Recommendations
Guidelines
on
the
use
of
ultrasound
guidance
for
vascular
access
Herve´ Bouaziz
a,*
,
Paul
J.
Zetlaoui
b,
Se´bastien
Pierre
c,
Eric
Desruennes
d,
Nicolas
Fritsch
e,
Denis
Jochum
f,
Fre´de´ric
Lapostolle
g,
Thierry
Pirotte
h,
Ste´phane
Villiers
ia
DepartmentofAnaesthesiaandIntensiveCare,HoˆpitalCentral,29,avenueduMare´chal-de-Lattre-de-Tassigny,54035Nancycedex,France
b
DepartmentofAnaesthesiaandIntensiveCare,HoˆpitaldeBiceˆtre,78,RueduGe´ne´ral-Leclerc,94275LeKremlin-Biceˆtre,France
c
DepartmentofAnaesthesia,InstitutUniversitaireduCancerToulouse–Oncopole,31059Toulouse,France
dDepartmentofAnaesthesia,InstitutGustave-Roussy,94805Villejuif,France
eDepartmentofAnaesthesiaandIntensiveCare,Hoˆpitald’InstructiondesArme´esRobert-Picque´,33140Villenaved’Ornon,France
fDepartmentofAnaesthesiaandIntensiveCare,GroupeHospitalierduCentreAlsace(GHCA),HoˆpitalAlbert-Schweitzer,68003Colmar,France g
Samu93–UFResearch-Teaching-Quality,Universite´ Paris13,SorbonneParisCite´,EA3509,HoˆpitalAvicenne,93009Bobigny,France
h
DepartmentofAnaesthesia,CliniquesuniversitairesSaint-Luc,Universite´ CatholiquedeLouvain,1348Bruxelles,Belgium
i
DepartmentofAnaesthesiaandIntensiveCare,HoˆpitalSaint-Louis,1,avenueClaude-Vellefaux,75010Pariscedex10,France
1. Steeringcommittee
PaulZetlaoui,Herve´ Bouaziz,Se´bastienPierre.
Workinggroup:EricDesruennes,NicolasFritsch,DenisJochum, Fre´de´ricLapostolle,ThierryPirotte,Ste´phaneVilliers.
DocumentvalidatedbytheSfar[FrenchSocietyofAnaesthesia andIntensiveCare]boardonFriday12September2014.
2. Introduction
2.1. Contextoftheguidelines 2.1.1. Background
Insertionofacentralvenousaccess,whetheritisbeingusedfor ashortoralongperiodoftime,isacommonprocedure,whichis oftenundertakenbyintensivistsandanaesthetists.Theassociated
morbiditiesincludepuncturedarteriesforalmost10%ofcasesand haemothoraxorpneumothoraxforabout3%[1].These complica-tionscanbeseriousorevenfatal[2].Althoughinsertionofradial arterialandperipheralvenousaccessesisnotassociatedwiththe sameiatrogenicrisks,itcancausepainanddiscomfort,delaycare and,intheeventoffailure,deprivethepatientofthebestpossible chances.
2.1.2. Rationalefortheseguidelines
The first guidelines from the National Institute for Clinical Excellence [3] to recommendthe systematic use of ultrasound guidance for puncture when inserting central venous access appearedin 2002,but only25%of anaesthetistsinthe English-speakingworldseemtofollowthem[4].Recently,Americanand internationalguidelineswerepublished[5,6].Althoughtheformer recommend a different method to that recommended by the FrenchSocietyofAnaesthesiaandIntensiveCare(Socie´te´ franc¸aise d’anesthe´sie et de re´animation [Sfar]), the latter – although comprehensive–donotprovideexplicit,transparentjustifications fortheirproposedguidelines.Inaddition,oneofthemainobstacles
ABSTRACT
Insertionofvascularaccessisacommonprocedurewithpotentialforiatrogenicevents,someofwhich
can be serious.The spread of ultrasound scanners in operating rooms, intensive care units and
emergencydepartmentshasmadeultrasound-guidedcatheterisationpossible.Thefirstguidelineswere
publishedadecadeagobutarenotalwaysfollowedinFrance.TheFrenchSocietyofAnaesthesiaand
IntensiveCarehasdecidedtoadoptapositiononthisissuethroughitsGuidelinesCommitteeinorderto
proposealimitednumberofsimpleguidelines.ThemethodusedwastheGRADE1
methodusingthe
mostrecentlypublishedmeta-analysesasthesourceofreferences.Thelevelofevidencefoundranged
fromlowtohighandallthepositiveaspectsassociatedwithultrasoundguidance,i.e.fewertraumatic
complications at puncture, probably or definitely outweigh the potential adverse consequences
regardlessofwhetheranadultorchildisinvolvedandregardlessofthesiteofinsertion.
