Radial Artery Catheter Research Articles

СРАВНЕНИЕ ДВУХ МЕТОДИК КАТЕТЕРИЗАЦИИ ЛУЧЕВОЙ АРТЕРИИ: ПАЛЬПАТОРНОЙ И С УЛЬТРАЗВУКОВЫМ КОНТРОЛЕМ

Anatomical landmarks and palpation are traditionally used for radial arterial catheterization in emergency units. Despite the successful use of ultrasound monitoring for central venous access, there is a lack of evidence about the benefits of the ultrasound guidance for peripheral arterial cannulation. The objective: to compare two methods of radial arterial catheterization (the traditional one based on palpation and the method under ultrasound guidance) in the patients undergoing planned surgery. Subjects and methods. 40 patients participated in the prospective cohort study, all of them had planned surgeries. In Group 1, the traditional method was used for arterial catheterization (the palpation group), and in Group 2 it was done under ultrasound guidance (the ultrasound group). The following parameters were recorded for both groups: number of attempts, number of puncture sites, complications and their type, time of catheterization. The number of cannulation attempts was taken as a primary endpoint. Results. The statistically significant correlation was found between the method of catheterization and the number of attempts (Pearson's ch i-s quared test = 29.562, df = 6, p < 0.001), places of puncture (Pearson's ch i-s quared test = 10.365, df = 3, p = 0.015). In the ultrasound group, the first attempt of cannulation was a success in 19 cases (95%; CI 73−99%), while in the palpation group, the first attempt was a success in 2 cases (10%; CI 2−33%). The one catheterization site was used in 95% of cases in the ultrasound group ( CI 73−99%; 1 observation). While in Group 2 (the palpation group), two sites of cannulation and more were required in 50% of patients ( CI 30−17%; 10 observations). Among complications there were hematomas, and no statistically significant correlations were found between the method of puncture and their number in the groups (Pearson's ch i-s quared test = 2.7706, df = 1, p = 0.09601). The time spent on catheterization in the ultrasound group was shorter versus the palpation group (W = 344, p < 0.001) and it made 101 sec. (51; 144) and 194 sec. (153; 311) respectively. Conclusion: Compared to the traditional (palpation) method, the radial arterial catheterization guided by ultrasound possesses such benefits as high chances of successful cannulation with the first attempt, fewer sites required to provide arterial access and total time required for the manipulation.

Ultrasound-Guided Radial Artery Catheterisation Increases the Success Rate among Anaesthesiology Residents: A Randomised Study

The palpation technique is generally used for radial artery catheterisation, but is associated with a high rate of failure and complications. Dynamic needle tip positioning (DNTP) is a new ultrasound-guided technique. We aimed to compare the traditional palpation technique with DNTP performed by four anaesthesiology residents. The study was a randomised, controlled, patient-blinded, crossover study. Fourty patients underwent bilateral radial artery catheterisation using both techniques. The primary endpoint was the first attempt success rate. The secondary endpoints were: 1) number of skin perforations, 2) number of needle retractions, 3) needle manipulation time, 4) total time, 5) attempts lasting >180 seconds, 6) number of catheters used, 7) frequency of aborted attempts or crossovers, and 8) pain scores (VAS). The first attempt success rate was significantly higher in the DNTP group compared with the palpation group (36/40 vs. 28/40, p = 0.022).The palpation technique group required a higher number of skin perforations (44 vs. 60, p = 0.016), needle retractions (p = 0.001) and catheters (42 vs. 52, p = 0.011) compared with the DNTP group. Neither the total time required for arterial catheterisation, the needle manipulation time nor the VAS scores were significantly different between the groups (all p>0.407). Aborted attempts were only seen in the palpation group (7/40, p = 0.016). Ultrasound-guided arterial catheterisation using the DNTP technique is superior to the standard palpation technique. This study favours the ultrasound-guided DNTP technique as the first choice rather than merely being viewed as a rescue procedure.

Validation of radial artery-based uncalibrated pulse contour method (PulsioFlex) in critically ill patients: A observational study.

