|Year : 2020 | Volume
| Issue : 3 | Page : 308-312
Ultrasound-guided arterial catheterization in critical patients with nonpulsatile continuous circulation conditions on ventricular assist devices or veno-arterial extracorporeal membrane oxygenation support
Mohamed Laimoud1, Mosleh Alanazi2
1 King Faisal Specialist Hospital & Research Center, Riyadh; Department of Critical Care, Cairo University, Cairo, Egypt, Saudi Arabia
2 King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
|Date of Submission||23-Oct-2019|
|Date of Acceptance||19-Jul-2020|
|Date of Web Publication||29-Sep-2020|
MD,PhD Mohamed Laimoud
King Faisal Heart Center, P.O Box 3354, Riyadh 11211
Source of Support: None, Conflict of Interest: None
Background Arterial catheterizations, especially of radial and femoral arteries, are very common procedures performed by physicians dealing with critical patients for invasive hemodynamic monitoring and frequent arterial blood sampling. Traditionally, the technique of locating surface landmarks and palpation was used in catheterization. Getting arterial access can be challenging in critical patients with hemodynamic instability, impalpable pulses, and coagulopathy. Our objective was to study the effectiveness of vascular ultrasound in arterial catheterization in critical patients with nonpulsatile circulation admitted at cardiac critical care units in comparison with the landmark technique.
Patients, methods, and results This retrospective study was conducted in a tertiary care hospital and included patients from January 2015 to November 2018 who were admitted to adult cardiac critical care unit with veno-arterial extracorporeal membrane oxygenation or left ventricular assist device and required arterial vascular access for invasive hemodynamic monitoring. A total of 124 vascular catheters were inserted in 109 critical patients. Overall, 87 (79.8%) patients were hemodynamically unstable and supported with vasopressors infusions. Heparin infusion was maintained in 91 (83.4%) patients, while 18 (16.51%) patients were anticoagulated with oral warfarin therapy during arterial catheterization. The first-attempt success was achieved in 78.9 versus 5.6% (P=0.001) and the procedural success rate was 100 versus 62.1% (P=0.001) in the ultrasound and landmark groups, respectively. The number of attempts was 1.2±0.4 versus 2.1±0.5 (P=0.001), and the hematoma occurred in 2.8 versus 11.1% (P=0.001) in the ultrasound and landmark groups, respectively.
Conclusion Ultrasound-guided arterial catheterization in critical patients with unstable hemodynamics and nonpulsatile continuous circulation was associated with higher first-attempt and procedural success and less complications compared with the landmark technique.
Keywords: arterial catheterization, landmark, left ventricular assist device (LVAD), nonpulsatile circulation, ultrasound (ECMO), veno-arterial extracorporeal membrane oxygenation
|How to cite this article:|
Laimoud M, Alanazi M. Ultrasound-guided arterial catheterization in critical patients with nonpulsatile continuous circulation conditions on ventricular assist devices or veno-arterial extracorporeal membrane oxygenation support. Res Opin Anesth Intensive Care 2020;7:308-12
|How to cite this URL:|
Laimoud M, Alanazi M. Ultrasound-guided arterial catheterization in critical patients with nonpulsatile continuous circulation conditions on ventricular assist devices or veno-arterial extracorporeal membrane oxygenation support. Res Opin Anesth Intensive Care [serial online] 2020 [cited 2020 Oct 23];7:308-12. Available from: http://www.roaic.eg.net/text.asp?2020/7/3/308/296611
| Background|| |
Continuous-flow nonpulsatile ventricular assist devices (VADs) pump blood from left ventricle into the ascending aorta throughout the cardiac cycle with loss of pulsatility. Anticoagulation is used with a heparinization and then oral anticoagulation warfarin and aspirin. These devices became a standard therapy for patients with advanced heart failure as a bridge to cardiac transplantation, a bridge to myocardial recovery, or a destination therapy ,,.
