Ultrasound Guidance for Pediatric Central Venous ... · that ultrasound guidance is an effective...
Transcript of Ultrasound Guidance for Pediatric Central Venous ... · that ultrasound guidance is an effective...
aDivision of Pediatric Critical Care, Department of Pediatrics, University of Campinas, Campinas, São Paulo, Brazil; and bDepartment of Pediatrics, School of Medicine, São Leopoldo Mandic, Campinas, São Paulo, Brazil
Dr de Souza conceptualized and designed the study, drafted the initial manuscript, and reviewed and revised the manuscript; Drs de Souza and Nadal designed the data collection instruments, collected data, conducted the initial analyses, and reviewed and revised the manuscript; Drs Brandão and Nogueira coordinated and
To cite: de Souza TH, Brandão MB, Nadal JAH, et al. Ultrasound Guidance for Pediatric Central Venous Catheterization: A Meta-analysis. Pediatrics. 2018;142(5):e20181719
CONTEXT: Central venous catheterization is routinely required in patients who are critically ill, and it carries an associated morbidity. In pediatric patients, the procedures can be difficult and challenging, predominantly because of their anatomic characteristics.OBJECTIVE: To determine whether ultrasound-guided techniques are associated with a reduced incidence of failures and complications when compared with the anatomic landmark technique.DATA SOURCES: We conducted a systematic search of PubMed and Embase.STUDY SELECTION: We included randomized controlled trials and nonrandomized studies in which researchers compare ultrasound guidance with the anatomic landmark technique in children who underwent central venous catheterization.DATA EXTRACTION: Study characteristics, sample sizes, participant characteristics, settings, descriptions of the ultrasound technique, puncture sites, and outcomes were analyzed. Pooled analyses were performed by using random-effects models.RESULTS: A total of 23 studies (3995 procedures) were included. Meta-analysis revealed that ultrasound guidance significantly reduced the risk of cannulation failure (odds ratio = 0.27; 95% confidence interval: 0.17–0.43), with significant heterogeneity seen among the studies. Ultrasound guidance also significantly reduced the incidence of arterial punctures (odds ratio = 0.34; 95% confidence interval: 0.21–0.55), without significant heterogeneity seen among the studies. Similar results were observed for femoral and internal jugular veins.LIMITATIONS: Potential publication bias for cannulation failure and arterial puncture was detected among the studies. However, no publication bias was observed when analyzing only the subgroup of randomized clinical trials.CONCLUSIONS: Ultrasound-guided techniques are associated with a reduced incidence of failures and inadvertent arterial punctures in pediatric central venous catheterization when compared with the anatomic landmark technique.
Ultrasound Guidance for Pediatric Central Venous Catheterization: A Meta-analysisTiago Henrique de Souza, MD, a Marcelo Barciela Brandão, MD, PhD, a José Antonio Hersan Nadal, MD, a Roberto José Negrão Nogueira, MD, PhDa, b
abstract
PEDIATRICS Volume 142, number 5, November 2018:e20181719 REVIEW ARTICLE
A central venous catheter (CVC) is a device that is frequently used in pediatric patients for hemodynamic monitoring, fluid infusion, the administration of medications and blood products, blood sampling, hemodialysis, and parenteral nutrition. In pediatric patients, the deep venous puncture can be technically challenging and carries a risk of several complications, such as arterial punctures, hematomas, thrombosis, pneumothorax, hemothorax, and nervous system injury.1 The traditional puncture technique based on palpation and the identification of anatomic landmarks is still widely used for CVC placement.2 However, the success of this method relies on the normal positioning of the vessels and the absence of thrombosis. Unfortunately, deep veins show significant anatomic variation: up to 18% for the internal jugular vein in children3 and 24% for femoral veins in infants.4
The ultrasound guidance technique emerged in the early 1990s as an alternative to overcome the limitations of the landmark technique.3 The image offered by using 2-dimensional ultrasonography allows the operator to predict variant anatomy and to assess the patency of a target vein. Moreover, when used in real time, it allows for a direct visualization of the relative position of the needle, vein, and surrounding structures. Current evidence reveals that ultrasound guidance is an effective and safe technique for central venous catheterization in adults and children.5, 6 However, this evidence should be interpreted cautiously owing to the participant characteristics (patients and operators), risk of bias, and heterogeneity among the studies. Although ultrasound guidance was associated with a reduced incidence of cannulation failures, a previous meta-analysis did not reveal a reduction in complication
rates.6 Furthermore, statistical tests were not performed to evaluate publication bias. The analysis of publication bias is critical in meta-analyses because it may compromise the validity of the presented results.7
We systematically searched the literature to investigate the effects of ultrasound guidance on clinical outcomes in pediatric patients undergoing central venous catheterization. Our main objective in this meta-analysis was to determine whether ultrasound-guided techniques are associated with a reduced occurrence of failures and complications when compared with the landmark technique. Additionally, we have carefully analyzed the characteristics of the studies to understand whether the results of this meta-analysis are universally true.
METHODS
This review was performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) statement8, 9 and the Cochrane Handbook.10 In March 2018, the study protocol was registered in the PROSPERO International Prospective Register of Systematic Reviews database (registration number CRD42018091333).
