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Background: Arterial puncture, for obtaining an analysis of blood gas, is an interventional procedure often performed in emergency departments and intensive care units. This study compares the ultrasound (US) guided method with the conventional digital palpation method in radial artery puncture (RAP) for blood gas analysis in septic shock patients. Methods: This is a prospective, single-centre study. Septic shock patients over 18 years of age who needed a RAP sample for blood gas analysis were included. Patients with local infection or trauma at the puncture site, arteriovenous fistula, vascular graft, coagulopathy, a positive Allen test, or did not want to participate were excluded. Patients were randomized into two groups and RAP was obtained with either the US-guided method or the conventional method. The main outcomes were success at first entry, the number of attempts before success, and the time to success. Results: The 50 eligible patients were randomized into two groups. First entry success rate for the US-guided group and the conventional group was 80% and 42%, respectively. The number of attempts before success and time to success was significantly higher in the conventional group. Conclusion: The US-guided method has been found to be more successful in terms of first entry success, the number of attempts before success, and the time to success when compared to the conventional method.

The pseudoaneurysm of the radial artery is an infrequent complication mainly after iatrogenic procedures, with an increased incidence over the last years. The aim of the current study was to present a rare case of a radial artery pseudoaneurysm that projected through the skin after a single arterial puncture for blood-gas analysis. A 79-year-old man, with a history of atrial fibrillation and coronary heart disease on anticoagulants, was admitted to the cardiological intermediate care unit, with pulmonary oedema due to heart failure deregulation. On the next day, his left radial artery was punctured for blood-gas analysis. No other catheterization of the vessel was executed in the following days. Six days later a pulsatile, palpable mass on the skin surface, over the site of puncture, was recognized. Subsequently a Doppler ultrasound that was performed, confirmed the diagnosis of pseudoaneurysm. The pseudoaneurysm was surgically removed under general anesthesia. The patient was hospitalized for four days for trauma monitoring and intravenous antibiotics and afterwards he was discharged from the Hospital. Three months postoperatively, no sign of recurrence was observed. The pseudoaneurysm of the radial artery is an uncommon complication that might occur even after simple iatrogenic procedures, like after a direct arterial puncture for blood-gas analysis. Therefore, specialists should always be aware of this complication in similar cases.

Background. Femoral approach in endovascular surgery remains relevant being, however, associated with the risk of fatal and non­fatal complications. Modern techniques for instrumental haemostasis achieved with the Angio­Seal device (Terumo Corporation, Japan) provide an opportunity to reduce the number of fatal and non­fatal complications. Aim. A multicentre assay of the efficacy and safety of instrumental puncture closure using Angio­Seal devices (Terumo Corporation, Japan) in various settings and clinical situations. Materials and methods . A multicentre retrospective analysis of 1088 use cases of the Angio­Seal device (Terumo Corporation, Japan) for “primary” and “complicated” instrumental haemostasis after femoral access has been conducted for the years 2018–2020. The mean patient age was 62.3 ± 11.6 years, including 845 men (78.0%) and 243 women (22.0%). Five centres for routine and emergency endovascular radiology participated in the study. Results. The Angio­Seal device (Terumo Corporation, Japan) demonstrated a high method efficiency, with a 97.0% success rate of “primary” instrumental haemostasis (1055 of 1088 total successful haemostatic procedures) in various clinical settings. Arterial thrombosis at the approach side had a 3.0% complication rate (5 of 33 observations), all other complication types associated with haemorrhagic events (8 cases) or device malfunction and damage (20 cases). Discussion . The assay conducted suggests that the incidence of “complicated” instrumental haemostasis relates to technical drawbacks of the device application that required advance planning. The key identified prerequisites for a successful Angio­Seal application (Terumo Corporation, Japan) are the alignment of anchor tube­delivery through soft tissue into the vessel lumen and its positioning inside the vessel. Conclusion. The constructive features and instrumental haemostatic technique realised in the Angio­Seal device (Terumo Corporation, Japan) enable an effective and safe primary sealing of arterial puncture site in 97% cases.

A vascular closure device is used for hemostasis after a procedure involving an arterial puncture. The increasing frequency of endovascular arterial interventions has caused these devices to play a more important role in clinical practice. FemoSeal is a popular vascular closure device, and its safety and effectiveness have been verified. However, complications still occur in some cases, including even disastrous complications on occasion. Even with little experience, it is possible to reduce the complication rate by using real-time ultrasonography monitoring during the deployment of this device. Based on our experiences, presented herein, we suggest that complications related to FemoSeal could be reduced by using our method.

Objective The current study assesses the feasibility of in vitro practice of percutaneous puncture techniques in a pulsatile flow-model. Design Prospective, controlled, randomized study. Setting The percutaneous access to endovascular aortic repair is considered safe, but success rates may be dependent on surgeon experience with the technique. Participants Fourteen vascular surgery trainees and consultants were enrolled and randomized to a study or control group with both groups receiving instructions by a tutor on how to perform ultrasound guided percutaneous puncture and closure using a suture-mediated closure device. The study group received additional hands-on training on a pulsatile flowmodel of the groin and the performance of both groups was then graded. Study group participants were timed during and after their training on the model. Results The study group achieved higher overall grading than the control group on a 5-point scale with higher scores indicating a better performance (mean overall scores 4.0 ± 0.7 versus 2.8 ± 1.0, respectively; p = 0.03). Experienced participants (more than 20 punctures performed before the study) achieved higher overall scores than trainees (3.8 ± 0.4 versus 2.5 ± 0.8, respectively; p = 0.01). Five participants in the study group could deploy and close the ProGlide closure device correctly without the help of a tutor while being graded (71% in the study versus 0% in the control group; p = 0.02). Study group participants improved their overall score from 3.2 ± 0.9 to 4.0 ± 0.7 during training (p = 0.02). Time needed to complete the puncture and closure reduced from 456 seconds on average before, to 302 seconds after training (p Conclusions Study group participants could improve their overall score while working on the simulator. More experienced participants performed better during the simulation, which may indicate the model to be life-like and a potential skills assessment tool. Simulation training may be a valuable adjunct to traditional forms of training when teaching an endovascular technique but is limited by its reliance on simulators and demo devices.

