A comparison of longitudinal and transverse approaches to ultrasound-guided axillary vein cannulation

ObjectiveThe axillary vein is an easily accessible vessel that can be used for ultrasound-guided central vascular access and offers an alternative to the internal jugular and subclavian veins. The objective of this study was to identify which transducer orientation, longitudinal or transverse, is better for imaging the axillary vein with ultrasound.MethodsEmergency medicine physicians at an inner-city academic medical center were asked to cannulate the axillary vein in a torso phantom model. They were randomized to start with either the longitudinal or transverse approach and completed both sequentially. Participants answered questionnaires before and after the cannulation attempts. Measurements were taken regarding time to completion, success, skin punctures, needle redirections, and complications.ResultsFifty-seven operators with a median experience of 85 ultrasound procedures (interquartile range, 26-120) participated. The frequency of first-attempt success was 39 (0.69) of 57 for the longitudinal method and 21 (0.37) of 57 for the transverse method (difference, 0.32; 95% confidence interval [CI], 0.12-0.51 [P = .001]); this difference was similar regardless of operator experience. The longitudinal method was associated with fewer redirections (difference, 1.8; 95% CI, 0.8-2.7 [P = .0002]) and skin punctures (difference, 0.3; 95% CI, ? 2 to + 0.7 [P = .07]). Arterial puncture occurred in 2 of 57 longitudinal and 7 of 57 transverse attempts; no pleural punctures occurred. For successful attempts, the time spent was 24 seconds less for the longitudinal method (95% CI, 3-45 [P = .02]).ConclusionsThe longitudinal method of visualizing the axillary vein during ultrasound-guided venous access is associated with greater first-attempt success, fewer needle redirections, and a trend of fewer arterial punctures compared with the transverse orientation.     

A randomized clinical trial of ultrasound-guided infra-clavicular cannulation of the subclavian vein in cardiac surgical patients: short-axis versus long-axis approach

Purpose

The aim of this study was to compare the success rate and safety of short-axis versus long-axis approaches to ultrasound-guided subclavian vein cannulation.

Methods

A total of 190 patients requiring central venous cannulation following cardiac surgery were randomized to either short-axis or long-axis ultrasound-guided cannulation of the subclavian vein. Each cannulation was performed by anesthesiologists with at least 3 years’ experience of ultrasound-guided central vein cannulation (>150 procedures/year, 50% short-axis and 50% long-axis). Success rate, insertion time, number of needle redirections, number of separate skin or vessel punctures, rate of mechanical complications, catheter misplacements, and incidence of central line-associated bloodstream infection were documented for each procedure.

Results

The subclavian vein was successfully cannulated in all 190 patients. The mean insertion time was significantly shorter (p = 0.040) in the short-axis group (69 ± 74 s) than in the long-axis group (98 ± 103 s). The short-axis group was also associated with a higher overall success rate (96 vs. 78%, p < 0.001), first-puncture success rate (86 vs. 67%, p = 0.003), and first-puncture single-pass success rate (72 vs. 48%, p = 0.002), and with fewer needle redirections (0.39 ± 0.88 vs. 0.88 ± 1.15, p = 0.001), skin punctures (1.12 ± 0.38 vs. 1.28 ± 0.54, p = 0.019), and complications (3 vs. 13%, p = 0.028).

Conclusions

The short-axis procedure for ultrasound-guided subclavian cannulation offers advantages over the long-axis approach in cardiac surgery patients.

     

Comparison of Ultrasound-Guided and Standard Landmark Techniques for Knee Arthrocentesis