Because of their simplicity, uncalibrated pulse contour (UPC) methods have been introduced into clinical practice in critical care but are often validated with a femoral arterial waveform. We aimed to test the accuracy of cardiac index (CI) measurements and trending ability from a radial artery with one UPC. An observational study. Tertiary care mixed-surgical ICU. Data were obtained from April 2015 to July 2016. We studied 20 critically ill mechanically ventilated patients monitored by UPC (PulsioFlex; Pulsion Medical Systems SE, Feldkirchen, Germany). We used transpulmonary thermodilution (PiCCO2) as a reference. Bland-Altman-analyses with percentage errors were calculated to assess the accuracy of CI values from radial pulse contour analysis (CIRAD), autocalibration (CIAC) and femoral pulse contour analysis (CIFEM). All were compared with a reference (CITD) at 4-h intervals for 24 h. Trending ability was assessed by polar-plots and four-quadrant-plots. CI is given in l min m. Bland-Altman-analyses: for CIRAD, the mean bias was -0.1 with limits of agreement (LOA) of -2.9 to 2.7 and a percentage error of 70%; for CIAC, the mean bias was 0 with LOA -2.8 to 2.7 and a percentage error of 70%; for CIFEM, the mean bias was 0 with LOA -1.2 to 1.2 and a percentage error of 30%, respectively. Polar plots for trending: for CIRAD, the angular bias was 12° with radial LOA of 39°, a polar concordance rate of 73% and a concordance rate of 67% in the four-quadrant-plot; for CIAC, the angular bias was 4° with radial LOA of 41°, polar concordance rate of 79% and a concordance rate of 74% in the four quadrant plot; for CIFEM, the angular bias was -2° with radial LOA of 50°, polar concordance rate of 74% and a concordance rate of 81%. In critically ill patients, the PulsioFlex system connected to a radial arterial catheter is inaccurate for CI measurements and does not track changes in CI adequately. We therefore recommend using validated thermodilution techniques for monitoring in the critical care setting.

Physiological dead space and arterial carbon dioxide contributions to exercise ventilatory inefficiency in patients with reduced or preserved ejection fraction heart failure.

Patients with heart failure (HF) with reduced (HFrEF) or preserved (HFpEF) ejection fraction demonstrate an increased ventilatory equivalent for carbon dioxide (V̇E /V̇CO2 ) slope. The physiological correlates of the V̇E /V̇CO2 slope remain unclear in the two HF phenotypes. We hypothesized that changes in the physiological dead space to tidal volume ratio (VD /VT ) and arterial CO2 tension (PaCO2 ) differentially contribute to the V̇E /V̇CO2 slope in HFrEF vs. HFpEF. Adults with HFrEF (n = 32) and HFpEF (n = 27) [mean ± standard deviation (SD) left ventricular ejection fraction: 22 ± 7% and 61 ± 9%, respectively; mean ± SD body mass index: 28 ± 4 kg/m2 and 33 ± 6 kg/m2 , respectively; P < 0.01] performed cardiopulmonary exercise testing with breath-by-breath ventilation and gas exchange measurements. PaCO2 was measured via radial arterial catheterization. We calculated the V̇E /V̇CO2 slope via linear regression, and VD /VT = 1 - [(863 × V̇CO2 )/(V̇E × PaCO2 )]. Resting VD /VT (0.48 ± 0.08 vs. 0.41 ± 0.11; P = 0.04), but not PaCO2 (38 ± 5 mmHg vs. 40 ± 3 mmHg; P = 0.21) differed between HFrEF and HFpEF. Peak exercise VD /VT (0.39 ± 0.08 vs. 0.32 ± 0.12; P = 0.02) and PaCO2 (33 ± 6 mmHg vs. 38 ± 4 mmHg; P < 0.01) differed between HFrEF and HFpEF. The V̇E /V̇CO2 slope was higher in HFrEF compared with HFpEF (44 ± 11 vs. 35 ± 8; P < 0.01). Variance associated with the V̇E /V̇CO2 slope in HFrEF and HFpEF was explained by peak exercise VD /VT (R2 = 0.30 and R2 = 0.50, respectively) and PaCO2 (R2 = 0.64 and R2 = 0.28, respectively), but the relative contributions of each differed (all P < 0.01). Relationships between the V̇E /V̇CO2 slope and both VD /VT and PaCO2 are robust, but differ between HFpEF and HFrEF. Increasing V̇E /V̇CO2 slope appears to be strongly explained by mechanisms influential in regulating PaCO2 in HFrEF, which contrasts with the strong role of increased VD /VT in HFpEF.

