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Three Part Question

In patients requiring [arterial line insertion] does[the use of ultrasound ] when compared to the manual palpation method lead to [improved success in catheter placement]?

Clinical Scenario

A septic hypotensive patient required an arterial line for early goal directed therapy but bilateral radial pulses were weak and multiple attempts were unsuccessful. A radial artery catheter was eventually secured under ultrasound guidance.

Search Strategy

Healthcare Database Advanced Search(NHS evidence) MEDLINE & EMBASE [(arter* ADJ cathet*).ti,ab OR (arter* ADJ cannula*).ti,ab] AND [exp (*ULTRASONOGRAPHY, INTERVENTIONAL/) OR (sonograph*.ti,ab) OR (doppler*.ti,ab)] [Limit to: Publication Year 1950-Current and Humans and English Language]

For EMBASE [exp (*ULTRASOUND) OR (sonograph*.ti,ab) OR (doppler*.ti,ab)] was used



Further searches were done via the Cochrane Database ;Google Scholar. A hand search of papers was also conducted.

Search Outcome

19 relevant papers were found. 13 were case series/case reports describing the use of ultrasound in arterial line insertion and 6 papers specifically compared the use of ultrasound with the manual palpation method.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Tada et al 2003 Japan	166 patients with a palpable radial artery(RA) pulse undergoing RA cannulation prior to elective surgery randomised to two groups 1.RA cannulated by using a doppler ultrasound detector (audio) to identify site and non touch insertion of catheter 2.RA cannulated by manual palpation method	prospective; randomised; non blinded	success defined as cannulation at first attempt	no difference found between the two groups	small numbers of elective surgery patients in each group; no mention of blinding of data analysis
Levin et al 2003 Israel	69 patients elective surgery patients underwent radial artery cannulation by anaesthetists either by manual palpation method or with the use of a 4MHz US transducer	prospective; randomised; non blinded	number of attempts	fewer attempts in US group (p=0.003)	small numbers; endpoint for failure not clear; crossover data between groups not included in analysis; level of experience with ultrasound not controlled for in operators
			time for succesful attempts	longer in US group (p=0.001)
			success at first attempt	higher rate in US group (p=0.03)
			number of cannulae used	fewer cannulae used in US group (p=0.001)
Dudeck et al 2004 Germany	112 patients undergoing femoral artery (FA) cannulation for angiography by 2 interventional radiologists divided into 2 groups-FA puncture via palpation method or with the use of 7.5MHz linear US probe on a mechanical swivel arm	prospective;randomised;non blinded	number of attempts for successful placement of catheter	no difference between groups	small numbers; equipment not generalisable to the emergency department
			patients with leg circumference greater than 60cm at puncture site (n=23)	fewer attempts (p<0.001) and less time (p<0.04) in US group
			patients with weak arterial pulses (n=42)	fewer attempts(p<0.05) and less time( p<0.04) in US group
			complications	no difference between groups

References

1. Tada T, Amagasa S et al Absence of efficacy of ultrasonic two-way Doppler flow detector in routine percutaneous arterial cannulation Journal of Anesthesia 2003 17: 206-207
2. Levin P, Sheinin O et al. Use of Ultrasound guidance in the insertion of radial artery catheters Critical Care Medicine 2003, Vol 31, No. 2 481-484
3. Dudeck O, Teichgraeber U et al A randomized trial assessing the value of ultrasound-guided puncture of the femoral artery for interventional investigations The international Journal of Cardiovascular Imaging 2004, 20: 363-368