Traditional Landmark Technique Research Articles

Real-time ultrasound-guided versus landmark-guided subclavian vein catheterization in the intensive care unit: a prospective randomized study

Abstract Background The subclavian vein (SCV) is an alternative to the internal jugular vein when it is difficult to locate, such as in patients with hypovolemia or obesity. Ultrasonography (USG) guidance for SVC cannulation has evolved, resulting in fewer complications and higher first-pass success rates. This study aimed to compare the effectiveness and safety of SCV cannulation with USG- and landmark-guided techniques. Methods In this prospective randomized interventional controlled study, 80 patients admitted to the intensive care unit between July 2022 and October 2022 were randomly assigned to the landmark method group (LM group) and USG group. In the LM group, SCV cannulation was performed using the traditional landmark technique, whereas in the USG group, it was performed using USG guidance. The primary objective of this study was to evaluate the ease of subclavian central venous cannulation in critically ill patients using the 2 techniques. The secondary objectives were to compare the success rate of cannulation between these 2 techniques, evaluate the number of attempts, assess cannulation failure, and assess mechanical complications. Results The first-pass success rates were 70% and 92.5% in the LM and USG groups, respectively (P < 0.001). The average numbers of attempts in the LM and USG groups were 1.275 (±0.520) and 1.075 (±0.266), respectively (P = 0.034). The average procedure durations were 7.45 (±1.10) and 8 (±0.933) minutes in the LM and USG groups (P = 0.018), respectively. The rates of complications in both groups were not statistically significant. Conclusion The USG guidance for SCV cannulation has an advantage over landmark-guided methods in a critical care setting. The SCV is a good alternative to internal jugular vein cannulation. The average time to cannulation was longer in the USG group than in the LM group, which can decrease with the frequent use of USG and increasing operator experience. Clinical trials This study was registered in the Clinical Trials Registry-India (CTRI Trial No. CTRI/2022/07/043694, dated May 7, 2022).

Comparison between ultrasound guided and landmark – based technique for superficial cervical plexus block in patients undergoing thyroid surgery

Background: The major advantage of ultrasound guided technique over the traditional landmark technique in bilateral superficial cervical plexus block is that, it helps to minimize the injury to cervical muscle, fascia and nerves. The study aimed to compare the effectiveness between landmark technique and ultrasound guided technique with respect to the post-operative analgesia, intra-operative hemodynamics and the complication rate of the procedure. Methodology: A total of 100 patients were included as our study sample which was divided into two groups of 50 each. Group A patients received Superficial Cervical Plexus Block (SCPB) using the landmark based technique and Group B patients received SCPB under ultrasound guided technique. Parameters such as success of the procedure performance time, time of onset of action, block pain score, post-operative pain score, intra-operative hemodynamics and complication rate were compared between the two groups. Results: The success rate of the block was found to be 72% in the landmark technique group compared to 90% in the ultrasound guided group. The onsite time of analgesia was found to be much earlier in ultrasound guided group (16.2 vs 11.1 mins). The hemodynamic parameters were found to be slightly higher among the landmark group compared to ultrasound guided group. Post-operative pain score was significantly better and the incidence of complication rate was nil among ultrasound guided group. Conclusion: Ultrasound guided technique is a better alternate for landmark technique for providing bilateral superficial cervical plexus block while performing thyroidectomy surgery. Keywords: cervical plexus block; landmark technique; ultrasound technique; thyroidectomy

Ultraschallgesteuerte periphere Venenpunktion bei schlechtem Venenstatus

Placement of a peripheral indwelling venous catheter is aroutinely performed invasive procedure, in which complications are often underestimated. In difficult venous conditions multiple puncture attempts are often required, which are time consuming, unnecessarily painful for the patients and nevertheless not always successful. Due to the close anatomical relationship between superficial veins and peripheral nerves in the arm, puncture-related nerve injury is not uncommon. Despite limited data it could be shown that ultrasound-guided peripheral venepunctures are superior to traditional landmark techniques in terms of success rates, time saving, avoidance of complications and patient satisfaction. In order to successfully integrate the sonographic puncture technique for vascular access into routine processes, astructured training and further education are prerequisites. This must include anatomical knowledge, basic knowledge of ultrasound formation and training in sonographic needle guidance techniques.

