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Effects of ultrasound-guided techniques for radial arterial catheterization: A meta-analysis of randomized controlled trials

a b s t r a c t

Objective: This study aimed to evaluate whether ultrasound-guided techniques are superior compared to tradi- tional palpation techniques in patients undergoing radial artery catheterization (RAC).

Methods: Electronic databases of PubMed, Embase, and the Cochrane Library were systematically searched to identify Randomized controlled trials . The Relative risks (RRs) or Weighted mean differences (WMDs) with corresponding 95% confidence intervals (CIs) were used to calculate the pooled effect estimates using the random effects model for categories and continuous data, respectively.

Results: A total of 19 RCTs comprising a total of 3220 individuals were selected for final analysis. The pooled RR sug- gested that Ultrasound-guided techniques were associated with higher incidence of first attempt success than tradi- tional palpation techniques (RR, 1.39; 95% CI, 1.21-1.59; P < 0.001). Moreover, we noted that ultrasound-guided techniques were associated with fewer mean attempts to success (WMD, -0.80 s; 95% CI, -1.35 to -0.25; P = 0.004) and a shorter mean time to success (WMD, -41.18 s; 95% CI, -75.43 to -6.93; P = 0.018) than traditional palpation techniques. Furthermore, individuals using ultrasound-guided techniques had a reduced risk of hema- toma (RR, 0.40; 95% CI, 0.22-0.72; P = 0.003).

Conclusions: This study indicated that ultrasound-guided techniques were superior compared to traditional palpa- tion techniques for RAC in terms of efficacy and complications.

Introduction

arterial catheterization, which is considered as an invasive proce- dure, is widely used in the intensive care unit and operating theater and provides accurate hemodynamic monitoring and blood gas sam- pling. The preferred site for arterial catheterization is the radial artery because this artery is easily palpable against the radial bone [1,2]. Tradi- tionally, the location of the radial artery is determined by palpation of the pulse based on anatomical knowledge [3,4]. However, traditional palpation techniques have several challenges including the anatomical variations of the patients’ arteries and presence of obesity, hypotension,

* Correspondence to: H. Zhang, Nursing Department, Henan Provincial People’s Hospital, Zhengzhou University People’s Hospital, Henan University People’s Hospital, No. 7 Wei Wu Road, Zhengzhou, Henan 450003, China.

?? Correspondence to: T. Li, Department of Cerebrovascular Disease, Henan Provincial People’s Hospital, Zhengzhou University People’s Hospital, Henan University People’s Hospital, Henan Provincial Neurointerventional Engineering Research Center, No. 7 Wei Wu Road, Zhengzhou, Henan 450003, China.

E-mail addresses: [email protected] (H. Zhang), [email protected] (T. Li).

edema, and atherosclerosis in patients receiving traditional palpation techniques [5]. Considering the above challenges, providers may require multiple attempts when undergoing traditional palpation, subsequently increasing the risk of hemorrhage and hematoma [6]. Therefore, an ef- fective and safe alternative technique is required to improve the clinical outcomes of radial arterial catheterization (RAC).

Ultrasound-guided techniques for RAC, which could visually distin- guish the arteries, veins, and surrounding structures, have already emerged as adjunct techniques for both adults and children [7]. Several studies have reported that ultrasound-guided techniques for RAC have significant advantages compared with traditional palpation techniques, including increased success rate and reduced potential complications [8-10]. Moreover, several systematic reviews and meta-analyses have already investigated whether ultrasound-guided techniques are supe- rior compared to traditional palpation techniques for patients undergo- ing RAC and found that ultrasound-guided techniques were associated with superior efficacy and lower complications compared to traditional palpation techniques [11-15]. However, recently, several RCTs that re- evaluate the efficacy and safety of ultrasound-guided versus traditional

palpation techniques for RAC have been completed. Therefore, the cur- rent updated meta-analysis was performed to determine the efficacy and safety of ultrasound-guided versus traditional palpation techniques for RAC.