Background: Arterial blood puncture is one of the most complex parts of nursing practice. Purpose: Evaluate effect of applying program based learning on nurse's performance and self-efficacy regarding arterial blood puncture. Method: Quasi experimental research design has been utilized in this study. This study was conducted at four hospitals affiliated to ministry of health. A convenient sample of 70 nurses was included. Three tools were utilized for collecting data; first tool was a questionnaire to assess nurses' knowledge regarding arterial blood puncture. Second tool was observational checklist of arterial blood puncture procedure. The last one was arterial blood puncture self-efficacy scale. Results: the study results revealed improvement in nurses' knowledge and practice regarding arterial blood puncture after applying the program based learning. A significant difference was founded between levels of nurses' self-efficacy about arterial puncture after program implementation with p-value of 0.000. While, hospitals where nurses working are associated significantly with total self-efficacy of nurses regarding arterial blood puncture. Conclusion: the current study concluded that the program based learning about arterial puncture improves nurses' knowledge, practice and self-efficacy. Additionally, regular training program regarding arterial blood puncture should be applied in hospitals. Conducting the same study in larger sample is recommended.

Introduction Incidental arterial puncture is one of the main complications associated with central venous catheter placement. Manual compression to achieve hemostasis in subclavian and carotid artery punctures is often ineffective because of the anatomical arterial position. Accidental cannulation has traditionally been treated with open surgery or endovascular treatment, but such procedures are not exempt from complications. Objectives Report our experience with ultrasound-guided off-label use of Perclose ProGlide (Abbott Vascular Inc., Santa Clara, CA, USA) in patients with iatrogenic arterial cannulation. Methods Six unstable patients with accidental arterial catheterization during placement of a central venous catheter: five of them in the subclavian artery and one in the right common carotid artery. Ultrasound-guided percutaneous closure was performed at bedside using a Perclose ProGlide (Abbott Vascular Inc., Santa Clara, CA, USA). Results All patients underwent duplex ultrasound 6, 12, 24, and 48 h postprocedure, and no complications associated with percutaneous closure (embolism, ischemia, stenosis, or arterial occlusion, bleeding, pseudoaneurysm, etc.) were described. Conclusions Accidental artery puncture during central venous catheterization is an uncommon situation but can be effectively managed by using percutaneous vascular closure device. It is a reliable alternative that should be considered as a first-line approach before endovascular or open surgery, specially in patients with unstable conditions in which it is possible to be performed without transfer to an operation room.

Central venous cannulation (CVC) is common and necessary in pediatric intensive care. However, this procedure is not without risks or complications. Although CVCs have classically been placed following anatomical landmarks, the use of ultrasound guidance has largely replaced the latter, given its better profile of efficacy and safety, demonstrated at least in adult populations.To compare the effectiveness and safety in the insertion of femoral central venous catheters guided by ultrasound (US) versus the anatomical method (LM) in critical care pediatric patients.100 patients were randomized: 50 were assigned to the US group and 49 to the LM group. In the LM group the traditional method consisted in palpating the femoral artery pulse as a; in the US group the CVC was inserted using a real time technique. Success at the first attempt, overall success in cannulation, number of attempts and arterial puncture were the variables studied in both groups.Success at the first attempt and overall success in cannulation were significantly higher in the US group versus the LM (US 42% vs. LM 18%, p 0.011, US 84% vs. LM 51% p0.001, respectively). The incidence of puncture of the femoral artery was lower in the US group (LM 12 vs. US 5, p 0.056) without achieving statistical significance.According to our results, the placement of central venous access via the femoral approach should be preferably performed under ultrasound guidance, however, further studies in larger populations are needed to confirm this findings.

Background: The radial artery is superficially palpable and easily accessible, making it the preferred site for arterial cannulation. Various placement techniques are available for radial artery catheter insertion. However, catheter insertion is sometimes difficult and requires multiple attempts, especially by inexperienced trainees, leading to technical failure and insertion-related complications. Guidewire-assisted cannulation is a simple and effective technique, but this maneuver requires practice. The main objective of this study was to compare the effects of a direct arterial puncture and a guidewire-assisted cannulation technique on the success rate of radial artery cannulation by inexperienced trainees.Methods: This study was a prospective, single-center, single-arm clinical trial with a historical control. Sixty patients with an American Society of Anesthesiologists physical status of I to III underwent elective surgery requiring radial artery cannulation. In the guidewire-assisted cannulation group (GW group), thirty radial artery cannulations were performed by inexperienced surgical residents using a guidewire-assisted cannulation technique. In the direct arterial puncture group (DP group), 30 patients underwent radial artery cannulation with a direct arterial puncture technique by inexperienced anesthesiology residents. The primary outcome was the success rate. Results: There were no differences in the baseline blood pressure or comorbidities between the two groups. Overall, the success rate of radial artery cannulation in the GW and DP groups were 90% and 50%, respectively (P = 0.001). The success rate of first-attempt cannulation in the GW and DP group were 66.7% and 26.7%, respectively (P = 0.002). The total procedural performance time was significantly shorter in the GW than DP group.Conclusion: The guidewire-assisted cannulation technique achieved a higher success rate than the direct arterial puncture technique when performed by inexperienced trainees.Trial registrationThe trial was registered on Thai Clinical Trials Registry (TCTR20200601004). Date of registration was January 19, 2020. (Retrospectively registered) http://www.thaiclinicaltrials.org/page_user/#

Problema: Neonatos internados em unidade de terapia intensiva passam por diversos desafios com uma gama maior de procedimentos necessários à sua sobrevivência, em sua grande maioria, dolorosos. Objetivo: verificar a efetividade da implementação de um bundle para manejo da dor durante a punção arterial no bebê internado em Unidade de Terapia Intensiva Neonatal. Método: trata-se de um estudo quase experimental, comparativo do tipo antes e depois, no qual os dados foram coletados por meio de observação não participante das punções, rodas de conversa e aplicação de questionário semiestruturado acerca do tema com os profissionais de enfermagem. Resultados preliminares: A análise preliminar permite afirmar que o bundle pode trazer diminuição dos escores de dor durante a punção arterial, porém a sensibilização dos profissionais ainda é falha e pautada em seu conhecimento subjetivo.

INTRODUCTION: In emergency departments, it is important to have tests that give fast results especially in the diagnosis and treatment of critically ill patients. Blood gas analysis has an important role in the diagnosis and treatment of patients applying for emergency services. On the other hand, taking samples for blood gas may differ based on clinic properties of patients. Puncture of arteries in sampling is a painful procedure. It is aimed to evaluate the differences between visual analogue pain scales of patients based on different punctured veins. METHODS: In this retrospective study, files of patients attempted to Ufuk University, Medical Faculty Dr Ridvan Ege Education and Research Hospital, Department of Emergency Medicine between 01.01.2015– 31.12.2017 with the punctured veins process at the age of 18–65 were examined. RESULTS: A total of 84 patient files, including 55 radial and 31 femoral punctured veins, were subjected to the research. 36.4% of patients in the radial group were female, and 63.6% of them were male. In the fem- oral group, 45.2% of patients were female and 54.8% were male. Gender differences between groups were found to be statistically insignificant (p > 0.05). BMI of groups was also statistically insignificant (p > 0.05). Chronic disease distribution was found to be statistically insignificant between the groups (p > 0.05). VA score of the femoral group (6.32 ± 1.70) was significantly higher than the radial group (5.15 ± 1.98) (p < 0.05). In the sampling difficulty groups, patients whose samplings were difficult were significantly higher than other groups (p < 0.05). CONCLUSIONS: In conclusion, VA score for femoral arterial puncture is higher than a radial arterial puncture. In other words, taking blood gas with the radial arterial procedure is less painful than the femoral arterial pro- cedure. In addition, hypertension is also an important factor affecting pain after arterial puncture with VAS.