Search Strategy
Searched literature databases included PubMed and Embase. Keywords used included combinations of “ultrasound, ” “ultrasonography, ” “central venous catheterization, ” “internal jugular vein, ” “femoral vein, ” “subclavian vein, ” “brachiocephalic vein, ” “neonate, ” “neonates, ” “infant, ” “infants, ” “child, ” “children, ” “pediatric, ” and “pediatrics.” The complete search strategy is presented in the Supplemental Information. No language or publication date restrictions were applied. No
attempts were made to contact the study authors to identify missing and confusing data. A manual search of the references found in the selected articles, reviews, and meta-analyses was also performed. The search was conducted in April 2018.
Study Selection
Two authors (T.H.d.S. and J.A.H.N.) screened the titles and abstracts independently and in duplicate for potential eligibility. They subsequently read the full texts to determine final eligibility. Discrepancies were resolved through discussion and consensus, and if necessary, the assistance of a third author (M.B.B.) was sought.
Eligible studies fulfilled the following criteria: (1) included a population that was limited to patients <18 years old; (2) included original data from interventional (randomized controlled trials [RCTs] or non-RCTs), cohort, or case-control studies; (3) included a comparison of the use of ultrasound guidance with anatomic landmark guidance for deep venous punctures; and (4) contained at least 1 outcome of interest. Studies were excluded if they met at least 1 of the following characteristics: (1) included patients ≥18 years old; (2) were case reports, case series, review articles, or observational studies without a control or comparator; or (3) included an evaluation of Doppler guidance or open cut-down techniques.
Outcomes Measures
The primary outcome for the current analysis was cannulation failure. Secondary outcomes included mean attempts to success, mean time to success, and incidence of complications, such as arterial puncture, hematoma, pneumothorax, hemothorax, or procedure-related infections. The definition of each outcome mentioned above was the same as that used in each study.
DE SOUZA et al2
Data Extraction
A structured data-extraction form was piloted and then used to extract data from the reports of all included studies in duplicate and independently by 2 authors (T.H.d.S. and J.A.H.N.). Discrepancies in the extracted data were resolved through discussion. The following data were extracted, when available, from each selected article: first author, publication year, study design, sample size, participants’ characteristics, settings, description of ultrasound technique, operators’ profiles (medical specialty and experience), puncture sites, success rates, procedure times, number of attempts, and rates of complications (hematomas, arterial punctures, pneumothorax, hemothorax, procedure-related infections, or other). No simplifications or assumptions were made.
Quality Assessment of Studies
The risk of bias assessment was independently assessed by 2 authors (T.H.d.S. and M.B.B.) using the Cochrane Risk of Bias Tool.11 This tool contains 7 items: (1) randomization sequence generation; (2) allocation concealment; (3) blinding of participants and personnel; (4) blinding of outcome assessors; (5) incomplete outcome data; (6) selective reporting; and (7) other sources of bias. One of the following 3 responses was assigned to each item: low risk of bias, high risk of bias, or unclear risk of bias according to the Cochrane Handbook.10 The evaluation was plotted in Review Manager version 5.3 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen, Denmark).
Discrepancies were addressed by rereading the study, in discussions between the 2 authors, and (if necessary) with the assistance of a third author (R.J.N.N.).
Data Synthesis and Analysis
Meta-analyses of the pooled data were performed by using Review Manager. When using the inverse variance method, fixed-effects and random-effects models generated similar findings. However, because of the heterogeneity detected among the studies, a random-effects model was used to estimate the odds ratio (OR) of dichotomous outcomes and associated 95% confidence intervals (CIs). To assess the heterogeneity among the studies, both Cochran’s Q statistic and the I2 statistic were used. Heterogeneity was considered to be statistically significant when P < .05 or I2 > 50.10 Potential publication bias was assessed by visually inspecting the Begg and Mazumdar12 funnel plots in which the log relative risks were plotted against their SEs. Publication bias was also assessed by using Begg and Mazumdar’s12 adjusted rank correlation test and Egger et al’s13 regression asymmetry test. Sensitivity analyses were conducted to determine the influence of a single study on the overall OR estimates by omitting 1 study in each turn.
We conducted a series of subgroup analyses stratified by ultrasound technique (real-time or prelocation), the type of study (randomized or nonrandomized), and the puncture site to explore the impacts of these variables on the outcomes.
RESULTS
Study Selection and Characteristics
Of 2631 potentially relevant articles identified by using the search strategy, 23 met the inclusion criteria.3, 14 – 34 A total of 3995 CVC placements were included in the meta-analysis (1852 ultrasound-guided procedures and 2143 landmark-guided procedures). In the flow diagram (Supplemental Fig 5), we summarize the steps followed
to identify the studies meeting the inclusion criteria.