Methods
1. Data sources, search strategy, and selection criteria

The present quantitative meta-analysis was performed and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Statement (PRISMA Checklist) [16]. Studies designed as RCTs and studies that compared the efficacy and safety of ultrasound- guided versus traditional palpation techniques for RAC were eligible for inclusion in this meta-analysis. PubMed, Embase, and the Cochrane Library were systematically searched through September 21, 2019, and no restrictions were set on published status and language. The core search terms included the following: (“ultrasound” OR “ultraso- nography” OR “ultrasonic”) AND (“catheterization” OR “cannulation” OR “catheter” OR “catheters” OR “insertion”) AND “radial artery.” Moreover, the reference lists of retrieved articles were also manually reviewed to identify any new eligible study.

Two independent authors conducted the literature search and study Selection processes, and any conflict between these two authors was settled by a discussion with each other. The inclusion criteria of this study were based on Patients, Intervention, Control, Outcomes, and Study design items, and the details are listed as follows: (1) Patients (P): individuals undergoing RAC, regardless of whether these were elec- tive or emergent procedures; (2) Intervention (I): ultrasound-guided technique; (3) Control (C): traditional palpation technique; (4) Out- comes (O): the primary endpoint was first attempt success, while the secondary endpoints were mean attempts to success, mean time to suc- cess, and risk of hematoma; and (5) Study design (S): study designed as an RCT. Observational studies were excluded due to the potential for confounding factors.

1. Data collection and quality assessment

Data extraction and quality assessment were performed by two in- dependent authors, and any disagreement was settled by an additional author who made the final decision by reviewing the original article. The extracted data items included the following: first authors’ surname, Publication year, country, population, sample size, age, percentage male, setting, operator experience, ultrasound equipment, ultrasound- guided approach, control, and reported outcomes. Quality assessment was conducted using the Jadad scale, which is based on randomization, blinding, allocation concealment, withdrawals, and dropouts, and intention-to-treat analysis to assess the quality of RCT in a meta- analysis was used [17]. The score system of individual trials ranged from 0 to 5, and a study with a score of 4 or 5 was considered as a high-quality study.

1. Statistical analyses

The investigated outcomes were assigned as categories and continu- ous data, respectively, and individual relative risks (RRs) or weighted mean differences (WMDs) with corresponding 95% confidence intervals (CIs) were calculated before data pooling. The pooled analyses for inves- tigated outcomes were calculated using the random effects model, which considers the potential variables underlying the included trials [18,19]. Heterogeneity among the included studies for each outcome was assessed using I² and Q-statistic, and I² > 50.0% or P < 0.10 was con- sidered as statistically significant heterogeneity [20,21]. The robustness of the pooled conclusion was assessed using sensitivity analysis by se- quential excluding individual trial [22]. A subgroup analysis for the inci- dence of first attempt success was performed based on the study

population, study setting, ultrasound-guided approach, and study quality. The difference between subgroups was also calculated using the interaction test [23]. Publication bias was conducted for first at- tempt success rate using the funnel plot and Egger and Begg’s tests [24,25]. All of the P values were two-sided, and P < 0.05 was considered statistically significant. All analyses in this meta-analysis were calcu- lated using the Stata software version 10.0 (Stata Corporation, College Station, TX, USA).

Results
1. Literature search

The literature search and study selection processes are shown in Fig. 1. The initial electronic searches yielded 1231 records, and 371 were excluded due to duplicate articles. Additional 813 studies were ex- cluded because of irrelevant topics, and the remaining 47 articles were retrieved for further detailed evaluations. Subsequently, 28 studies were excluded due to the following reasons: (1) the studies had no ap- propriate control (n = 13), (2) the studies were not designed as RCTs (n

= 9), and (3) the studies were categorized as reviews or meta-analyses (n = 6). A total of 37 studies were identified by reviewing the reference lists of retrieved studies and the inconsistency between two authors for study selection, while no new eligible study was detected considering that these studies were contained in electronic searches. Finally, 19 RCTs were selected for final quantitative meta-analysis [4,26-43].

