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Arterial puncture is a common procedure performed almost daily in most medical facilities including medical wards, and emergency departments. Despite how common it is, due to the traditional techniques of placing the artery, a variety of complications can occur, some of which can lead to prolonged discomfort, suffering and even death. The unit should be able to provide the best possible care for the patients, especially when the procedure is performed with high enough frequency to put a lot of people in danger. At the moment ultrasound equipment is starting to become common among emergency departments, but traditional methods of artery placement are still used. The unit fully supports the project due to the positive results shown by the studies. If ultrasound-guidance becomes the norm for this procedure, the unit, patients, and medicine, in general, would benefit from it.
Literature Review: Topic
The primary goal of this paper is to address the issues that arise from arterial puncture complications, as well as how to reduce or prevent these problems altogether. To provide an example of these problems a review of literature should be performed. This section of the paper will present two scientific articles about the arterial puncture complications.
The first article was created by an international team of physicians in 2014. It is titled “Incidence of Mechanical Complications of Central Venous Catheterization Using Landmark Technique: Do Not Try More Than Three Times.” Although the title singles out central venous catheterization, it concerns all types of mechanical complications including arterial puncture, pneumothorax, hemothorax, and subcutaneous hematoma. The purpose of this study was to determine how these complications occur and their potential risk factors. This study specifically concerns the traditional method of catheterization and was performed by a mixed group of practitioners (Calvache et al., 2016).
The introduction to the paper notes that mechanical complications are reported to happen in at least five percent of cases and depending on the study, this percentage can rise to 34%. It goes on to describe that mechanical complications are separated into four main categories. These include catheter-related factors, patient-related factors, site-related factors, and use- or care-related factors. Subsequently, the risk factors are defined as subclavian versus other sites, female gender, advanced age, extremes of body mass index, prior catheterization, surgery, radiotherapy, the number of punctures performed, time needed for placement of the artery or vein, and the overall experience of the operator. As the site of the research a university-affiliated ICU in Popayan, Columbia was chosen. As the title suggests, the authors focused their attention on the mechanical complications of central venous catheterization. This paper was selected due to similar complications being common during arterial puncture (Calvache et al., 2016).
This study was approved by an ethics committee board of the surgical ICU in La Estancial Clinic. The data of all patients over the age of 18 who were undergoing this procedure was collected. All the anthropometric and demographic variables were recorded, as well as the main diagnosis of admission, comorbidities, the placement of the central venous catheter, and the course of the procedure. The operator was responsible for choosing the site for the catheter. The operators were divided into three groups depending on their roles. The first group included house medical intensivists and specialist staff. The second included residents in anesthesiology, surgery, and internal medicine, with less than three years of experience of working in intensive care. The last group included general practitioners. The number of attempts and punctures was counted, with every subsequent one increasing the risk of mechanical complications. Successful application of the catheter was confirmed by the free flow of the fluid. Later, all patients were given an x-ray to confirm the results. Patients that suffered from the mechanical complications were observed for 24 hours after the application of the catheter. Overall, 300 patients participated in the trial (Calvache et al., 2016).
The results show that mechanical complications were strongly related to the number of punctures performed by the operator. This conclusion suggests that the accuracy of this type of procedure is essential to avoid the serious mechanical complications. Therefore, a more precise technique should be considered (Calvache et al., 2016).
Although the second study approaches the area of the literature review of possible solutions, it is chosen due to its attention to access site-related complications. This study was performed by the physicians from Boston, Massachusetts in 2015. The study is titled “Routine Use of Ultrasound-Guided Access Reduces Access Site-Related Complications after Lower Extremity Percutaneous Revascularization. While the methods are results of the study are important, this section will focus on how the paper defines these complications and their risk factors (Lo et al., 2015).
The study describes these complications as one of the main causes of perioperative mortality among patients who have to undergo percutaneous endovascular intervention. It approximates their rate of occurrence at one to nine percent. As the effects of access site-related complications, the study lists discomfort, prolonged hospital stay, increased costs of health care, and increased mortality rates even a year after the procedure. The study goes on to show how the occurrence of these complications can be reduced with routine ultrasound-guided access. Due to the severity of these complications and the positive results found during studies of ultrasound-guidance, it could be considered a possible solution to improve the procedure of arterial puncture for a variety of purposes (Lo et al., 2015).