Background Since the femoral artery frequently overlaps the femoral vein, femoral central venous catheterization carries the risk of arterial puncture in pediatric patients. Aims We evaluated the angle range of leg abduction with external hip rotation to minimize the overlap between the femoral artery and vein in pediatric patients undergoing general anesthesia. Methods Eighty-two pediatric patients who underwent elective surgery with general anesthesia were enrolled in this study. Using ultrasonography, patients were divided into groups N (patients with non-overlap) and O (patients with continuing overlap) based on the presence of non-overlap range between the femoral artery and vein. The range minimizing the overlap was defined as the range without overlap in group N and as the range presenting the overlap that was less-than-half of the radius of the femoral vein in group O. By increasing the angle of leg abduction with external hip rotation, the starting and ending angles minimizing the overlap were found using ultrasonographic images. Results The angle range of leg abduction with external hip rotation minimizing the overlap between the femoral artery and vein was defined as the range from the maximum 99% confidence interval of starting angles to the minimum 99% confidence interval of ending angles, which was between 45° and 65° in group N and between 48° and 58° in group O, respectively. Conclusion Positioning patients in a range of 48° and 58° leg abduction with external hip rotation can minimize the overlap between the femoral artery and vein. However, the clinical usefulness of this positioning for femoral venous catheterization remains to be seen.

Background This case report describes a subclavian vein cannulation that inadvertently led to an arterial puncture with the catheter tip radiologically seen at the level of the aorta. This case emphasizes the importance of postprocedural imaging and the disadvantages of not using ultrasound guidance in central venous catheterization. Case presentation A 24-year-old Caucasian man with diabetes mellitus type 1 presented himself to the emergency department due to abdominal pain accompanied by nausea and vomiting. The patient’s vital signs revealed blood pressure of 84/53 mmHg, heart rate of 103 beats per minute, respiratory rate of 18 breaths per minute, and temperature of 98.2 °F (36.7 °C). On physical examination, he was found to have dry oral mucosa with poor skin turgor, with diagnostics showing that he was in diabetic ketoacidosis after running out of insulin for 2 days. The patient was transferred to the intensive care unit to receive a higher level of care. Unfortunately, due to difficulty of peripheral line placement, only a gauge-22 cannula was secured at the left dorsum of the hand. Efforts to replace the current peripheral line were unsuccessful, and a decision to perform a central vein cannulation via the internal jugular vein was made. This was futile as well due to volume depletion, prompting a subsequent right subclavian vein route attempt. The procedure inadvertently punctured the arterial circulation, leading to the catheter tip being visible at the level of the aorta on postprocedure X-ray. The subclavian line was immediately removed with no adverse consequences for the patient. A right femoral line was successfully placed, and continuous management of the diabetic ketoacidosis ensued until normalization of the high anion gap was achieved. Conclusion Utilization of real-time ultrasound guidance via the subclavian approach could have allowed for direct visualization of needle insertion to the anatomical structures, guidewire location, and directionality, all of which can lead to decreased complications and improved cannulation success compared with the landmark technique. A leftward direction of the catheter seen on postprocedural X-rays should raise high suspicion of inadvertent catheter placement and immediate correction. This complication should have been prevented if ultrasound guidance had been used.

To develop a nursing outcome, consistent with the standardized format of outcomes within the nursing Outcomes Classification (NOC). This outcome will include an outcome label, an outcome definition, and clinical indicators. The proposed use for this outcome is to evaluate the access site of a percutaneous procedure.Concept analysis with a scoping review. Initially, content experts were recruited to validate the indicators of the proposed outcome in order to complete a consensus validation. After consensus validation, a review of the proposed outcome and its indicators was completed by two of the editors of the NOC team to confirm that the outcome label, definition, and indicators were consistent with the NOC taxonomy. During this review, edits were made on the label name and definition.After a series of reviews, the initial outcome of Vascular Status: Percutaneous Procedure Access was changed to Tissue Injury Severity: Percutaneous Procedure. In addition, the original definition of the condition of an access site for percutaneous procedure by venous or arterial puncture and health of surrounding tissues was edited to: Severity of complications from a needle-puncture access through the skin and into deeper tissues. The outcome has 11 indicators to be used to formulate a target rating for use in the clinical setting. The indicators were not edited over the course of the reviews.The proposed outcome will assist nurses in evaluating the access site of percutaneous procedures and in identifying possible complications.This research contributes to the refinement of the NOC taxonomy by having a new outcome that meets clinical practice needs.Desenvolver um resultado de enfermagem, consistente com o formato padronizado de resultados da Classificação dos Resultados de Enfermagem (NOC). Este resultado incluirá um título de resultado, uma definição de resultado e indicadores clínicos. O uso proposto para esse resultado é avaliar o local de acesso de um procedimento percutâneo. MÉTODOS: Análise de conceito com revisão de escopo. Inicialmente, especialistas de conteúdo foram utilizados para validar os indicadores do resultado proposto em uma validação por consenso. Após a validação por consenso, uma revisão do resultado proposto e de seus indicadores foi realizada por dois editores da equipe da Classificação dos Resultados de Enfermagem para confirmar o título do resultado, definição e indicadores para serem consistentes com a taxonomia NOC. Durante esta revisão, foram feitas edições no título e na definição.Após uma série de revisões, o resultado denominado inicialmente de Estado Vascular: Acesso Procedimento Percutâneo foi alterado para Gravidade da Lesão Tecidual: Procedimento Percutâneo. Além disso, a definição original de condição de um local de acesso de procedimento percutâneo por punção venosa ou arterial e saúde dos tecidos adjacentes foi editada para - Gravidade das complicações de um acesso por punção com agulha através da pele e em tecidos mais profundos. O resultado tem 11 indicadores a serem usados para formular uma classificação-alvo para uso no ambiente clínico. Os indicadores não foram editados ao longo das revisões. CONCLUSÃO: O resultado proposto auxiliará o enfermeiro a avaliar o local de acesso dos procedimentos percutâneos e identificar possíveis complicações. IMPLICAÇÕES PARA A PRÁTICA DE ENFERMAGEM: Esta pesquisa contribui para o refinamento da taxonomia NOC por ter um novo resultado que atende às necessidades da prática clínica.