Prehospital portable ultrasound for safe and accurate prehospital needle thoracostomy: a pilot educational study

BackgroundSimulated needle thoracostomy (NT) using ultrasound may reduce potential injury, increase accuracy, and be as rapid to perform as the traditional landmark technique following a brief educational session. Our objective was to determine if the use of an educational session demonstrating the use of handheld ultrasound to Emergency Medical Services (EMS) staff to facilitate NT was both feasible, and an effective way of increasing the safety and efficacy of this procedure for rural EMS providers.MethodsA pre/post-educational intervention on a convenience sample of rural North American EMS paramedics and nurses. Measurement of location and estimated depth of placement of needle thoracostomy with traditional landmark technique was completed and then repeated using handheld ultrasound following a training session on thoracic ultrasound and correct placement of NT.ResultsA total of 30 EMS practitioners participated. Seven were female (23.3%). There was a higher frequency of dangerous structures underlying the chosen location with the landmark technique 9/60 (15%) compared to the ultrasound technique 1/60 (1.7%) (p = 0.08). Mean time-to-site-selection for the landmark technique was shorter than the ultrasound technique at 10.7 s (range 3.35–45 s) vs. 19.9 s (range 7.8–50 s), respectively (p < 0.001). There was a lower proportion of correct location selection for the landmark technique 40/60 (66.7%) when compared to the ultrasound technique 51/60 (85%) (p = 0.019). With ultrasound, there was less variance between the estimated and measured depth of the pleural space with a mean difference of 0.033 cm (range 0–0.5 cm) when ultrasound was used as compared to a mean difference of 1.0375 cm (range 0–6 cm) for the landmark technique (95% CI for the difference 0.73–1.27 cm; p < 0.001).ConclusionsTeaching ultrasound NT was feasible in our cohort. While time-to-site-selection for ultrasound-guided NT took longer than the landmark technique, it increased safe and accurate simulated NT placement with fewer identified potential iatrogenic injuries.

ULTRASOUND GUIDED CENTRAL VENOUS CANNULATION BY ANESTHESIA TRAINEE: NEED OF THE HOUR DURING COVID PANDEMIC

Covid pandemic has created deciency of doctors needed to administer skilled procedures in ICUs and operating rooms. Post graduate trainees need to acquire skills fast and perform it safely on patients. Ultrasound (USG)-guided central venous cannulation (CVC) is one such. The study aimed at nding the feasibility of training USG-guided CVC cannulation to anesthesia trainee as opposed to landmark method in terms of ease, speed and safety. Patients needing CVC were divided into 2 groups of 50 each, where Group 1 was subjected to Landmark method and Group 2 to USG-guided method. Continuous variables were compared using unpaired t test and categorical variables using either the Chi square test. Access time (in seconds) was signicantly less in the USG group (258.78 ± 11.17) as opposed to Landmark technique (301.60 ± 14.03) (p 0.03). Accidental carotid artery puncture was seen in 9 patients in Landmark group as opposed to none in the USG group. No patient in any group developed pneumothorax. USG-guided technique is superior and safer than the traditional landmark technique in hands of anaesthesia trainee in terms of a shorter access time, and less incidence of arterial puncture which is desirable in COVID patients to shorten the exposure time. USG-guided method needs an assistant to focus the probe. Nonetheless, this training should be imparted to the trainee to ll the gap created by skilled doctors falling sick during COVID pandemic.

Comparison of the time taken for subarachnoid block using ultrasound-guided method versus landmark technique for cesarean section - A randomized controlled study.