Literature Review: Solution
A review of the literature on the topic of ultrasound use for arterial puncture and catheterization shows promising results. To show their results, it would be useful to showcase two recent studies on the subject.
The first of the two was done by a Chinese team of physicians in 2014 and was titled “Ultrasound Guidance for Radial Artery Catheterization: An Updated Meta-Analysis of Randomized Controlled Trials.” This meta-analysis has been done to update information about the use of ultrasound guidance in first-attempt cases. The first meta-analysis has shown a rise in success rate during catheterization of the radial artery, but since then some new randomized controlled trials have reported inconsistent results, leading to the need of a new meta-analysis. The authors utilized the databases of PubMed, Embase and Cochrane Central Register of Controlled Trials. They searched for studies that involved randomized controlled trials while comparing ultrasound guidance with traditional palpation for radial artery catheterization. The authors used the Mantel-Haenszel method and the random effects model to create this meta-analysis (Tang et al., 2014).
The study begins with an introduction to the concept of arterial catheterization. It defines its main purpose as continuous hemodynamic monitoring in critically ill patients, as well as blood gas sampling in a variety of other situations. The radial artery has a superficial blood course. This makes it the most common choice for catheterization. Then it talks about how despite the relative safety of the procedure, the traditional palpation method can require multiple attempts due to its reliance on the technical skill of the physician. Multiple attempts at artery puncture can lead to pain and suffering of the patient, especially in pediatric patients and patients with edema, obesity, and hypotension. Worse cases can lead to hematoma and infections which the study estimates at being about 5%. This frequency shows why ultrasound guidance is such an important tool for arterial puncture. The study covers how such machines as SonoSite 180 plus, the GE Vivid S6, and the Flex-Focus 400 can visually distinguish between arteries, veins, and surrounding structures, as well as assess the patency of a target vessel, and predict variant anatomies. These features make these machines highly effective when vascular access is required. Finally, the introduction provides a brief overview of the available techniques for vascular visualization. The main two include the long axis in-plane approach which shortens to LA-IP and the short axis out-of-plane approach known as SA-OOP. A newer modification of SA-OOP approach called dynamic needle tip positioning (DNTP) is tested to be more effective than the LA-IP in a gelatin phantom (Tang et al., 2014).
The initial search for studies uncovered 803 publications on this topic, but only seven RCTs were eligible for this study. These seven studies included a total of 482 patients. The covered studies took place from 2003 to 2014. Four of them were conducted in Europe, two in the United States and one in Asia. The primary outcome of the meta-analysis was the first-attempt success rate, with mean-attempts, mean-time, and the occurrence of hematoma being the secondary outcomes. This study shows that traditional methods provide worse effects than the ultrasound approach. These effects are demonstrated by a higher first-attempt success rate, reduced occurrence of hematoma, shorter mean-time to success, and fewer mean-attempts to success. As a possible explanation for these benefits, the authors cite the ultrasonic clarification of the relative position of the needle and the radial artery, among its surroundings. However, the authors point out that these results depend on the operator’s ability to use the ultrasound guidance (Tang et al., 2014).
The second paper is an example of a randomized controlled trial performed by a French team of physicians. The study is titled “Ultrasound Guidance for Radial Arterial Puncture: a Randomized Controlled Trial.” This study compares the method of ultrasound guidance with the conventional method of arterial puncture. This study specifically notes the process of arterial puncture can be difficult in the case of emergency, even though it is a common procedure. Anybody who needs arterial blood gas at admission in the emergency unit is included in the study, except for those who are Hallen test positive, have a local sepsis, local trauma, those who do not provide consent, and those suffering from cardiac arrest. Patients were assembled into two randomized groups. The first would experience arterial puncture with the ultrasound guidance, and the second would go through the conventional method. The primary objective of this study is to measure the number of attempts after enrollment. Secondary objectives include time to success, patient satisfaction, pain, and physician satisfaction. These groups were compared with nonparametric analysis (Bobbia et al., 2013).