Background Continuous monitoring of critically ill patients requires an important procedure as arterial puncture. The first site of choice for arterial puncture is radial artery. To minimize the risk of ischemic damage to the hands as a radial artery puncture complication, many experts suggest confirming adequate collateral circulation before puncture. Assessment of hands’ collateral circulation can be done by modified Allen’s test (MAT) and Barbeau test (BT). Aim To compare between MAT and BT for the assessment of hands’ collateral circulation before arterial puncture among critically ill patients. Study design A descriptive research design was used. Method The study was conducted at three general intensive care units at university hospital, Egypt. Subjects: A convenience sample of 100 newly admitted patients on the first day and aged from 18 to 60 years old was included. Exclusion criteria were patients with unstable hemodynamics, surgery or burn in upper limbs and arteriovenous shunt. Tool “Hands’ collateral circulation assessment” was used. MAT and BT were done once by the same researcher for all patients. Results The studied patients showed that 70% had a positive MAT, and 84 % had a positive BT with significant difference between the results of the two tests (p = 0.009). Higher percentages of the patients with a positive BT had normal heart rate (58%), mean arterial blood pressure (58%), body temperature (34%), peripheral pulse (50%), capillary refill time (73%) and warm skin (54%). Conclusion BT can predict and is more sensitive than MAT in assessing hands’ collateral circulation before arterial puncture.

The chapter starts with the indications of performing arterial blood gas analysis. Then it highlights the principal indications of performing the test. A few common conditions in which the blood gas analysis is done, are, critical illness, hypoxia, and any condition in which acid- base balance is disturbed. The importance of patient information and consent are the two steps, before doing arterial puncture. Ensuing paragraphs provide the tips on actual procedure of arterial puncture. The chapter goes further to mention the practical complications of arterial puncture such as, pain, bleeding, clotting, anxiety, and anaphylaxis to local anaesthetic agents. The importance of saving patient’s hand from ischaemic damage after the radial puncture is emphasized, in the Allen test. Inadvertent puncture of a vein instead of an artery is a common error. The difference in the arterial blood and the venous blood is explained.

Introduction A significant number of acute ischemic strokes occur while patients are hospitalized for other reasons. No national data have been reported on endovascular therapy (EVT) for in-hospital onset stroke. Here we compare the patient characteristics, process measures of quality, and outcomes for in-hospital onset vs. community-onset of strokes in a large US national registry. Methods We performed a retrospective cohort study of Get With The Guidelines-Stroke (GTWG-Stroke) from January 2008 to June 2018 from 2,333 participating sites that included 2,428,178 patients with acute ischemic stroke. Among 67,493 in-hospital onset strokes, 2494 (3.7%) underwent EVT. We examined the association between key patient characteristics (in-hospital onset, demographics, comorbidities, treatment with EVT) and functional outcomes using multivariable logistic regression models. Results The rate of EVT increased from 2.5% in 2008 to 6.4% in 2018 (p Conclusions Though use of EVT in GWTG-Stroke for in-hospital stroke remains low, it more than doubled in the past decade. Compared with community onset stroke, these patients have longer intervals to CT and arterial puncture, with associated worse functional outcomes. While there may be important differences in baseline patient characteristics between the groups, efforts must still be made to shorten time to reperfusion for in-hospital strokes. Disclosures F. Akbik: None. H. Xu: None. Y. Xian: None. S. Shah: None. E. Smith: None. D. Bhatt: None. R. Matsouaka: None. G. Fonarow: None. L. Schwamm: None.

Background Mobile stroke units (MSUs), specialized ambulances with a built-in computed tomography (CT) scanner and telemedicine connected stroke team, have been on the rise in recent years largely due to the ‘time is brain’ concept. We aim to report our initial experience since establishing our MSU, the first unit in the Tri-state area, and assess its impact on the stroke standards of care timeline. Methods We conducted a retrospective analysis of a prospectively maintained database of all MSU dispatched cases from August 2019 to March 2020. Results Of 195 MSU responses, 101 were treated and transported by the MSU. The mean time (hr:mm) of dispatch to scene arrival was 0:07 + 0:03, scene arrival to CT start was 0:10 + 0:03, CT start to teleneuro start was 0:05 + 0:03, teleneuro start to scene departure was 0:06 + 0:05, scene departure to hospital arrival was 0:12 + 0:06, and hospital arrival to arterial puncture was 2:59 + 1:01. The mean time of dispatch to arterial puncture was 3:34 + 1:02. The mean teleneuro consult duration was 0:04 + 0:02. The mean time of last know well (LKW) to tPA administration was 1:28 + 0:48 with 4 (57.1 %) patients receiving tPA within 60 min of LKW and 5 (71.4 %) patients receiving tPA within 90 min. The mean time of dispatch to tPA was 0:37 + 0:09 and scene arrival to tPA administration was 0:28 + 0:07. Conclusion MSUs may expedite each step along the stroke standards of care. In theory, this should drastically improve functional outcomes. However, the impact on functional outcomes or reductions in stroke-related morbidity is still unknown.

Background and Purpose: Efficacy of mechanical thrombectomy for acute cerebral large vessel occlusion depends on time from symptom onset to reperfusion. While time to treatment in hospital has been optimized in these days, it is not well-known about improving time in pre-hospital when suspected stroke. We sought to analyze time from emergency medical services (EMS) dispatch to arterial puncture in stroke patients eligible for mechanical thrombectomy. Methods: We analyzed time components from EMS dispatch to puncture in patients with acute large vessel occlusion within 6 hours from onset treated with mechanical thrombectomy between April 2015 and December 2018. We assessed the associated factors with each time component and patient outcomes. Results: Consecutive 195 patients were included in this analysis. The median EMS dispatch-to-scene, on-scene, transport, door-to-puncture (DTP), and scene-to-puncture (STP) times were 4, 16, 12, 40, and 70 minutes, respectively. Percentage of favorable outcomes were significantly higher in patients with STP within 60 minutes (57.5% vs 35.8%, p Conclusions: Reducing time in pre-hospital and in-hospital interact with each other. Education program and use of direct call from EMS contributed to reducing these times.