Background: Ultrasound is a useful adjunct to many Emergency Department (ED) procedures. Arthrocentesis is typically performed using a landmark technique but ultrasound may provide an opportunity to improve arthrocentesis performance. Objective: To assess the success of emergency physicians performing landmark (LM) vs. ultrasound (US)-guided knee arthrocentesis techniques. Methods: This was a prospective, randomized, controlled study of patients requiring knee arthrocentesis who presented to one urban university ED and two community EDs between June 2005 and February 2007. Results: There were 66 patients enrolled (39 US-guided, 27 LM). Among all users, there was no difference in arthrocentesis success (US 37/39 vs. LM 25/27); p = 1.0. Secondary Endpoints: 1) Patients reported less pain with ultrasound; US-guided 3.71 (95% confidence interval [CI] 2.61–4.80) cm vs. LM 5.19 (95% CI 3.94–6.45) cm; p = 0.02. 2) Providers felt the US-guided technique was easier to perform than LM; 1.67 units on 5-point scale (95% CI 1.37–1.97) vs. 2.11 (95% CI 1.79–2.42) units; p = 0.02. 3) The total procedure time was shorter with the US-guided technique; 10.58 (95% CI 7.36–13.80) min vs. LM 13.37 (95% CI 9.83–16.92) min; p = 0.05. 4) There was no difference in the amount of fluid obtained between techniques; US-guided 45.33 (95% CI 35.45–55.21) mL vs. LM 34.7 (95% CI 26.09–43.32) mL; p = 0.17. Conclusion: US-guided knee arthrocentesis technique does not improve overall success of obtaining joint fluid aspirate vs. the standard LM and palpation technique. An US-guided approach does not result in more pain for the patient, takes no additional time to perform and, at least for novice physicians, leads to more fluid aspiration and greater novice provider confidence with the procedure. Further studies with more participants and standardization of anesthetic quantity are required to validate these findings.     

Ultrasound-Guided Peripheral Venous Access vs. the External Jugular Vein as the Initial Approach to the Patient with Difficult Vascular Access

Background: Traditionally, Emergency Physicians (EPs) have used the external jugular (EJ) vein to gain vascular access in patients who have failed nursing attempts at peripheral access. Recently, some EPs have used ultrasound (USIV) to gain peripheral access. Study Objective: This study seeks to determine which initial approach by EPs would lead to greater success. Methods: This was a prospective, randomized study of all adult patients who presented to the Emergency Department (ED) between June and December 2007. Inclusion criteria were failed nursing attempts at peripheral access (at least three). EPs were 2^nd- or 3^rd-year residents who had previously performed more than five each of EJs and USIVs. Patients were randomized into either an initial EJ or USIV approach. Results: Sixty patients were enrolled, 32 in the ultrasound group, 28 in the EJ group. Fifteen different EPs performed access. Initial Success: USIV 84% (95% confidence interval [CI] 68–93%) vs. EJ 50% (95% CI 33–67%), p = 0.006. Success if EJ visible: USIV 84% vs. EJ 66% (p = 0.18). Overall success, including data from the crossover pathway: a total of 41 lines were successfully placed by ultrasound out of 46 attempts (89%) vs. 18 out of 33 for EJ (55%), p = 0.001. In total, 59/60 patients (98%) had a peripheral i.v. successfully placed. The percentage of functioning lines when the patient left the ED was: USIV 89% (95% CI 72–96%) vs. EJ 93% (95% CI 68–98%), p = 0.88. Conclusion: As an initial approach to all patients with difficult venous access, ultrasound-guided peripheral lines are superior to the EJ approach. However if the EJ was visible, there was no difference in success among the initial approaches. Both techniques, when used together, could achieve peripheral vascular access in 98% of difficult access patients.     

Factors associated with quality of bystander CPR: The presence of multiple rescuers and bystander-initiated CPR without instruction

Aims

To identify the factors associated with good-quality bystander cardiopulmonary resuscitation (BCPR).

Methods

Data were prospectively collected from 553 out-of-hospital cardiac arrests (OHCAs) managed with BCPR in the absence of emergency medical technicians (EMT) during 2012. The quality of BCPR was evaluated by EMTs at the scene and was assessed according to the standard recommendations for chest compressions, including proper hand positions, rates and depths.

Results

Good-quality BCPR was more frequently confirmed in OHCAs that occurred in the central/urban region (56.3% [251/446] vs. 39.3% [42/107], p = 0.0015), had multiple rescuers (31.8% [142/446] vs. 11.2% [12/107], p < 0.0001) and received bystander-initiated BCPR (22.0% [98/446] vs. 5.6% [6/107], p < 0.0001). Good-quality BCPR was less frequently performed by family members (46.9% [209/446] vs. 67.3% [72/107], p = 0.0001), elderly bystanders (13.5% [60/446] vs. 28.0% [30/107], p = 0.0005) and in at-home OHCAs (51.1% [228/446] vs. 72.9% [78/107], p < 0.0001). BCPR duration was significantly longer in the good-quality group (median, 8 vs. 6 min, p = 0.0015). Multiple logistic regression analysis indicated that multiple rescuers (odds ratio = 2.8, 95% CI 1.5–5.6), bystander-initiated BCPR (2.7, 1.1–7.3), non-elderly bystanders (1.9, 1.1–3.2), occurrence in the central region (2.1, 1.3–3.3) and duration of BCPR (1.1, 1.0–1.1) were associated with good-quality BCPR. Moreover, good-quality BCPR was initiated earlier after recognition/witness of cardiac arrest compared with poor-quality BCPR (3 vs. 4 min, p = 0.0052). The rate of neurologically favourable survival at one year was 2.7 and 0% in the good-quality and poor-quality groups, respectively (p = 0.1357).