Use of 'ideal' alveolar air equations and corrected end-tidal PCO2 to estimate arterial PCO2 and physiological dead space during exercise in patients with heart failure.

Arterial CO2 tension (PaCO2) and physiological dead space (VD) are not routinely measured during clinical cardiopulmonary exercise testing (CPET). Abnormal changes in PaCO2 accompanied by increased VD directly contribute to impaired exercise ventilatory function in heart failure (HF). Because arterial catheterization is not standard practice during CPET, this study tested the construct validity of PaCO2 and VD prediction models using 'ideal' alveolar air equations and basic ventilation and gas-exchangegas exchange measurements during CPET in HF. Forty-seven NYHA class II/III HF (LVEF=21±7%; age=55±9years; male=89%; BMI=28±5kg/m2) performed step-wise cycle ergometry CPET to volitional fatigue. Breath-by-breath ventilation and gas exchange were measured continuously. Steady-state PaCO2 was measured at rest and peak exercise via radial arterial catheterization. Criterion VD was calculated via 'ideal' alveolar equations, whereas PaCO2 or VD models were based on end-tidal CO2 tension (PETCO2), tidal volume (VT), and/or weight. Criterion measurements of PaCO2 (38±5 vs. 33±5mmHg, P<0.01) and VD (0.26±0.07 vs. 0.41±0.15L, P<0.01) differed at rest vs. peak exercise, respectively. The equation, 5.5+0.90×PETCO2-0.0021×VT, was the strongest predictor of PaCO2 at rest and peak exercise (bias±95%LOA=-3.24±6.63 and -0.98±5.76mmHg; R2=0.57 and 0.75, P<0.001, respectively). This equation closely predicted VD at rest and peak exercise (bias±95%LOA=-0.03±0.06 and -0.02±0.13L; R2=0.86 and 0.83, P<0.001, respectively). These data suggest predicted PaCO2 and VD based on breath-by-breath gas exchange and ventilatory responses demonstrate acceptable agreement with criterion measurements at peak exercise in HF patients. Routine assessment of PaCO2 and VD can be used to improve interpretability of exercise ventilatory responses in HF.

Endovascular treatment for acute basilar thrombosis via a transradial approach: Initial experience and future considerations.

Acute basilar artery occlusion (BAO) secondary to emergent large vessel occlusion (ELVO) has an extremely poor natural history, with a reported mortality rate up to 95%. Mechanical thrombectomy in the setting of ELVO is generally performed via a transfemoral approach. However, radial access is increasingly being utilized as an alternative. We report our initial multi-institutional experience using primary radial access in the treatment of acute BAO in nine consecutive cases. Technical success defined as a TICI score of 2B or 3 was achieved in 89% of cases. Average puncture to revascularization time was 35.8 minutes. There were no complications related to radial artery catheterization. We contend radial access should potentially be considered as the first-line approach given inherent advantages over femoral access for mechanical thrombectomy for BAO.

Iatrogenic carpal tunnel syndrome induced by wrist extension for placement of an indwelling radial artery catheter: a case report

A 38-year-old man with pancreatic cancer was scheduled to undergo pancreaticoduodenectomy. He had an unremarkable past medical history. After inducing general anesthesia, a left radial arterial catheter was successfully placed at first attempt. A wrist splint was used to obtain good arterial pulse waveforms.After the operation, he was transferred to the intensive care unit. The radial artery catheter was removed on the fourth postoperative day. He experienced numbness and a tingling sensation in the left thumb, the second and third fingers, and the lateral half of the fourth finger. He was diagnosed with carpal tunnel syndrome. Diagnostic imaging revealed a swollen median nerve, but no hematoma or injury.Some studies have suggested that excessive extension of the wrist may cause neuropathy. We recommend that patients’ wrists not be over-extended, even if good arterial waveforms cannot be obtained.