1. Study characteristics

The baseline characteristics of the included studies and participants are summarized in Table 1. A total of 3220 individuals were included from 19 included RCTs for final analysis. The publication year of the in- cluded studies ranged from 2003 to 2019, and 30-698 individuals were included in each individual trial. Five RCTs included children, and the re- maining 14 trials included adults. The study quality was significant for a Jadad score of 4 in 8 studies, 3 in 7 studies, and 2 in 4 studies (Table 2).

1. Primary endpoint

All of the included trials reported the incidence of first attempt success between the ultrasound-guided and traditional palpation techniques for RAC. After pooling all trials, we noted that ultrasound- guided techniques were associated with higher incidence of first at- tempt success than traditional palpation techniques (RR, 1.39; 95% CI, 1.21-1.59; P < 0.001 [Fig. 2]). Moreover, a significant heterogeneity was detected across the included trials (I² = 87.0%, P < 0.001). Sensitiv- ity analysis indicated that the conclusion was robust and not altered by excluding any particular trial (Supplemental 1).

1. Secondary endpoints

Data regarding the effect of ultrasound-guided versus traditional palpation techniques for RAC on mean attempts to success were avail- able in five trials. The pooled WMD indicated that the ultrasound- guided technique for RAC was associated with fewer mean attempts to success (WMD, -0.80; 95% CI, -1.35 to -0.25; P = 0.004 [Fig. 3])

than the traditional palpation techniques. Furthermore, a significant heterogeneity among the included trials was observed (I² = 93.9%, P < 0.001). The pooled conclusion was not stable because of the smaller number of included trials reporting the mean attempts to success (Supplemental 1).

Data regarding the effect of ultrasound-guided versus traditional pal- pation techniques for RAC on mean time to success were available in eight trials. We noted that ultrasound-guided techniques were associated with shorter mean time to success than traditional palpation techniques (WMD, -41.18 s; 95% CI, -75.43 to -6.93; P = 0.018 [Fig. 4]). Moreover,

Fig. 1. Flow diagram of the literature search and trials selection process.

a significant heterogeneity across the included trials was observed (I² = 98.4%, P < 0.001). The result of a sensitivity analysis indicated that the conclusion was variable and could affect several trials (Supplemental 1).

Data regarding the effect of ultrasound-guided versus traditional palpation techniques for RAC on the risk of hematoma were available in eight trials. The pooled RR indicated that the ultrasound-guided tech- nique was associated with a lower risk of hematoma than the traditional palpation techniques for RAC (RR, 0.40; 95% CI, 0.22-0.72; P = 0.003 [Fig. 5]). Moreover, there was a significant heterogeneity among the in- cluded trials (I² = 69.4%, P = 0.002). A sensitivity analysis indicated that the conclusion was not changed by sequentially excluding individ- ual trials (Supplemental 1).

1. Subgroup analyses

Subgroup analyses for the incidence of first attempt success are shown in Table 3. We noted ultrasound-guided techniques for RAC were associated with higher incidence of first attempt success than traditional palpation techniques in all subgroups. Moreover, the superior effects of ultrasound-guided techniques versus traditional palpation techniques for RAC was more evident if pooled trials included children (P < 0.001), patients undergoing emergent procedure (P = 0.006), using short axis out-of-plane ultrasound-guided approach (P < 0.001), or trials with low qual- ity (P = 0.002).

1. Publication bias

Based on a review of the funnel plot, the potential publication bias for First attempt success rate was not ruled out (Fig. 6). Although the Begg’s test indicated no publication bias (P = 0.484), the result of Egger’s test suggested a potential publication bias for first attempt

success rate (P = 0.004). After adjustment using the trim-and-fill method, the conclusion was not altered [44].

Discussion

The current updated meta-analysis was performed based on RCTs and compared the efficacy and safety of ultrasound-guided with traditional palpation techniques for RAC. The findings of this study suggested that ultrasound-guided techniques were associated with higher first attempt success rate, fewer mean attempts to success, shorter mean time to suc- cess, and lower risk of hematoma than traditional palpation techniques.

