Ultrasound-guided arterial cannulation in the paediatric population.

BACKGROUND: In arterial line cannulation in children and adolescents, traditional methods of locating the artery include palpation and Doppler auditory assistance. It is unclear whether ultrasound guidance is superior to these methods. This is an update of a review originally published in 2016. OBJECTIVES: To evaluate the benefits and harms of ultrasound guidance compared with traditional techniques (palpation, Doppler auditory assistance) for assisting arterial line placement at all potential sites in children and adolescents. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, and Web of Science from inception to 30 October 2022. We also searched four trials registers for ongoing trials, and we checked the reference lists of included studies and relevant reviews for other potentially eligible trials. SELECTION CRITERIA: We included randomised controlled trials (RCTs) comparing ultrasound guidance versus other techniques (palpation or Doppler auditory assistance) to guide arterial line cannulation in children and adolescents (aged under 18 years). We planned to include quasi-RCTs and cluster-RCTs. For RCTs with both adult and paediatric populations, we planned to include only the paediatric population data. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the risk of bias of included trials and extracted data. We used standard Cochrane meta-analytical procedures, and we applied the GRADE method to assess the certainty of evidence. MAIN RESULTS: We included nine RCTs reporting 748 arterial cannulations in children and adolescents (under 18 years of age) undergoing different surgical procedures. Eight RCTs compared ultrasound with palpation, and one compared ultrasound with Doppler auditory assistance. Five studies reported the incidence of haematomas. Seven involved radial artery cannulation and two involved femoral artery cannulation. The people performing arterial cannulation were physicians with different levels of experience. The risk of bias varied across studies, with some studies lacking details of allocation concealment. It was not possible to blind practitioners in any case; this adds a performance bias that is inherent to the type of intervention studied in our review. Compared to traditional methods, ultrasound guidance probably causes a large increase in first-attempt success rates (risk ratio (RR) 2.01, 95% confidence interval (CI) 1.64 to 2.46; 8 RCTs, 708 participants; moderate-certainty evidence) and probably causes a large reduction in the risk of complications such as haematoma formation (RR 0.26, 95% CI 0.14 to 0.47; 5 RCTs, 420 participants; moderate-certainty evidence). No studies reported data about ischaemic damage. Ultrasound guidance probably improves success rates within two attempts (RR 1.78, 95% CI 1.25 to 2.51; 2 RCTs, 134 participants; moderate-certainty evidence) and overall rate of successful cannulation (RR 1.32, 95% CI 1.10 to 1.59; 6 RCTs, 374 participants; moderate-certainty evidence). In addition, ultrasound guidance probably reduces the number of attempts to successful cannulation (mean difference (MD) -0.99 attempts, 95% CI -1.15 to -0.83; 5 RCTs, 368 participants; moderate-certainty evidence) and duration of the cannulation procedure (MD -98.77 seconds, 95% CI -150.02 to -47.52, 5 RCTs, 402 participants; moderate-certainty evidence). More studies are needed to confirm whether the improvement in first-attempt success rates is more pronounced in neonates and younger children compared to older children and adolescents. AUTHORS' CONCLUSIONS: We identified moderate-certainty evidence that ultrasound guidance for arterial cannulation compared with palpation or Doppler auditory assistance improves first-attempt success rate, second-attempt success rate and overall success rate. We also found moderate-certainty evidence that ultrasound guidance reduces the incidence of complications, the number of attempts to successful cannulation and the duration of the cannulation procedure.

Ultrasound-guided arterial cannulation for paediatrics.

BACKGROUND: Arterial line cannulation in paediatric patients is traditionally performed by palpation or with Doppler auditory assistance in locating the artery before catheterization. It is not clear whether ultrasound guidance offers benefits over these methods. OBJECTIVES: To assess first attempt success rates and complication rates when ultrasound guidance is used for arterial line placement in the paediatric population, as compared with traditional techniques (palpation, Doppler auditory assistance), at all potential sites for arterial cannulation (left or right radial, ulnar, brachial, femoral or dorsalis pedis artery). SEARCH METHODS: We searched CENTRAL, MEDLINE (Ovid) and Embase (Ovid). We also searched databases of ongoing trials (ClinicalTrials.gov (www.clinicaltrials.gov/), Current Controlled Trials metaRegister (www.controlled-trials.com/), the EU Clinical Trials register (www.clinicaltrialsregister.eu/) and the WHO International Clinical Trials Registry Platform (http://apps.who.int/trialsearch/). We tried to identify other potentially eligible trials by searching the reference lists of retrieved included trials and related systematic or other reviews. We searched until January 2016. SELECTION CRITERIA: We included randomized controlled trials (RCTs) comparing ultrasound guidance versus palpation or Doppler auditory assistance to guide arterial line cannulation in paediatrics. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the risk of bias of included trials and extracted data. We used standard Cochrane meta-analytical procedures, and we applied the GRADE method to assess the quality of evidence. MAIN RESULTS: We included five RCTs reporting 444 arterial cannulations in paediatric participants. Four RCTs compared ultrasound with palpation, and one compared ultrasound with Doppler auditory assistance.Risk of bias varied across studies, with some studies lacking details of allocation concealment. It was not possible to blind practitioners in all of the included studies; this adds a performance bias that is inherent to the type of intervention studied in our review. Only two studies reported the rate of complications.Meta-analysis showed that ultrasound guidance produces superior success rates at first attempt (risk ratio (RR) 1.96, 95% confidence interval (CI) 1.34 to 2.85, 404 catheters, four RCTs, moderate-quality evidence) and fewer complications, such as haematoma formation (RR 0.20, 95% CI 0.07 to 0.60, 222 catheters, two RCTs, moderate-quality evidence). Our results suggest, but do not confirm, that a possible advantage of ultrasound guidance for the first attempt success rate over other techniques is more pronounced in infants and small children than in older children. Similarly, our results suggest, but do not confirm, the possibility of a positive influence of expertise in the use of ultrasound on the first attempt success rate. We also found improved success rates within two attempts (RR 1.78, 95% CI 1.25 to 2.51, 134 catheters, two RCTs, moderate-quality evidence) with ultrasound guidance compared with other types of guidance. No studies reported data about ischaemic damage. We rated the quality of evidence for all outcomes as moderate owing to imprecision due to wide confidence intervals, modest sample sizes and limited numbers of events. AUTHORS' CONCLUSIONS: We identified moderate-quality evidence suggesting that ultrasound guidance for radial artery cannulation improves first and second attempt success rates and decreases the rate of complications as compared with palpation or Doppler auditory assistance. The improved success rate at the first attempt may be more pronounced in infants and small children, in whom arterial line cannulation is more challenging than in older children.