Regional cerebral saturation monitoring during withdrawal of life support until death

AimsThe aim of this pilot study was to explore the regional cerebral oxygen saturation (rSO2) during the process of dying in Intensive Care Unit (ICU) patients in whom it was decided to withdraw life support. MethodsRegional cerebral saturation was measured from the moment active treatment was stopped until the moment of death, defined as the onset of asystole. Simultaneously, heart rate and arterial blood pressure were recorded using a radial arterial catheter. Baseline rSO2 values were calculated as mean values over one hour in stable haemodynamic conditions immediately after the decision to withdraw life support. ResultsCerebral saturation was measured in six dying ICU patients. The mean age of patients was 64year. The median baseline rSO2 value was 64% (58%–68%). At time of death, median rSO2 was 33% (7%–40%). The median decrease in rSO2 from baseline until death was 31% (25%–45%). The median decrease in rSO2 observed during the last hour before time of death was 20% (12%–31%). ConclusionA continuous and patient specific decrease in rSO2 was observed in all patients with a simultaneous decrease in MAP. However, the absolute rSO2 value at moment death was clinically determined, had a broad range, indicating that there is no clear cut-off rSO2 value for death probably due to the heterogeneity of the studied population. Taken together, these observations highlight the importance of following trends and comparing rSO2 values in the cardiac arrest setting.

Intravascular catheters-an ultrasound imaging based observational study of position and function.

Peripheral intravenous and intra-arterial catheters often block with movement of the limb in which they are inserted. Although the cause of this blockage is commonly attributed to a valve or other structure within the vein, evidence for this is lacking. We used ultrasound to assess the cause of blockage on movement, and degree of tip movement, of 62 venous and 21 radial arterial catheters. In both venous and arterial catheters, blockage was predominantly caused by impingement of the catheter on the vessel wall, with catheter kinking and spasm of the vessel also seen. Mean potential tip movement was 12.3 mm and 5.7 mm in hand and forearm venous catheters respectively and 9.5 mm in radial artery catheters. There was a significantly lower rate of blockage for forearm (20%) compared to dorsal hand venous catheters (83%, P <0.001) and 52% of radial artery catheters showed damping and blockage on wrist flexion. This study emphasises the advantages of placement of venous catheters in the straight veins of the forearm.

Brachial Arterial Pressure Monitoring during Cardiac Surgery Rarely Causes Complications.

Brachial arterial catheters better estimate aortic pressure than radial arterial catheters but are used infrequently because complications in a major artery without collateral flow are potentially serious. However, the extent to which brachial artery cannulation promotes complications remains unknown. The authors thus evaluated a large cohort of cardiac surgical patients to estimate the incidence of related serious complications. The institutional Society of Thoracic Surgeons Adult Cardiac Surgery Database and Perioperative Health Documentation System Registry of the Cleveland Clinic were used to identify patients who had brachial artery cannulation between 2007 and 2015. Complications within 6 months after surgery were identified by International Classification of Diseases, Ninth Revision diagnostic and procedural codes, Current Procedural Terminology procedure codes, and Society of Thoracic Surgeons variables. The authors reviewed electronic medical records to confirm that putative complications were related plausibly to brachial arterial catheterization. Complications were categorized as (1) vascular, (2) peripheral nerve injury, or (3) infection. The authors evaluated associations between brachial arterial complications and patient comorbidities and between complications and in-hospital mortality and duration of hospitalization. Among 21,597 qualifying patients, 777 had vascular or nerve injuries or local infections, but only 41 (incidence 0.19% [95% CI, 0.14 to 0.26%]) were potentially consequent to brachial arterial cannulation. Vascular complications occurred in 33 patients (0.15% [0.10 to 0.23%]). Definitely or possibly related infection occurred in 8 (0.04% [0.02 to 0.08%]) patients. There were no plausibly related neurologic complications. Peripheral arterial disease was associated with increased risk of complications. Brachial catheter complications were associated with prolonged hospitalization and in-hospital mortality. Brachial artery cannulation for hemodynamic monitoring during cardiac surgery rarely causes complications.