Conclusions

The presence of multiple rescuers and bystander-initiated CPR are predominantly associated with good-quality BCPR.     

What You See (Sonographically) Is What You Get: Vein and Patient Characteristics Associated With Successful Ultrasound‐guided Peripheral Intravenous Placement in Patients With Difficult Access

Objectives: Ultrasound (US) has been shown to facilitate peripheral intravenous (IV) placement in emergency department (ED) patients with difficult IV access (DIVA). This study sought to define patient and vein characteristics that affect successful US‐guided peripheral IV placement. Methods: This was a prospective observational study of US‐guided IV placement in a convenience sample of DIVA patients in an urban, tertiary care ED. DIVA patients were defined as having any of the following: at least two failed IV attempts or a history of difficult access plus the inability to visualize or palpate any veins on physical exam. Patient characteristics (demographic information, vital signs, and medical history) were collected on enrolled patients. The relationships between patient characteristics, vein depth and diameter, US probe orientation, and successful IV placement were analyzed. Results: A total of 169 patients were enrolled, with 236 attempts at access. Increasing vessel diameter was associated with a higher likelihood of success (odds ratio [OR] = 1.79 per 0.1‐cm increase in vessel diameter, 95% confidence interval [CI] = 1.37 to 2.34). Increasing vessel depth did not affect success rates (OR = 0.96 per 0.1‐cm increase of depth, 95% CI = 0.89 to 1.04) until a threshold depth of 1.6 cm, beyond which no vessels were successfully cannulated. Probe orientation and patient characteristics were unrelated to success. Conclusions: Success was solely related to vessel characteristics detected with US and not influenced by patient characteristics or probe orientation. Successful DIVA was primarily associated with larger vessel, while vessel depth up to >1.6 cm and patient characteristics were unrelated to success. Clinically, if two vessels are identified at a depth of <1.6 cm, the larger diameter vessel, even if comparatively deeper, should yield the greatest likelihood of success.     

超声引导下平阳霉素瘤体内注射与DSA引导下平阳霉素肝动脉栓塞治疗肝血管瘤对比分析

目的 对比分析超声引导下平阳霉素(PYM)瘤体内注射与DSA引导下PYM肝动脉栓塞治疗肝血管瘤的临床应用价值。方法 收集50例肝血管瘤患者,对其中26例(超声组)行超声引导下PYM瘤体内注射治疗,24例(栓塞组)行DSA引导下PYM肝动脉栓塞治疗,对比两种治疗方法的治疗时间、费用、术后疗效及并发症情况。结果 对50例患者均顺利完成治疗。超声组治疗时间[(10.54±3.33)min]及治疗费用[(2250.00±244.15)元]均明显低于栓塞组[(55.56±15.56)min及(12 555.56±2069.03)元],差异均有统计学意义(P=0.033、0.012)。超声组术后发热[15.38%(4/26)]及肝功能异常发生率[19.23%(5/26)]均低于栓塞组[70.83%(17/24),50.00%(12/24)],差异有统计学意义(P均<0.05);两组间术后肝区疼痛发生率[61.54%(16/26) vs 54.17%(13/24)]差异无统计学意义(P=0.775)。共59个肝血管瘤中,超声组31个,栓塞组28个。术后12个月,超声组及栓塞组治疗总有效率均为100%(31/31,28/28)。超声组瘤体平均缩小率[(93.10±6.85)%]明显高于栓塞组[(68.81±4.23)%],差异有统计学意义(P=0.004)。结论 两种治疗方法效果均可靠,但超声引导下PYM瘤体内注射治疗肝血管瘤在治疗时间、费用、术后并发症及瘤体缩小率方面更具优势。     