Nineteen studies (9 RCTs14, 25, 28 – 34 and 10 nonrandomized studies17 – 24, 26, 27) investigated the real-time ultrasound (RTUS) guidance technique, 3 RCTs investigated the ultrasound-assisted prelocation technique, 3, 15, 16 and 1 nonrandomized study evaluated both techniques.35 With the exception of 2 multicenter studies, 19, 35 all others were unicentric studies. Of the 23 included studies, 9 were conducted in the United States, * 3 were in Japan, 15, 23, 26 2 were in Brazil, 14, 25 1 was in China, 16 1 was in Colombia, 17 1 was in Egypt, 29 1 was in Lebanon, 30 1 was in Russia, 31 1 was in Spain, 35 1 was in Turkey, 20 1 was in Tunisia, 18 and 1 was in the United Kingdom.32
Fifteen studies examined procedures performed exclusively in the operating room.† Three studies analyzed procedures performed exclusively in the PICU.14, 24, 35 Three studies evaluated procedures performed in multiples settings.17, 22, 25 One study was conducted in the emergency department, 21 and researchers in 1 study did not describe the study settings.31 Anesthesiologists were operators in 9 studies, 15, 17, 22, 23, 27, 30, 32 – 34 surgeons were operators in 5, 17, 19, 22, 25, 28 intensivists were operators in 4, 14, 22, 24, 35 and pediatricians were operators in 3.17, 21, 29 Attending physicians were involved in 11 studies, 15, 17, 19, 21 – 25, 28, 32, 35 fellows were involved in 6 studies, 22, 24, 28, 29, 33, 34 and residents were involved in 6 studies.14, 21, 24, 27, 30, 35 Researchers in 5 studies did not specify the medical specialty of the operators, 3, 16, 18, 26, 31 and researchers in 4 studies did not specify their graduation (resident, fellow, or attending physician).3, 16, 26, 31
Regarding the puncture sites, researchers in most RCTs evaluated internal jugular vein catheterizations3, 14 – 16, 25, 31 – 34;
* Refs 3, 19, 21, 22, 24, 27, 28, 33, and 34.† Refs 3, 15, 16, 18– 20, 23, 26– 30, and 32–34.
PEDIATRICS Volume 142, number 5, November 2018 3
researchers in 2 evaluated femoral vein punctures, 29, 30 and researchers in 1 compared the RTUS guidance technique for internal jugular vein catheterization with the landmark technique for subclavian vein catheterization.28 Of the nonrandomized studies, 2 evaluated only internal jugular vein procedures23, 27; 2 evaluated only femoral vein procedures, 22, 26 and 6 evaluated >1 puncture site.17 – 19, 21, 24, 35 The sample size calculation was described only in 4 RCTs.14, 15, 28, 30
The main characteristics of the 23 studies are presented in Table 1.
Risk of Bias
The details for risk of bias are shown in Supplemental Figs 6 and 7.
Most RCTs had adequate random sequence generation; researchers in only 3 studies did not specify the used method of randomization.3, 15, 29 In addition to the methods described in the Cochrane Handbook, 10 we considered that allocation concealment was appropriate when randomization occurred immediately before the procedure. Thus, 6 RCTs had adequate allocation concealment, 14, 25, 28 – 30, 32 whereas researchers in the other 6 studies did not describe this process.3, 16, 31, 33, 34 Because blinding participants and personnel was impossible, all studies of this meta-analysis were considered to be at high risk for performance bias. The blinding of outcome assessment was also impossible, but we believe that the outcome measurement is not likely to be influenced by the lack of blinding. Therefore, all studies were considered to have a low risk of detection bias. Six RCTs were considered to have an unclear risk of attrition bias because the researchers did not state the number of patients who were randomly assigned or provide sufficient information on follow-up.3, 15, 16, 29, 31, 34 Because of a significant loss of participants in
the intervention group, 1 RCT was classified as having a high risk of attrition bias.32
Once the outcomes depend on the operators’ skills, we considered that studies in which researchers did not describe the number of operators nor the operators’ experience in the evaluated techniques were at an unclear risk of other bias.15, 16, 20, 22, 23, 26 – 34 Studies were considered to be at a high risk for other biases if they were performed with only 1 operator3, 25; researchers jointly analyzed the procedures performed by operators with heterogeneous experience17, 19; or researchers jointly analyzed procedures performed at different sites of puncture.17, 18, 21, 24, 28, 35
Primary Outcome: Cannulation Failure
Of the 23 selected studies, researchers in 22 reported the primary outcome, and these were used to calculate the pooled estimate for assessing cannulation failure.3, 14 – 16, 18 – 35 Pooled overall ORs for the primary outcome are shown in Fig 1. Overall, the rates of cannulation failure in the ultrasound group and control group were 9.1% and 19.2%, respectively. The analysis revealed that ultrasounds significantly reduced the risk of cannulation failure (OR = 0.27; 95% CI: 0.17–0.43; P < .00001), with significant heterogeneity seen among the studies (I2 = 66%; P < .00001).