Several systematic reviews and meta-analyses focusing on these topics have already been conducted. A meta-analysis performed by Gu et al. included seven RCTs and found that ultrasound-guided techniques for RAC were effective and safe, even in small children and infants [11]. Tang et al. performed a meta-analysis of seven RCTs and reported simi- lar results. They emphasized that preliminary training and familiariza- tion with the ultrasound-guided techniques for RAC is required, specifically for inexperienced operators [12]. White et al. performed a meta-analysis of 11 RCTs and found that the use of ultrasound-guided techniques for RAC could improve first attempt success rate in both the adult and Pediatric populations [14]. Moussa Pacha et al. performed a meta-analysis comprising 12 RCTs and concluded that ultrasound- guided techniques for RAC were associated with higher first attempt success rate and lower failure rate than traditional palpation techniques alone. However, the risk of hematoma and mean time to success were statistically insignificant between groups [15]. However, these studies only provide pooled results regarding the efficacy and complications of ultrasound-guided and traditional palpation techniques for RAC, but pooled results of whether the efficacy of ultrasound-guided versus tra- ditional palpation techniques differs according to the study population, study setting, ultrasound-guided approach, and study quality are not il- lustrated in these studies. Gu et al. updated their meta-analysis based on

Table 1

The summary baseline characteristics of included studies.^a

Study	Country	Population	Sample size	Age (years)	Percentage male (%)	Setting	Operator experience	Ultrasound equipment	Ultrasound-guided approach	Control
Levin 2003	Israel	Adults	69	63.2	65.2	Elective abdominal,	Anesthetists with	4-MHz transducer	Short axis	Palpation
[26]						cardiothoracic, vascular surgery	experience of ultrasound- guided	of the portable Ultrasound device	out-of-plane
						and neurosurgery	central venous	(Site Rite II, Dymax
							catheterization but	Corporation,
							no experience of	Pittsburgh, PA)
							ultrasound- guided
							arterial
							catheterization
Schwemmer	Germany	Small	30	3.4	NA	Elective major	Anesthetists with	15-MHz transducer	Short axis	Palpation
2006 [27]		children				neurosurgery in	experience of.20	of small parts	out-of-plane
		and				operating room	ultrasound-guided	imaging capability
		infants					arterial	(Sonos 5000;
							catheterization	Hewlett- Packard,
								Andover, MA, USA)
Shiver 2006	US	Adults	60	>= 18.0	NA	Emergency	Attending	SonoSite Ilook 25	Long axis in-plane	Palpation
[4]						department	physicians with experience of	(Bothell, WA) US machine with a
							ultrasound- guided	5-10 MHz
							peripheral and	transducer
							central venous
							catheterization but
							no experience of
							ultrasound- guided
							arterial
							catheterization
Ganesh 2009	US	Children	152	8.3	48.7	Elective abdominal,	Anesthetists with	5-10 MHz	Short axis	Palpation
[28]						craniofacial, orthopedic,	experience of,10 ultrasound-guided	transducer of the portable US device	out-of-plane
						thoracic surgery	arterial	(SonoSite 180 plus,
						and neurosurgery	catheterization	SonoSite, Bothell,
								WA)
Bobbia 2013	France	Adults	72	70.0	40.3	Emergency	Physicians	10-MHz transducer	NA	Palpation
[29]						department	receiving 3 h of	of GE Vivid S6
							simulator training	machine (General
							on	Electric Company,
							ultrasound-guided	Fairfield, CT)
							Arterial puncture
Ishii 2013	Japan	Small	59	1.5	NA	Elective cardiac	Anesthetists with	2-7 MHz	short axis	Palpation
[30]		children				surgery for	experience of	transducer of	out-of-plane
		and				congenital heart	ultrasound-guided	SonoSite 180
		infants				disease	central venous	Ultrasound imaging
							catheterization but	device (SonoSite,
							no experience of	Bothell, WA)
							ultrasound- guided
							arterial
							catheterization
Zaremski	Switzerland	Adults	183	>= 18.0	NA	Cardiology	Experienced	A Sonosite M-Turbo	NA	Palpation
2013 [31]						interventional	interventionalist	(SonoSite, Inc) with
						suites of a		a linear 13-6 MHz
						tertiary-care center		transducer
Hansen 2014	Denmark	Adults	40	65.8	82.0	Elective cardiac	Anesthetists with	18-MHz transducer	Short axis	Palpation
[32]						surgery	20-year experience	of a Flex-Focus 400	out-of-plane
							in transesophageal	Anesthesia
							and transthoracic	ultrasonography
							ultrasonography,	system (BKMedical,
							1-year experience	Herlev, Denmark)
							with
							ultrasonography
							dynamic needle tip
							positioning
Ueda 2015	US	Adults	505	NA	NA	Continuous arterial	Participating	915 BL Doppler	Long axis in-plane	Palpation
[33]						pressure	anesthetists with	Ultrasound,
						monitoring during	1-4 years’ training	9-MHz 1/4 -inch
						scheduled surgery	gave voluntary	diameter skinny
							verbal consent.	pencil style; Parks,
								Las Vegas, NV, USA
Seto 2015	US	Adults	698	61.9	73.9	Elective cardiac	Operators	M-Turbo with L25x	Axis in the plane	Palpation
[34]						surgery	experienced in	or HFL38x 6 to 13
							transradial	MHz transducer
							catheterization	(Sonosite Inc.,
								Bothell,
								Washington), the
								Site-Rite Vision

