Ultrasound-guided pediatric vascular cannulation by inexperienced operators: outcomes in a training model.

OBJECTIVE: To present the results of an ultrasound vascular cannulation (UGVC) training program for inexperienced operators using a training model. METHOD: This was a descriptive observational study developed in the paediatric intensive care unit (PICU) of a third-level hospital. Operators received basic theoretical training in the USVC technique, followed by practical training with a model designed for USVC-inexperienced healthcare professionals. RESULTS: The study included 25 healthcare professionals, who carried out a total of 300 ultrasound-guided cannulation procedures (12 per participant) at equidistant sites on the longitudinal axis/in-plane (LA/IP) and the transverse axis/out-of-plane (TA/OP). The mean depth of cannulated vessels was 0.90 (0.34) cm and their mean diameter was 0.41 (0.1) cm. In 41.7% of cases, complete view of the needle (CVN) was accomplished; in 49% of cases, repositioning of the needle/guidewire (RNG) was necessary for successful UGVC. The rate of successful UGVC in the training model was 79.7%. The mean time required for the procedure was 74.70 (73.72) seconds. The time to successful cannulation was 58.72 (56.87) seconds. The mean number of attempts needed until successful UGVC was 1.31 (0.72). Complications were: (a) 26.3% vessel perforation/wrong guidewire positioning (VP/WGP) and (b) 4.3% successful vessel puncture followed by failure to accomplish subsequent cannulation. CONCLUSIONS: Through the present theoretical-practical training program for inexperienced operators using a training model: (a) high success rates and short procedural times were attained; (b) complete view of needle and need for repositioning the needle/guidewire occurred in half of the procedures; and (c) complications occurred in a third of the procedures.

Evaluation of Training in Pediatric Ultrasound-guided Vascular Cannulation Using a Model.

BACKGROUND: The study objective was to evaluate a training program and a training model for pediatric ultrasound-guided vascular cannulation (USGVC) by inexperienced operators. METHODS: An observational descriptive study was conducted at the pediatric intensive care unit of a level-III hospital. The study protocol comprised the following parts: (1) pretraining test; (2) theory and practice training session consisting of an explanation of basic vascular ultrasound concepts plus performing vascular cannulation in a model; (3) posttraining test; and (4) evaluation of the training model. RESULTS: A total of 25 health-care professionals participated in the study. All of them possessed the skills to locate vessels and ultrasound planes, and they performed USGVC using the training model. On a 1-5 scale, the model was rated to have 87.6% fidelity with real pediatric patients; the best regarded aspect of it was utility (93%). Differences were found between pre- and post-training scores: 2.72 ± 0.84 versus 4.60 ± 0.50; P < 0.001 (95% confidence interval: -2.28, -1.47). Altogether, 300 ultrasound-guided cannulation procedures were carried out (12 per participant) distributed along the longitudinal axis in plane and the transverse axis out of plane, with 150 punctures in each of them. The success rate for USGVC in the training model was 79.7%, the mean time for the procedure was 115.6 ± 114.9 s, and the mean time for achieving successful cannulation was 87.69 ± 82.81 s. The mean number of trials needed for successful USGVC was 1.49 ± 0.86. CONCLUSION: After undergoing the theory-practice training, participants: (a) improved their knowledge of ultrasound-guided vascular access; (b) positively evaluated the USGVC training model, in particular its utility and fidelity as compared with cannulation in pediatric patients; and (c) achieved a high USGVC success rate in a relatively short time.

Wilson disease: revision of diagnostic criteria in a clinical series with great genetic homogeneity.

BACKGROUND: Wilson disease is an autosomal recessive disorder of copper metabolism caused by mutations in the ATP7B gene. An early diagnosis is crucial to prevent evolution of the disease, as implantation of early therapeutic measures fully prevents its symptoms. As population genetics data predict a higher than initially expected prevalence, it was important to define the basic diagnostic tools to approach population screening. METHODS: A highly genetically homogeneous cohort of 70 patients, belonging to 50 unrelated families, has been selected as a framework to analyze all their clinical, biochemical and genetic characteristics, to define the disease in our population, with an estimated prevalence of 1 in 12,369, and determine the most useful features that reach diagnostic value. RESULTS: Serum ceruloplasmin below 11.5 mg/dL and cupremia below 60 µg/mL, were the best analytical predictors of the disease in asymptomatic individuals, while cupruria or hepatic copper determination were less powerful. Genetic analysis reached a conclusive diagnosis in all 65 patients available for complete testing. Of them, 48 were carriers of at least one p.Leu708Pro mutant allele, with 24 homozygotes. Nine patients carried a promoter deletion mutation, revealing that extended sequencing beyond the ATP7B gene-coding region is essential. All mutations caused hepatic damage since early ages, increasing its severity as diagnosis was delayed, and neurological symptoms appear. CONCLUSION: Serum ceruloplasmin determination followed by genetic screening would reduce costs and favor the prioritization of non-invasive procedures to reach a definitive diagnosis, even for asymptomatic cases.

