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Hemorrhagic shock can develop due to severe bleeding, such as after major trauma, postpartum or gastrointestinal bleeding. At least two peripheral intravenous routes with large-bore catheters are recommended to reverse hemorrhagic shock, and such functional intravenous routes are essential for the proper management of other concurrent diseases as well. Conditions during helicopter transportation are different from those seen in-hospital, and the primary concerns are to maintain aseptic conditions, protect patient’s privacy, and prevent infection risk, especially during pandemics, such as the ongoing COVID-19. Herein, I describe two recent experiences of improper management during helicopter transport due to intravenous line malfunction. Subsequently, based on my experience, I suggest the use of multiple intravenous routes or preemptive central catheterization in patients requiring helicopter transportation.

Central venous catheters (CVCs) are commonly used in patients with trauma. The placement and removal of the CVCs can result in various complications regardless of the skill of the professionals. Herein, two cases of rare complications are presented— an inadvertent subclavian artery catheterization and a cerebral air embolism after a CVC removal. Moreover, practical solutions for each complication are provided in detail.

Background: Central venous catheterization (CVC) is a routine procedure in patients admitted in Intensive Care Units (ICU) worldwide. Most commonly, seldinger technique is being practiced irrespective of the site of insertion. Though considered very safe, guide wire related complications have been reported in the literature and incidence has increased in the COVID era where intensivists have to work in personal protective equipment (PPE). Case Report: We are reporting about a patient of severe COVID-19, admitted in ICU. His right femoral venous catheterization was done to start vasopressors. The guide wire accidentally slipped inside the femoral vein during the procedure. It was immediately detected and managed with the assistance of interventional radiologist under fluoroscopic guidance. Conclusion: Complications like misplacement of guide wire can be catastrophic during CVC. We have discussed the measures that can prevent or reduce such complications while working in PPE in COVID ICUs. Keywords: Central venous catheter, Guide wire, PPE, COVID- 19.

OBJECTIVE To describe an ultrasound-guided technique for central venous catheter placement via the external jugular vein (EJV) in pigs. ANIMALS 96 healthy Landrace–Poland China barrows (approx 16 weeks old with a mean weight of 70 kg). PROCEDURES Pigs were anesthetized. With ultrasound guidance, a needle was inserted into the EJV without a large incision or cutdown procedure. A guidewire was inserted through the needle into the vein. A modified Seldinger technique was used to advance a catheter into the vessel until the tip was in the cranial vena cava near the right atrium. A trocar was used to create a tunnel through the subcutaneous tissues from the catheter insertion site to between the dorsal borders of the scapulae. The free end of the catheter was passed through that tunnel. An extension was attached to the catheter and secured to the skin. Pigs were euthanized and underwent necropsy at completion of the study for which they were catheterized. RESULTS Central venous catheters were successfully placed in all 96 pigs and facilitated collection of serial blood samples with minimal stress. Catheters remained in place for a mean of 6 days (range, 4 to 10 days). Necropsy revealed abscesses along the subcutaneous catheter tract in 9 pigs. Twenty pigs had histologic evidence of phlebitis and fibroplasia in the cranial vena cava. CONCLUSIONS AND CLINICAL RELEVANCE The described technique, in combination with extensive socialization, allowed serial collection of blood samples with minimal stress and restraint and is an alternative to surgical cutdown procedures for catheter placement. (Am J Vet Res 2021;82:760–769)

We describe a subaortic left brachiocephalic vein, a congenital anomaly that can be suspected during the rapid central vein assessment before central venous catheterization. Since the vein descends vertically/obliquely rapidly from its origin, we suggest that the puncture should be made at a greater angle (50°–60°) than what is usually used to puncture this vein (20°–30°). Failure to identify this anomaly may cause a failed puncture or complications from the puncture of adjacent blood vessels.