Epinephrine Does Not Influence Baroreflex Sensitivity During Lower Body Negative Pressure to Physiological Tolerance

BackgroundThe baroreflex plays an integral role in blood pressure maintenance by altering heart rate and sympathetic activity in response to changes in arterial pressure. Baroreflex sensitivity (BRS) has been shown to decrease linearly during progressive exposure to central hypovolemia as induced by lower body negative pressure (LBNP), and can be used as an index of decompensation status during hemorrhage. Circulating epinephrine is significantly elevated during high stress situations such as hemorrhage; however, it is unclear whether epinephrine influences BRS during progressive exposure to central hypovolemia. Based on previous work, we hypothesized epinephrine would attenuate any reduction in spontaneous cardiac baroreflex sensitivity during LBNP.MethodsTen young (35±3 yrs), healthy (BMI 24±1 kg/m2) men and women (6M/4F) underwent LBNP protocols on 2 separate days consisting of a 10‐min pre‐infusion baseline, 15‐min infusion period (randomized to saline or epinephrine, 0.1 μg/kg/min), 10‐min post‐infusion baseline, and 5 minutes of LBNP at −15, −30, −45, −60, −70, and −80 mmHg until the onset of presyncope (range= −30 to −80 mmHg). Presyncope was defined as a rapid decrease in systolic blood pressure greater than 15 mmHg, systolic blood pressure less than 80 mmHg, bradycardia, or voluntary termination due to presyncopal symptoms. Heart rate (HR; electrocardiogram) and blood pressure (BP; radial arterial catheter) were recorded continuously. Spontaneous cardiac BRS was determined using the sequence method (WinCPRS). Data are reported from both 10‐min baselines and from 1 minute at 20, 40, 60, 80, and 100 percent of each individual's total LBNP exposure time.ResultsWe observed no significant differences in total exposure time (1475±150 vs. 1415±79s; p=0.69) or cumulative stress index (820±135 vs. 699±69 min*mmHg; p=0.37) between saline and epinephrine visits, respectively. Baroreflex sensitivity did not change during post‐infusion baselines (ΔDown‐Down =−2±1 vs. −2±2 ms/mmHg; saline vs. epinephrine, respectively; p=0.09). Baroreflex sensitivity was significantly reduced with LBNP (p&lt;0.01 main effect of LBNP). There was no difference between the change in baroreflex sensitivity during LBNP with saline or epinephrine infusion (ΔDown‐Down =−14±4 vs. −8±4 ms/mmHg, p=0.17).ConclusionsConsistent with previous work, spontaneous cardiac baroreflex sensitivity fell during LBNP. Contrary to our hypothesis, epinephrine infusion did not attenuate the fall in spontaneous cardiac baroreflex sensitivity observed during simulated blood loss. Because epinephrine did not alter the effect of LBNP on BRS, these data suggest that BRS may accurately reflect decompensation status during traumatic hemorrhage independent of elevated circulating epinephrine.Support or Funding InformationUS Army Medical Research and Materiel Command Contract W81XWH‐13‐2‐0038

Group III/IV muscle afferents contribute to carotid baroreflex resetting during evoked contractions in humans

