Uncategorized

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.

(C) 2020 Published by Elsevier Inc.

  1. 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

https://doi.org/10.1016/j.ajem.2020.04.064 0735-6757/(C) 2020 Published by Elsevier Inc.

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.

  1. 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).

  1. 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].

  1. 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.

  1. 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

  1. Hack WW, Vos A, Okken A. Incidence of forearm and hand ischaemia related to ra- dial artery cannulation in newborn infants. Intensive Care Med. 1990;16:50-3.
  2. Scheer B, Perel A, Pfeiffer UJ. Clinical review: complications and risk factors of pe- ripheral arterial catheters used for haemodynamic monitoring in anaesthesia and in- tensive care medicine. Crit Care. 2002;6:199-204.
  3. Ailon J, Mourad O, Chien V, et al. Ultrasound-guided insertion of a radial arterial catheter. N Engl J Med. 2014;371:e21.
  4. Shiver S, Blaivas M, Lyon M. A prospective comparison of ultrasound-guided and blindly placed radial arterial catheters. Acad Emerg Med. 2006;13:1275-9.
  5. Gao YB, Yan JH, Gao FQ, et al. Effects of ultrasound-guided radial artery catheteriza- tion: an updated meta-analysis. Am J Emerg Med. 2015;33:50-5.
  6. Rhee KH, Berg RA. Antegrade cannulation of radial artery in infants and children. Chest. 1995;107:182-4.
  7. Weiner MM, Geldard P, Mittnacht AJC. Ultrasound-guided vascular access: a com- prehensive review. J Cardiothor Vasc An. 2013;27:345-60.
  8. Hind D, Calvert N, McWilliams R, et al. Ultrasonic locating devices for central venous cannulation: meta-analysis. BMJ. 2003;327:361.
  9. Calvert N, Hind D, McWilliams R, et al. Ultrasound for central venous cannulation: economic evaluation of cost-effectiveness. Anaesthesia. 2004;59:1116-20.
  10. Froehlich CD, Rigby MR, Rosenberg ES, et al. Ultrasound-guided central venous cath- eter placement decreases complications and decreases placement attempts com- pared with the landmark technique in patients in a pediatric intensive care unit. Crit Care Med. 2009;37:1090-6.
  11. Gu WJ, Tie HT, Liu JC, et al. Efficacy of ultrasound-guided radial artery catheteriza- tion: a systematic review and meta-analysis of randomized controlled trials. Crit Care. 2014;18:R93.
  12. Tang L, Wang F, Li Y, et al. Ultrasound guidance for radial artery catheterization: an updated meta-analysis of randomized controlled trials. PLoS One. 2014;9:e111527.
  13. Gu WJ, Wu XD, Wang F, et al. Ultrasound guidance facilitates radial artery catheter- ization: a meta-analysis with trial sequential analysis of randomized controlled tri- als. Chest. 2016;149:166-79.
  14. White L, Halpin A, Turner M, et al. Ultrasound-guided Radial artery cannulation in adult and Paediatric populations: a systematic review and meta-analysis. Br J Anaesth. 2016;116:610-7.
  15. Moussa Pacha H, Alahdab F, Al-Khadra Y, et al. Ultrasound-guided versus palpation- guided radial artery catheterization in adult population: a systematic review and meta-analysis of randomized controlled trials. Am Heart J. 2018;204:1-8.
  16. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6:e1000097.
  17. Jadad AR, Moore RA, Carroll D. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials. 1996;17:1-12.
  18. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7: 177-88.
  19. Ades AE, Lu G, Higgins JP. The interpretation of random-effects metaanalysis in de- cision models. Med Decis Making. 2005;25:646-54.
  20. Deeks JJ, Higgins JPT, Altman DG. Analyzing data and undertaking meta-analyses. In: Higgins J, Green S, editors. Cochrane handbook for systematic reviews of interven- tions 5.0.1. Oxford, UK: The Cochrane Collaboration; 2008 [chap 9].
  21. Higgins JPT, Thompson SG, Deeks JJ, et al. Measuring inconsistency in meta-analyses.

BMJ. 2003;327:557-60.