Objective This meta-analysis was performed to evaluate the safety and efficacy of the oblique-axis plane in ultrasound-guided internal jugular vein puncture. Methods We searched Embase, PubMed, the Cochrane Library, Web of Science, and China National Knowledge Infrastructure for relevant randomized clinical trials comparing the oblique axis with the short axis in ultrasound-guided internal jugular vein puncture. Results Five randomized clinical trials were included in this meta-analysis. The pooled meta-analysis showed that the incidence of arterial puncture in the oblique-axis group was significantly lower than that in the short-axis group. No significant difference was found in the first-pass success rate between the oblique-axis group and short-axis group. Additionally, there were no significant differences in the puncture success rate or number of attempts required between the two groups. Conclusion Ultrasound-guided internal jugular vein puncture using the oblique-axis plane reduced the risk of arterial puncture, but no difference was found in the first-pass success rate, puncture success rate, or number of attempts required.

Eine 81-jahrige Patientin wurde im infarktbedingten kardiogenen Schock zur Herzkatheteruntersuchung ubernommen. In der Koronarangiographie zeigte sich ein Verschluss des Ramus interventricularis anterior. Bei unvollstandigem Fluss nach perkutaner Koronarintervention mit Implantation von 3 Koronarstents und erhohter Thrombogenitat erfolgte die Gabe von Tirofiban. Im Rahmen der anschliesenden Anlage eines zentralvenosen Venenkatheters (ZVK) via V. jugularis interna kam es zu einer arteriellen Fehlpunktion der A. carotis communis mit der Folge von akuter Dyspnoe und eines hamorrhagischen Schocks bedingt durch ein massives zervikales Hamatom. Obwohl die ZVK-Anlage eine haufig angewandte Intervention in der Intensivmedizin darstellt, birgt der Eingriff dennoch ein gewisses Risiko iatrogener Verletzungen. Die Kenntnis uber das Notfallmanagement von ZVK-assoziierten Komplikationen ist daher unabdingbar.

Background Arterial puncture for blood gas analysis is a common procedure in hospitals. The aim of the study is to determine if standardizing technique elements of the arterial puncture process could improve the success rate of technicians through the full scope of an academic medical center. Methods The study is conducted by the Blood Gas Laboratory at University of Utah Health's main campus. During the baseline period, technicians tallied whether arterial puncture attempts were successful or unsuccessful from December 2014 through February 2015. A small team reviewed the steps of performing arterial puncture and selected segments of the process for standardization. Starting in March 2015, staff were trained individually in the standard processes. All staff continued to tally outcomes of puncture attempts through March 2017. Results During the baseline period, the puncture success rate was 83.6%. From April 2015 through March 2017 the success rate was 89.2%. Conclusion Standardizing arterial puncture technique for blood gas analysis leads to fewer punctures.

Objective To assess the anaesthetic management of treatment for endovascular acute ischaemic stroke (AIS) in Spain. Materials and method A survey was designed by the SEDAR Neuroscience Section and sent to the Spanish anaesthesiology departments with a primary stroke centre between July and November 2016. Results Of the 47 hospitals where endovascular treatment of AIS is performed, 37 anaesthesiology departments participated. Thirty responses were obtained; three of which were eliminated due to duplication (response rate of 72.9%). Health coverage for AIS endovascular treatment was available 24 h a day in 63% of the hospitals. The anaesthesiologist in charge of the procedure was physically present in the hospital in 55.3%. There was large inter-hospital variability in non-standard monitoring and type of anaesthesia. The most important criterion for selecting type of anaesthesia was multidisciplinary choice made by the anaesthesiologist, neurologist and neuroradiologist (59.3%). The duration of time from arrival to arterial puncture was 10–15 min in 59.2%. In 44.4%, systolic blood pressure was maintained between 140 and 180 mmHg, and diastolic blood pressure Conclusions The wide variability observed in the anaesthetic management and the organisation of the endovascular treatment of AIS demonstrates the need to create common guidelines for anaesthesiologists in Spain.

The development of squamous cell carcinoma in sites of split skin graft harvest is a rare complication with only 12 documented cases in the literature. The growth of squamous cell carcinoma after arterial puncture is a rarer phenomenon, with no previous cases documented. This series describes two cases. The first case is of a 70-year-old male who developed rapidly growing squamous cell carcinoma in a graft donor site, 9 weeks after split skin graft repair of pretibial squamous cell carcinoma excision. The second case is of an 84-year-old male who developed a large exophytic squamous cell carcinoma in the right wrist that developed 5 months after radial artery puncture. This case series explores the various mechanisms of de-novo squamous cell carcinoma development in areas of cutaneous surgical intervention, including graft harvest. It also provides recommendations regarding the necessary precautions to avoid implantation of squamous cell carcinoma into distant sites. Lastly it highlights the importance of surveillance for any suspicious lesions arising from areas of previous cutaneous surgical intervention.

Aim: Urgent hemodialysis in patients with renal insufficiency is usually provided by catheter insertions. Early complications of hemodialysis catheter insertions can increase morbidity and mortality. In this study, we investigated the characteristics of patients undergoing temporary hemodialysis catheter insertion in our nephrology clinic and complications. Methods: In this study, we reviewed the records of 151 patients in whom temporary hemodialysis catheters were inserted by the nephrologists of our clinic between August 2012 and August 2013. Demographic features, catheter insertion indications, and catheter insertion sites were assessed and complications were noted. Results: A total of 151 patients (94 female and 57 male) were included in the study. The average age of the patients was 58.66±16.8 years (minimum: 17, maximum: 92). No complication was observed in 112 (74.2%) patients during catheter insertions. Catheter insertion was repeated in 39 (25.8%) patients for various reasons. Arterial puncture occurred in 12 (7.9%) of 151 patients who had catheter insertions for the first time. None of the patients required surgical intervention. Conclusion: Temporary catheter insertions are required in patients needing urgent hemodialysis. However, they bring along the risk for many complications. Early referral of patients who require hemodialysis to nephrology clinic and application of permanent vascular interventions will reduce the need for temporary catheters and complications.

Iatrogenic hepatic artery dissection is a serious complication that can progress to complete hepatic artery occlusion and graft loss. Restoration of arterial flow to the graft is urgent but the severity and extent of the dissection may interfere with endovascular techniques. The authors describe a technique of percutaneous retrograde transhepatic arterial puncture to regain access into the true lumen of the dissected hepatic artery to restore in-line flow to the liver graft. This article is protected by copyright. All rights reserved.