We investigated whether two needle insertion techniques for ultrasound-guided internal jugular vein (IJV) catheterization differ in the number of needling attempts and complication rate between inexperienced and experienced practitioners. A total of 308 patients requiring IJV catheterization were randomly assigned into one of four groups: IJV catheterization performed by inexperienced practitioners using either Seldinger (IE-S; n = 78) or modified Seldinger technique (IE-MS; n = 76) or IJV catheterization performed by experienced practitioners using either Seldinger (E-S; n = 78) or modified Seldinger technique (E-MS; n = 76). All catheterizations were performed under the real-time ultrasound guidance. The number of needling attempts was not significantly different between the two techniques within each experience group (between IE-S vs. IE-MS P = 0.550, between E-S and E-MS P = 0.834). Time to successful catheterization was significantly shorter in the E-S group compared to E-MS group (P P = 0.226). Complication rate was not significantly different between the two techniques within each experience group. Practitioner’s experience did not significantly affect the clinical performance of needle insertion techniques during ultrasound-guided IJV catheterization except the time to successful catheterization. Regarding the number of needling attempts and complication rate, both techniques could be equally recommended regardless of practitioner’s experience.Trial registration: clinicaltrials.gov (https://clinicaltrials.gov/ct2/show/NCT03077802).

The Dynamic Haptic Robotic Trainer (DHRT) was developed to minimize the up to 39% of adverse effects experienced by patients during Central Venous Catheterization (CVC) by standardizing CVC training, and provide automated assessments of performance. Specifically, this system was developed to replace manikin trainers that only simulate one patient anatomy and require a trained preceptor to evaluate the trainees’ performance. While the DHRT system provides automated feedback, the utility of this system with real-world scenarios and expertise has yet to be thoroughly investigated. Thus, the current study was developed to determine the validity of the current objective assessment metrics incorporated in the DHRT system through expert interviews. The main findings from this study are that experts do agree on perceptions of patient case difficulty, and that characterizations of patient case difficulty is based on anatomical characteristics, multiple needle insertions, and prior catheterization.

Objective To examine and compare different methods of dressing change on skin tears at the periductal wound for ICU patients with central venous catheterization (CVC). Methods This research used a quasi-experimental design. Participants included 98 patients from the ICU of a medical center in Taiwan using a convenience sampling technique from April 1, 2017 to March 31, 2018. Results Applying skin barrier film at the CVC insertion site effectively protected the skin and significantly reduced the risk of skin tears among ICU patients (P Conclusions This study showed that use of skin barrier film at the site of CVC insertion can increase skin strength, maintain skin integrity, and decrease the incidence of skin tears. Skin barrier film is thus recommended for routine use in peripheral skin care for patients receiving CVC.

Objectives: Aim of this study was to compare the effects of two different shoulder positions on infraclavicular subclavian venous catheterization in critically ill patients. Study Design: Prospective Comparative study. Setting: Sheikh Zayed Medical College Rahim Yar Khan Pakistan. Period: 1st July 2017 to 30th June 2018. Material & Methods: Enrolling 100 patients thru convenient sampling, divided into two groups, Group A & Group B, 50 in each group. In group A patients were put in supine position, with head turned to contra lateral side and caudal pull was applied on ipsilateral shoulder. While in group B patients were lying supine, head turned to contra lateral side and shoulders were retracted by placing a small pillow vertically under the chest between the scapulae. In both groups, subclavian vein was approached through infra clavicular route. Number of attempts of venous punctures (1st attempt / 2nd attempt), total time spent on procedure (from 1st skin puncture to CVC insertion), complications (arterial puncture, pneumothorax, hydrothorax, malpositioning), any hemodynamic irregularity (ECG changes), radiographic findings to confirm successful CVC insertion was recorded. Results: Number of successful subclavian venous catheterizations was same in both groups (94% vs. 94%) with no significant difference (p= 1.000). 1st attempt success was more in group A as compared to group B, though statistically this was not significant (p= 0.275). Total time spent on CVC insertion (from 1st skin puncture to catheter insertion) was less than 05 mints in 84% patient in group A and 82% in group B. While more than 05 mints were spent on 16% vs. 18% patients in group A vs. B. This was also not statistically significant (p=0.790). In group A 2/50 (4%) while in group B 1/50 (2%) cases were recorded as malpositioning on post-CVC radiograph. Other complications were not encountered in either group. Conclusion: Lowered shoulder and retracted shoulder positions are equally effective for SVC insertion in terms of success, 1st attempt success, total time spent and number of complications.