Canalización vascular ecoguiada: Experiencia en el paciente pediátrico crítico / Ultrasound-guided vascular cannulation: Experience in critically-ill pediatric patients

Introducción. La canalización vascular central en niños presenta alta complejidad técnica y dificultades. La ecografía vascular puede facilitar este procedimiento. Objetivo. Describir las características de las canalizaciones vasculares ecoguiadas en el paciente pediátrico crítico. Población y métodos. Las variables de interés registradas prospectivamente fueron los vasos más comúnmente canalizados, su localización, la medición del diámetro/profundidad, la tasa de éxito y las complicaciones presentadas, entre otras. Resultados. En 86 pacientes pediátricos, se realizaron 124 punciones vasculares. Los accesos vasculares fueron la vena femoral (39,7%), seguida de la arteria femoral (27,2%) y la vena yugular interna (14,7%). Los vasos femorales se localizaron a una profundidad de 0,75 ± 0,25 mm con un diámetro medio de 0,31 ± 0,16 mm. La profundidad de los vasos venosos yugulares fue menor (0,64 ± 0,24 mm) y su diámetro global, mayor (0,44 ± 0,19 mm). El número medio de intentos en las canalizaciones vasculares ecoguiadas fue de 2,2 ± 1,3. La tasa de éxito fue del 79% asociada a un mayor diámetro del vaso (0,39 ± 0,20 mm vs. 0,28 ± 0,13 mm, p 0,01) y un menor número de intentos (1,90 ± 1,16 vs. 3,45 ± 1,77, p= 0,001). Las complicaciones, fueron la punción accidental de otro vaso (5,3%) y el desarrollo de un hematoma durante la punción (2,3%). Conclusiones. La canalización vascular ecoguiada en los pacientes pediátricos estudiados permite visualizar los vasos y medir su profundidad y diámetro; presenta una alta tasa de éxito y se asocia a una baja tasa de complicaciones.

Introduction. Central vascular cannulation in children is a highly complex technique and poses many difficulties. Vascular ultrasound can make this procedure easier. Objective. To describe the characteristics of ultrasound-guided vascular cannulation in critically-ill pediatric patients. Population and methods. Outcome measures prospectively recorded were vessels most frequently cannulated, their localization, the measurement of their diameter/depth, the success rate and complications developed, among others. Results. One hundred and twenty four vascular punctures were performed in 86 pediatric patients. Vascular accesses were the femoral vein (39.7%), followed by the femoral artery (27.2%) and the internal jugular vein (14.7%). Femoral vessels were localized at a depth of 0.75 ± 0.25 mm, with a mean diameter of 0.31 ± 0.16 mm. The depth of jugular vein vessels was smaller (0.64 ± 0.24 mm) and their overall diameter, larger (0.44 ± 0.19 mm). The mean number of attempts in ultrasound-guided cannulations was 2.2 ± 1.3. The success rate was 79% and was associated to a larger vessel diameter (0.39 ± 0.20 mm vs. 0.28 ± 0.13 mm, p= 0.01) and a lower number of attempts (1.90 ± 1.16 vs. 3.45 ± 1.77, p= 0.001). Complications were accidental puncture of another vessel (5.3%) and hematoma formation during puncture (2.3%). Conclusions. In the pediatric patients studied, ultrasound-guided vascular cannulation allowed vessel visualization and measurement of their depth and diameter; the success rate was high and it was associated to a low complication rate.

Ultrasound-guided vascular cannulation. Experience in critically-ill pediatric patients. / Canalización vascular ecoguiada. Experiencia en el paciente pediátrico crítico.