Background and Aims:Spinal anesthesia is the regional technique preferred for cesarean section and is usually administered using the traditional landmark technique. Ultrasonography of the spine appears to be helpful in locating the puncture site and increasing the success rate. The primary objective of this study was to assess the use of ultrasonogram in locating the lumbar interspinous space for spinal anesthesia in laboring parturients brought for elective cesarean section.Material and Methods:Sixty parturients scheduled to undergo elective cesarean section under spinal anesthesia were included in this prospective randomized controlled trial, after obtaining the institutional ethical clearance. In Group I, 30 patients received spinal anesthesia by landmark technique and in Group II, 30 patients underwent ultrasound-guided spinal anesthesia. The statistical analysis was done using SPSS software version 17 (SPSS Inc., Chicago, Illinois, USA) for Microsoft windows.Results:The time taken for spinal in Group I was longer than in Group II (62 ± 18s; 41 ± 11s; P = 0.0001). The number of attempts of needle insertion was significantly less in Group II (group I 1.86 ± 1.04: group II 1.06 ± 0.25). However, the total preparation time (28 8.30 ± 92 vs 804.73 ± 77; P = 0.0001) was more in the ultrasound-guided than in the landmark group. The patients had better satisfaction in group II.Conclusion:Preprocedural ultrasound is a useful tool for successful lumbar puncture in parturients as it minimizes the number of attempts of needle insertion and provides better patient satisfaction.

Ultrasound-guided arterial cannulation or by pulse palpation in the intensive care unit

IntroductionUltrasound (US) guidance increases the success rate and decreases complications during central venous catheterisation (CVC). The benefits of US guidance in arterial catheterisation are less clear. The aim of this study is to compare the outcomes of US-guided arterial catheterisation with the traditional landmark (LM) technique in critically ill children. MethodsA prospective multicentre study was carried out in 18 Paediatric Intensive Care units in Spain during a 6-months period. Ultrasound guided and landmark techniques were compared in terms of cannulation technical success and immediate mechanical complications. ResultsA total of 161 procedures were performed on 128 patients (78 procedures in the US group and 83 in the LM groups).. The median (interquartile range) age and weight of the cohort was 11 months (2–52), and 10 kg (4–17) respectively. More than half (59.6%) were male. US was used mainly in high-volume-high-complexity hospitals (cardiac surgery program 76.9% vs. 25.6%, P < .001) as well as in smaller children [weight 5.7 kg (3.8−13) vs 11.5 kg (4.9−22.7), P < .001]. Almost half (49.7%) of the procedures were performed by an inexperienced operator (paediatric resident, or staff with less than 5 years of clinical experience in the PICU), and only 24.4% had performed more than 50 US-guided vascular access procedures before the study. There were no significant differences between US and LM techniques in terms of first-attempt success (35.8% vs 33.7%, P = .773), overall success (75.6% vs 71.1%, P = .514), number of puncture attempts [2 (1−4) vs 2 (1−3), P = .667] and complications (16.6% vs 25.6%, P = .243). Adjustment by potential confounders using multivariate regression models did not modify these results. Subgroup analyses showed that US outperformed LM technique in terms of overall success (83.7% vs 62.7%, P = .036) and complications (10.8% vs 32.5%, P = .020) only when procedures where performed by less-experienced operators. ConclusionsIn this prospective observational multicentre study, US did not improve arterial cannulation outcomes compared to the traditional LM technique in critically ill children. US-guided arterial cannulation may offer advantages when cannulation is performed by inexperienced operators.

Sonogram of safety: Ultrasound outperforms the fifth intercostal space landmark for tube thoracostomy site selection.

Identification of tube thoracostomy insertion location is currently performed using a blind, landmark based approach at either the fifth intercostal space (ICS) or inframammary crease in the midaxillary line. A significant percentage of thoracostomies at this site result in complications. This pilot study aimed to assess whether bedside ultrasound could aid in identifying safer tube thoracostomy insertion sites in emergency department patients. Fifty emergency department patients were enrolled in this study. Right and left hemidiaphragms were evaluated with ultrasound at the fifth ICS. Observations were made on if the diaphragm was below, above, or crossed the fifth ICS during an entire respiratory cycle. Eighty-one (95% confidence interval 72-82) of the diaphragms were below, 13 (95% confidence interval 8-21) of the diaphragms were at, and 6 (95% confidence interval 3-12) of the diaphragms were above the location marked using traditional landmark techniques. On the right and left hemidiaphragms, 20% (95% confidence interval 19.9%-20.1%) and 18% (95% confidence interval 17.9%-18.1%) of diaphragms were above or crossing the fifth ICS, respectively CONCLUSIONS: Ultrasound identified a significant number of potential chest tube insertion sites at the fifth ICS that would result in subdiaphragmatic insertion or diaphragmatic injury. Based on this data ultrasound can be used to identify safer insertion sites and reduce thoracostomy complications.