Influence of Measurement Depth on the Stiffness Assessment of Healthy Liver with Real-Time Shear Wave Elastography

The purpose of this study was to determine the measurement depth range within which liver stiffness can be reliably assessed using real-time shear wave elastography (SWE) technology. Measurements were performed on phantoms and healthy volunteers. In the first group of patients, measurements were performed at depths of 2–8 cm from the probe surface. In the second group of patients, measurements were conducted 0–7 cm below the liver capsule. Success rate of measurements (SRoM), success rate of patients (SRoS) and coefficients of variation (CVs) of repeated measurements were compared. The SRoMs at 3–7 cm and the CVs at 2–5 cm from the probe surface were significantly higher and lower than those at other depths (p < 0.001), respectively. SRoS was zero 0–1 cm below the liver capsule. Furthermore, the features of 2-D stiffness mapping images were also found to change with depth. According to our results, the depth range for the most reliable liver stiffness assessment using SWE should be 3–5 cm from the probe surface and simultaneously 1–2 cm below the liver capsule.     

Pediatric resident resuscitation skills improve after “Rapid Cycle Deliberate Practice” training

Introduction

Previous studies reveal pediatric resident resuscitation skills are inadequate, with little improvement during residency. The Accreditation Council for Graduate Medical Education highlights the need for documenting incremental acquisition of skills, i.e. “Milestones”. We developed a simulation-based teaching approach “Rapid Cycle Deliberate Practice” (RCDP) focused on rapid acquisition of procedural and teamwork skills (i.e. “first-five minutes” (FFM) resuscitation skills). This novel method utilizes direct feedback and prioritizes opportunities for learners to “try again” over lengthy debriefing.

Participants

Pediatric residents from an academic medical center.

Methods

Prospective pre-post interventional study of residents managing a simulated cardiopulmonary arrest. Main outcome measures include: (1) interval between onset of pulseless ventricular tachycardia to initiation of compressions and (2) defibrillation.

Results

Seventy pediatric residents participated in the pre-intervention and fifty-one in the post-intervention period. Baseline characteristics were similar. The RCDP-FFM intervention was associated with a decrease in: no-flow fraction: [pre: 74% (5–100%) vs. post: 34% (26–53%); p < 0.001)], no-blow fraction: [pre: 39% (22–64%) median (IQR) vs. post: 30% (22–41%); p = 0.01], and pre-shock pause: [pre: 84 s (26–162) vs. post: 8 s (4–18); p < 0.001]. Survival analysis revealed RCDP-FFM was associated with starting compressions within 1 min of loss of pulse: [Adjusted Hazard Ratio (HR): 3.8 (95% CI: 2.0–7.2)] and defibrillating within 2 min: [HR: 1.7 (95% CI: 1.03–2.65)]. Third year residents were significantly more likely than first years to defibrillate within 2 min: [HR: 2.8 (95% CI: 1.5–5.1)].

Conclusions

Implementation of the RCDP-FFM was associated with improvement in performance of key measures of quality life support and progressive acquisition of resuscitation skills during pediatric residency.     

Emergency cricothyrotomy—A comparative study of different techniques in human cadavers

Background

Emergency cricothyrotomy is the final lifesaving option in “cannot intubate–cannot ventilate” situations. Fast, efficient and safe management is indispensable to reestablish oxygenation, thus the quickest, most reliable and safest technique should be used. Several cricothyrotomy techniques exist, which can be grouped into two categories: anatomical-surgical and puncture.

Methods

We studied success rate, tracheal tube insertion time and complications of different techniques, including a novel cricothyrotomy scissors technique in human cadavers. Sixty-three inexperienced health care providers were randomly assigned to apply either an anatomical-surgical technique (standard surgical technique, n = 18; novel cricothyrotomy scissors technique, n = 14) or a puncture technique (catheter-over-needle technique, n = 17; wire-guided technique, n = 14).

Results

Airway access was almost always successful with the anatomical-surgical techniques (success rate in standard surgical group 94%, scissors group 100%). In contrast, the success rate was smaller (p < 0.05) with the puncture techniques (catheter-over-needle group 82%, wire-guided technique 71%). Tracheal tube insertion time was faster overall (p < 0.05) with anatomical-surgical techniques (standard surgical 78 s [54–135], novel cricothyrotomy scissors technique 60 s [42–82]; median [IQR]) than with puncture techniques (catheter-over-needle technique 74 s [48–145], wire-guided technique 135 s [116–307]). We observed fewer complications with anatomical-surgical techniques than with puncture techniques (p < 0.001).