Objetivo: Analizar las producciones científicas que abordan las estrategias de prevención y atención en la obstrucción de los catéteres venosos centrales totalmente implantados en pacientes con cáncer.Material y método: Esta es una revisión bibliográfica integradora, que se realizó en las bases de datos MEDLINE, LILACS, CINAHL y EMBASE, del 20 de julio de 2019 al 31 de julio de 2019, utilizando los siguientes descriptores: Cateterización venosa central; Obstrucción del catéter y oncología, más el uso de términos libres: catéter completamente implantado y neoplasia.Resultados: En total, se seleccionaron e incluyeron 10 estudios. Después del análisis, surgieron las siguientes categorías de análisis: Estrategias para prevenir la obstrucción en CVC-TI y Atención establecidas en el despacho de CVC-TI; teniendo como principales temas abordados: la comparación entre la eficacia en el uso de heparina y solución salina para el mantenimiento y el intervalo de tiempo entre ellos; métodos de despacho y evaluación de permeabilidad CVC-IT.Conclusión: A pesar de la aparición de nuevas formas posibles de prevención de obstrucciones y estrategias de atención en la eliminación de CVC-IT, la literatura no presenta consenso sobre el uso de soluciones con o sin heparina y el intervalo de tiempo entre el mantenimiento para la efectividad de permeabilidad de estos dispositivos en pacientes con cáncer. Objective: To analyze scientific productions that address prevention and care strategies in the obstruction of central venous catheters that are fully implanted in cancer patients.Material and Method: This is an integrative literature review, which took place on the MEDLINE, LILACS, CINAHL and EMBASE databases, from 20 July 2019 to 31 July 2019, using as descriptors: Central venous catheterization; Catheter obstruction and Oncology, in addition to the use of free terms: Catheter fully implanted and Neoplasia.Results: In total, 10 studies were selected and included. After the analysis, the following analysis categories emerged: Strategies for preventing obstruction in CVC-TI and Care established in clearing the CVC-TI; having as main subjects approached: the comparison between the effectiveness in the use of heparin and saline solution for maintenance and time interval between them; unblocking methods and permeability assessment of CVC-TI.Conclusion: Despite the emergence of new possible ways of preventing obstruction and care strategies for clearing CVC-TI, the literature does not have a consensus on the use of solutions with or without heparin and the time interval between maintenance for the effectiveness of the permeability of these devices in cancer patients. Objetivo: Analisar produções científicas que abordem a prevenção e estratégias de cuidado na obstrução de cateteres venosos centrais totalmente implantados em pacientes oncológicos.Material e Método: Trata-se de uma revisão integrativa da literatura, que ocorreu nas bases de dados MEDLINE, LILACS, CINAHL e EMBASE, no período 20 de Julho de 2019 a 31 de Julho de 2019, utilizando-se como descritores: Cateterismo venoso central; Obstrução de cateter e Oncologia, além do uso dos termos livres: Cateter totalmente implantado e Neoplasia.Resultados: Ao total, 10 estudos foram selecionados e incluídos. Após a análise, emergiram as seguintes categorias de análise: Estratégias de prevenção da obstrução em CVC-TI e Cuidados estabelecidos na desobstrução do CVC-TI; tendo então como principais assuntos abordados: a comparação entre a eficácia no uso da heparina e solução salina para manutenções e tempo de intervalo entre as mesmas; métodos de desobstrução e avaliação de permeabilidade dos CVC-TI.Conclusão: Apesar do surgimento de novas formas possíveis de prevenção de obstrução e estratégias de cuidado na desobstrução dos CVC-TI, a literatura não apresenta consenso sobre o uso de soluções com ou sem heparina e o tempo de intervalo entre as manutenções para a efetividade da permeabilidade desses dispositivos em pacientes oncológicos.

For critically ill patients, central venous catheterization may not always be placed in a correct tip position, even when guided by ultrasound. A case of inadvertent catheterization into azygos vein is described.