Ultrasound-guided cannulation or by pulse palpation in the intensive care unit

Ultrasound (US) guidance increases the success rate and decreases complications during central venous catheterisation (CVC). The benefits of US guidance in arterial catheterisation are less clear. The aim of this study is to compare the outcomes of US-guided arterial catheterisation with the traditional landmark (LM) technique in critically ill children. A prospective multicentre study was carried out in 18 Paediatric Intensive Care units in Spain during a 6-months period. Ultrasound guided and landmark techniques were compared in terms of cannulation technical success and immediate mechanical complications. A total of 161 procedures were performed on 128 patients (78 procedures in the US group and 83 in the LM groups). The median (interquartile range) age and weight of the cohort was 11months (2-52), and 10kg (4-17), respectively. More than half (59.6%) were male. US was used mainly in big (number of beds 11 [8-16] vs 6 [4-10], p < 0,001) and high complexity intensive care units (cardiac surgery program 76.9% vs. 25.6%, P<.001) as well as in smaller children [weight 5.7kg (3.8-13) vs 11.5kg (4.9-22.7), P<.001]. Almost half (49.7%) of the procedures were performed by an inexperienced operator (paediatric resident, or staff with less than 5years of clinical experience in the PICU), and only 24.4% had performed more than 50 US-guided vascular access procedures before the study. There were no significant differences between US and LM techniques in terms of first-attempt success (35.8% vs 33.7%, P=.773), overall success (75.6% vs 71.1%, P=.514), number of puncture attempts [2 (1-4) vs 2 (1-3), P=.667] and complications (16.6% vs 25.6%, P=.243). Adjustment by potential confounders using multivariate regression models did not modify these results. Subgroup analyses showed that US outperformed LM technique in terms of overall success (83.7% vs 62.7%, P=.036) and complications (10,8% vs 32.5%, P=.020) only when procedures where performed by less-experienced operators. In this prospective observational multicentre study, US did not improve arterial cannulation outcomes compared to the traditional LM technique in critically ill children. US-guided arterial cannulation may offer advantages when cannulation is performed by inexperienced operators.

361 Emergency Physician Workflow Disruptions Due to Ultrasound-Guided IV Placement

The purpose of this pilot study was to quantify the time disruption emergency physicians experience in placing ultrasound-guided peripheral IVs (USPIV) in emergency department patients in which EM nurses are unable to obtain peripheral access using traditional landmark techniques.

379 Novel Approach to Ultrasound Guided Thoracostomy (NoGUT)

Traditional landmark thoracostomy technique has a known complication rate of 30%. While early data suggests that ultrasound can be a beneficial tool for identifying the correct thoracostomy tube insertions site, clinical studies are limited. We designed a pilot prospective randomized study to assess if ultrasound guidance can improve thoracostomy site identification over traditional landmark technique. 43 emergency medicine residents were randomly assigned to use either palpation or ultrasound to identify a safe insertion site for chest thoracostomy placement. We defined “safe” as above the diaphragm. The study was performed on a convenience sample reflecting a heterogenous mix of emergency department patients. The target patient population was comprised of hemodynamically stable trauma patients who received extended focused assessment with sonography in trauma (eFAST) and a chest computed tomography (CT) exam. The resident was instructed to place a small radiopaque marker on the skin of the patient where he/she believed was a safe intercostal space. Clinical ultrasound faculty then reviewed the chest CT to confirm radiopaque marker placement in relationship to the diaphragm. Fischer exact test was used to analyze the differences between the two groups. 97 patients were enrolled in the study resulting in the placement of 91 thoracostomy site markers by ultrasound and 89 by palpation. The average weight was 84kg with a BMI of 29kg/m2 (BSA 2.02) and these were comparable in both groups. The ultrasound group correctly identified thoracostomy tube insertions site above the diaphragm in 97.8% (89/91) of patients while landmark group identified a safe insertion site 89.9% (80/89) (p=0.0316). The ability to accurately locate a safe intercostal space for chest thoracostomy insertion was improved under ultrasound guidance. This technique is an excellent adjunct for novice providers and for patients with difficult landmarks or abnormal anatomy. Further studies are warranted to determine if this method can decrease complications with chest thoracostomy insertion.