Conclusions

In inexperienced health care personnel, anatomical-surgical techniques showed a higher success rate, a faster tracheal tube insertion time and a lower complication rate compared with puncture techniques, suggesting that they may be the techniques of choice in emergencies.     

A Comparison Between Over-The-Head and Standard Cardiopulmonary Resuscitation Performed by Two Rescuers: A Simulation Study

Background: In cardiopulmonary resuscitation (CPR) of a patient with an unsecured airway performed by two health care professionals, two methods are possible: 1) Standard CPR according to the guidelines, with one rescuer performing chest compressions from the side and the other rescuer performing ventilations from over the head of the patient. Additional tasks (like attaching the electrocardiogram and defibrillator) must be performed by the second rescuer during the time between ventilations. 2) Over-the-head CPR, with one rescuer performing chest compressions and ventilations from over the head and the other rescuer performing additional tasks. Objectives: The aim of this study was to compare the quality of CPR achieved by the two methods. Methods: After a standardized theoretical introduction and practical training, 106 medical students with limited knowledge and training in CPR participated in this randomized crossover study. Students performed a 2-min CPR test of standard CPR in both positions and over-the-head CPR alone on a manikin. Results: Standard CPR led to a significantly shorter hands-off-time over a 2-min interval than over-the-head CPR (median 25 s [interquartile range (IQR) 22–26 s] vs. 38 s [IQR 36–43 s], respectively, p < 0.001), and significantly more chest compressions (167 [IQR 158–176] vs. 142 [IQR 132–150], respectively, p < 0.001), more correct chest compressions (72 [IQR 11–136] vs. 45 [IQR 13–88], respectively, p = 0.004), inflations (10 [IQR 10–10] vs. 8 [IQR 8–8], respectively, p < 0.001), and correct inflations (5 [IQR 2–7] vs. 3 [IQR 1–4], respectively, p < 0.001). Conclusions: In the case of a two-professional-rescuer CPR scenario, standard CPR enables a quantitatively better resuscitation than over-the-head CPR.     

Changes in migraine interictal burden following treatment with galcanezumab: Results from a phase III randomized,placebo-controlled study

Objective

To evaluate changes in interictal burden with galcanezumab versus placebo in patients with episodic (EM) or chronic migraine (CM).

Background

The disruptive effects of migraine occur both during attacks (ictal period) and between attacks (interictal period), affecting work, school, family, and social life. Migraine clinical trials typically assess ictal burden endpoints, neglecting interictal burden.

Methods

CONQUER was a 3-month, double-blind study that randomized adult patients with EM or CM who had experienced failure of two to four standard-of-care migraine preventive medication categories to receive monthly galcanezumab (n = 232) or placebo (n = 230), followed by 3 months of open-label galcanezumab. The mean change in interictal burden, a secondary objective, was measured using the four-item Migraine Interictal Burden Scale (MIBS-4). The total score for MIBS-4 can range from zero to 12, with scores ≥5 indicating severe interictal burden. Post hoc analyses evaluated shifts in MIBS-4 severity categories and item-level improvement.

Results

The MIBS-4 total score indicated severe interictal burden at baseline (mean [SD]: all patients, 5.5 [3.5]; EM, 5.0 [3.4]; CM, 6.2 [3.5]). Reductions in the MIBS-4 score were significantly greater with galcanezumab versus placebo at Month 3 (mean [SE]: all patients −1.9 [0.2] vs. −0.8 [0.2], p < 0.0001; EM, −1.8 [0.3] vs. −1.1 [0.3], p = 0.033; CM, −1.8 [0.4] vs. −0.3 [0.4], p < 0.001), with further improvement at Month 6 after all patients had received galcanezumab (mean [SE]: all patients, −2.4 [0.2] vs. −2.0 [0.2]; EM, −2.3 [0.3] vs. −2.2 [0.3]; CM, −2.1 [0.4] vs. −1.5 [0.4]). The percentage of patients with severe interictal burden decreased substantially for the galcanezumab-treated patients, from 59% (137/232) at baseline to 27% (58/217) at Month 6 (EM from 51% [70/137] to 23% [30/131]; CM from 71% [67/95] to 33% [28/86]).