A subgroup analysis of the 9 RCTs that compared RTUS versus landmark techniques14, 25, 28 – 34 revealed a significant reduction of failure (5.3% vs 25%; OR = 0.16 [95% CI: 0.04–0.56]; P = .004), with significant heterogeneity seen among the studies (I2 = 76%; P < .0001). In the analysis of the ultrasound-assisted vein prelocation technique, significantly lower rates of cannulation failure were observed (1% vs 27%; OR = 0.06 [95% CI: 0.01–0.28];
P = .0003), without heterogeneity seen among the 3 studies3, 15, 16 (I2 = 0%; P = .97). Finally, the analysis of nonrandomized studies also revealed a significant reduction of cannulation failure in RTUS guidance over the landmark technique (10.1% vs 16.9%; OR = 0.44 [95% CI: 0.29–0.66]; P < .0001), with moderate heterogeneity seen among the studies (I2 = 50%; P = .03).18 – 24, 26, 27, 35
Analyses of the studies in which procedures were performed exclusively in the internal jugular veins revealed a significant reduction of cannulation failure in the ultrasound group (6.4% vs 27.3%; OR = 0.15 [95% CI: 0.06–0.39]; P < .0001; Fig 2), with significant heterogeneity seen among the studies (I2 = 71%; P = .0001).3, 14 –16, 23, 25, 27, 31 – 34
A reduction in cannulation failure with the ultrasound guidance technique was also observed in studies in which researchers evaluated procedures performed exclusively on the femoral vein (10.4% vs 21.8%; OR = 0.41 [95% CI: 0.17–0.99]; P = .05; Fig 3), without significant heterogeneity seen among the studies (I2 = 23%; P = .27).22, 26, 29, 30
Secondary Outcome: Arterial Puncture
The secondary outcome of arterial puncture was addressed in 22 studies.3, 14 – 16, 18 – 22, 24 – 35 Pooled overall ORs for the secondary outcome are shown in Fig 4. Ultrasound guidance significantly reduced the incidence of arterial punctures compared with the landmark technique (5.4% vs 8.4%; OR = 0.34 [95% CI: 0.21–0.55]; P < .0001). Moderate heterogeneity was observed among the studies (I2 = 46%; P = .01).
The highest heterogeneity was observed in the subgroup of RCTs that compared RTUS guidance with the landmark technique (I2 = 65%; P = .004). In this subgroup, the pooled OR was 0.26 (95% CI: 0.08–0.84; P = .02). Nonrandomized studies had a pooled OR of 0.42 (95%
DE SOUZA et al4
PEDIATRICS Volume 142, number 5, November 2018 5
TABL
E 1
Char
acte
rist
ics
of th
e In
clud
ed S
tudi
es
Stud
yna
Sett
ing
Oper
ator
s’ P
rofil
e an
d Ul
tras
ound
Gu
idan
ce A
ppro
ach
Site
Wt (
kg)a,
bSu
cces
s Ra
te,
%a
Atte
mpt
a, c
Proc
edur
es
Tim
ea, d
Arte
rial
Pu
nctu
re (
%)
Othe
r Co
mpl
icat
ions
, %a
RCTs
: RTU
S gu
idan
ce v
ersu
s an
atom
ic la
ndm
ark
de
Sou
za e
t al14
41 v
s 39PI
CUSi
x pe
diat
ric
criti
cal c
are
resi
dent
s w
ith p
revi
ous
expe
rien
ce o
f at l
east
20
punc
ture
s pe
rfor
med
by
the
land
mar
k te
chni
que
and
5 w
ith u
ltras
ound
gui
danc
e;
ultr
asou
nd-g
uide
d pu
nctu
res
perf
orm
ed in
tran
sver
se
appr
oach
, with
out n
eedl
e gu
ide
IJV
5.5
[3.4
–8.
8]
vs 6
.1
[4.5
–11
.2]
95 v
s 61
(P
< .0
01)
1 [1
–1]
vs 1
[1
–3]
(P =
.0
01)
16”
[8–3
9] v
s 81
” [1
6–34
6]
(P =
.003
)
2.6
vs 2
2 (P
=
.015
)He
mat
omas
, 2.
6 vs
26.
8 (P
= .0
03);
pneu
mot
hora
x,
0 vs
0;
cent
ral l
ine–
asso
ciat
ed B
SI,
0 vs
0
Za
nolla
et a
l2523
vs 28
Oper
atin
g ro
om,
PICU
, NIC
U
One
pedi
atri
c su
rgeo
n w
ith 1
3 y
of e
xper
ienc
e; u
ltras
ound
-gu
ided
pun
ctur
es p
erfo
rmed
in
tran
sver
se a
ppro
ach
IJV
18 [
11–4
0]
vs 1
4 [6
.5–3
0]
95.7
vs
71.4
(P
= .0
31)
1 [1
–2]
vs 3
[2
–5]
(P <
.0
01)
31”
[15–
720]
vs
108
.5”
[71–
251]
(P
< .0
01)
0 vs
14.
3 (P
NM
)He
mat
omas
: 4.3
vs
25
(P N
M)
Br
uzon
i et a
l2810
0 vs
10
1Op
erat
ing
room
No. o
pera
tors
not
spe
cifie
d;
pedi
atri
c su
rgeo
ns o
r pe
diat
ric
surg
ery
fello
ws
who
com
plet
ed
an o
nlin
e co
urse
on
surg
ical
ul
tras
ound
and
wer
e pr
octo
red
for
at le
ast 2
0 pr
oced
ures
w
ith th
e ul
tras
ound
-gui
ded
tech
niqu
e be
fore
the
stud
y. A
ll pu
nctu
res
in th
e co
ntro
l gro
up
wer
e pe
rfor
med
in th
e SC
V.
Ultr
asou
nd-g
uide
d pu
nctu
res
wer
e pe
rfor
med
in th
e IJ
V in
a
tran
sver
se a
ppro
ach.
IJV,
SCV
27 (
4–81
) vs
36
(5–1
06)
95 v
s 74
(P
= .0
001)
NM35
” (2
–220
) vs
43
” (4
–410
) (N
S)
4.5
vs 8
.3 (
NS)
Hem
atom
as, 2
vs
2; h
emot
hora
x,
1 vs
0 (
NS);
pneu
mot
hora
x,
0 vs
2 (
NS)
El
daba
a et
al29
40 v
s 40Op
erat
ing
room
No s
peci
fied
No. o
pera
tors
, pr
evio
us e
xper
ienc
e, o
r tr
aini
ng in
any
of t
he
tech
niqu
es; a
ll op
erat
ors
in th
is s
tudy
wer
e pe
diat
ric
fello
ws.