BackgroundArterial baroreflexes play an important role in the control and regulation of the cardiovascular response to exercise. In fact, carotid baroreflex control of arterial blood pressure needs to be reset during exercise to tolerate the higher blood pressures associated with physical activities. This resetting of carotid baroreflex control to operate at a higher blood pressure during exercise is thought to be mediated by both feedback and feed forward mechanisms.PurposeTo investigate the contribution of group III/IV muscle afferents to the carotid baroreflex control during evoked quadriceps contractions, devoid of feed forward input (i.e. no central command).MethodsEight recreationally active males (29 ± 5 yrs) performed electrically evoked isometric quadriceps contractions for 10 min (femoral nerve stimulation, 40 Hz, 50‐s on, 10‐s off) under control conditions (CTRL) and following lumbar intrathecal fentanyl (FENT) injection to impair feedback from μ‐opioid receptor sensitive lower limb muscle afferents. Carotid baroreflex function was assessed by applying rapid 5‐s pulses of neck pressure (NP, +40 mmHg) or suction (NS, −60 mmHg) via a customized collar. Heart rate (HR) and mean arterial pressure (MAP) were derived from a 12‐lead ECG and a radial arterial catheter, respectively. The carotid baroreflex operating point was determined using the average pre‐stimulus values for HR and MAP.ResultsResting HR (~70 bpm) and MAP (~87 mmHg) were similar between CTRL and FENT conditions (P &gt; 0.4). FENT administration did not alter the cardiac response to NP (+9 ± 3 bpm; P = 0.99) or NS (−24 ± 11 bpm; P = 0.49) at rest. Similarly, FENT did not alter changes in MAP in response to NP (+13 ± 5 mmHg; P = 0.85) or NS (−13 ± 5 mmHg; P = 0.99) at rest. During exercise, FENT attenuated both HR (82 ± 10 bpm vs 93 ± 14 bpm; P &lt; 0.05) and MAP (100 ± 14 mmHg vs 112 ± 14 mmHg; P &lt; 0.05). However, similar to resting responses (P &gt; 0.4), the cardiac response to NP (+11 ± 4 bpm) or NS (−23 ± 9 bpm) was similar during CTRL and FENT exercise (P &gt; 0.5). Furthermore, changes in MAP in response to NP (+12 ± 4 mmHg) or NS (−14 ± 5 mmHg) were similar during CTRL and FENT exercise (P &gt; 0.4).ConclusionInhibition of group III/IV muscle afferents during evoked muscle contractions reduced the operating point for both HR and MAP, suggesting this feedback pathway is important for carotid baroreflex resetting during exercise. However, carotid baroreflex responsiveness at rest and during exercise was preserved despite muscle afferent blockade, indicating that group III/IV muscle afferents do not govern the carotid baroreflex control of HR and MAP.Support or Funding InformationThe authors were supported by National Heart, Lung, and Blood Institute grants (HL‐103786 and HL‐116579) and a Veterans Affairs Spire grant (E1572P).

Continuous Non-invasive finger cuff CareTaker\xae comparable to invasive intra-arterial pressure in patients undergoing major intra-abdominal surgery

BackgroundDespite increased interest in non-invasive arterial pressure monitoring, the majority of commercially available technologies have failed to satisfy the limits established for the validation of automatic arterial pressure monitoring by the Association for the Advancement of Medical Instrumentation (AAMI). According to the ANSI/AAMI/ISO 81060–2:2013 standards, the group-average accuracy and precision are defined as acceptable if bias is not greater than 5 mmHg and standard deviation is not greater than 8 mmHg. In this study, these standards are used to evaluate the CareTaker® (CT) device, a device measuring continuous non-invasive blood pressure via a pulse contour algorithm called Pulse Decomposition Analysis.MethodsA convenience sample of 24 patients scheduled for major abdominal surgery were consented to participate in this IRB approved pilot study. Each patient was monitored with a radial arterial catheter and CT using a finger cuff applied to the contralateral thumb. Hemodynamic variables were measured and analyzed from both devices for the first thirty minutes of the surgical procedure including the induction of anesthesia. The mean arterial pressure (MAP), systolic and diastolic blood pressures continuously collected from the arterial catheter and CT were compared. Pearson correlation coefficients were calculated between arterial catheter and CT blood pressure measurements, a Bland-Altman analysis, and polar and 4Q plots were created.ResultsThe correlation of systolic, diastolic, and mean arterial pressures were 0.92, 0.86, 0.91, respectively (p < 0.0001 for all the comparisons). The Bland-Altman comparison yielded a bias (as measured by overall mean difference) of −0.57, −2.52, 1.01 mmHg for systolic, diastolic, and mean arterial pressures, respectively with a standard deviation of 7.34, 6.47, 5.33 mmHg for systolic, diastolic, and mean arterial pressures, respectively (p < 0.001 for all comparisons). The polar plot indicates little bias between the two methods (90%/95% CI at 31.5°/52°, respectively, overall bias = 1.5°) with only a small percentage of points outside these lines. The 4Q plot indicates good concordance and no bias between the methods.ConclusionsIn this study, blood pressure measured using the non-invasive CT device was shown to correlate well with the arterial catheter measurements. Larger studies are needed to confirm these results in more varied settings. Most patients exhibited very good agreement between methods. Results were well within the limits established for the validation of automatic arterial pressure monitoring by the AAMI.

