempts in this group (80.8% vs 67.8% for the first attempt, 9.4% vs 16.7% for the second attempt, 3.8% vs 5.6% for the third and further attempts, and 6% vs 10% unsuccessful attempts, P = .04). In the univariable analysis, profound shock was associated with requirement for an increased number of IV attempts (odds ratio [OR], 1.94; confidence interval [CI], 1.17-3.15). The ordinal logistic regression multivariable analysis demonstrated that profound shock was associated with worse results regarding primary outcome (adjusted odds ratio [AOR], 1.84; CI, 1.07-3.10). The presence of profound shock in trauma patients in the prehospital scenario is associated with an increased number of attempts required for IV access establishment.

397 Direct Carotid Puncture for Mechanical Thrombectomy After Failed Peripheral Access: A Systematic Review and Meta-Analysis

INTRODUCTION: Direct carotid puncture (DCP) is an alternative route for mechanical thrombectomy (MT), especially in patients with difficult anatomy preventing access through the femoral or radial routes. However, DCP has increased morbidity and mortality due to access site complications related to cervical hematomas. METHODS: A systematic search of electronic databases from inception to March 2022 identified 197 related articles for screening. After applying inclusion and exclusion criteria, 10 studies were included, and data was extracted and analyzed using meta-analysis of proportions. RESULTS: 213 patients were included in this analysis, of which 44% also received intravenous thrombolysis. The overall success rate was 84% (95% CI, 73.66–90.85%; I2 = 25.6%; p = 0.64). The average time to recanalization was 30.33 minutes (95%CI, 23.04–37.62 min; I2 = 89.5%; p &lt; 0.01) and 74% had good reperfusion (TICI &gt;2a) (95% CI, 67–79%; I2 = 0%; p = 0.81). The overall complication rate was 20.38% (95%CI, 15.48–26.35%; I2 = 0%; p = 0.55). The rate of cervical hematomas was 18% (95% CI, 12–16%; I2 = 70%; p = 0.27), of which 24.92% required surgical evacuation (95% CI, 27.5–95.9%; I2 = 70%; p = 0.67). Other reported complications included carotid dissection, pseudoaneurysm, jugular vein puncture, and stroke related to access. The 90-day mortality rate from all causes was 35% based on 7 studies (95% CI, 22.5– 49.9%; I2 = 44.8%; p = 0.08). The mRS at last follow-up was 4.09 (95% CI, 3.68–4.49; I2 = 6.8%; p = 0.37). CONCLUSIONS: DCP is a reasonable alternative in patients that fail femoral and radial access for MT and the success rate of access with DCP is 84% with a TICI 2B or TICI 3 achieved in 74% of patients. The complications are mostly related to bleeding at the access site. The high rate of morbidity and mortality warrant further studies to improve the safety of DCP.