Ultr
asou
nd-g
uide
d pu
nctu
res
wer
e pe
rfor
med
in a
tr
ansv
erse
app
roac
h.
FV8.
1 ±
0.7
vs
7.9
±
0.8
100
vs 8
7.5
(P
= .0
2)1
(1–8
) vs
4
(1–2
2) (
P =
.001
)
55 (
20–6
00)
vs 2
90
(16–
1500
) (P
=
.02)
0 vs
7.5
(P
= .5
)He
mat
omas
: 0 v
s 7.
5 (P
= .5
)
Ao
uad
et a
l3024
vs 24
Oper
atin
g ro
omNo
. ope
rato
rs n
ot s
peci
fied;
an
esth
esia
res
iden
ts w
ith
no e
xper
ienc
e in
ultr
asou
nd
guid
ance
and
min
imal
ex
peri
ence
usi
ng th
e la
ndm
ark
tech
niqu
e; u
ltras
ound
-gui
ded
punc
ture
s pe
rfor
med
in
tran
sver
se a
ppro
ach
FV14
.3 ±
7.2
vs
11
±
5.5
95.8
vs
95.8
3 (1
–21)
vs
1 (1
–8)
(P =
.0
01)
300”
(18
–156
0)
vs 5
5”
(20–
600)
(P
= .0
2)
4.2
vs 1
2.5
(NS)
Hem
atom
as: 0
vs
0
DE SOUZA et al6
Stud
yna
Sett
ing
Oper
ator
s’ P
rofil
e an
d Ul
tras
ound
Gu
idan
ce A
ppro
ach
Site
Wt (
kg)a,
bSu
cces
s Ra
te,
%a
Atte
mpt
a, c
Proc
edur
es
Tim
ea, d
Arte
rial
Pu
nctu
re (
%)
Othe
r Co
mpl
icat
ions
, %a
Ov
ezov
et a
l3110
7 vs
10
2Op
erat
ing
room
No d
escr
iptio
n of
the
oper
ator
s’
profi
le, N
o. o
pera
tors
, ex
peri
ence
, or
trai
ning
in a
ny
of th
e te
chni
ques
; ultr
asou
nd-
guid
ed p
unct
ures
per
form
ed in
tr
ansv
erse
app
roac
h
IJV
15 v
s 16
.499
.2 v
s 65
(P
< .0
01)
1.28
± 0
.07
vs
2.7
± 0
.17
(P
= .0
03)
32”
vs 1
08”
(P
= .0
05)
0.9
vs 2
7.4
(P <
.0
01)
NM
Gr
eben
ik e
t al32
59 v
s 65Op
erat
ing
room
Thre
e pe
diat
ric
anes
thet
ists
w
ith v
aryi
ng e
xper
ienc
e in
ul
tras
ound
gui
danc
e te
chni
que
(the
leas
t exp
erie
nced
with
5
prev
ious
pro
cedu
res)
; ul
tras
ound
-gui
ded
punc
ture
s pe
rfor
med
in tr
ansv
erse
ap
proa
ch, w
ith n
eedl
e gu
ide
assi
stan
ce
IJV
8.57
± 5
.39
vs 8
.89
± 5
.99
78 v
s 89
.2 (
NS)
NM1.
63’ [
0.3–
6]
vs 1
.54’
[0
.2–1
0.5]
(N
S)
11.9
vs
6.2
(NS)
NM
Ve
rghe
se e
t al33
16 v
s 16Op
erat
ing
room
No. o
pera
tors
not
spe
cifie
d;
pedi
atri
c an
esth
etis
ts u
nder
pe
diat
ric
anes
thes
iolo
gist
su
perv
isio
n, a
ll of
them
trai
ned
in b
oth
tech
niqu
es in
5 c
ases
be
fore
the
stud
y; u
ltras
ound
-gu
ided
pun
ctur
es p
erfo
rmed
in
tran
sver
se a
ppro
ach,
w
ith o
r w
ithou
t nee
dle
guid
e as
sist
ance
IJV
6.0
± 1
.8
vs 6
.4 ±
2.
3
94 v
s 81
.3 (
NS)
1 vs
2 (
P <
.05)
4.5’
± 3
.7 v
s 6.
6’ ±
5.3
(N
S)
6 vs
19
(NS)
NM
Ve
rghe
se e
t al34
43 v
s 52Op
erat
ing
room
No. o
pera
tors
not
spe
cifie
d;
pedi
atri
c an
esth
etis
ts u
nder
pe
diat
ric
anes
thes
iolo
gist
su
perv
isio
n, a
ll tr
aine
d in
bo
th te
chni
ques
in 5
cas
es
befo
re th
e st
udy;
ultr
asou
nd-
guid
ed p
unct
ures
per
form
ed
in tr
ansv
erse
app
roac
h, w
ith
need
le g
uide
ass
ista
nce
IJV
5.8
± 2
.0
vs 6
.0 ±
2.