Table 1 (continued)

Study	Country	Population	Sample size	Age (years)	Percentage male (%)	Setting	Operator experience	Ultrasound equipment	Ultrasound-guided approach	Control
								with linear 5 to 10
								MHz transducer
								(Bard Access, Salt
								Lake City, Utah),
								and the iU22
								Xmatrix with
								L12-55 to 12 MHz
								transducer (Philips
								Healthcare,
								Andover,
								Massachusetts)
Peters 2015	Canada	Adults	125	67.0	78.4	Cardiac operating	Attending	A 10-5 MHz 25-mm	short axis	Palpation
[35]						rooms of an urban academic	Canadian cardiac anesthesiologists	linear array US transducer for the	out-of-plane
						tertiary/quaternary	with prior	SonoSite iLook
						care centre	experience	system (SonoSite,
								Inc., Bothell, WA,
								USA)
Li 2016 [36]	China	Adults	80	63.0	66.3	Intensive care unit	1 specialized nurse	Site Rite 5,	Short axis	Palpation
							and 3	frequency 5-10	out-of-plane
							nurse-in-charge	MHz (Bard
							leaders with >10	Company, UT, USA)
							years of experience
							in artery blind
							cannulation
Tangwiwat	Thailand	Adults	100	50.7	39.0	Neurosurgery	The coaching	Ultrasound	Short axis	Palpation
2016 [37]							anesthesiologist	transducer 6-13	out-of-plane
							had performed USG	MHz (Micromaxx,
							procedures >200	SonoSite Inc.; US)
							times with >3
							years’ experience
Anantasit	Thailand	Small	84	2.2	66.7	Pediatric intensive	Operators had	Ultrasound-guided	short axis	Palpation
2017 [38]		children				care unit in a	experience of >10	technique using a	out-of-plane
		and				tertiary care	cases in either the	vascular transducer
		infants				academic center	ultrasound-guided	(8-12 MHz) and a
							or traditional	2-dimensional
							palpation	MTurbo ultrasound
							technique	system (SonoSite,
								Inc., Bothell, WA)
Burad 2017	Oman	Adults	100	14.0-90.0	NA	Intensive care unit	All cannulations	NA	NA	Palpation
[39]						of Sultan Qaboos	were performed by
						University Hospital	physicians well
							experienced with
							both techniques
Cao 2018	China	Adults	120	52.1	49.2	Intensive care unit	NA	Ultrasound	NA	Palpation
[40]								transducer 7.5-10.0
								MHz (Micromaxx,
								SonoSite Inc.; US)
Kiberenge	US	Adults	260	59.5	53.7	Elective surgical	The operators	NA	Short axis	Palpation
2018 [41]						procedure	(anesthesia		out-of-plane
							residents, fellows,
							and faculty)
							placing the arterial
							catheters were
							required to have
							placed at least 10
							radial arterial
							catheters
Yeap 2019	US	Adults	412	NA	50.5	Elective surgery	Trained	portable ultrasound	NA	Palpation
[42]							postgraduate year	device (Venue, GE
							3 (PGY-3) or PGY-4	Healthcare,
							anesthesiology	Chicago, IL)
							residents with
							similar levels of
							experience
Min 2019	Korea	Infants	74	0.2	57.0	Elective cardiac	One of two	A 15 to 7-MHz	Short axis	Palpation
[43]						surgery	anaesthesiologists	linear transducer	out-of-plane
							with >2 years of	(Philips iE33
							experience in	L15-7io transducer;
							pediatric cardiac	Philips Healthcare,
							anesthesia	Seattle,
								Washington, USA)