  1. Tobias A. Assessing the influence of a single study in meta-analysis. Stata Tech Bull. 1999;47:15-7.
  2. Altman DG, Bland JM. Interaction revisited: the difference between two estimates. BMJ. 2003;326:219.
  3. Egger M, Davey Smith G, Schneider M, et al. Bias in meta-analysis detected by a sim- ple, graphical test. BMJ. 1997;315:629-34.
  4. Begg CB, Mazumdar M. Operating characteristics of a rank correlation test for publi- cation bias. Biometrics. 1994;50:1088-101.
  5. Levin PD, Sheinin O, Gozal Y. Use of ultrasound guidance in the insertion of radial ar- tery catheters. Crit Care Med. 2003;31:481-4.
  6. Schwemmer U, Arzet HA, Trautner H, et al. Ultrasound-guided arterial cannulation in infants improves success rate. Eur J Anaesthesiol. 2006;23:476-80.
  7. Ganesh A, Kaye R, Cahill AM, et al. Evaluation of ultrasound-guided radial artery can- nulation in children. Pediatr Crit Care Med. 2009;10:45-8.
  8. Bobbia X, Grandpierre RG, Claret PG, et al. Ultrasound guidance for radial arterial puncture: a randomized controlled trial. Am J Emerg Med. 2013;31:810-5.
  9. Ishii S, Shime N, Shibasaki M, et al. Ultrasound-guided radial artery catheterization in infants and small children. Pediatr Crit Care Med. 2013;14:471-3.
  10. Zaremski L, Quesada R, Kovacs M, et al. Prospective comparison of palpation versus ultrasound-guided radial access for cardiac catheterization. J Invasive Cardiol. 2013; 25:538-42.
  11. Hansen MA, Juhl-Olsen P, Thorn S, et al. Ultrasonography-guided radial artery cath- eterization is superior compared with the traditional palpation technique: a pro- spective, randomized, blinded, crossover study. Acta Anaesthesiol Scand. 2014;58: 446-52.
  12. Ueda K, Bayman EO, Johnson C, et al. A randomised controlled trial of radial artery cannulation guided by Doppler vs palpation vs ultrasound. Anaesthesia. 2015;70: 1039-44.
  13. Seto AH, Roberts JS, Abu-Fadel MS, et al. Real-time ultrasound guidance facilitates transradial access RAUST (radial artery access with ultrasound trial). JACC Cardiovasc Interv. 2015;8:283-91.
  14. Peters C, Schwarz SK, Yarnold CH, et al. Ultrasound guidanceversusdirect palpation for radial artery catheterization by expert operators: a randomized trial among Ca- nadian cardiac anesthesiologists. Can J Anesth/J Can Anesth. 2015;62:1161-8.
  15. Li X, Fang G, Yang D, et al. Ultrasonic technology improves radial artery puncture and cannulation in intensive care unit (ICU) shock patients. Med Sci Monit. 2016;22: 2409-16.
  16. Tangwiwat S, Pankla W, Rushatamukayanunt P, et al. Comparing the success rate of radial artery cannulation under ultrasound guidance and palpation technique in adults. J Med Assoc Thai. 2016;99:505-10.
  17. Anantasit N, Cheeptinnakorntaworn P, Khositseth A, et al. Ultrasound versus tradi- tional palpation to guide radial artery cannulation in critically ill children: a random- ized trial. J Ultrasound Med. 2017;36:2495-501.
  18. Burad J, Date R, Kodange S, et al. Comparison of conventional and ultrasound guided techniques of radial artery cannulation in different haemodynamic subsets: a randomised controlled study. Intensive Care Med. 2017;43:140-1.
  19. Cao L, Zhang L, Ai M, et al. Application of radial arterial puncture cannulation under ultrasonic guidance in patients with critical diseases. Zhong Nan Da Xue Xue Bao Yi Xue Ban. 2018;43:447-51.
  20. Kiberenge RK, Ueda K, Rosauer B. Ultrasound-guided dynamic needle tip positioning technique versus palpation technique for radial arterial cannulation in adult surgical patients: a randomized controlled trial. Anesth Analg. 2018;126:120-6.
  21. Yeap YL, Wolfe JW, Stewart J, et al. Prospective comparison of ultrasound- guided versus palpation techniques for Arterial line placement by residents in a teaching in- stitution. J Grad Med Educ. 2019;11:177-81.
  22. Min JJ, Tay CK, Gil NS, et al. Ultrasound-guided vs. palpation-guided techniques for radial arterial catheterisation in infants: a randomised controlled trial. Eur J Anaesthesiol. 2019;36:200-5.
  23. Duvall S, Tweedie R. A nonparametric “trim and fill” method for assessing publica- tion bias in meta-analysis. J Am Stat Assoc. 2000;95:89-98.
  24. Resnick JR, Cydulka RK, Donato J, et al. Success of ultrasound guided peripheral intra- venous access with skin marking. Acad Emerg Med. 2008;15:723-30.
  25. Christopher A, Gregg S, Kathryn E, et al. Guidelines for performing ultrasound guided vascular cannulation: recommendations of the American society of echocardiogra- phy and the society of cardiovascular anesthesiologists. JASE. 2011;24:1291-318.