3
100
vs 7
6.9
(P <
.0
01)
1.3
± 0
.6 v
s 3.
3 ±
2.8
(P
< .0
01)
4.2’
± 2
.8 v
s 14
.0’ ±
15.
1 (P
< .0
01)
0 vs
25
(P <
.0
01)
Hem
atom
as,
0 vs
7.6
; he
mot
hora
x,
0 vs
2;
pneu
mot
hora
x,
0 vs
2 (
P NM
)
RCTs
: ultr
asou
nd-a
ssis
ted
vein
pre
loca
tion
vers
us
anat
omic
land
mar
k
Shim
e et
al15
30 v
s 34Op
erat
ing
room
Two
anes
thes
iolo
gist
s w
ith a
t le
ast 3
y o
f exp
erie
nce;
ther
e w
as n
o de
scri
ptio
n of
pre
viou
s ex
peri
ence
or
trai
ning
in th
e ul
tras
ound
gui
danc
e te
chni
que.
IJV
7.7
(2.2
–14)
vs
7.4
(2
.7–1
9)
97 v
s 62
(P
< .0
01)
NMNM
NMTo
tal:
0 vs
0 (
NS)
Ch
uan
et a
l1632
vs 30
Oper
atin
g ro
omNo
spe
cifie
d No
. ope
rato
rs,
profi
le, p
revi
ous
expe
rien
ce,
or tr
aini
ng in
any
of t
he
tech
niqu
es
IJV
8.9
± 2
.09
vs 8
.8 ±
1.
97
100
vs 8
0 (P
<
.05)
1.57
± 1
.04
vs
2.55
± 1
.76
(P =
.007
)
NM3.
1 vs
26.
7 (P
<
.025
)NM
TABL
E 1
Cont
inue
d
PEDIATRICS Volume 142, number 5, November 2018 7
Stud
yna
Sett
ing
Oper
ator
s’ P
rofil
e an
d Ul
tras
ound
Gu
idan
ce A
ppro
ach
Site
Wt (
kg)a,
bSu
cces
s Ra
te,
%a
Atte
mpt
a, c
Proc
edur
es
Tim
ea, d
Arte
rial
Pu
nctu
re (
%)
Othe
r Co
mpl
icat
ions
, %a
Al
ders
on e
t al3
20 v
s 20Op
erat
ing
room
One
expe
rien
ced
card
iac
anes
thet
ist;
ther
e w
as n
o de
scri
ptio
n of
pre
viou
s ex
peri
ence
or
trai
ning
in th
e ul
tras
ound
gui
danc
e te
chni
que.
IJV
6.6
± 2
.5
vs 6
.8 ±
2.
5
100
vs 8
0 (N
S)1.
35 ±
0.7
vs
2.0
± 1
.0 (
P <
.05)
23.0
± 2
7.4
vs
56.4
± 4
8.9
(P <
.05)
5 vs
10
(NS)
Inab
ility
to p
ass
guid
ewir
e: 1
5 vs
40
(P <
.05)
Nonr
ando
miz
ed s
tudi
es: R
TUS
guid
ance
ver
sus
anat
omic
la
ndm
ark
Ri
vera
-Toc
anci
pá e
t al17
(r
etro
spec
tive)
58 v
s 14
3Op
erat
ing
room
, PI
CU, E
D
No s
peci
fied
No. o
pera
tors
, pr
evio
us e
xper
ienc
e, o
r tr
aini
ng
in a
ny o
f the
tech
niqu
es;
pedi
atri
cs, s
urge
ons
and
anes
thes
iolo
gist
s; n
o de
scri
ptio
n of
the
ultr
asou
nd
appr
oach
IJV,
EJV
, FV
, SC
V
19.8
(15
.4–
24.2
) vs
14.
4 (1
2.7–
16.2
)
NMNM
NM0
vs 3
.5 (
P NM
)He
mat
omas
, 1.7
vs
2; i
nabi
lity
to p
ass
guid
ewir
e, 5
.2
vs 5
.6 (
NS)
Ou
lego
-Err
oz e
t al
35 (
pros
pect
ive
mul
ticen
ter)
323
vs
177
PICU
No. o
pera
tors
not
spe
cifie
d;
oper
ator
s w
ere
pedi
atri
c in
tens
ive
care
res
iden
ts o
r at
tend
ing
phys
icia
ns w
ith
vary
ing
degr
ees
of e
xper
ienc
e.
The
ultr
asou
nd-g
uide
d te
chni
que
was
defi
ned
as
the
use
of u
ltras
ound
for
eith
er r
eal-t
ime
guid
ance
or
prel
ocat
ion
of th
e ve
ssel
.
FV, I
JV,
SCV
9 (4
.9–
17.9
) vs
9.8
(4
.4–
18.7
)
80.8
vs
72.9
(N
S)2
[1–3
] vs
2
[1–4
] (P
<
.01)
60 (
30–2
42)
vs
90 (
32–3
00)
(NS)
5.9
vs 1
0.7
(NS)
Pneu
mot
hora
x,
0.7
vs 2
(NS
); he
mat
omas
, 9.
3 vs
14.