ß2015Socie´te´ franc¸aised’anesthe´sieetdere´animation(Sfar).PublishedbyElsevierMassonSAS.All
rightsreserved.
* Correspondingauthor.
E-mailaddress:h.bouaziz@chu-nancy.fr(H.Bouaziz).
http://dx.doi.org/10.1016/j.accpm.2015.01.004
topractitionersacceptinginternationalguidelinesisunfamiliarity with the latter and inability to understand texts written in a foreign language [7]. For that reason the Board of the French SocietyofAnaesthesiaand IntensiveCarehasdecidedtotake a position on the subject by convening the Clinical Guidelines CommitteetocompilealimitedsetofsimpleguidelinesinFrench accessibletoallpractitioners.
2.1.3. Aimsoftheseguidelines
Theaimoftheseguidelinesistoissuerecommendationsonthe useofultrasoundguidanceforinsertingvenousandarterialaccess, whetheritisbeingusedforashort-oralong-termdurationinboth adultsand children.Pre-proceduralultrasoundassessment only usedtomarktheskinfor subsequentcannulationand Doppler ultrasonographyarenotaddressedbecausethesetechniquesare lessefficient[6].
2.1.4. Literaturesearchandselectioncriteria
Meta-analysesbyWuetal.[1],Guetal.[8]andLiuetal.[9]
wereusedasthesourceofreferences.Onlyrandomized,controlled trialswithaJadadscore[10]ofatleast2wereincluded.Thestudies byBobbiaetal.[11],Hansenetal.[12],Iwashimaetal.[13]and Eldabaa et al. [14] were added to complete the analysis. No relevantpublishedworkaddressingpatients’ valuesand prefer-encesin relation tothesubject of theseexpert guidelines was found.Thequestionofusingultrasoundguidanceforthefemoral arteryin adultsand childrenwasnot addressedbecauseof the absenceofanypublishedmaterial.
2.1.5. Populationandcomparisons
Thepopulationsofadultsandchildrenwerestudiedseparately, comparing the technique of ultrasound-guided catheterization witheitheranatomicalcutaneouslandmark-basedcannulationor palpation(dependingontheinsertionsite:InternalJugularVein, SubclavianVein,FemoralVein,RadialArteryandperipheralveins inwhichinsertionisdeemeddifficult).
2.1.6. Criteria
For centralvascularaccess,themaincriteria selectedby the expertswere: failedpuncture, arterialpuncture,pneumothorax andhaemothorax,asapplicable.Forothertypesofvascularaccess, onlysuccessratewasconsidered.Insertiontimewasnotstudied since widelydisparate definitions are used.Risk reduction and heterogeneitycalculationswereredoneusingRevman1
software andevidenceprofileswerecompiledusingGRADEpro1
software (seeFurtherMaterials).
2.1.7. Medico-economicanalysis
Themedico-economicanalysiswascarriedoutbyCalvertetal.
[15]in2003fortheNationalHealthServicebyanalyticaldecision modelling.Themarginalcostofultrasoundguidanceforinsertinga centralvenousaccessislessthan12
s
.Thescenarioisbasedona rateofatleast15proceduresaweek.Theeconomicanalysisshows asavingofover2000s
per1000procedures,basedonpurchasing andmaintenance costs,resourcesconsumed,single-use devices andtrainingcosts.However,theseresultsarehighlydependenton thenumberofproceduresperformed.2.1.8. Clinicalpracticeguidelines
Formostofthevascularapproachesinvestigated,theguidelines belowshowthat ultrasound guidanceis superior totraditional anatomical cutaneous landmark-based cannulation techniques. Theexpertsareawarethat,inallestablishmentswherevascular approaches(central,peripheralandarterial)arecarriedout,the availabilityofultrasoundequipmentisstillrestricted.Theexperts are also aware that practitioners involved in performing such
proceduresarenotallfullytrainedinthetechniquesof ultrasound-guidedpuncture.Thisiswhytheseexpertguidelinesareexpected toserveasafoundationforestablishingatrainingprogrammeand toprovideaframeworkfortheacquisitionofsuitableequipment (ultrasoundscannersandaccessories).