The introduction to this study focuses on arterial puncture for blood gas analysis. It talks about how this procedure is very common in the medicine ward, intensive care units, and emergency departments. It points how the emergency department of the authors has 8% to 12% of patients benefiting from arterial blood gas. However, less invasive procedures have gained popularity in the recent years. They describe how blood gas analysis is necessary for precise diagnosis and monitoring of such diseases as respiratory disease in decompensation, thromboembolism disease, carbon monoxide poisoning and a multitude of other diseases. This technique was first developed in the 19th century and received numerous revisions and developments in the following years. It stresses how Ultrasonography could be a valuable tool for insertion of venous catheters and how the results provided so far are encouraging. The investigation was done over a one-month period in the emergency ward (Bobbia et al., 2013).
The patients participating in the study had to be at least 18 years old, required a radial artery sample, and had to give consent to the procedure. 13 physicians participated in the study. They were graduates of accredited French Society of Emergency Medicine and were all trained in both theory and practice of the procedure. For safety, three hours of simulator training were given before the start of the study. For the ultrasonic group, a GE Vivid S6 machine with a 10-MHz linear transducer was used. 74 patients participated in the study, with two of them being later excluded. 72 patients were divided into groups of 37 in the first and 35 being assigned to the second group. Surprisingly, the study found that the use of ultrasonic guidance did not result in the lower number of attempts when taking blood gas samples making it an outlier among research concerning ultrasound guidance. However, the authors point out that it has proven to be an effective technique for the majority of procedures concerning arterial puncture, and that during the study all radial arteries were seen while using ultrasonography (Bobbia et al., 2013).
Implementation
Ultimately, the solution to the artery puncture complications lies in the implementation of ultrasound guidance during the majority of procedures concerning access to arteries and veins. Although ultrasound-guidance is not yet the norm, the equipment for it is common in emergency departments. Therefore implementation would mostly concern training of the staff. Studies show that this type of training significantly improves the ability of emergency department technicians to perform arterial procedures. The course of training would be brief but comprehensive (Duran-Gehring et al., 2016).
The majority of the studies covered in this paper, as well as others, point to the increased safety of ultrasound-guidance (Powell et al., 2014). With the reduction of adverse effects, more patients would pass this common procedure without complications, leading to increased satisfaction of both patients and physicians. Due to the relatively short training process, even a less experienced registered nurse would be able to provide a safe procedure, which would otherwise require a more experienced physician to guarantee the same result. With the complete implementation of the ultrasound-guidance policy, the unit is expected to see better results which in turn should lead to increased interest in this technology. In the future, ultrasonography is expected to become even more advanced, which should lead to an even higher level of patient care. Such common procedures should become almost completely safe for the patients, and physicians with any amount of experience should be able to perform them.
References
Bobbia, X., Grandpierre, R., Claret, P., Moreau, A., Pommet, S., Bonnec, J., … Coussaye, J. (2013). Ultrasound guidance for radial arterial puncture: A randomized controlled trial.The American Journal of Emergency Medicine, 31(5), 810-815.
Calvache, J., Rodríguez, M., Trochez, A., Klimek, M., Stolker, R., & Lesaffre, E. (2016). Incidence of mechanical complications of central venous catheterization using landmark technique. Journal of Intensive Care Medicine, 31(6), 397-402.
Duran-Gehring, P., Bryant, L., Reynolds, J., Aldridge, P., Kalynych, C., & Guirgis, F. (2016). Ultrasound-guided peripheral intravenous catheter training results in physician-level success for emergency department technicians. Journal of Ultrasound in Medicine, 35(11), 2343-2352.
Lo, R., Fokkema, M., Curran, T., Darling, J., Hamdan, A., Wyers, M., … Schermerhorn, L. (2015). Routine use of ultrasound-guided access reduces access site-related complications after lower extremity percutaneous revascularization. Journal of Vascular Surgery, 61(2), 405-412.
Powell, J., Mink, J., Nomura, J., Levine, B., Jasani, N., Nichols, W., … Sierzenski, P. (2014). Ultrasound-guidance can reduce adverse events during femoral central venous cannulation.The Journal of Emergency Medicine, 46(4), 519-524.
Tang, L., Wang, F., Li, Y., Zhao, L., Xi, H., Guo, Z., … Zhou, L. (2014). Ultrasound guidance for radial artery catheterization: An updated meta-analysis of randomized controlled trials. Plos ONE, 9(11), 1-7.
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