7 (N
S)
Fe
rhi e
t al18
(pr
ospe
ctiv
e)30
vs 15
PICU
No s
peci
fied
No. o
pera
tors
, pr
ofile
, pre
viou
s ex
peri
ence
, or
trai
ning
in a
ny o
f the
te
chni
ques
IJV,
FV
NM96
.6 v
s 80
(P
NM)
1.1
vs 3
(P
NM)
3’ v
s 7’
(P
NM)
0 vs
20
(P N
M)
—
Gu
rien
et a
l19 (r
etro
spec
tive
mul
ticen
ter)
360
vs
774
Oper
atin
g ro
omNo
spe
cifie
d No
. ope
rato
rs,
prev
ious
exp
erie
nce,
or
trai
ning
in a
ny o
f the
te
chni
ques
; ped
iatr
ic s
urge
ry
resi
dent
s, p
edia
tric
sur
gery
fe
llow
s, a
nd p
edia
tric
su
rgeo
ns; n
o de
scri
ptio
n of
the
ultr
asou
nd a
ppro
ach
IJV,
SCV
19 [
11–4
1]
vs 2
0 [1
1–42
]
Succ
ess
on
first
site
: 88
.9 v
s 93
(P
= .0
3)
NM42
’ vs
43’ (
NS)
Arte
rial
pu
nctu
re o
n fir
st s
ite: 1
.2
vs 2
.2 (
NS)
Pneu
mot
hora
x,
1.1
vs 2
.3 (
NS);
hem
otho
rax,
0.
2 vs
1.5
(P
= .0
2)
Ç
elik
et a
l20 (
pros
pect
ive)
36 v
s 36Op
erat
ing
room
No. o
pera
tors
not
spe
cifie
d;
inex
peri
ence
d op
erat
ors
unde
r ex
peri
ence
d at
tend
ing
supe
rvis
ion;
ultr
asou
nd-g
uide
d pu
nctu
res
perf
orm
ed in
rea
l tim
e
SCV
8.86
± 5
.9
vs 7
.7 ±
7.
7
91.7
vs
94.7
(P
= .6
3)NM
179.
7 ±
68.
1 vs
15
3.6
± 8
2.6
(P =
.1)
0 vs
9 (
P =
.07)
Pneu
mot
hora
x.
2.8
vs 0
(P
= .3
1);
hem
atom
as, 0
vs
0 (
P NM
)
TABL
E 1
Cont
inue
d
DE SOUZA et al8
Stud
yna
Sett
ing
Oper
ator
s’ P
rofil
e an
d Ul
tras
ound
Gu
idan
ce A
ppro
ach
Site
Wt (
kg)a,
bSu
cces
s Ra
te,
%a
Atte
mpt
a, c
Proc
edur
es
Tim
ea, d
Arte
rial
Pu
nctu
re (
%)
Othe
r Co
mpl
icat
ions
, %a
Ga
llagh
er e
t al21
(r
etro
spec
tive)
98 v
s 70ED
No. o
pera
tors
not
spe
cifie
d;
pedi
atri
c em
erge
ncy
phys
icia
n at
tend
ing
or r
esid
ent w
ith
atte
ndin
g su
perv
isio
n; th
e op
erat
ors
wer
e su
bmitt
ed to
a
form
al tr
aini
ng p
rogr
am
on u
ltras
ound
gui
danc
e. T
he
oper
ator
s’ e
xper
ienc
e w
as
sign
ifica
ntly
hig
her
in th
e ul
tras
ound
gro
up.
FV, I
JV40
(20
–57)
vs
22
(11–
45.9
)
98 v
s 79
NMNM
5.1
vs 8
.6 (
P NM
)He
mat
omas
: 2 v
s 0
(P N
M)
Al
ten
et a
l22 (
retr
ospe
ctiv
e)76
vs 39
PICU
, op
erat
ing
room
In th
e ul
tras
ound
gro
up, t
he
oper
ator
s w
ere
2 in
tens
ivis
ts
expe
rien
ced
in th
e te
chni
que
(4–6
y o
f exp
erie
nce)
or
fello
ws
unde
r di
rect
sup
ervi
sion
(n
= 9)
. In
the
cont
rol g
roup
, the
op
erat
ors
wer
e 4
pedi
atri
c an
esth
etis
ts o
r 1
surg
eon,
eac
h w
ith a
t lea
st 1
0 y
of e
xper
ienc
e.
Ultr
asou
nd-g
uide
d pu
nctu
res
wer
e pe
rfor
med
in r
eal t
ime
in
a lo
ngitu
dina
l app
roac
h.
FV3.
07 ±
0.4
7 vs
3.0
8 ±
0.2
9
94.7
vs
79.5
(P
= .0
2)1.
6 ±
1.5
vs
3.3
± 2
.7 (
P <
.001
)
NM4
(5.3
) vs
9
(23.
1) (
P =
.01)
Cent
ral l
ine–
asso
ciat
ed B
SI:
9.2
vs 7
.6 (
NS)
Yo
shid
a et
al23
(r
etro
spec
tive)
101
vs
55Op
erat
ing
room
No s
peci
fied
No. o
pera
tors
, pr
evio
us e
xper
ienc
e, o
r tr
aini
ng
in a
ny o
f the
tech
niqu
es;
the
oper
ator
s in
all
case
s w
ere
anes
thes
iolo
gist
s. N
o de
scri
ptio
n of
the
ultr
asou
nd
appr
oach
was
giv
en.
