Seldinger vs modified Seldinger techniques for ultrasound-guided central venous catheterisation in neonates: a randomised controlled trial.

BACKGROUND: Central venous catheterisation in neonates is difficult. The purpose of this study was to compare the Seldinger and modified Seldinger techniques for ultrasound-guided internal jugular vein catheterisation in neonates. METHODS: In this randomised, controlled trial, 120 neonates (≤1 month old) requiring central venous catheterisation under general anaesthesia were allocated into either the Seldinger (n=60) or the modified Seldinger (n=60) group. The primary outcome was the incidence of successful catheterisation on the first attempt. We also assessed the incidences of successful puncture on the first attempt, successful guide wire insertion on the first attempt, and successful final catheterisation. RESULTS: The primary outcome, the incidence of successful catheterisation on the first attempt was higher in the modified Seldinger group than in the Seldinger group (83% vs 65%; relative risk=1.282; 95% confidence interval, 1.032-1.594; P=0.025). The incidence of successful guide wire insertion on the first attempt was also higher in the modified Seldinger group (95% vs 75%; relative risk=1.267; 95% confidence interval, 1.082-1.482; P=0.003). Other incidences did not differ significantly between the groups. CONCLUSIONS: For ultrasound-guided internal jugular vein catheterisation in neonates, the modified Seldinger technique showed superiority over the Seldinger technique in terms of successful catheterisation and guide wire insertion on the first attempt. CLINICAL TRIAL REGISTRATION: NCT02688595.

Flexion decreases the ventilation quality of the Ambu® AuraGain™ laryngeal mask in paralysed children: A prospective randomised crossover study.

BACKGROUND: The influence of different head and neck positions on ventilation with the Ambu® AuraGain™ remains unevaluated in children. This study assessed the influence of different head and neck positions on ventilation with the AuraGain™ in paediatric patients. METHODS: In this prospective, randomised crossover study, children ≤7 years of age who were scheduled for elective surgery under general anaesthesia were enrolled. An AuraGain™ was placed in all patients; mechanical ventilation was performed using a volume-controlled mode with a tidal volume of 10 mL/kg. Respiratory rate was adjusted to maintain a ET CO2 of 35-40 mm Hg. The oropharyngeal leak pressure, expiratory tidal volume, peak inspiratory pressure, ventilation score and fibreoptic bronchoscopic view score were assessed for the neutral head and neck position, and then for the flexed, extended and rotated head and neck positions in a random order. RESULTS: Compared with the neutral position, the oropharyngeal leak pressure increased in the flexed position (P < .001), and decreased in the extended (P = .014) and rotated position (P = .002). The expiratory tidal volume and ventilation score were significantly reduced during flexion (all P < .005), and were comparable among the neutral, extended and rotated positions. The fibreoptic score improved in the extended and rotated position (all P < .001). Only the flexion ventilation score was lower compared with the neutral position (P = .014). CONCLUSIONS: Clinically, the flexed head and neck positions negatively affected ventilation due to obstruction of the airway. Ventilation with AuraGain™ can be effectively performed with the head and neck in the neutral, extended and rotated position in paediatric patients.

Comparison of various anthropometric indices for the identification of a predictor of incident hypertension: the ARIRANG study.

We compared the predictive capability of weight, waist circumference (WC), waist-to-height ratio (WHtR), waist-to-hip ratio (WHR), body mass index (BMI), body roundness index (BRI), and a body shape index (ABSI) to identify incident hypertension, and to determine whether any of these indices may be used as a better single predictor of incident hypertension. A total of 1718 participants aged 39-72 years were collected  in a longitudinal study. Logistic regression models were used to evaluate various anthropometric indices as significant predictors of hypertension. During 2.8 years of follow-up, 185 new cases of hypertension (10.8%) were reported. The BRI and ABSI were significantly higher in the participants who had developed hypertension than in those who had not (4.15 ± 1.01 vs. 3.57 ± 1.03, 0.80 ± 0.04 vs. 0.78 ± 0.05; respectively, p < 0.001). After adjusting for confounding variables, logistic regression analysis indicated that participants within the highest quartile of WC and WHtR were 4.79 and 4.51 times more likely to have hypertension than those within the lowest quartile (OR 4.79, 95% CI 2.49-9.20 vs. OR 4.51, 95% CI 2.41-8.43, respectively, p < 0.0001); in contrast, no such correlation was found for BMI, WHR, BRI, and ABSI. WC (AUC: 0.672) showed a more powerful predictive ability for hypertension (p < 0.0001) than BMI (AUC: 0.623), and an equal predictive power for hypertension as WHtR (AUC: 0.662) and BRI (AUC: 0.662) in the general population. We concluded that WC and/or WHtR but not BMI, showed superior prediction capability compared to WHR, BRI, and ABSI, for determining the incidence of hypertension in a community-based prospective study.

Real-time ultrasound-guided axillary vein cannulation in children: a randomised controlled trial.

The axillary vein is a good site for ultrasound-guided central venous cannulation in terms of infection rate, patient comfort and its anatomical relationship with the clavicle and lungs. We compared real-time ultrasound-guided axillary vein cannulation with conventional infraclavicular landmark-guided subclavian vein cannulation in children. A total of 132 paediatric patients were randomly allocated to either ultrasound-guided axillary vein (axillary group) or landmark-guided subclavian vein (landmark group). The outcomes measured were success rate after two attempts, first-attempt success rate, time to cannulation and complication rate. The success rate after two attempts was 83% in the axillary group compared with 63% in the landmark group (odds ratio 2.85, 95%CI 1.25-6.48, p = 0.010). The first-attempt success rate was 46% for the axillary group and 40% for the landmark group (p = 0.274) and median time to cannulation was 156 s for the axillary group and 180 s for the landmark group (p = 0.286). There were no differences in complication rates between the two groups, although three episodes of subclavian artery puncture occurred in the landmark group (p = 0.08). We conclude that axillary vein cannulation using a real-time ultrasound-guided in-plane technique is useful and effective in paediatric patients.

The effect of lung deflation on the position of the pleura during subclavian vein cannulation in infants receiving mechanical ventilation: an ultrasound study.

We evaluated the effect of lung deflation on the relative position of the pleura compared with a reference line during supra- and infraclavicular approaches to the right subclavian vein. The reference line was drawn relative to the predicted pathway of the needle. The distances between the pleura and the reference line for supra- and infraclavicular approaches were measured during inspiration and expiration in 41 infants. Measurements were repeated with the application of 5 cmH2O positive end-expiratory pressure (PEEP) and in the Trendelenburg position. Lung deflation during the supraclavicular approach significantly decreased the volume of lung crossing the reference line by a median (IQR [range]) of 1.0 (0.6 to 1.3 [0.0 to 4.8]) mm, p < 0.001, irrespective of the application of PEEP or patient position. However, during the infraclavicular approach, lung deflation showed no change in the distance of the pleura from the reference line regardless of PEEP or patient position. We conclude that lung deflation moves the lung apex caudally and can reduce the potential risk of pneumothorax during a supraclavicular approach to the right subclavian vein in infants.