2.2. TheGRADE1
method
Theworkingmethodusedtocompiletheseguidelineswasthe GRADE1
method.Afteraquantitativeanalysisoftheliterature,this method determines evidence levels separately and therefore assesses the confidence that can be placed in the quantitative analysisandalevelofrecommendation.Thequalityofevidenceis gradedintofourlevels:
high:futureresearchisunlikelytochangethelevelofconfidence intheassessmentoftheeffect;
moderate: future research probably will change the level of confidenceintheassessmentoftheeffectandcouldchangethe assessmentoftheeffectitself;
low:futureresearchisverylikelytohaveanimpactonthelevel ofconfidenceintheassessmentoftheeffectandwillprobably changetheassessmentoftheeffectitself;
verylow:theassessmentoftheeffectishighlyuncertain. Thelevelofevidenceisanalysedforeachcriteriaandthena global level of evidenceis defined on the basis of the various evidencelevelsforthemaincriteria.
Thefinalformulationofguidelinesisalwaysbinary,i.e.either positiveornegativeandeitherstrongorweak:
strong:recommendedornotrecommended(GRADE1+or1 ); weak:probablyrecommended orprobablynot recommended
(GRADE2+or2 ).
Thestrengthoftheguidelineisdeterminedonthebasisoffour keyfactors andvalidatedby theexperts aftera vote,usingthe GRADEGridmethod[16]:
assessmentoftheeffect;
overall level of evidence: the higher this is, the more the guidelinewillbestrong;
balancebetweenpositiveandnegativeeffects:themorepositive thisis,themorelikelythattheguidelinewillbestrong; values and preferences: the greater the uncertainty and
variability,themorelikelytheguidelinewillbeweak. Values andpreferencesmustbeascertained,ifpossible,directlyfrom thoseconcerned(patient,physician,decision-maker);
cost:thehigherthecostorconsumptionofresources,themore likelytheguidelinewillbeweak.
3. Guidelines
3.1. Guideline1:internaljugularveininadults 3.1.1. Questionasked
Toinsertacentralvenousaccessviatheinternaljugularveinin an adult, should ultrasound-guided puncture or anatomical cutaneouslandmark-basedcannulationbeused?
3.1.2. Data
2653patients, an 80%reduction in arterialpuncturerates (RR: 0.20; 95%CI: 0.13–0.32) in 13 randomised, controlled trials including 2675 patients, a 78% reduction in the number of haematomas (RR: 0.22; 95%CI: 0.14–0.36) in 9 randomised, controlledtrialsincluding2309patients,a 90%reductioninthe numberofcasesofpneumothorax(RR:0.1;95%CI:0.02–0.56)in 3 randomised, controlled trials including 1110 patients, a 94% reductioninthenumberofcasesofhaemothorax(RR:0.06;95%CI: 0–1)inonerandomised,controlled trialincluding900 patients. Theoveralllevelofevidenceisgoodandtherisk-to-benefitandthe cost-to-benefitratiosarepositive.
Inall,positiveaspectsclearlyoutweighnegativeaspectsand weproposeastrongrecommendation.
3.1.3. Guideline
Itis recommendedthatultrasound-guidedpuncturebeused ratherthananatomicalcutaneouslandmark-basedcannulationto insertvenousaccesscatheterstheinternaljugularveininadults (level1+).
3.2. Guideline2:subclavianveininadults 3.2.1. Questionasked
Toinsertcentralvenousaccessviathesubclavianveininan adult, should ultrasound-guided puncture or anatomical cuta-neouslandmark-basedcannulationbeused?
3.2.2. Data
Theresultsofthemeta-analysisdemonstrateda94%reductionin the rateof catheterization failure(RR:0.06; 95%CI:0.01–0.2)in 3 randomised, controlled trials including 498 patients, an 85% reductioninarterialpuncturerates(RR:0.18;95%CI:0.04–0.65)in 3 randomized, controlled trials including 498 patients, a 77% reductioninthenumberofhaematomas(RR:0.23;95%CI:0.09– 0.68)in3randomized,controlledtrialsincluding498patients,a78% reductioninthenumberofcasesofpneumothorax(RR:0.22;95%CI: 0.05–0.92)in2randomized,controlledtrialsincluding446patients, a95%reductioninthenumberofcasesofhaemothorax(RR:0.05; 95%CI: 0–0.88) in one randomized, controlled trial including 401patients.Fewstudiesfocusonthisapproachbutthe overall levelofevidenceishighdespiteheterogeneityandlackofprecision intheresultsforcertainkeycriteria.Therisk-to-benefitandthe cost-to-benefitratiosarepositive.