Landmark Technique vs Ultrasound Guided Approach for Posterior Tibial Nerve Block in Cadaver Models

Category:Ankle, Basic Sciences/BiologicsIntroduction/Purpose:Until recently, many regional anesthetic blocks were performed without the assistance of ultrasound, relying on methods such as anatomical landmarks and nerve stimulation. The use of ultrasound for peripheral nerve blocks has proven extremely useful for improving the efficacy of many regional anesthetic techniques. There remain a few nerve blocks which have lagged in employing the assistance of ultrasound consistently, one of which is the ankle block. This block is commonly utilized for either surgical anesthesia or post-operative analgesia for a variety of foot and ankle procedures. In this study, we compared the accuracy of traditional landmark technique with an ultrasound guided approach for ankle block by assessing the spread of injectate (dye) along the posterior tibial nerve (PTN) in cadaver models.Methods:Ten below-knee cadaver specimens were used for this study. Five were randomly chosen to undergo landmark guided PTN blocks, and five were selected for ultrasound-guided PTN blocks. The landmark technique was performed by identifying the medial malleolus and Achilles tendon and inserting the needle (4 cm long, 21G Braun® Stimuplex) at the midpoint of the two structures, aiming toward the medial malleolus and advancing until bone was contacted. 2 cc of blue acrylic dye was injected at this location. The ultrasound technique was performed with a linear probe identifying the medial malleolus and the PTN. The needle was advanced in-plane with a posterior to anterior trajectory until the tip of the needle was adjacent to the nerve. 2 cc of blue acrylic dye was injected surrounding the nerve. The extremities were then dissected to determine which nerves had been coated with dye.Results:100% of the ultrasound guided blocks resulted in completely stained PTN with dye. In the landmark group, only 40% of the landmark technique blocks resulted in completely stained PTN with dye. Of the nerves not stained with dye, 2 were noted to have had dye injected posterior to the nerve and 1 was noted to have had dye injected into the flexor digitorum longus tendon.Conclusion:The base of evidence has dramatically increased in recent years in support of the use of ultrasound in regional anesthesia. This study substantiates the superiority of ultrasound guidance for ankle block by demonstrating a 100% success rate amongst the ultrasound guided group.

Thoracic paravertebral block: comparison of different approaches and techniques. A study on 27 human cadavers

Background and objectivesThe success rate and spread of thoracic paravertebral block (TPVB) are variable and difficult to predict. It is now recommended that an ultrasound guidance technique should replace the traditional landmark technique. The objective was to compare anatomical outcomes of both techniques on cadavers. MethodsA landmark technique (loss of resistance technique [LOR]) and a USG technique (three approaches: sagittal, transversal in-plane, transverse out-of-plane) were performed on 27 thawed non-embalmed cadavers. Each of the four approaches was performed in each body (T3–T5 and T9-T11 × right and left). A coloured solution (13 mL, saline 0.9%) was injected in the targeted thoracic paravertebral space (TPVS). A successful thoracic paravertebral injection (TPVI) was defined by the presence of dye in at least one TPVS during anatomical dissection. ResultsIn 104 TPVIs analysed, the overall success rate was 78%. Factors associated with success were: USG versus LOR technique (85% vs. 52%, P < 0.0007), sagittal versus both transversal approaches (93%/81%/83%, P < 0.0007) and right side (86% vs. 66%). The median spread was 2 TPVS (min – max 1–5) with a median cephalad-caudal spread of 5 cm (min - max 1-18). By multivariate analysis, the sagittal approach was an independent factor of success (OR 2.75). Dye spread and pleural entry were influenced by neither the approach nor the site of injection. ConclusionsParavertebral spread of TPVI is variable. USG technique has higher anatomical success rates than the LOR technique, the sagittal USG approach being the most successful.

A Comparison of Internal Jugular Vein Cannulation by Ultrasound-Guided and Anatomical Landmark Technique in Resource-Limited Emergency Department Setting.