Mycotic pseudoaneurysm following radial artery catheterization

Mycotic pseudoaneurysm following radial artery catheterization

The value of brachial artery peak velocity variation during the Valsalva maneuver to predict fluid responsiveness

Objective: To evaluate whether brachial artery peak velocity variation(ΔVp) during a Valsalva maneuver(VM) could predict fluid responsiveness in spontaneously breathing patients. Methods: Ninety-six patients required radial artery catheter for elective surgery of Ningbo Yinzhou People's Hospital from December 2014 to June 2016 were enrolled. The brachial artery Doppler signal was recorded to measure the ΔVp while the VM was performed.Then doing the volume expansion (VE) , the cardiac output variation (ΔCO) before and after VE were measured.Pearson correlational analyses were conducted between ΔVp and ΔCO. Also the sensitivity and specificity of ΔVp were determined in predicting fluid responsiveness by the receiver operating characteristic (ROC) curve. Results: Patients were classified as group responders (n=24) and group non-responders (n=72). Responder was defined as cardiac output increased≥15% after VE.The ΔVp correlated well with ΔCO (r=0.792, P<0.01). The area under ROC curve was 0.903, with the ΔVp cut-off of 33%, the sensitivity of 87% and the specificity of 82%(P<0.01). Conclusion: Brachial artery peak velocity variation during a valsalva maneuver is a feasible method for predicting fluid responsiveness in spontaneously breathing patients.

Procedural Variations in Performing Primary Percutaneous Coronary Intervention in Patients With ST-Elevation Myocardial Infarction

Multiple variations exist in performing a primary percutaneous coronary intervention (pPCI) in ST-segment elevation myocardial infarction (STEMI) among various cardiologists. These variations range from the choice of peripheral access artery (radial vs femoral), performance or time of complete angiography including left ventriculography, and nonculprit vessel angiography before or after intervening on the culprit vessel. The reasons for such variations include emphasis on door-to-balloon time, knowledge of cardiac anatomy before proceeding with pPCI, physician expertise, and the level of comfort with radial approach. Over the last 2 decades, the field of interventional cardiology has changed dynamically leading to marked improvements in the clinical outcomes of patients with STEMI. This includes upstreaming of pPCI along with technical advancements ranging from radial artery catheterization to culprit lesion–guided approach. Increased comfort with use of radial access approach by cardiologists and availability of multiuse guide catheters would both reduce door-to-balloon time and enable complete coronary angiography before performance of percutaneous coronary intervention. There are no clear guidelines or consensus dictating on cardiologists a correct sequence of action during STEMI, or even suggesting what the preferred approach is. Lack of guidelines results in a substantive variation in methodology. This review aims to highlight and to better understand the variations in the current practice, and to emphasize the advantages as well as the disadvantages of each approach. It is also perhaps a call out for guidelines that direct cardiologists to the best practice.

Oblique approach for ultrasound-guided radial artery catheterization vs transverse and longitudinal approaches, a randomized trial

Study objectiveTo investigate the value of using a new technique for ultrasound-guided radial artery catheterization; oblique approach; vs transverse and longitudinal views are the traditionally used approaches aiming to combine benefits and avoid drawbacks of aforementioned approaches. DesignA prospective randomized nonblinded study. SettingGastroenterology Center, Mansoura University, Egypt from February 2015 to August 2015. PatientsOne hundred twenty-six surgical and intensive care unit patients indicated for arterial catheterization. InterventionPatients were randomly allocated into 3 groups according to the US-guided technique used; group T (n=42) using transverse view, group L (n=42) using longitudinal view, group O (n=42) using oblique view. MeasurementsPrimary objective was overall success rate; secondary objectives were first attempt success, time to cannulate, and operator satisfaction with the used technique. Main resultsForty-two patients were included for each study group. Overall success rate of radial artery catheterization was significantly higher in group O than in group T and clinically higher than group L (60% for group T, 70% for group L, 90% for group O; P<.02). Likewise, time needed to cannulate the radial artery was significantly lower in group O than in both group T and group L (28±19 s for group T, 66±5 s for group L, 16±7 s for group O; P<.00]. ConclusionThese results support the conclusion that the oblique approach for US-guided radial artery catheterization may replace the 2 classic approaches owing to its superior success rate, higher first attempt success and shorter time consumed for catheterization with more operator satisfaction after the procedure.