Inall,positiveaspectsclearlyoutweighnegativeaspectsand weproposeastrongrecommendation.
3.2.3. Guideline
Itis recommendedthatultrasound-guidedpuncturebeused ratherthananatomicalcutaneouslandmark-basedcannulationto insertvenousaccessviathesubclavianveininadults(level1+). 3.3. Guideline3:femoralveininadults
3.3.1. Questionasked
Toinsertacentralvenousaccessviathefemoralveininadults, should ultrasound-guided puncture or anatomical cutaneous landmark-basedcannulationbeused?
3.3.2. Data
The results of the meta-analysis demonstrated an 85% reductionintherateofcatheterisationfailure(RR: 0.15;95%CI:
0.04–0.52) in 2 randomised, controlled trials including 150 patients, an 86% reduction in arterial puncture rates (RR: 0.14; 95%CI: 0.02–0.74) in 2 randomised, controlled trials including150patientsandapossible50%reductioninthenumber of cases of haemothorax (RR: 0.50; 95%CI: 0.09–2.43) in one randomised, controlled trial including 110 patients. Although therearenotmanystudiesonthisapproachandtheoveralllevelof evidenceis onlymoderatebecauseofa lackofprecision inthe results, the risk-to-benefit and the cost-to-benefit ratios are positive.
Inall,positiveaspectsclearlyoutweighnegativeaspectsand weproposeastrongrecommendation.
3.3.3. Guideline
Toinsertacentralvenousaccessviathefemoralveininadults, ultrasound-guided punctureshould beused rather than anato-micalcutaneouslandmark-basedcannulation(level1+).
3.4. Guideline4:radialarteryinadults 3.4.1. Questionasked
Toinsertaradialarterialcatheterinadults,should ultrasound-guided puncture oranatomicalcutaneouslandmark-based can-nulationbeused?
3.4.2. Data
Theresultsofthemeta-analysisdemonstrateda39%reduction intherateofcatheterisationfailureatthefirstattempt(RR:0.61; 95%CI: 0.41–0.84) in 4 randomised, controlled trials including 281patients,an83%reductioninthenumberofhaematomas(RR: 0.17; 95%CI: 0.05–0.54) in 2 randomised, controlled trials including132patients.Theoverall successrateisnotreported. Fewstudiesfocusonthisapproachrouteandtheoveralllevelof evidenceislowbecauseoftheheterogeneityandlackofprecision oftheresultsforthecriticalendpointselected.Therisk-to-benefit andthecost-to-benefitratiosareprobablypositive.
Inall,positiveaspectsprobablyoutweighnegativeaspectsand weproposeaweakrecommendation.
3.4.3. Guideline
Itisprobablyrecommendedthatultrasound-guidedpuncture shouldbeusedratherthananatomicalcutaneouslandmark-based cannulationtoinsertaradialarterialcatheterinadults(level2+). 3.5. Guideline5:peripheralveinsinadults
3.5.1. Questionasked
When difficult accessfor peripheral venousaccess is antici-pated inadults, shouldultrasound-guidedpuncturerather than anatomicalcutaneouslandmark-basedcannulation(orpalpation) beused?
3.5.2. Data
Inall,positiveaspectsprobablyoutweighnegativeaspectsand weproposeaweakrecommendation.
3.5.3. Guideline
Itisprobablyrecommendedthatultrasound-guidedpuncture shouldbeusedratherthananatomicalcutaneouslandmark-based cannulationwhendifficultaccessforperipheralvenousaccessis anticipatedinadults(level2+).
3.6. Guideline6:internaljugularveininchildren 3.6.1. Questionasked
Toinsertcentralvenousaccessviatheinternaljugularveinin children, should ultrasound-guided puncture or anatomical cutaneouslandmark-basedcannulationbeused?
3.6.2. Data
Theresultsofthemeta-analysisdemonstrateda69%reductionin therateofcatheterisationfailure(RR:0.31;95%CI:0.18–0.52)in 4 randomised, controlled trials including 460 patients, a 77% reductioninarterialpuncture rates(RR:0.23;95%CI:0.11–0.44) in4randomised,controlledtrialsincluding460patients.Theoverall levelofevidenceismoderatebecauseoftheheterogeneityofthe results;therisk-to-benefitandthecost-to-benefitratiosarepositive.
Inall,positiveaspectsclearlyoutweighthenegativeaspects andweproposeastrongrecommendation.