Background and Objectives:Central venous catheter placement is a frequently performed procedure in emergency medicine as well as critical care unit. We aimed to compare real-time ultrasonography (USG)-guided and the traditional anatomical landmark (AL) technique for the insertion of internal jugular vein (IJV) catheters in an emergency department (ED) setting.Materials and Methods:Patients requiring IJV catheterization were prospectively recruited over a period of 1 year at a single center. Cannulation was done either by the AL or USG technique, according to ED physician's discretion. A preset pro forma was completed for each central line placed. Variables were compared using the independent t-test, Fisher's exact test, and the nonparametric Mann–Whitney U-test.Results and Discussion:Seventy patients were enrolled, of which 35 patients underwent IJV cannulation by USG-guided technique (USG group) and 35 patients by the AL technique (AL group). There were a 100% success rate (35/35) for cannulation in the USG group and a 91.4% success rate (32/35) in the AL group. The catheter was placed on the first attempt in 17 (48.6%) patients in the AL group and 32 (91.4%) patients in the USG group. In th AL group, there were three failed cannulation attempts in comparison to the USG group. The mean start to flash time for the AL technique was 16.59 s (±10.67) and 4.86 s (±2.18) in the USG group. The mean cannulation time was 305.88 s (±66.84) in the AL group and 293.03 s (±71.15) in the USG group. A total of seven acute complications were noted, of which 2 (5.7%) in the USG group and 5 (14.3%) in the AL group.Conclusion:The real-time USG guided technique significantly reduces the number of attempts to cannulate, has a higher first-pass success rate, a quicker flash time, and fewer complications when compared to the AL technique. In EDs equipped with USG, insertion of IJV catheters under real-time USG guidance should become the standard of care.

Technical success of the ultrasound-guided supra-inguinal fascia iliaca compartment block in older children and adolescents for hip arthroscopy.

Hip arthroscopic surgery is performed on older pediatric patients. Fascia iliaca compartment block has proven efficacy in providing analgesia following hip surgery and can be performed with target location of local anesthetic below or above the inguinal ligament. The reported success of ultrasound-guided infra-inguinal fascia iliaca compartment block is lower when compared to traditional landmark technique, while the reliability of supra-inguinal fascia iliaca compartment block is unreported. The primary aim was to report the results in obtaining sensory changes in the distribution of the femoral and lateral femoral cutaneous nerves following supra-inguinal fascia iliaca compartment block in patients undergoing arthroscopic hip surgery. Secondary outcomes are the ability to find echogenic landmarks and to report pain scores and opioid consumption. We reviewed the electronic medical record and regional anesthesia database of patients receiving ultrasound-guided fascia iliaca compartment block for arthroscopic hip surgery. Sensory changes to the femoral and lateral femoral cutaneous nerves were determined. Identification of echogenic landmarks was quantified. Pain scores and opioid consumption were determined. Seventeen patients of mean age 15.4years old (SD 1.3; range 13-17years) were included. Sensory changes to both the femoral and lateral femoral cutaneous nerves occurred in 94% of patients (95% CI: 82%-100%). The average volume of ropivacaine 0.2% was 0.53mL/Kg (SD 0.11mL/Kg). Echogenic landmarks were identified in all patients. Pain scores and opioid consumption were generally low. A supra-inguinal location for the deposition of local anesthetic when performing fascia iliaca nerve block for hip surgery is reliable in anesthetizing the femoral and lateral femoral cutaneous nerves and should encourage investigation into the clinical efficacy.

Techniques, Advantages, and Pitfalls of Ultrasound-Guided Internal Jugular Cannulation: A Qualitative Study

BackgroundNational guidelines advocating ultrasound guidance for internal jugular venous cannulation were introduced in the United Kingdom in 2002, followed by international guidelines a decade later. However, the benefits of ultrasound guidance do not appear to have universally translated into clinical practice. This study aimed to investigate the effect of ultrasound on the practice of internal jugular vein cannulation. MethodsWe conducted an ethnographic study incorporating observations, interviews, and focus groups in 2 hospitals in the north of England over a 4-month period. ResultsTwenty-seven clinical observations, 10 interviews, and 3 focus groups were conducted. In 25 clinical episodes, ultrasound guidance was used. Four distinct needling techniques were observed, which we classified in terms of needle angulation: the traditional landmark technique, the ultrasound-guided traditional approach, ultrasound-guided medial angulation, and the ultrasound-guided steep approach. The latter 2 techniques represent a departure from conventional practice and appear to have developed alongside ultrasound guidance. Although no serious complications were observed, there appears to be enhanced potential for complications to occur with medial angulation and the steep approach. Participants described a loss of anatomic knowledge and a false sense of security associated with the adoption of ultrasound guidance, which may account for the emergence of new, potentially riskier needling techniques. ConclusionsThe introduction of safe technologies may lead to unintended consequences, and clinicians should attempt to recognize and mitigate them when they occur. Education to increase awareness of the pitfalls of ultrasound guidance is recommended.