Background Real-time ultrasound (US) in central venous catheterization is superior to pre-procedure US. However, ensuring real-time US into routine practice is impeded by its perceived expense and difficulty. This expertise requires hand–eye coordination and learning curve. Moreover, availability of multiple US machines and probes for multiple operation theatres may not be possible even at the tertiary level care set-up. Currently, pre-procedure US and landmark methods are most widely used. We investigated both the techniques with application of skin markings in the pre-procedure group to ascertain efficacy and safety with a view to incorporate pre-procedure US in our practice. Methods In this randomized study, we investigated 66 patients. Thirty-three patients in the pre-procedure ultrasound group and 33 patients in the landmark group were included for right internal jugular vein (RIJV) cannulation. We recorded the first needle pass success rate, cannulation time and complications. Results Pre-procedure US was associated with more successful attempts, shorter cannulation times and less complications. Under pre-procedure US, 75.76% of first attempts were successful with a cannulation time of 50 (25–180) seconds. Under landmark technique, 27.27% of first attempts were successful with a cannulation time of 85 (20–200) seconds. First puncture success rates were higher in pre-procedure US than landmark technique, 66.67% vs 27.27%, respectively. Conclusion Pre-procedure US for RIJV catheterization is safer, quicker and superior to landmark technique.

Objectives The aim of this study was to compare the occurrence of posterior wall puncture between the long-axis in-plane and the short-axis out-of-plane approaches in a randomized controlled trial of pediatric patients who underwent cardiovascular surgery under general anesthesia. Design Prospective randomized controlled trial. Setting Operating room of Osaka Women's and Children's Hospital. Patients Pediatric patients less than 5 years old who underwent cardiovascular surgery. Interventions Ultrasound-guided central venous catheterization using the long-axis in-plane approach and short-axis out-of-plane approach. Measurements and main results The occurrence of posterior wall puncture was compared between the long-axis in-plane and short-axis out-of-plane approaches for ultrasound-guided central venous catheterization. Patients were randomly allocated to a long-axis group or a short-axis group and underwent ultrasound-guided central venous catheterization in the internal jugular vein using either the long-axis in-plane approach (long-axis group) or the short-axis out-of-plane approach (short-axis group). After exclusion, 97 patients were allocated to the long-axis (n = 49) or short-axis (n = 48) groups. Posterior wall puncture rates were 8.2% (4/49) and 39.6% (19/48) in the long-axis and short-axis groups, respectively (relative risk, 0.21; 95% CI, 0.076-0.56; p = 0.0003). First attempt success rates were 67.3% (33/49) and 64.6% (31/48) in the long-axis and short-axis groups, respectively (relative risk, 1.04; 95% CI, 0.78-1.39; p = 0.77). Overall success rates within 20 minutes were 93.9% (46/49) and 93.8% (45/48) in the long-axis and short-axis groups, respectively (relative risk, 0.99; 95% CI, 0.90-1.11; p = 0.98). Conclusions The long-axis in-plane approach for ultrasound-guided central venous catheterization is a useful technique for avoiding posterior wall puncture in pediatric patients, compared with the short-axis out-of-plane approach.

The quality of life and patient survival rate in terminal chronic renal insufficiency depends on the duration of vascular approaches. Dialysis catheters are used to establish an adequate vascular approach when emergency hemodialysis is indicated and when all approaches are exhausted. Complications of CVC can be classified into three categories: mechanical (hematoma, arterial puncture, pneumothorax, hemothorax, catheter misplacement, and stenosis), infectious (insertion site infection, CVC colonization, and bloodstream infection) and thrombotic (deep vein thrombosis). Despite the increasing prevalence of haemodialysis patients with complex access issues, there remains no consensus on the definition of vascular access failure or end-stage vascular access. The dilema in these cases remains whether the generalized vascular insufficiency is the cause or a complication of exhausted vascular accesses. This case report is one of the examples of combined complications with generalized vascular access insufficiency. During the year and a half of the chronic dialysis program, the patient had several changes of vascular approaches, and each approach became dysfunctional in certain time due to various causes. After six months of successful hemodialysis, the patient was admitted with signs of infection and during hospitalization was again subjected to multiple changes of the vascular approach due to infection, thrombosis, and vascular access failure.