Objective: to compare the pain response of preterm newborns submitted to arterial puncture who received musical intervention with those who received 25% glucose intervention. Methods: randomized, double-blind clinical trial; the sample consisted of 48 videos of preterm infants of the experimental group (music, n= 6), who listened to music for 10 minutes, and the control group (25% glucose, n=22), who received 25% glucose two minutes before puncture. The pain was evaluated by the Neonatal Facial Coding System at moments: Baseline, Treatment, Painful, Recovery 1 and Recovery 2. Results: there were similarities between groups at the moments Baseline, Recovery 1 and 2. A statistically significant difference was observed at the moment Treatment (p=0.014), Painful (p=0.029) for the control group. Conclusion: 25% glucose differed from music when comparing the pain response in the Treatment and Painful moments. razilian Registry of Clinical Trials: UTN: U1111-1123-4821. Objetivo: comparar resposta de dor de recém-nascidos pré-termo submetidos à punção arterial que receberam intervenção musical com os que receberam intervenção de glicose 25%. Métodos: ensaio clínico randomizado, duplo cego, amostra de 48 vídeos de prematuros dos grupos, Experimental (música, n=26), ouviu música por 10 minutos e; Controle (glicose 25%, n=22), recebeu glicose 25% dois minutos antes da punção. A dor foi avaliada pela Neonatal Facial Coding System n os momentos: Basal, Tratamento, Doloroso, Recuperação 1 e Recuperação 2. Resultados: houve semelhanças entre grupos nos momentos Basal, Recuperação 1 e 2. Constatou-se diferença estatisticamente significante no momento Tratamento (p=0,014), Doloroso (p=0,029) para grupo Controle. Conclusão: glicose 25% diferiu da música ao se comparar a resposta de dor nos momentos Tratamento e Doloroso. Registro Brasileiro de Ensaio Clínico: UTN: U1111-1123-4821.

Resumo Objetivo Avaliar se um workshop de simulação e curta duração sobre punção da artéria radial melhoraria a competência de alunos de enfermagem em um nível em que pudessem praticar o procedimento em um paciente vivo sem comprometer sua segurança. Métodos Estudo quase-experimental do tipo pré-teste e pós-teste com um grupo de 111 estudantes do terceiro ano de enfermagem. Foi implementado um workshop de simulação e 1,5 horas de duração. Isso incluiu uma vídeo-palestra, demonstrações ao vivo, prática simulada autodirigida em díades e feedback intermitente individual. As habilidades, conhecimentos e autoeficácia dos participantes em punção arterial foram medidos antes e depois da participação no workshop. Resultados Após a intervenção, 61,1% dos participantes demonstraram o nível de competência necessário para a prática segura da punção da artéria radial em um paciente vivo sob supervisão. Conclusão O treinamento efetivo em punção arterial baseado em simulação para estudantes de enfermagem não necessariamente precisa ser intensivo em recursos. Sessões de treinamento bem planejadas e baseadas em evidências, com uso de simuladores de baixa tecnologia podem ajudar os educadores a alcançarem bons resultados educacionais e promover a segurança do paciente. Abstract Objective To evaluate whether a short simulation-based workshop in radial artery puncture would improve nursing students’ competence to a level in which they could practise the procedure on a live patient without compromising his safety. Methods Quasi-experimental one-group pretest-posttest study with 111 third-year nursing students. A 1.5-hour simulation-based workshop was implemented. This included a video-lecture, live demonstrations, self-directed simulated practice in dyads and individual intermittent feedback. Participants’ skills, knowledge and self-efficacy in arterial puncture were measured before and after attending the workshop. Results After the intervention, a total of 61.1% of the participants showed the level of competence required to safely practice radial artery puncture on a live patient under supervision. Conclusion Effective simulation-based training in arterial puncture for nursing students does not necessarily need to be resource-intensive. Well-planned, evidence-based training sessions using low-tech simulators could help educators to achieve good educational outcomes and promote patient safety.

Background Several studies have recently reported regarding feasibility and safety of distal transradial access (d-TRA) in the anatomical snuff-box (ASB); however, literature comparing it with the conventional TRA at the wrist (w-TRA) is sparse. This study compares the technical efficiency and safety of ASB and wrist approaches for TRA for coronary angiography (CAG) and evaluates the radial artery (RA) anatomy at these sites. Methods Two hundred consecutive patients undergoing CAG via w-TRA or d-TRA (100 in each group) were investigated. The primary endpoint was comparison of procedural efficiency of the two methods, defined as CAG completion from the intended access site. The secondary endpoints assessed d-TRA approach in terms of achievement of successful cannulation, arterial puncture, access time (AT), and total procedure time (TPT) in comparison with the conventional method. Safety endpoints included radiation parameters and complications. Furthermore, in 112 normal adults, RA anatomy was assessed at wrist and at ASB. Results In d-TRA group, 77% patients achieved primary endpoint compared with 93% in w-TRA group (p = 0.004). The success of arterial puncture was comparable for d-TRA and w-TRA (93% and 99%, respectively; p = 0.065), but the cannulation rate was lower for d-TRA. Safety endpoints were similar in both the groups. AT and TPT were longer for d-TRA. Conclusions The ASB approach for CAG lowers the success rate and prolongs AT and TPT. The RA at ASB is smaller, has a curved course, and more anatomical variations than the RA at the wrist.

The present study was done to find out whether there is any change occurring during delay in ABG analysis. In our study we first took baseline reading and from the remaining blood sample, stored at room temperature, repeat analysis were done from it after 30minute, 60 minute and after 90 minute and the change in result is compared with the baseline result. In our study if the sample is stored for more than 30 minutes at room temperature there is no significant changes occurs in pH, pCo2, but there is significant change in the pO2. The value of pO2 increase 20.23 mmHg if the sample is stored for more than 30 minutes at room temperature. In our study although the changes in pH, pCo2 are statistically greater in sample kept at room temperature, those changes do not appear to have major clinical significance until the time of analysis after arterial puncture exceeds 90 minutes. The PCO2 remained very stable with the different sampling methods. In our study there is no significance change found in Hco3- and O2sat if sample is stored for more than 30 minutes at room temperature. Keywords: ABG analysis; PCO2 ; pH; Arterial puncture; ABG analyzer

Background Vascular interventions imply radiation exposure to the operating physician (OP). To reduce radiation exposure, we propose a novel passive robotic device for fluoroscopy-guided arterial puncturing. Methods X-ray dose rates were measured for a total of 30 fluoroscopy-guided puncture femoral arteries in 15 pigs. Fifteen punctures were performed with the device while the other 15 were performed without the device by an interventional cardiologist with 10 years of experience. Parametric t test was used. Results The success rate with the device was 100%. Overall, the OP received more radiation (0.41 mSv/h) as compared to the assistant (0.06 mSv/h) (p

Background The objective of this study was to validate the transfer of ultrasound-guided Internal Jugular Central Venous Catheterization (US-IJCVC) placement skills from training on a Dynamic Haptic Robotic Trainer (DHRT), to placing US-IJCVCs in clinical environments. DHRT training greatly reduces preceptor time by providing automated feedback, standardizes learning experiences, and quantifies skill improvements. Methods Expert observers evaluated DHRT-trained (N = 21) and manikin-trained (N = 36) surgical residents on US-IJCVC placement in the operating suite using a US-IJCVC evaluation form. Performance and errors by DHRT-trained residents were compared to traditional manikin-trained residents. Results There were no significant training group differences between unsuccessful insertions (p = 0.404), assistance on procedure (p = 0.102), arterial puncture (p = 0.998), and average number of insertion attempts (p = 0.878). Regardless of training group, previous central line experience significantly predicted whether residents needed assistance on the procedure (p = 0.033). Conclusion The results failed to show a statistical difference between DHRT- and manikin-trained residents. This study validates the transfer of skills from training on the DHRT system to performing US-IJCVC in clinical environments.