3.6.3. Guideline
Toinsertcentralvenousaccessviatheinternaljugularveinin children,ultrasound-guidedpunctureshouldbeusedratherthan anatomicalcutaneouslandmark-basedcannulation(level1+). 3.7. Guideline7:subclavianveininchildren
3.7.1. Questionasked
To insert central venous access via the subclavian vein in children, should ultrasound-guided puncture or anatomical cutaneouslandmark-basedcannulationbeused?
3.7.2. Data
Norandomisedcontrolledstudyontheuseofultrasound-guided puncturecomparedtoananatomicalcutaneouslandmark-based technique isavailable on the reductionin complications during insertionofcentralvenousaccessviathesubclavianveininchildren. Theauthors pointoutthat feasibilitystudies have beencarriedout inchildrenfocusingonaccessviathesubclavianveinoritsextension, thebrachiocephalicvein.Infra-orsupra-clavicularapproacheshave beenaddressedin7articles.Nocomplications(arterialpunctureor pneumothorax) were reported in any of these studies, which includedmorethan400babiesandchildren.Nevertheless,further expertanalysisandcontrolledstudiesneedtobeperformed. 3.7.3. Guideline
Noguidelinecanbeformulated. 3.8. Guideline8:femoralveininchildren 3.8.1. Questionasked
Toinsertcentralvenousaccessviathefemoralveininchildren, should ultrasound-guided puncture or anatomical cutaneous landmark-basedcannulationbeused?
3.8.2. Data
Theresultsofthemeta-analysisdemonstrateda62%reduction intherateofcatheterisationfailure(RR:0.38;95%CI:0.19–0.73) anda65%reductioninarterialpuncturerates(RR:0.35;95%CI: 0.14–0.83) in 3 randomised, controlled trials including 215patients.The overalllevelof evidenceis moderatebecause ofariskofbiasandlackofprecisionintheresults;the risk-to-benefitandthecost-to-benefitratiosarepositive.
Inall,positiveaspectsclearlyoutweighnegativeaspectsand weproposeastrongrecommendation.
3.8.3. Guideline
To insert a central venous access via the femoral vein in children,ultrasound-guidedpunctureshouldbeusedratherthan anatomicalcutaneouslandmark-basedcannulation(level1+). 3.9. Guideline9:radialarteryinchildren
3.9.1. Questionasked
To insert a radial arterial catheter in children, should ultrasound-guidedpunctureoranatomicalcutaneous landmark-basedcannulationbeused?
3.9.2. Data
Theresultsofthemeta-analysisdemonstrateda33%reductionin the rate ofcatheterisation failure atthe firstattempt (RR:0.67; 95%CI: 0.45–0.91) in 3 randomised, controlled trials including 300patientsandan80%reductioninthenumberofhaematomas (RR: 0.2; 95%CI: 0.05–0.65) in one randomised, controlled trial including 118patients. Theoverall success rate is notreported. Althoughtherearenotmanystudiesonthisapproachandtheoverall levelofevidenceismoderatebecauseofheterogeneousresults,the risk-to-benefitandthecost-to-benefitratiosareprobablypositive.
Inall,positiveaspectsprobablyoutweighnegativeaspectsand weproposeaweakrecommendation.
3.9.3. Guideline
Itisprobablyrecommendedthatultrasound-guidedpuncture shouldbeusedratherthananatomicalcutaneouslandmark-based cannulationtoinsertaradialarterialcatheterinchildren(level2+). 3.10. Guideline10:peripheralveinsinchildren
3.10.1. Questionasked
When difficultaccess for peripheral venousaccess is antici-patedinchildren,shouldultrasound-guidedpunctureratherthan anatomicalcutaneouslandmark-basedcannulation(orpalpation) beused?
3.10.2. Data
Theresultsofthemeta-analysisprobablydemonstrateda20% increaseintherateofsuccessfulcatheterisation(RR:1.20;95%CI: 0.89–1.43) in 3 randomised, controlled trials including 134patients.Fewstudiesfocusonthisapproachandtheoverall level ofevidenceis low becauseofthe lackof precisionof the results. The risk-to-benefit and the cost-to-benefit ratios are probablypositive.
3.10.3. Guideline
Itisprobablyrecommendedthatultrasound-guidedpuncture shouldbeusedratherthananatomicalcutaneouslandmark-based cannulationwhendifficultaccessforperipheralvenousaccessis anticipatedinchildren(level2+).