^a NA: not available.

Table 2

Risk of bias in studies

Study	Randomization	Blinding	Allocation concealment	Withdrawals and dropouts	Use of intention-to-treat analysis	Total
Levin 2003 [26]	Yes	No	No	Yes	No	2
Schwemmer 2006 [27]	Yes	No	No	Yes	Yes	3
Shiver 2006 [4]	Yes	Yes	Unclear	Yes	Yes	4
Ganesh 2009 [28]	Yes	No	No	Yes	Yes	3
Bobbia 2013 [29]	Yes	No	No	Yes	No	2
Ishii 2013 [30]	Yes	No	No	Yes	Yes	3
Zaremski 2013 [31]	Yes	No	No	Yes	No	2
Hansen 2014 [32]	Yes	Yes	Unclear	Yes	Yes	4
Ueda 2015 [33]	Yes	Yes	Unclear	Yes	Yes	4
Seto 2015 [34]	Yes	No	No	Yes	Yes	3
Peters 2015 [35]	Yes	Yes	Unclear	Yes	Yes	4
Li 2016 [36]	Yes	No	No	Yes	Yes	3
Tangwiwat 2016 [37]	Yes	Yes	Unclear	Yes	Yes	4
Anantasit 2017 [38]	Yes	No	No	Yes	Yes	3
Burad 2017 [39]	Yes	No	No	Yes	Yes	3
Cao 2018 [40]	Yes	No	No	Yes	No	2
Kiberenge 2018 [41]	Yes	Yes	Unclear	Yes	Yes	4
Yeap 2019 [42]	Yes	Yes	Unclear	Yes	Yes	4
Min 2019 [43]	Yes	Yes	Unclear	Yes	Yes	4

Fig. 2. Ultrasound-guided versus traditional palpation for RAC on first attempt success rate.

Fig. 3. Ultrasound-guided versus traditional palpation for RAC on mean attempts to success.

Fig. 4. Ultrasound-guided versus traditional palpation for RAC on mean time to success.

Fig. 5. Ultrasound-guided versus traditional palpation for RAC on the risk of hematoma.

12 RCTs and found that dynamic two-dimensional ultrasound-guided techniques have lower first attempt failure rate, fewer mean attempts to success, shorter mean time to success rate, and lower risk of hema- toma than traditional palpation techniques for RAC. This suggests that the former techniques are superior compared to the latter techniques for RAC [13]. This meta-analysis included additional trials published be- tween 2017 and 2019, and given a comprehensive updated result re- garding the efficacy and safety of ultrasound-guided versus traditional palpation techniques for RAC.

The results of this study indicated that ultrasound-guided techniques for RAC provide better efficacy and safer clinical outcomes compared with traditional palpation techniques. Although most of the included

trials reported similar conclusions, according to a study conducted by Bobbia et al. [29], ultrasound-guided techniques for RAC were associated with increased puncture number and Procedure duration in emergency departments. These results are possibly attributed to the insufficient ex- perience of the operator, who only underwent a 3-hour training simula- tion, performing the procedure and the simple puncture site localization in selected patients. Therefore, they emphasized that ultrasound-guided techniques for RAC should be performed if difficulty in accessing the puncture site is observed since these techniques can clearly assess the anatomy of the arterial vessels and their surrounding tissues. Moreover, the thickness, depth, and course of the radial artery could be clearly assessed by imaging the vessels. Additionally, with the radial artery’s