Background Placing central venous lines under ultrasonographic guidance reduces the complications of the procedure. Aim To compare prevalences of complications of central venous line placements with or without ultrasonographic guidance. Material and methods Descriptive study that contemplated the comparison of two groups of patients subjected to a central venous line placement at a nephrology service for renal replacement therapy. In one group of 100 patients, the line was placed without ultrasonographic guidance between 2008 and 2012. Between 2015 and 2017 the line was placed in 138 patients using ultrasonographic guidance. The prevalences of complications with both types of procedures were recorded. Results The frequency of complications of procedures with and without ultrasonographic guidance was 0.7 and 18% respectively (prevalence ratio 0.04, 95% confidence interval 0-0.3). Ninety five percent of recorded complications were arterial puncture, followed by hematomas in 10% and pneumothorax in 5%. The higher prevalence of complications was observed in emergency line placement without ultrasonographic guidance. There was a direct association between the number of line placement attempts in a single procedure and the prevalence of complications. Conclusions Ultrasonographic guidance is associated with a reduction in the prevalence of central venous line complications.

Introduction: Vascular closure devices are commonly used to achieve rapid haemostasis and early ambulation following arterial puncture for endovascular procedures. Although device failure rates are low, the consequences of arterial occlusion include severe limb ischaemia. We describe a novel endovascular technique for the treatment of Angio-Seal arterial closure device (Terumo, Europe NV) failure causing femoral artery occlusion. Materials and methods: We describe 2 cases of lower limb angioplasty performed for critical limb ischaemia where the access site was closed using an Angio-Seal according to the manufacturer instructions for use (IFU). In both cases, however, ultrasound could not be used during deployment of the Angio-Seal due to body habitus and small subcutaneous haematoma. In both cases, the device failed and occluded the femoral artery. Results: Access was achieved via a retrograde approach from the contralateral limb in one case and a retrograde approach from the ipsilateral profunda artery in the other case. Angiography confirmed that the footplate of the Angio-Seal had occluded the femoral artery. Subsequently, the occlusion was crossed and a short balloon-mounted bare metal stent placed to push the footplate against the arterial wall that resulted in resolution of the occlusion and haemorrhage control. Conclusions: Crossing the occlusion caused by failure of the Angio-Seal closure device and subsequent stenting resulted in satisfactory relief of the femoral artery occlusion and haemostasis without the added risks of open surgical revascularisation and general anaesthetic.

Background: Arterial puncture is considered the gold standard for obtaining blood gas and acid-base values and facilitates the assessment of acutely and critically ill patients, as well as control of patients in long-term oxygen therapy (LTOT). Substitutional capillary sampling has been proposed, as researchers cite lower complication rates, physician independence, lower degree of invasiveness and higher degree of patient comfort. An arterialised earlobe is considered the method of choice to obtain capillary blood sampling, but in an acute setting, the need for vasodilating pastes may be time-consuming and impractical. The aim of this study is to examine whether accurate blood gas and acid-base measurements can be obtained using non-arterialised fingertip blood. Materials and methods: Consecutive arterial punctures and non-arterialised capillary blood samples were drawn from 62 patients with stable-phase chronic obstructive pulmonary disease (COPD), and subsequently analysed. Agreement between arterial and capillary blood gas values was compared using the method recommended by Bland and Altman. Results: Results show that limits of agreement (LoA) regarding PO 2 (LoA: -1.27-4.45 kPa); Base Excess (LoA: -1.35-0.55); lactate (LoA: -0.77-0.20 mmol/l) and SO 2 (LoA: -0.02-0.06) are wider than what would be applicable for clinical use. However, clinically acceptable LoA were obtained regarding PCO 2 (LoA: -0.64-0.38 kPa); pH (LoA: -0.02-0.03), and HCO 3 - (LoA: -1.06-0.55 mmol/l). Conclusion: LoA for PCO 2, pH and HCO 3 - indicate that measurement of these parameters in non-arterialised capillary blood may be useful in clinical practice/an acute setting. What this paper adds: Capillary blood sampling provides a fast, non-invasive means of obtaining blood gas-values;Traditionally, capillary blood sampling for blood gas analysis is obtained from the earlobe using arterialisation;The present study presents accurate measurements of PCO 2, HCO 3 - and pH using non-arterialised fingertip capillary blood;The present study is the first to show this in a population of stable-phase COPD patients.

The time-dependence of the clinical outcome of mechanical thrombectomy is higher in the "fast progressor" in whom cerebral ischemia progresses rapidly. The impact of time-consuming interhospital transfer (IT) on the clinical outcome of such patients is unknown. The effect on clinical outcomes of IT of fast progressors was investigated.Among the patients enrolled in the Tokyo/Tama REgistry of Acute endovascular Thrombectomy, fast progressor cerebral ischemia cases were retrospectively investigated. In this study, a fast progressor was defined as a case with an Alberta Stroke Program Early CT Score less than 6 and last known well (LKW) to arterial puncture within 6 h. Patients' background characteristics, treatment progress, and the modified Rankin Scale (mRS) score at 3 months were examined.Of a total of 1182 patients, 92 (7.8%) were included, with 76 patients in the direct transfer (DT) group, and 16 patients in the IT group. Median LKW to reperfusion was 190 min and 272 min, respectively (P.001). The number of patients with mRS scores 0-2 at three months was 22 (28.9%) in the DT group and 1 (6.2%) in the IT group. Interhospital transfer was an independent factor associated with worse outcomes (odds ratio 0.08, 95% confidence interval 0.01-0.87, P=.038).This study showed that, among fast progressor patients, the IT group had a worse prognosis than the DT group. To provide good clinical outcomes for fast progressor patients, those who are likely to undergo mechanical thrombectomy should be sent directly to a thrombectomy-capable center.