Veno-arterial extracorporeal membrane oxygenation (VA ECMO) is ideally used in a patient with a potentially reversible cardiac conditions and is commonly placed in those with hemodynamic collapse refractory to medical management. VA ECMO support allows the physicians time to determine the suitability of the patient for recovery or as a candidate for transplantation or placement of left ventricular assist device (LVAD). Heparinization is used to decrease the risk of extracorporeal circuit and oxygenator thrombosis .
Peripheral arterial catheterizations are very common procedures performed by physicians in critical care units. Traditionally, the technique of locating surface landmarks and palpation was used during radial and femoral catheterization. This can be challenging in patients with impalpable pulses, hemodynamic instability, thrombocytopenia, and coagulopathy.
| Aim|| |
Our objective was to study the effectiveness of vascular ultrasound in arterial catheterization in critical patients with nonpulsatile circulation admitted at cardiac critical care units in comparison with the landmark technique.
| Patients and methods|| |
We conducted this retrospective study after getting approval from our Institute Ethics Committee for waiver of informed consents. The study was approved by KFSHRC Ethical Committee and got a reference number 2181239. The ethical committee exempted the study from a specific consent, being a retrospective analytic study that reveals no identifiable private information. We used the hospital Integrated Compliance Information System to collect the data of patients admitted to adult cardiac critical care units from January 2015 to November 2018. They were supported with LVADs (Heart Mate III) or VA ECMO and required arterial vascular access.
The operators used the MicroMaxx (038QP2) and SonoSite M-Turbo (WK1HJZ) (SonoSite, Inc., Bothell, WA, USA) portable ultrasound devices with small footprint linear high-frequency transducers (13–6 MHz) in a dynamic guidance to help real-time visualization of needle insertion and guide wire introduction. The B-mode allowed gray scale images, showing the vessels. The color Doppler was used to detect the vessel flow and differentiate between arteries and veins.
All catheters were inserted by senior physicians (consultants or assistant consultants) under sterile conditions. The catheterizations were done via Seldinger’s technique either by ultrasound-guided technique or landmark technique according to the operator preferences after skin cleaning by povidone-iodine and infiltration with 1% lidocaine.
Demographic data of patients and type of circulatory support device were collected. Clinical and laboratory data were collected including coagulation parameters and anticoagulation during the catheterization procedures. The number of attempts for catheter insertion was collected, and the successful placement of lines was detected by blood gases sampling from arterial catheters. The complications were documented including hematomas during insertion or arteriovenous fistula formation. The access time which is the time between first skin puncture to successful placement of line could not be detected from the medical records.
Data were statistically analyzed with the Statistical Package of Social Science Software program, version 23. Data were summarized using mean and SD for quantitative variables and frequency and percentage for qualitative ones. Comparison between groups was performed using the independent sample t test or Mann–Whitney test for quantitative variables and the c2 test for qualitative ones. P values less than 0.05 were considered statistically significant.
| Results|| |
Demographic and clinical data
A total of 124 vascular catheters were inserted in 109 patients. Vascular ultrasound was used in group I, while landmark technique was used in group II. Overall, 64 (58.7%) patients were supported with VA ECMO, while 45 (41.3%) patients were supported LVAD (Heart Mate III) devices. Moreover, 87 (79.8%) patients were hemodynamically unstable and supported with vasopressors infusions. Heparin infusion was maintained in 91 (83.4%) patients, while 18 (16.51%) patients were anticoagulated with oral warfarin therapy during arterial catheterization. The patients in the ultrasound group were more obese with higher BMI than those in the landmark group. There were no significant statistical differences between both groups regarding age, hemodynamics, or left ventricular ejection fraction ([Table 1] and [Table 2]).
There were no statistically significant differences between both groups regarding platelet count or coagulation profile. There were no significant differences between both groups regarding the renal and hepatic markers except for the alanine transaminase and aspartate transferase ([Table 2]).