Conclusion

In addition to the known efficacy of galcanezumab in the ictal period, these findings suggest treatment with galcanezumab results in a significant reduction in interictal burden.     

Real-Time Ultrasound Perfusion Imaging in Acute Stroke: Assessment of Cerebral Perfusion Deficits Related to Arterial Recanalization

We investigated whether real-time ultrasound perfusion imaging (rt-UPI) is able to detect perfusion changes related to arterial recanalization in the acute phase of middle cerebral artery (MCA) stroke. Twenty-four patients with acute territorial MCA stroke were examined with rt-UPI and transcranial color-coded duplex ultrasound (TCCD). Ultrasound studies were consecutively performed within 24 h and 72–96 h after stroke onset. Real-time UPI parameters of bolus kinetics (time to peak, rt-TTP) and of refill kinetics (plateau A and slope β of the exponential replenishment curve) were calculated from regions of interest of ischemic versus normal brain tissue; these parameters were compared between early and follow-up examinations in patients who recanalized. At the early examination, there was a delay of rt-TTP in patients with MCA occlusion (rt-TTP [s]: 13.09 ± 3.21 vs. 10.16 ± 2.6; p = 0.01) and a lower value of the refill parameter β (β [1/s]: 0.62 ± 0.34 vs. 1.09 ± 0.58; p = 0.01) in ischemic compared with normal brain tissue, whereas there were no differences of the parameters A and Axβ. At follow-up, the delay of rt-TTP was reversible once recanalization of an underlying MCA obstruction was demonstrated: rt-TTP [s], 13.09 ± 3.21 at 24 h versus 10.95 ± 1.5 at 72–96 h (p = 0.03). Correspondingly, β showed a higher slope than at the first examination: β [1/s]: 0.55 ± 0.29 at 24 h versus 0.71 ± 0.27 at 72–96 h (p = 0.04). We conclude that real-time UPI can detect hemodynamic impairment in acute MCA occlusion and subsequent improvement following arterial recanalization. This offers the chance for bedside monitoring of the hemodynamic compromise (e.g. during therapeutic interventions such as systemic thrombolysis).     

Ultrasound-Guided Peripheral Intravenous Access in the Emergency Department Using a Modified Seldinger Technique

Background: The utility of ultrasound-guided peripheral intravenous access (USGPIV) has been well described. However, few studies have investigated USGPIV techniques. Objectives: To describe a modified Seldinger technique for USGPIV. Methods: Emergency Department patients with difficult i.v. access (three or more failed landmark attempts) were prospectively enrolled. USGPIV was attempted using modified Seldinger technique. A 20-gauge, 3.81-cm catheter with integral wire was used for all procedures. The basilic vein was identified using a high-frequency linear probe (5–10 MHz). The needle was inserted into the vein with dynamic guidance in short axis, and the cannula was advanced over a wire. Time from skin puncture to catheter insertion, number of needle sticks, and overall procedure time were recorded. Results: Twenty-five patients were enrolled and underwent USGPIV; success rate was 96% (24/25). The mean number of needle sticks was 1.32 (95% confidence interval 1.12–1.52). Median time from skin to catheter insertion was 68 s (± SD 70.5 s). Median total procedure time was 7 min (420 s) (± SD 5.23 min). Conclusions: Modified Seldinger technique is an effective method of USGPIV and is worthy of a prospective comparison with non-Seldinger technique.     

Lung Ultrasound Can Predict the Clinical Course and Severity of COVID-19 Disease

Coronavirus disease 2019 (COVID-19) compromises the lung in large numbers of people. The development of minimally invasive methods to determine the severity of pulmonary extension is desired. This study aimed to describe the characteristics of sequential lung ultrasound and to test the prognostic usefulness of this exam in a group of patients admitted to the hospital with COVID-19. We prospectively evaluated patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection admitted to our hospital between April and August 2020. Bedside lung ultrasound exams were performed at three time points: at inclusion in the study, after 48 h and on the seventh day of follow-up. Lung ultrasound scores were quantified according to the aeration loss in each of eight zones scanned. Sixty-six participants were included: 42 (63.6%) in the intensive care unit and 24 (36.3%) in the ward. Lung ultrasound scores were higher in participants admitted to the intensive care unit than in those admitted to the ward at the time of inclusion (16 [13–17] vs. 10 [4–14], p < 0.001), after 48 h (15.5 [13–17] vs. 12.5 [8.2–14.7], p = 0.001) and on the seventh day (16 [14–17] vs. 7 [4.5–13.7], p < 0.001) respectively. Lung ultrasound score measured at the time of inclusion in the study was independently associated with the need for admission to the intensive care unit (odds ratio = 1.480; 95% confidence interval, 1.093–2.004; p = 0.011) adjusted by the Sequential Organ Failure Assessment score.     