Disclosureofinterest
NicolasFritsch, Fre´de´ric Lapostolle, Se´bastienPierre, Thierry PirotteandSte´phaneVilliersdeclarethattheyhavenoconflictsof interestconcerningthisarticle.
Herve´ Bouazizdeclareshavingreceivedinthepastpayments for expert advice from the following companies: B/Braun1
, Gamida1
,GeneralElectric1
andSonosite1
.
EricDesruennesdeclareshavingreceivedinthepastpayments forexpert advicefromthefollowing companies:B/Braun1
and Perouse1
.
DenisJochumdeclareshavingreceivedinthepastpaymentsfor expertadvicefromthefollowingcompanies:B/Braun1
,Gamida1
andSonosite1
.
PaulZetlaouideclareshavingreceivedinthepastpaymentsfor expertadvicefromthefollowingcompanies:BKMedical1
,General Electric1
,Mindray1
,andSonosite1
. AppendixA. Supplementarydata
Supplementarydataassociatedwiththisarticlecanbefound,in theonlineversion,atdoi:10.1016/j.accpm.2015.01.004.
References
[1]WuS-Y,LingQ,CaoLH,WangJ,XuMX,ZengWA.Real-timetwo-dimensional ultrasoundguidanceforcentralvenouscannulation:ameta-analysis. Anes-thesiology2013;118:361–75.
[2]ReuberM,DunkleyLA,TurtonEPL,BellMDD,BamfordJM.Strokeafterinternal jugularvenouscannulation.ActaNeurolScand2002;105:235–9.
[3]NICE.Guidanceontheuseofultrasoundlocatingdevicesforplacingcentral venouscatheters;2002,https://www.nice.org.uk/guidance/TA49.
[4]McGrattanT,DufftyJ,GreenJS,O’DonnellN.Asurveyoftheuseofultrasound guidanceininternaljugularvenouscannulation.Anaesthesia2008;63:1222– 5.
[5]RuppSM,ApfelbaumJL,BlittC,etal.Practiceguidelinesforcentralvenous access:areportbytheAmericanSocietyofAnesthesiologistsTaskForceon CentralVenousAccess.Anesthesiology2012;116:539–73.
[6]LampertiM,BodenhamAR,PittirutiM,etal.Internationalevidence-based recommendationsonultrasound-guidedvascularaccess.IntensiveCareMed 2012;38:1105–17.
[7]CabanaMD,RandCS,PoweNR,WuAW,WilsonMH,AbboudPA,etal.Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA1999;282:1458–65.
[8]GuWJ,LiuJC.Ultrasound-guidedradialarterycatheterization:ameta-analysis ofrandomizedcontrolledtrials.IntensiveCareMed2014;40:292–3.
[9]LiuYT,AlsaawiA,BjornssonHM.Ultrasound-guidedperipheralvenousaccess: a systematic review of randomized-controlled trials. Eur J Emerg Med 2014;21:18–23.
[10]JadadAR,MooreRA,CarrollD,JenkinsonC,ReynoldsDJ,GavaghanDJ,etal. Assessingthequalityofreportsofrandomizedclinicaltrials:is blinding necessary?ControlClinTrials1996;17:1–12.
[11]BobbiaX,GrandpierreRG,ClaretPG,etal.Ultrasoundguidanceforradial arterial puncture: a randomized controlled trial. Am J Emerg Med 2013;31:810–5.
[12]HansenMA,Juhl-OlsenP,ThornS,FrederiksenCA,SlothE. Ultrasonography-guidedradialarterycatheterizationissuperiorcomparedwiththetraditional palpationtechnique:aprospective, randomized,blinded,crossoverstudy. ActaAnaesthesiolScand2014;58:446–52.
[13]IwashimaS, IshikawaT, OhzekiT.Ultrasound-Guided Versus Landmark-GuidedFemoral VeinAccess inPediatric CardiacCatheterization.Pediatr Cardiol2008;29:339–42.
[14]EldabaaAA,ElgebalyAS,ElhafzAAA,BassuniAS.Comparisonof ultrasound-guidedvs.anatomicallandmark-guidedcannulationofthefemoralveinatthe optimumpositionininfant.SAfrJAnaesthAnalg2012;18:162–6.
[15]CalvertN,HindD,McWilliamsRG,ThomasSM,BeverleyC,DavidsonA:.The effectivenessandcost-effectivenessofultrasoundlocatingdevicesforcentral venousaccess:asystematicreviewandeconomicevaluation.HealthTechnol Assess2003;7:1–84.
