Ultrasound Guided Vascular Access in Pediatric Intensive Care Patients
Condition: Critical Illness
MeSH terms: Critical Illness
Study type: Observational

Summary: 
      The purpose of this study is to see how fast and accurate two different techniques used by
      physicians to insert catheters in children are. Catheters are tiny tubes which carry fluids,
      blood and sometimes liquid food into a person's vein. The technique currently used relies on
      the physical landmarks and using fingers to feel the anatomy in which to place the catheter
      in the vein or artery. The investigators are changing to a technique where they will use
      ultrasound at the patient's bedside to help physicians with placing the catheter into the
      blood vessel. They are comparing the use of these two methods to determine which is faster
      and requires fewer needle sticks.
    

Detailed description: 
      In critically ill patients, central venous access is essential for volume resuscitation,
      administration of medicines (such as vasoactive drugs, antibiotics or chemotherapy),
      administration of blood products, and hemodynamic monitoring. Placement of central venous
      catheters (CVC) occurs commonly with over 200,000 CVCs placed in adults and children yearly.
      At Egleston 222 central venous lines were placed last year and 178 CVCs YTD through October.
      Obtaining central venous access in critically ill children can be a difficult procedure with
      many potential complications. These complications can include, but are not limited to,
      hematoma at the site, hemothorax, pneumothorax, need to change sites, and injury to
      surrounding structures. The complication rates for CVCs in children is reported anywhere from
      2.5% to 22%. All too frequently CVC placement in children is unsuccessful anywhere from 5% of
      the time to greater than 19%.

      Studies in adults have shown ultrasound guided central venous access to decrease the number
      of attempts required to cannulate the vein. Ultrasound (US) guidance is also able to decrease
      the time required to cannulate the vessel. A meta analysis of ultrasound guided central
      venous access in adults concluded that for internal jugular procedures ultrasound guidance
      was significantly more successful than the landmark technique alone. With the recent focus on
      patient safety and clinical outcomes the American College of Emergency Physicians published a
      policy statement included in the guidelines use of US guidance for central venous access in a
      list of primary applications for ultrasound in the emergency department.

      Evidence for US guidance in children is currently found mainly in the anesthesia literature.
      The 2003 NICE sponsored meta-analysis showed an overall relative risk reduction of 85% for
      failed placement and 73% for complications of internal jugular placement in pediatric
      patients in an operating room. Because of small sample sizes (each < 100 patients) and only
      the internal jugular approach being studied, definitive conclusions regarding other sites are
      ongoing. Currently there are no prospective studies evaluating the use of ultrasound guided
      central venous access in children in a pediatric intensive care unit. Also, studies
      addressing the use of US guided CVC placement in femoral access, the major site used in
      children, is also lacking.

      Our proposal is to prove that US guided CVC will decrease the overall time required to
      cannulate the vessel by increasing the probability of successful cannulation by the first
      operator, decreasing the number of skin punctures to obtain access, eliminating the need to
      change sites for access, and improving the probability of access. Additionally we believe
      that US guided CVC placement would decrease the likelihood of untoward effects including but
      not limited to severe hematoma requiring attempts at additional sites, inadvertent puncture
      of the wrong vessel, or hemothorax/pneumothorax.
    

Observational model: Cohort
Time perspective: Prospective
Sampling method: Non-Probability Sample
Study population: 
        All patients admitted to the Pediatric Intensive care Unit (PICU) at Children's Healthcare
        of Atlanta at Egleston
      
Keywords: Vascular Access; Ultrasound; Pediatric; Pediatric intensive care patient