Comparison of High-Frequency Contrast-Enhanced Ultrasound With Conventional High-Frequency Ultrasound in Guiding Pleural Lesion Biopsy

The goal of the work described here was to compare high-frequency contrast-enhanced ultrasound (HF-CEUS) and conventional high-frequency ultrasound (HFU) with respect to performance and safety during ultrasound-guided biopsy of pleural lesions. We performed a retrospective study on patients with pleural lesions who received the puncture biopsy under the guidance of conventional HFU or HF-CEUS between August 2018 and August 2021. These patients received either a conventional HF-U (HF-U group) or HF-CEUS (HF-CEUS group) examination. Clinical characteristics, pathological results, ultrasonic images and complications were compared between these two groups. A total of 144 patients were enrolled, with 70 in the HFU group and 74 in the HF-ECUS group. Except for the time required for ultrasonic localization (p < 0.05), there were no significant differences in clinical characteristics between the two groups. The success rate of biopsy in the HF-CEUS group was higher than that in the HFU group (93.2% vs. 81.4%, p < 0.05). There were significant differences between the two groups in terms of measurements of pleural thickness, necrotic areas, large blood vessels and lesion boundaries (p < 0.05). The complication rates were 2.7% and 12.9% in the HF-CEUS and HFU groups, respectively, with a significant difference (p < 0.05). Compared with conventional HFU, the HF-CEUS–guided pleural biopsy had a better success rate and fewer complications. HF-CEUS could facilitate the biopsy in patients with pleural lesions.     

超声监测单绒毛膜囊双羊膜囊双胎脐带胎盘附着预测胎儿预后的价值

目的探讨产前超声监测单绒毛膜囊双羊膜囊(MCDA)双胎脐带胎盘附着预测妊娠结局的临床应用价值。方法回顾性分析127名MCDA双胎妊娠孕妇的产前超声检查结果和产后临床资料,比较两胎儿脐带胎盘附着一致组(59名)和不一致组(68名)的复杂性双胎发生率。结果脐带胎盘附着不一致组复杂性双胎的发生率为51.47%(35/68),脐带胎盘附着一致组为23.73%(14/59),差异有统计学意义(P<0.05);其中双胎之一脐带帆状附着的复杂性双胎发生率为59.09%(13/22),双胎之一脐带边缘附着的复杂性双胎发生率为47.83%(22/46),差异无统计学意义(P=0.444);双胎之一帆状附着中双胎输血综合征(TTTS)的发生率为40.91%(9/22),双胎之一边缘附着中TTTS的发生率为13.04%(6/46),差异有统计学意义(P<0.05)。结论产前超声监测MCDA双胎脐带胎盘附着能预测胎儿预后。     

A randomized controlled trial comparing one-operator versus two-operator technique in ultrasound-guided basilic vein cannulation

The basilic vein offers an alternative site for peripheral intravenous access for emergency access. The use of a two-operator ultrasound-guided basilic vein cannulation technique has been shown to be a safe and effective technique for use on Emergency Department patients. However, the one-operator technique is more customary by other services. We sought to compare the more customary one-person technique to the two-person technique in basilic vein cannulation in novice operators. This was a prospective, randomized controlled trial of two techniques of ultrasound-guided basilic vein cannulation (one-operator vs. two-operators) in healthy adult volunteers. Each volunteer underwent each technique, one technique on each arm. We selected the initial arm and technique using computer-generated block randomization. In the one-operator technique, a single operator held the transducer in transverse short-axis plane while attempting cannulation using a 20-gauge, 1.88-inch catheter. In the two-operator technique, a second operator held the transducer in place while the first operator attempted cannulation. The primary outcome variable was first-attempt cannulation success. Secondary outcome variables were overall success, number of attempts, time-to-cannulation, complications, and ease-of-technique rated by the operators. There were 32 subjects enrolled. One-operator first-attempt success was 18/32 (56%); two-operator was 21/32 (65%), with a mean difference in proportion of −9% (95% confidence interval [CI] −33–14%). Overall success for one operator was 23/32 (72%) and two-operator was 24/32 (75%), with mean difference in proportion of −3% (95% CI −24–18). The median number of attempts for one-operator was 1.6 (interquartile range [IQR] 1–5) and two-operator was 1.4 (IQR 1–5) (p = 0.8). Time to cannulation for one-operator was 57 s (± 62) and two-operator was 44 s (± 37) (p = 0.33). The median score for ease-of-technique for one-operator was 4.3 (IQR 1–6) and for two-operator was 3.6 (IQR 1–6) (p = 0.26). There were no complications with either technique (95% CI 0–10%). Novice operators can reliably perform a basilic vein cannulation using ultrasound guidance. However, we were unable to demonstrate any advantage for any particular technique in cannulating the basilic vein.     