Introduction: Pediatric patients with severe burns often require long-term venous access over the course of their recovery. The need for long-term venous access in these critically ill patients often necessitates the placement of a central venous catheter (CVC). Many techniques exist for the establishment of a CVC in pediatric burn patients, and each technique poses its own set of inherent risks. No studies to date have clearly delineated the risk associated with tunneled central venous catheterization in the pediatric burn patient population. The primary aim of this study was to evaluate the use of tunneled CVCs in pediatric burn patients at the University Medical Center Hospital in Lubbock, Texas. Methods: To evaluate this method of central venous catheterization, we retrospectively reviewed the charts of pediatric burn patients who received a tunneled CVC to determine the incidence of specific complications associated with this catheterization technique. We present our findings here in a case series format. Results: Our initial search of patient charts yielded 86 potential candidates for inclusion in the study. After reviewing each chart, 26 pediatric patients were found to have received a CVC. Of these 26 patients, five met all of the inclusion criteria of our study. In these five patients, eight tunneled CVCs were placed. The average age of the patients in this series at the time of their respective burn injuries was 3.9 years old. Mean percent TBSA involvement was 38% with an average length of stay totaling 64.6 days. The average dwell time of the tunneled CVCs in this series was 28 days, and our analysis of the data revealed one tunneled catheterrelated infection and one hemodynamic complication. Conclusions: Overall, our data show that placement of long-term tunneled CVCs in pediatric burn patients appears to be a relatively safe practice. However, our small sample size warrants more investigation into this topic.Keywords: pediatrics, burns, central vein catheters

Gamification, or adding elements of games to training systems, has the potential to increase learner engagement and information retention. However, the use of gamification has yet to be explored in Central Venous Catheterization (CVC) trainers which teach a commonly performed medical procedure with high incidence rates. In order to combat these errors, a Dynamic Haptic Robotic Trainer (DHRT) was developed, which focuses on vessel identification and access. A DHRT+ system is currently under development that focuses on whole procedure training (e.g. sterilization and catheter insertion), including a gamified Graphical User Interface. The goal of this paper was to (1) develop a game-like, patient-centered interface to foster personalized learning and (2) understand the perceived utility of gamification for CVC skill development with expert doctors. This paper outlines some of the potential benefits and deficits of the use of gamification in medical trainers that can be used to drive simulation design.

Recent guidelines recommend the umbilical venous catheter (UVC) as the optimal vascular access method during neonatal resuscitation. In emergencies the UVC securement may be challenging and time-consuming. This experimental study was designed to test the feasibility of new concepts for the UVC securement. Umbilical cord remnants were catheterized with peripheral catheters and secured with disposable umbilical clamps. Three different securement techniques were investigated. Secure 1: the disposable umbilical clamp was closed at the level of the inserted catheter. Secure 2: the clamp was closed at the junction of the catheter and plastic wings. Secure 3: the setting of Secure 2 was combined with an umbilical tape. The main outcomes were the feasibility of fluid administration and the maximum force to release the securement. This study shows that inserting peripheral catheters into the umbilical vein and securing them with disposable umbilical clamps is feasible. Rates of lumen obstruction and the effectiveness of the securement were superior with Secure 2 and 3 compared to Secure 1. This new approach may be a rewarding option for umbilical venous catheterization and securement particularly in low-resource settings and for staff with limited experience in neonatal emergencies. However, although promising, these results need to be confirmed in clinical trials before being introduced into clinical practice.

This review discusses complications unique to pediatric surgical populations. Here the authors focus primarily on five of the most common procedures performed in children: appendectomy, central venous catheterization, pyloromyotomy, gastrostomy, and inguinal/umbilical hernia repair.