Vascular catheterization data
The first-attempt success and the whole procedural success were significantly achieved in the ultrasound group with fewer access attempts and fewer complications. Access site hematoma occurred more significantly in the landmark group but required only compression of the puncture site without vascular intervention. There was no arteriovenous fistula formation in both groups. The landmark technique was applied in 29 catheterization process but succeeded in 18 (62.1%) cases, and the others were shifted to the ultrasound group ([Table 3]).
| Discussion|| |
Arterial catheterization is challenging to physicians dealing with critical patients with hemodynamic instability, absent peripheral pulsations, with coagulopathy owing to anticoagulation, acquired Von Willebrand syndrome, and thrombocytopenia.
Our study revealed that the procedural success and the first-attempt success were significantly achieved in the ultrasound group (P=0.001) with less attempts and less complications (P=0.001). Approximately 37.9% of arterial catheters failed to be inserted by landmark technique, and the ultrasound was used to guide insertion. Sometimes, the catheter or the wire could not be passed successfully into the artery, despite apparent good blood flow from the needle, making any further attempts more difficult or resulting in arterial spasm or thrombosis. Ultrasound allows assessment of target arteries before catheter insertion to confirm vessel patency and absence of thrombosis or anomalies. Moreover, real-time ultrasound helps to guide and see the needle tip and wire into the artery during catheterization.
The radial artery is the preferred site for arterial catheterization owing to its superficial course and a low rate of complications that occur in ∼5% of cases . It was reported that variants of the radial artery are as high as 30% in individuals, although less aberration occurs at the distal forearm . The meta-analysis by Shiloh et al.  concluded a clear benefit from ultrasound guidance for radial artery catheterization compared with palpation method, as manifested by a higher first-attempt success rate, fewer mean-attempts to success, shorter mean-time to success, and reduced hematoma formation.
Ultrasound allows to take short-axis and long-axis views to get static and dynamic images of a target blood vessel and allowing real-time catheterization. Ultrasound can also differentiate between arteries and veins by performing a compression test by which the thinner-walled vein collapses when the probe applies pressure, and also, color-flow ultrasound differentiates arterial and venous flows especially in cases of absent pulsation and verify the patency of a target vessel. If the flow moves toward the transducer, it gives a red signal, and if the flow moves away from the transducer, it gives a blue signal ,.
Femoral catheterization is widely used in patients mechanically supported with nonpulsatile devices. Femoral arterial catheterization is used for invasive hemodynamic monitoring, while the femoral vein is cannulated for central venous access and hemodialysis and during right heart catheterization.
Ultrasound guidance was found to be effective in decreasing the attempts for successful catheterization of common femoral artery and reducing the time to get access and the risk of puncturing the wrong vessel or vessel segment, and vascular complications. It helps avoid punctures into the superficial femoral artery or profunda femoris branch, decreases inappropriate punctures of the femoral vein, and may prevent sticks above the inguinal ligament ,. Ultrasound will help in patients with absent pulsation and coagulopathy to ensure the arterial patency before the puncture to achieve the first-attempt success with less procedure time and minimize the risks of vascular complications, including hematoma and arteriovenous fistula formation.The meta-analysis by Sobolev et al.  concluded the benefit of real-time ultrasound guidance for femoral artery catheterization and decreasing vascular complications and improving first-pass success rate. Previous studies in the literature revealed the benefit of ultrasound guidance in stable patients with palpable pulses and without coagulopathy. We studied ultrasound guidance in unstable patient with absent pulsations.
This was a retrospective single-center study. The procedure time could not be recorded.
| Conclusion|| |
Ultrasound-guided arterial catheterization in critical patients with unstable hemodynamics and nonpulsatile continuous circulation was associated with higher first-attempt and procedural success and less complications compared with the landmark technique.
The authors appreciate the team of cardiac surgical critical care unit of King Faisal Specialist Hospital for their excellent work.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]