Today, the number of endovascular procedures is steadily growing. For example, there were 40.005 endovascular interventions in 2018. Most patients are discharged within 1-2 days after intervention due to its effectiveness and minimal invasiveness. However, physicians do not always note local postoperative complications. Multidisciplinary approach in follow-up and treatment of such patients is important. In particular, we talk about awareness of doctors of polyclinics about possible complications after arterial puncture. Effectiveness and favorable result of surgical treatment of local postoperative complications after arterial puncture are reported in the manuscript.Описан клинический пример пациентки, у которой после пункции локтевой артерии сформировалась пульсирующая гематома, а затем и ложная аневризма локтевой артерии.

Arterial blood gas analysis is a common investigation in emergency departments and intensive care units for monitoring patients with acute respiratory failure. It also has some applications in general practice, such as assessing the need for domiciliary oxygen therapy in patients with chronic obstructive pulmonary disease. An arterial blood gas result can help in the assessment of a patient’s gas exchange, ventilatory control and acid–base balance. Nurses are usually involved in taking and analyzing the ABGs and normally they report these results to the doctors or anesthesiologists. Out of these results the anesthesiologists will then prescribe further treatment for the critically ill patient. Hence, it is important that nurses are familiar with the information obtained to be able to detect the disturbances in ventilation, oxygen delivery and acid–base balance.

With a reported incidence of 0.048%, radial artery pseudoaneurysm (PA) is a rare but serious complication of arterial cannulation. We report a case of PA developing after a single puncture of the right radial artery for arterial blood-gas analysis diagnosed by Doppler ultrasound in young male patient. The development of PA after puncture of radial artery for continuous blood pressure monitoring and serial blood-gas analysis has been reported in the past; however, to the best of our knowledge, there is only one case report of development of PA after a single arterial puncture for blood-gas analysis is reported in the past.

Background: Although some investigations have shown higher rates of successful first attempt and fewer attempts by using ultrasound-guided Internal Jugular Vein (IJV) catheterization, arterial puncture is still common.. Objectives: The present study aimed to investigate US-guided catheterization of the right IJV via medial-oblique technique and also compare this technique to short-axis technique in open-heart surgery patients.. Patients and Methods: In this randomized clinical trial, 80 patients referred to cardiac operating room of Namazi hospital, Shiraz, Iran from March to July 2014 were selected using census method. Block randomization with website was also done. Then, the patients were divided into two groups of 40, Short Axis Group (SAG) and Medial-Oblique Group (M-OG). For short-axis technique, patient’s head was positioned at zero degree angulation with his trunk. For medial-oblique technique, on the other hand, patient’s head was tilted to left to 45 degrees between the head and trunk. Sex, age, Body Mass Index (BMI), access time, guidewire time, cannulation time, total attempts for catheterization, first, second, and third attempt success, arterial puncture, hematoma, bleeding, and catheter malposition were recorded. The overlap between the carotid artery and IJV in zero- and 45-degree angulation was estimated through ultrasound print. After all, Kolmogorov-Smirnov test was used to assess normal distribution of the data. Then, the data were analyzed through Student’s t-test, Mann-Whitney U test, and chi-square test. P < 0.05 was considered as statistically significant.. Results: The results showed no significant differences between the two groups regarding the duration of different catheterization steps (P = 0.376). In all the cases in both groups, accessing the vein was successful with three attempts or less. There were no clinical complications of catheterization in the two groups. The mean of overlap was 23.60 ± 33.47 in zero-degree angulation between the head and trunk and 32.72 ± 36.38 in 45-degree angulation and this difference was statistically significant (P = 0.001).. Conclusions: The results of the present study showed that both US-guided techniques under investigation had the same duration in different catheterization steps, total success rate, and primary mechanical complications, and could be used in clinics..

We report successful transvenous treatment of direct carotid–cavernous fistula in a patient with Ehlers–Danlos syndrome type IV using a novel triple-overlay embolization (TAILOREd) technique without the need for arterial puncture, which is known to be highly risky in this patient group. The TAILOREd technique allowed for successful treatment using preoperative MR angiography as a three-dimensional overlay roadmap combined with cone beam CT and live fluoroscopy, precluding the need for an arterial puncture.

Purpose: To describe a simple maneuver to facilitate the retrograde puncture of challenging tibial vessels in the lower leg. Technique: Because of the depth of the tibial vessels at the mid to upper calf, especially in obese or muscular patients, a 7- or 9-cm, 21-G micropuncture needle is often needed to reach the artery. However, the low profile of the needle contributes to its flexibility and therefore the tendency to bend as it progresses through the deep tissues, hindering access to the target vessel. To overcome this obstacle, a 4- to 5-cm, 18-G needle is initially placed pointing to the artery. The 21-G needle is advanced through it to the target site. This simple maneuver increases the support to the 21-G needle, preventing its bending and facilitating arterial puncture in the presence of calcified vessels. Conclusion: The telescoping needle technique may be considered as a bailout procedure in the retrograde tibial approach after failed attempts secondary to needle bending or calcified vessels.

Using a two-dimensional ultrasound-guided approach does not guarantee success during the first attempt at internal jugular vein cannulation. Our randomized, parallel simulation study examined whether a new disposable device could improve the success rate of the first attempt at ultrasound-guided internal jugular vein cannulation of a simulated internal jugular vein.Eighty-eight participants were randomized to perform needle insertion for internal jugular vein cannulation of a phantom using the ultrasound-guided approach with (case group) or without (control group) this new device. The primary outcome was the success rate of the first attempt. The secondary outcome was the frequency of mechanical complications such as arterial puncture and posterior wall puncture, procedure time, and level of difficulty.Among 44 participants using the device, 33 (75.0%) achieved successful cannulation on the first attempt. However, only 12 (27.3%) of the 44 participants not using the device recorded success during the first attempt (risk difference, 0.477; 95% confidence interval [CI] 0.294-0.661; P0.001). The number of attempts was significantly lower (risk difference, -3.955; 95% CI, -5.014 to -3.712; P0.001) when participants performed cannulation with the device (1.63±1.71) than without the device (5.59±5.78). Our study also showed that participants were comfortable when performing the ultrasound-guided approach with the new device (risk difference, -1.955; 95% CI, -2.016 to -1.493; P0.0001).The new disposable device was effective for successful first attempts at needle insertion during ultrasound-guided internal jugular vein cannulation. Future clinical trials are needed to assess the effectiveness of this device.

Malpositioning of a pacemaker lead in the left ventricle is a rare device-related complication, which can lead to serious complications. Herein, we describe the case of a malpositioned lead, which entered the left ventricle via a direct transcutaneous puncture of the left common carotid artery.