Background: The objective of this study was to evaluate incidence and influencing factors of complications related to central venous catheters (CVCs) in the Pediatric intensive care unit (PICU) of Xi'an Children's Hospital.Methods: We analyzed the complications of all children that had CVCs and were hospitalized between June 2020 to February 2021. A total of 334 CVCs were inserted in 310 children.Results: We noted 102 (30.54%) CVCs-related complications. Complications related to CVCs insertion were infection of catheter (13.17%) and malposition of catheter (8.38%), occlusion of CVCs (2.99%), accidental removal (0.6%), puncture site exudate (4.79%), central venous thrombosis (0.6%). Infection mainly due to Staphylococcus epidermidis. 88 cases (24.55%) of CVCs were extubated due to complications. Analysis of the frequency of maintenance-related complications except for center vein thrombosis showed no differences between the jugular, femoral and subclavian vein access (P > 0.05). It was found that the duration of the catheterization use was critical for the occurrence of CVCs-related infections, puncture site exudate, occlusion (P < 0.05). Suture-off, bleeding of insertion site, and the maximum channels of intravenous infusion in patients were dominant risk factors of catheter-related complications. Conclusion: The risk factors of complications during catheter indwelling are suture-off, bleeding of insertion site and the maximum channels of intravenous infusion in patients. Therefore, strict aseptic operation in various operations, control of the infusion channel, effective fixation of the central venous catheter, reduce the malposition and pull of the catheter, and reduce the infiltration of blood at the puncture point, are particularly important to prevent the complications related to the central venous catheter.

In patients with subcutaneous neck emphysema, ultrasound images of the internal jugular vein are unclear due to air bubbles. Central venous catheterization can be safely achieved by pushing the accumulated air laterally using an ultrasound probe.

Iatrogenic arteriovenous fistula of major neck vessels is a rare complication but can occur after central venous catheterization. Symptoms can range from nothing to severe heart failure and management can be particularly complex. We report a case that we treated recently in our department.

Objective The authors compared the occurrence of posterior wall puncture using the short-axis out-of-plane and long-axis in-plane approaches with that using the combined short-axis-and-long-axis approach that the authors previously showed to be effective in observational and manikin studies. Design Randomized controlled study. Setting Single tertiary institution. Participants One hundred twenty patients who underwent cardiac or vascular surgery under general anesthesia. Interventions The patients were divided randomly into combined short-axis-and-long-axis (n = 40), short-axis out-of-plane (SA-OOP) (n = 40), and long-axis in-plane (LA-IP) (n = 40) groups and received ultrasound-guided central venous catheterization at the right internal jugular vein. Measurements and Main Results Successful guidewire insertion without posterior wall puncture was performed in 40 patients (100%) in the combined short-axis-and-long-axis approach group, 28 (70%) in the short-axis out-of-plane approach group, and 38 (95%) in the LA-IP approach group (combined short-axis-and-long-axis v SA-OOP, p = 0.0002 [relative risk = 1.43; 95% CI: 1.17-1.75]; combined short-axis-and-long-axis v LA-IP, p = 0.49 [relative risk = 1.05; 95% CI: 0.98-1.13]). Procedure durations were 28.5 (24.1-36.4) seconds in the combined short-axis-and-long-axis group, 31.7 (24.4-40.6) seconds in the SA-OOP group, and 24.3 (20.8-32.1) seconds in the long-axis in-plane group (combined short-axis-and-long-axis v SA-OOP, p = 0.53; combined short-axis-and-long-axis v LA-IP, p = 0.044). Conclusion The combined short-axis-and-long-axis approach for ultrasound-guided central venous catheterization had a lower posterior wall puncture rate than the SA-OOP approach, but there was no significant difference with the long-axis in-plane approach.

This paper introduces a flexible puncture method that can improve the efficiency and safety of robot-assisted central venous catheterization (CVC) surgery systems. Current CVC surgery-assisted mani...

Patient: Male, 52 Final Diagnosis: Retained guidewire Symptoms: Knee pain Medication: — Clinical Procedure: — Specialty: General and Internal Medicine Objective: Unusual clinical course Background: Retained guidewire is a recognized complication of intravascular interventions. The majority of cases are identified immediately or shortly after the procedure. In rare cases, the guidewire is identified incidentally by X-ray after the procedure. This report presents a rare case of a retained venous guidewire that was discovered two years after central venous catheterization. Case Report: A 52-year-old African-American man presented with a wire that was emerging from the skin near his right knee. He had undergone a right femoral central venous catheter placement two years previously. Imaging showed that the end of the guidewire was sited at the left pulmonary artery, and was associated with two small broken fragments of wire. During surgery to remove the guidewire, it had become adherent to the pulmonary artery wall. Most of the guidewire was removed, but the portion adherent to the pulmonary artery wall was left in place. Conclusions: It is very rare for a retained guidewire to be discovered when it protrudes through the skin, two years after central venous catheter placement, as the majority of cases are discovered by physical inspection or imaging following intravascular interventions. Skill and attention in the clinical setting are required to minimize such complications.