Ultrasound-Guided Peripheral Intravenous Access Program for Emergency Physicians, Nurses, and Corpsmen (Technicians) at a Military Hospital.

Peripheral intravenous (PIV) access is a common procedure in the emergency department (ED). However, conditions such as obesity and hypovolemia can often make access difficult by the traditional landmark technique. The use of ultrasonography has improved the success of PIV placement in this setting. A novel Ultrasound (US)-Guided PIV Access program was initiated in our ED to train emergency nurses, U.S. Navy corpsmen, and physicians. This was an observational study of emergency providers performing US-guided PIV placement. After a training session, all ED providers began utilizing the US for difficult intravenous access patients. All complications, location of access, and previous experience level were recorded. The choice of a transverse, longitudinal, or a combination approach was also recorded. We did not observe significant differences in ability with US-guided PIV access when comparing success rates between emergency physicians, nurses, and technicians (p = 0.13). In the novice user, a transverse or a novel combination of a transverse and longitudinal method appears to be the most successful. ED physicians, nurses, and corpsmen can successfully place US-guided peripheral catheters for venous access. Developing a training program for emergency providers in US-guided venous cannulation is feasible and safe.

Ultrasound guided internal jugular venous cannulation: comparison with land-mark technique.

To compare real-time ultrasonography-guided technique versus the traditional land-mark technique for internal Jugular venous cannulation. Randomized controlled trial. Department of Anaesthesia, Combined Military Hospital, Rawalpindi, from September 2013 to July 2014. A total of 200 patients who required internal jugular vein cannulation were randomly assigned using either real-time ultrasound-guided technique or land-mark technique. Access time, number of attempts until successful cannulation, complications and the demographics of each patient were recorded. Access time was significantly less in real-time ultrasound group (34.95 ± 11.47 vs. 146.59 ± 40.20 seconds, p < 0.001). Cannulation was performed in first attempt in 99% of patients in ultrasound group as compared to 89% of landmark group. Complication rate was significantly higher in the land-mark group than in the ultrasound-guided group. Carotid artery puncture rate (9% vs. 1%) and haematoma formation (7% vs. 0%) were more frequent in the land-mark group than in the ultrasound-guided group. Brachial plexus irritation was also more in land-mark group (6% vs. 0%). Access time, failure rate and procedure related complications are reduced when real-time ultrasonography is used to cannulate internal Jugular vein.

Current use of ultrasound for central vascular access in children and infants in the Nordic countries--a cross-sectional study.

The use of ultrasound (US) guidance for central vascular access in children has been advocated as a safer approach compared to traditional landmark techniques. We therefore collected data on the current use of US for central vascular access in children and infants in the Nordic countries. A cross-sectional survey using an online questionnaire was distributed to one anaesthesiologist at every hospital in the Nordic countries; a total of 177 anaesthesiologists were contacted from July till August 2012. The use of US for placing central venous catheters (CVCs) seems widespread across the Nordic countries. Close to 80% of respondents were using it "almost always" or "frequently" across all paediatric age groups for internal jugular vein cannulation. US was least frequently used when catheterizing the subclavian vein. The two most common reasons given when not using US were lack of training followed by lack of equipment. We found no difference in the use of US between high-volume centres and low-volume centres. (High-volume centres placed paediatric CVCs at least weekly.). US was commonly used for cannulation of the internal jugular vein but infrequently for the subclavian vein. A lack of training seems to be a barrier for further increasing the use of US. Establishing standardized training programmes based on current evidence should alleviate this.

THU0335 Identification of the Optimum Puncture Level by A Lumbar Spine Ultrasonography Decreases the Pain during the Epidural Injection Procedure in Patients with A Presumed Difficult Puncture

BackgroundUltrasound (US) is widely used in rheumatology to study and guide infiltration of peripheral joints. This imaging modality can also provide useful information about the anatomy of the lumbar spine....