Table 3

Subgroup analyses for first-attempt success.^a

Factors	Subgroup	RR and 95%CI	P value	Heterogeneity (%)	P value for heterogeneity	P value between subgroups
Population	Adults	1.30 (1.13-1.48)	<0.001	87.1	<0.001	<0.001
	Children	1.95 (1.56-2.43)	<0.001	1.1	0.400
Setting	Elective	1.38 (1.17-1.63)	<0.001	89.0	<0.001	0.006
	Emergency	1.41 (1.08-1.84)	0.013	77.5	<0.001
Ultrasound-guided approach	Short	1.61 (1.31-1.98)	<0.001	73.5	<0.001	<0.001
	Long	1.42 (1.09-1.84)	0.009	48.4	0.164
Study quality	High	1.36 (1.11-1.66)	0.003	89.5	<0.001	0.002
	Low	1.42 (1.15-1.77)	0.001	83.9	<0.001

^a RR: relative risk; CI: confidence interval.

fewer mean attempts to success and mean time to success, and lower risk of hematoma than traditional palpation techniques. Future large- scale, high-quality RCT focusing on specific populations to analyze the effects of ultrasound-guided versus traditional palpation techniques for RAC should be conducted.

CRediT authorship contribution statement

Wenli Zhao: Data curation, Writing - original draft, Visualization, Investigation. Huizhen Peng: Visualization, Investigation. Haiyun Li: Visualization, Investigation. Yinping Yi: Supervision. Yufeng Ma: Super- vision. Yingkun He: Formal analysis. Hongmei Zhang: Conceptualiza- tion, Methodology, Software, Writing - review & editing. Tianxiao Li: Conceptualization, Methodology, Software, Writing - review & editing.

Acknowledgement

Fig. 6. Funnel plot for first attempt success rate.

image placed in the middle of the probe and kept fixed with the punc- ture needle using the middle point of the probe as the reference, the suc- cess rate of RAC is significantly improved and potential complications are reduced [45]. Finally, the success rate of RAC is significantly associ- ated with the operator’s proficiency in performing the ultrasound- guided technique, the number of operations the operator has per- formed, and the operator’s hand-eye coordination [46].

The results of the subgroup analyses indicated that the first at- tempt success rate between ultrasound-guided and traditional pal- pation techniques for RAC is possibly associated with the study population, study setting, ultrasound-guided approach, and study quality. We noted that the benefits of ultrasound-guided techniques for RAC were superior in children compared to adults, which is possibly because the radial artery in children is more difficult to lo- cate than that in adults. The difference between subgroups when based on the other factors was unstable, and further RCT should be conducted to evaluate the efficacy and safety of ultrasound-guided techniques for RAC according to patients’ characteristics.

This study has the following strengths: (1) the current study was based on RCTs, subsequently avoiding uncontrolled biases regarding ob- servational studies; (2) the current analysis was based on a large sample size, and the results of this study were more robust compared to any in- dividual trial; and (3) stratified analyses according to patients’ charac- teristics were performed in this study.

1. Limitations

Although this study has several strengths, it also has some limita- tions. First, operators’ experiences and ultrasound equipment used vary across the included trials, which might play an important role in deter- mining the efficacy and complications of ultrasound-guided techniques for RAC. Second, the current study was based on published articles, and unpublished data were not available, suggesting the possibility of uncon- trolled publication bias. Third, a significant heterogeneity regarding the investigated outcomes was not fully explained, and detailed characteris- tics that could affect the effectiveness of ultrasound-guided techniques for RAC were not available. Fourth, the overall quality of most trials (11/19) was low to moderate. Finally, the analysis of this study was based on study level, and individual data were not available, preventing us from performing a more detailed analysis.

Conclusion

The results of this study suggest that ultrasound-guided techniques for RAC were associated with higher incidence of first attempt success,

None.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi. org/10.1016/j.ajem.2020.04.064.

References

BMJ. 2003;327:557-60.

AJEM

Effects of ultrasound-guided techniques for radial arterial catheterization: A meta-analysis of randomized controlled trials

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