Ultrasound Guidance and Other Determinants of Successful Peripheral Artery Catheterization in Critically Ill Children.

Peripheral arterial catheterization is a common invasive procedure performed in critically ill children. However, the benefits of using ultrasound guidance for this procedure in critically ill children, especially when used by inexperienced trainees, are unclear. Our aims were to evaluate whether the use of ultrasound guidance for the placement of radial arterial catheters reduced time and improved success when compared with the palpation method and also to determine patient and trainee variables that influence procedure outcomes. Finally, we evaluated whether adoption of ultrasound guidance among trainees comes at the expense of learning landmark-based methods. Prospective observational cohort. University affiliated PICU. A total of 208 procedures performed by 45 trainees in 192 unique patients (1 mo to 20 yr old) were observed. Implementation of ultrasound curriculum. The main outcome measures were time and number of attempts required for the procedure. Compared with palpation method, ultrasound guidance was associated with reduced procedure time (8.1 ± 5.2 min compared with 16.5 ± 8.8 min; p < 0.001), reduced number of attempts (3.1 ± 2.6 attempts compared with 6.9 ± 4.2 attempts; p < 0.001), and improved first attempt success rate (28% compared with 11%; p = 0.001) even after adjusting for key confounders in multivariate random effects models. The factors most likely to interfere with peripheral arterial catheterization are patient age, patient systolic blood pressure, patient body mass index, degree of fluid overload, and trainee months in fellowship. The use of ultrasound guidance mitigates the influence of each of these factors. We found no evidence that the adoption of ultrasound guidance by trainees is associated with reduced proficiency in landmark-based methods. The use of ultrasound guidance by trainees for radial artery catheterization in critically ill children is associated with improved outcomes compared with the palpation method.

Dose requirements of alfentanil to eliminate autonomic responses during rapid-sequence induction with thiopental 4 mg/kg and rocuronium 0.6 mg/kg

Study objectiveOpioids are integral part of anesthesia induction, but information on optimal dosing is limited. We aimed to determine doses of alfentanil needed to eliminate increases in 5 autonomic response variables (plasma concentrations of epinephrine, norepinephrine and vasopressin, arterial blood pressure [ABP], and heart rate) during rapid-sequence induction of anesthesia with thiopental 4 mg/kg and rocuronium 0.6 mg/kg. DesignProspective, randomized, observer-blinded, interventional clinical study. SettingLarge academic institution. PatientsEighty-four healthy patients, aged 18 to 55 years, received 1 of 7 assessor-blinded doses of alfentanil (0, 10, 20, 30, 40, 50, and 60 μg/kg) together with thiopental 4 mg/kg and rocuronium 0.6 mg/kg, administered in rapid succession (15 seconds). Laryngoscopy was initiated 40 seconds after rocuronium, and tracheal intubation was concluded within 15 seconds thereafter. MeasurementsAn indwelling radial artery catheter was used for hemodynamic monitoring and blood sampling. Relationships between alfentanil dose and response variables were tested with linear regression, and the influence of covariates (sex, body weight, and age) was determined. Alfentanil dose needed to prevent increases in ABP >10% above baseline with 95% probability was estimated with logistic regression. Main resultsSignificant relationships were determined between alfentanil dose and response variables. Clinically interesting influence of covariates was not found. Alfentanil 55 μg/kg was needed to prevent increases in ABP postintubation >10% above baseline with 95% probability. One individual needed a bolus of vasopressor postintubation. ConclusionsOptimal control of autonomic responses during rapid-sequence induction was achieved with clinically relevant doses of alfentanil in healthy patients anesthetized with thiopental 4 mg/kg and rocuronium 0.6 mg/kg.

Сравнительный анализ различных методов катетеризации лучевой артерии у пациентов с полиорганной дисфункцией и при проведении ангиографии

Сравнительный анализ различных методов катетеризации лучевой артерии у пациентов с полиорганной дисфункцией и при проведении ангиографии