Manikins have traditionally been used to train ultrasound-guided Central Venous Catheterization (CVC), but are static in nature and require an expert observer to provide feedback. As a result, virtual simulation and personalized learning has been increasingly adopted in medical education to efficiently provide quantitative feedback. The Dynamic Haptic Robotic Trainer (DHRT) trains surgical residents in CVC needle insertions by simulating various patient profiles and presenting personalized feedback on objective performance. However, no studies have examined the learning gains of the personalized learning feedback or the relation of feedback to what the user is focusing on during the training. Thus, this study was developed to determine the effectiveness of the current personalized learning interface through a long-term investigation with 7 surgical residents. The eye tracking analysis showed that residents spent significantly more time fixated on percent aspiration throughout the study; the more time participants spent looking at the Number of Insertions, Percent Aspiration and the Angle of Insertion on the DHRT GUI, the better they performed on subsequent trials on the DHRT system.

Introduction: The ultrasound-guided axillary vein is becoming a compulsory alternative vessel for central venous catheterization and the anatomical position offers several potential advantages over blind, subclavian vein techniques. Objective: To determine the degree of dynamic variation of the axillary vein size measured by ultrasound prior to the induction of general anesthesia and after starting controlled mechanical ventilation. Design: Prospective, observational study. Methods: One hundred ten patients undergoing elective surgery were enrolled and classified according to sex, age, and body mass index. Two-dimensional cross-sectional vein diameter, area, and mean flow velocity were performed using ultrasound on both the left and right axillary veins of each subject before and after induction of anesthesia. Results: There was statistically significant evidence showing that the axillary vein area increases when patients are mechanically ventilated. When considering venous flow velocity as a primary outcome, velocity decreased after patients moved from spontaneous to mechanical ventilation (coefficient = −0.267), but this relationship failed to achieve statistical significance ( t = –1.355, p = 0.179). Conclusions: Anatomical variations in depth and diameter as well as the collapsibility due to intrathoracic pressures changes represent common challenges that face clinicians during central venous catheterization of the axillary vein. A noteworthy increase in vessel size as patients transition from spontaneous to mechanical ventilation may theoretically improve first-pass cannulation success with practitioners skilled in both ultrasound and procedure. As a result, placing a centrally inserted central catheter after the induction of anesthesia may be beneficial.

Objective Visualizing the needle tip using the short-axis out-of-plane (SA-OOP) ultrasound-guided central venous catheterization approach is difficult and results in posterior wall puncture (PWP). To improve needle tip visualization in the long-axis view, combining the SA-OOP and the long-axis in-plane approaches has been suggested. The authors, who previously reported on the utility of this technique using a manikin model, examined the feasibility of this novel method (referred to as the combined short-axis and long-axis [CSLA] approach) and compared the CSLA approach with the SA-OOP approach in humans for the present study. Design Prospective observational study. Setting Single institution, Rakuwakai Otowa Hospital. Participants Patients undergoing cardiac or vascular surgeries. Interventions The CSLA and SA-OOP approaches were used for ultrasound-guided right jugular venous puncture. The puncturing procedures were determined arbitrarily preoperatively without consideration of the patient's neck anatomy and were based on the operator's preference without randomization. Measurements and Main Results The study comprised 100 patients. Successful guidewire insertion without PWP was performed in 48 patients (96%) in the CSLA approach group and 33 (66%) in the SA-OOP approach group; the rate was significantly higher in the CSLA approach group (p = 0.0001). The procedural durations were 27.5 (range 17.0-122.0) seconds in the CSLA approach group and 25.0 (range 15.0-158.0) seconds in the SA-OOP approach group (p = 0.19). Conclusions This study showed that the CSLA approach to ultrasound-guided central venous catheterization might help prevent PWP.