Community-phenotype-methicillin-resistant Staphylococcus aureus infections: a retrospective chart review of outcomes after treatment with daptomycin

BACKGROUND: Daptomycin, a cyclic lipopeptide antibiotic, was approved by the US Food and Drug Administration (FDA) in September 2003 for the treatment of complicated skin and skin structure infections due to susceptible strains of certain gram-positive microorganisms, including methicillin-resistant Staphylococcus aureus (MRSA). In May 2006, daptomycin was approved by the FDA for treatment of bacteremia and right-sided endocarditis due to MRSA and methicillin-sensitive S aureus. OBJECTIVE: The aim of this study was to assess the use of daptomycin in community-phenotype (CP)-MRSA infections. Methods: This was a retrospective chart review of data from patients enrolled in a postlabeling registry who received daptomycin for MRSA infections from January to December 2005. CP-MRSA was defined as MRSA susceptible to clindamycin and trimethoprim/sulfamethoxazole; all other phenotypes were considered other-phenotype MRSA (OP-MRSA). Success rates were calculated by dividing success (defined as cure plus improved) by success and failure (including non-evaluable patients). RESULTS: A database search identified 352 patients (100 patients with CP-MRSA [57 men; 43 women]; 252 patients with OP-MRSA [136 men, 116 women]) who met study criteria. Most patients (79.2%) received gram-positive antibiotics before daptomycin. Compared with OP-MRSA, a greater proportion of patients with CP-MRSA were <50 years of age (50.0% vs 35.7%; P = 0.014) and had fewer underlying diseases (mean [SD], 1.7 [1.3] vs 2.5 [1.5]; P < 0.001). Success rate, time to clinical response, and duration of therapy were similar in both groups. CONCLUSION: Daptomycin was found to be equally effective in treating CP-MRSA and OP-MRSA infections in this selected group of patients.     

Short- vs long-axis approach to ultrasound-guided peripheral intravenous access: a prospective randomized study

Objective

The objective of the study was to determine if the short-axis approach and long-axis approach to ultrasound-guided peripheral intravenous access (USGPIV) differ in success rate, catheter insertion time, and number of needle sticks.

Methods

A convenience sample of emergency department patients aged 18 to 65 years with difficult IV access (2 or more failed landmark attempts) was prospectively randomized to short-axis or long-axis USGPIV. Time from skin puncture to catheter insertion (insertion time) and number of needle sticks were recorded. Number of needle sticks and insertion time were compared using Mann-Whitney U tests.

Results

Forty subjects were enrolled; 20 were randomized to the short-axis and 20 to the long-axis approach. Success rate was 95% (19/20; 95% confidence interval, 85%-100%) in the short-axis group compared with 85% (17/20; 95% confidence interval, 69%-100%) in the long-axis group. All 3 subjects with failed IV placement in the long-axis group had successful rescue USGPIV placement in short axis. Median insertion time was 34 seconds (interquartile range, 35 seconds) for the short-axis group compared with 91 seconds (interquartile range, 59 seconds) for the long-axis group (P = .02). Mean number of needle sticks was 1.5 (±SD 0.7) in the short-axis group compared with 1.4 (±SD 0.7) in the long-axis group (P = .82).

Conclusions

Short-axis USGPIV technique required less insertion time than the long-axis technique. Success rate was higher in the short-axis group, but this difference was not statistically significant. However, all of the failed IVs in the long axis were rescued successfully in short axis.