Ultrasound-guided insertion of intra-aortic balloon counterpulsation in intensive care: description of the technique.

Intra-aortic balloon counterpulsation (IAoBC) is a mechanical circulatory support device that has been used for more than 50 years, mainly for cardiogenic shock. Although its effect on mortality is controversial, IAoBC is still used in a wide variety of pre- and postoperative clinical settings in cardiac surgery centers. IAoBC has a complication rate of approximately 30%, mostly associated with problems during insertion and malpositioning. Thus, an insertion technique based on the use of ultrasound at the patient's bedside in the intensive care unit (ICU) is proposed.

Comparison of effectiveness between a conventional catheter and a manual commercial catheter: randomized trial of simulation of intraosseous access in a biological model / Comparación de la eficacia entre un catéter convencional y un catéter comercial manual: ensayo aleatorizado de simulación de acceso intraóseo en modelo biológico

Abstract Introduction: In the emergency services an action of paramount importance in critically ill patients is to obtain an early vascular access. When vascular access is not established, an intraosseous route should be obtained; otherwise, the mortality of these critically ill patients is almost 100%. In Colombia, the intraosseous access is not used because of the high costs of the devices and the lack of training of the healthcare staff to conduct the procedure. Objective: To determine the efficacy of a low-cost device to establish intraosseous access. Materials and methods: Quantitative approach, experimental design in a simulated environment with chicken tarsus and metatarsus. An analysis was conducted using frequency tables and central tendency measurements. Likewise, further analyses were done using Fisher's exact test, Chi2, and Mann-Whitney test. Results: A total of 99% of the procedures were successful with both catheters. The average time for intraosseous access was 6.6 seconds with Insyte 14 catheter and 4.7 seconds with Din 1515x Illinois Desch device (P = 0.001). There were no significant differences in the number of attempts to secure a successful intra-osseous access using any of the 2 devices (P = 0.56). Conclusion: There was no significant difference between the Ci 14 and the Si 14 catheter to establish a successful intraosseous access in the chicken tarsus and metatarsus in a simulated environment.

Resumen Introducción: En los servicios de urgencias una acción de primordial importancia en pacientes críticamente enfermos es obtener un acceso vascular temprano. En los casos en que no se logre obtener un acceso venoso, se debe obtener una vía intraósea, o de lo contrario la mortalidad de estos pacientes críticamente enfermos asciende casi al 100%. En Colombia no se realiza el uso del acceso intraóseo por los altos costos de los dispositivos requeridos y la falta de entrenamiento del personal de salud para dicho procedimiento. Objetivo: Determinar la eficacia de un dispositivo de bajo costo para el acceso intraóseo. Materiales y métodos: Enfoque cuantitativo, diseño experimental en ambiente simulado con tarso-metatarso de pollo. Se realizó un análisis mediante tablas de frecuencia y medidas de tendencia central. Así mismo, se realizaron análisis mediante el test exacto de Fisher, ji cuadrado y test de Mann Whitney. Resultados: El 99% de los procedimientos fueron exitosos con los dos catéteres. La mediana del tiempo para el acceso intraóseo fue de 6.6 segundos con el catéter Insyte 14® y de 4.7 segundos con el dispositivo Din 1515x Illinois Desch® (p=0.001). No se encontraron diferencias significativas en el número de intentos para lograr un acceso intraóseo exitoso con ambos dispositivos (p = 0.56). Conclusiones: No existe diferencia significativa entre el catéter Ci 14 y el Di 15 para lograr un acceso intraóseo exitoso en el tarso metatarso del pollo en un ambiente simulado.

Learning process and improvement of point-of-care ultrasound technique for subxiphoid visualization of the inferior vena cava.

BACKGROUND: Medical residents' training in ultrasonography usually follows the recommendations of the American College of Emergency Physicians (ACEP), even though these do not provide specific technical guidelines. Adequate training is considered to require 25 practical iterations in the majority of ultrasound procedures. However, the effectiveness of this approach has not been verified experimentally. We set out to determine the number of repetitions required for an acceptable ultrasound procedure of the inferior vena cava (IVC), as an important and emerging ultrasound procedure in cardiology. METHODS: Using three human models, each of eight medical residents in the Emergency Medicine (EM) Program at the Universidad del Rosario performed 25 iterations of the recommended procedure, with image quality evaluation by an EM physician expert in the technique. Logistic regression analysis was used to determine the lowest number of repetitions required to achieve an adjusted probability of success of 80 and 90 %, respectively. RESULTS: We obtained 200 ultrasound images. The percentage success by each resident ranged from 52 to 96 %. There was no statistical significance in the relation between gender and success (p = 0.83), but there was an association between year of residency and success (p < 0.001). The average time taken for each procedure was 17.3 s (SD 8.1); there was no association between the time taken and either repetition number or image quality. We demonstrate that eleven repetitions are required to achieve acceptable image quality in 80 %, and that 21 repetitions are required to achieve acceptable image quality in 90 %. CONCLUSIONS: This is the first study to formally evaluate the effectiveness of recommended training in ultrasound techniques. Our findings demonstrate that training comprising 25 procedural repetitions is easily sufficient to achieve optimal image quality, and they also provide empiric knowledge toward elucidating the times and minimum repetitions needed to acquire and improve ultrasonographic technique in novice operators to a level which fulfills quality requirements for interpretation.