Systematic review: is real-time ultrasonic-guided central line placement by ED physicians more successful than the traditional landmark approach?

INTRODUCTION: The superiority of ultrasonic-guided compared with landmark-guided central venous catheter (CVC) placement is not well documented in the Emergency Department. OBJECTIVE: To systematically review the literature comparing success rates between ultrasonic- and landmark-guided CVC placement by ED physicians. METHODS: PubMed and EMBASE databases were searched for randomised controlled trials from 1965 to 2010 using a search strategy derived from the following PICO formulation: PATIENTS: Adults requiring emergent CVC placement except during cardiopulmonary resuscitation. INTERVENTION: CVC placement using real-time ultrasonic guidance. Comparator: CVC placement using anatomical landmarks. OUTCOME: Comparison of success rates of CVC placement between ultrasonic- versus landmark-guided techniques. ANALYSIS: Success rates between CVC placement methods using a Forest Plot (95% CI) calculated by Review Manager Version 5.0. RESULTS: Search identified 944 articles of which 938 were excluded by title/abstract relevance, two not randomised, one cardiac arrest, one no landmark control, one success rate not calculated. A single study of 130 patients (65 ultrasonic- vs 65 landmark-guided) selected for internal jugular vein placement remained. Successful internal jugular CVC was significantly (p=0.02) more likely in the ultrasound-guided (93.9%) compared with landmark-guided (78.5%) techniques with an OR of 1.2 (95% CI 1.0 to 1.4). Complications rates were significantly (p=0.04) lower in ultrasonic (4.6%) versus landmark (16.9%) technique, OR=3.7 (95% CI 1.1 to 12.5). CONCLUSION: Only one single high quality study illustrating that ED ultrasound- versus landmark-guided internal jugular catheter placement had higher success rates with lower complication rates.

Focused Training for Humanitarian Responders in Regional Anesthesia Techniques for a Planned Randomized Controlled Trial in a Disaster Setting.

BACKGROUND: Lower extremity trauma during earthquakes accounts for the largest burden of geophysical disaster-related injuries. Insufficient pain management is common in disaster settings, and regional anesthesia (RA) has the potential to reduce pain in injured patients beyond current standards. To date, no prospective research has evaluated the use of RA in a disaster setting. This cross-sectional study assesses knowledge translation and skill acquisition outcomes for lower extremity RA performed with and without ultrasound guidance among a cohort of Médecins Sans Frontières (MSF) volunteers who will function as proceduralists in a planned randomized controlled trial evaluating the efficacy of RA for pain management in an earthquake setting. METHODS: Generalist humanitarian healthcare responders, including both physicians and nurses, were trained in ultrasound guided femoral nerve block (USGFNB) and landmark guided fascia iliaca compartment block (LGFICB) techniques using didactic sessions and interactive simulations during a one-day focused course. Outcome measures evaluated interval knowledge attainment and technical proficiency in performing the RA procedures. Knowledge attainment was assessed via pre- and post-test evaluations and procedural proficiency was evaluated through monitored simulations, with performance of critical actions graded by two independent observers. RESULTS: Twelve humanitarian response providers were enrolled and completed the trainings and assessments. Knowledge scores significantly increased from a mean pre-test score of 79% to post-test score of 88% (p<0.001). In practical evaluation of the LGFICB, participants correctly performed a median of 15.0 (Interquartile Range (IQR) 14.0-16.0) out of 16 critical actions. For the USGFNB, the median score was also 15.0 (IQR 14.0-16.0) out of 16 critical actions. Inter-rater reliability for completion of critical actions was excellent, with inter-rater agreement of 83.3% and 91.7% for the LGFICB and USGFNB evaluations, respectively. DISCUSSION: Prior to conducting a trial of RA in a disaster setting, providers need to gain understanding and skills necessary to perform the interventions. This evaluation demonstrated attainment of high knowledge and technical skill scores in both physicians and nurses after a brief training in regional anesthesia techniques. This study demonstrates the feasibility of rapidly training generalist humanitarian responders to provide both LGFICB and USGFNB during humanitarian emergencies.

Accuracy of Inferior Vena Cava Ultrasound for Predicting Dehydration in Children with Acute Diarrhea in Resource-Limited Settings.

INTRODUCTION: Although dehydration from diarrhea is a leading cause of morbidity and mortality in children under five, existing methods of assessing dehydration status in children have limited accuracy. OBJECTIVE: To assess the accuracy of point-of-care ultrasound measurement of the aorta-to-IVC ratio as a predictor of dehydration in children. METHODS: A prospective cohort study of children under five years with acute diarrhea was conducted in the rehydration unit of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b). Ultrasound measurements of aorta-to-IVC ratio and dehydrated weight were obtained on patient arrival. Percent weight change was monitored during rehydration to classify children as having "some dehydration" with weight change 3-9% or "severe dehydration" with weight change > 9%. Logistic regression analysis and Receiver-Operator Characteristic (ROC) curves were used to evaluate the accuracy of aorta-to-IVC ratio as a predictor of dehydration severity. RESULTS: 850 children were enrolled, of which 771 were included in the final analysis. Aorta to IVC ratio was a significant predictor of the percent dehydration in children with acute diarrhea, with each 1-point increase in the aorta to IVC ratio predicting a 1.1% increase in the percent dehydration of the child. However, the area under the ROC curve (0.60), sensitivity (67%), and specificity (49%), for predicting severe dehydration were all poor. CONCLUSIONS: Point-of-care ultrasound of the aorta-to-IVC ratio was statistically associated with volume status, but was not accurate enough to be used as an independent screening tool for dehydration in children under five years presenting with acute diarrhea in a resource-limited setting.