INTRODUCTION: Central vascular cannulation in children is a highly complex technique and poses many difficulties. Vascular ultrasound can make this procedure easier. OBJECTIVE: To describe the characteristics of ultrasound-guided vascular cannulation in critically-ill pediatric patients. POPULATION AND METHODS: Outcome measures prospectively recorded were vessels most frequently cannulated, their localization, the measurement of their diameter/depth, the success rate and complications developed, among others. RESULTS: One hundred and twenty four vascular punctures were performed in 86 pediatric patients. Vascular accesses were the femoral vein (39.7%), followed by the femoral artery (27.2%) and the internal jugular vein (14.7%). Femoral vessels were localized at a depth of 0.75 ± 0.25 mm, with a mean diameter of 0.31 ± 0.16 mm. The depth of jugular vein vessels was smaller (0.64 ± 0.24 mm) and their overall diameter, larger (0.44 ± 0.19 mm). The mean number of attempts in ultrasound-guided cannulations was 2.2 ± 1.3. The success rate was 79% and was associated to a larger vessel diameter (0.39 ± 0.20 mm vs. 0.28 ± 0.13 mm, p= 0.01) and a lower number of attempts (1.90 ± 1.16 vs. 3.45 ± 1.77, p= 0.001). Complications were accidental puncture of another vessel (5.3%) and hematoma formation during puncture (2.3%). CONCLUSIONS: In the pediatric patients studied, ultrasound-guided vascular cannulation allowed vessel visualization and measurement of their depth and diameter; the success rate was high and it was associated to a low complication rate.

Introducción. La canalización vascular central en niños presenta alta complejidad técnica y dificultades. La ecografía vascular puede facilitar este procedimiento. Objetivo. Describir las características de las canalizaciones vasculares ecoguiadas en el paciente pediátrico crítico. Población y métodos. Las variables de interés registradas prospectivamente fueron los vasos más comúnmente canalizados, su localización, la medición del diámetro/profundidad, la tasa de éxito y las complicaciones presentadas, entre otras. Resultados. En 86 pacientes pediátricos, se realizaron 124 punciones vasculares. Los accesos vasculares fueron la vena femoral (39,7%), seguida de la arteria femoral (27,2%) y la vena yugular interna (14,7%). Los vasos femorales se localizaron a una profundidad de 0,75 ± 0,25 mm con un diámetro medio de 0,31 ± 0,16 mm. La profundidad de los vasos venosos yugulares fue menor (0,64 ± 0,24 mm) y su diámetro global, mayor (0,44 ± 0,19 mm). El número medio de intentos en las canalizaciones vasculares ecoguiadas fue de 2,2 ± 1,3. La tasa de éxito fue del 79% asociada a un mayor diámetro del vaso (0,39 ± 0,20 mm vs. 0,28 ± 0,13 mm, p 0,01) y un menor número de intentos (1,90 ± 1,16 vs. 3,45 ± 1,77, p= 0,001). Las complicaciones, fueron la punción accidental de otro vaso (5,3%) y el desarrollo de un hematoma durante la punción (2,3%). Conclusiones. La canalización vascular ecoguiada en los pacientes pediátricos estudiados permite visualizar los vasos y medir su profundidad y diámetro; presenta una alta tasa de éxito y se asocia a una baja tasa de complicaciones.

[Epidemiology of traumatic spinal cord injury in Gran Canaria]. / Epidemiología de la lesión medular de origen traumático en Gran Canaria.

OBJECTIVE: To evaluate the epidemiological and clinical trends in acute traumatic spinal cord injuries. MATERIAL AND METHODS: A retrospective study was conducted of traumatic spinal cord injury patients in Gran Canaria (Canary Islands, Spain) from 2000 to 2014. Demographic and spinal injury severity trends were analysed by year of injury grouped into 3 periods: 2000-2005, 2006-2010, and 2011-2014. RESULTS: The sample included 141 patients. The mean incidence for the entire period was 12 cases/million/year. There was a decrease in cases in the second and third period. While the male/female ratio was 3.8/1 and was maintained in all periods, the mean patient age increased from 38.8 in 2000-5 to 54.5 years in 2011-4 (P<.05). Falls have been the leading cause of spinal cord injury (48.2%), followed by traffic accidents (37.6%). Falls have increased, especially in the older population. Incomplete tetraplegia has been the most prevalent group (30.5%). A vertebral fracture was suffered by 70.3% of all patients, with 93.2% of them requiring surgery. CONCLUSIONS: There has been a decrease in the incidence of traumatic spinal cord injury in recent years. The target population has changed, and the older population is currently the most affected. This reality suggests the need to change the local prevention campaigns for spinal cord injury in the elderly.