IJV
8.7
± 5
.0
vs 1
0.4
± 6
.1
90 v
s 76
(P
< .0
5)NM
35.0
± 1
6.6
vs
26.7
± 1
1.2
(P <
.01)
NMNM
Fr
oehl
ich
et a
l24
(pro
spec
tive)
119
vs
93PI
CUNo
spe
cifie
d No
. ope
rato
rs,
prev
ious
exp
erie
nce,
or
trai
ning
in a
ny o
f the
te
chni
ques
; res
iden
ts, c
ritic
al
care
fello
ws,
att
endi
ng
phys
icia
ns, a
nd a
nur
se
prac
titio
ner;
ultr
asou
nd-g
uide
d pu
nctu
res
perf
orm
ed in
rea
l tim
e in
tran
sver
se a
ppro
ach
IJV,
FV,
SC
V18
[9–
41]
vs 1
3.6
[5.4
–30]
90.8
vs
88.2
(P
= .5
4)NM
150”
[76.
5–43
5]
vs 2
69”
[75–
900]
(N
S)
8.5
vs 1
9.4
(P
= .0
3)NM
TABL
E 1
Cont
inue
d
CI: 0.26–0.67 [P = .0003]; I2 = 26% [P = .20]), and RCTs that analyzed ultrasound-assisted vein prelocation technique had a pooled OR of 0.18 (95% CI: 0.04–0.92 [P = .04]; I2 = 0% [P = .32]).
A meta-analysis on data from other secondary outcomes was not conducted because of a small number of reports and a wide range of definitions between studies.
Sensitivity Analyses
Significant heterogeneity was observed among the included studies in the subgroup “RTUS versus landmark (RCTs)” for the primary and secondary outcomes (I2 = 76% and 65%, respectively). As shown in Fig 1, the study conducted by Grebenik et al32 revealed a higher failure rate with RTUS guidance than with the anatomic landmark technique, and this probably contributed to the heterogeneity. After excluding this study, the results suggested that compared with controls, RTUS cannulation was associated with increased success (OR = 0.10; 95% CI: 0.05–0.20; P < .00001). Insignificant heterogeneity was observed among the remaining studies (I2 = 1%; P = .42). The same was true for the secondary outcome (OR = 0.18 [95% CI: 0.06–0.56 (P = .003)]; I2 = 49% [P = .06]).
Sensitivity analyses revealed that the overall ORs estimated in the subgroup RTUS versus landmark (RCTs) were substantially modified by the inclusion of 2 studies, 31, 32 with a range of ORs from 0.10 to 0.21 (95% CI: 0.06–0.74; P = .02) for cannulation failure and from 0.18 to 0.38 (95% CI: 0.13–1.13; P = .08) for the incidence of arterial punctures.
The other 2 subgroups did not show significant heterogeneity; therefore, no sensitivity analysis was performed.
PEDIATRICS Volume 142, number 5, November 2018 9
Stud
yna
Sett
ing
Oper
ator
s’ P
rofil
e an
d Ul
tras
ound
Gu
idan
ce A
ppro
ach
Site
Wt (
kg)a,
bSu
cces
s Ra
te,
%a
Atte
mpt
a, c
Proc
edur
es
Tim
ea, d
Arte
rial
Pu
nctu
re (
%)
Othe
r Co
mpl
icat
ions
, %a
Iw
ashi
ma
et a
l26
(pro
spec
tive)
43 v
s 44Op
erat
ing
room
Each
ultr
asou
nd-g
uide
d pr
oced
ure
was
per
form
ed
by 2
ope
rato
rs (
assi
stan
t m
aint
aine
d th
e tr
ansd
ucer
). Pr
evio
us e
xper
ienc
e or
trai
ning
in
any
of t
he te
chni
ques
wer
e no
t des
crib
ed. U
ltras
ound
-gu
ided
pun
ctur
es w
ere
perf
orm
ed in
a tr
ansv
erse
ap
proa
ch.
FV10
.5 (
2.9–
84.2
) vs
8.6
(2
.9–
55.6
)
67.4
vs
59.1
(N
S)NM
NM7
vs 3
1.8
(P <
.0
1)NM
Le
yvi e
t al27
(pr
ospe
ctiv
e)47
vs
102
Oper
atin
g ro
omNo
spe
cifie
d No
. ope
rato
rs,
prev
ious
exp
erie
nce,
or
trai
ning
in
any
of t
he te
chni
ques
; an
esth
esia
res
iden
ts w
ith
facu
lty a
nest
hesi
olog
ists
pr
ovid
ing
dire
ctio
n; u
ltras
ound
-gu
ided
pun
ctur
es p
erfo
rmed
in
tran
sver
se a
ppro
ach
IJV
15.7
± 9
.1
vs 1
8.5
± 1
5.6
91.5
vs
72.5
(P
= .0
1)NM
NM4.
3 vs
2.9
(NS
)He
mat
omas
: 2.1
vs
2 (
NS)
BSI,
bloo
d st
ream
infe
ctio
n; E
D, e
mer
genc
y de
part
men
t; EJ
V, e
xter
nal j
ugul
ar v
ein;
FV,
fem
oral
vei
n; IJ
V, in
tern
al ju
gula
r ve
in; N
M, n
ot m
entio
ned;
NS,
not
sig
nific
ant;
SCV,
sub
clav
ian
vein
.a
Pres
ente
d as
inte
rven
tion
(ultr
asou
nd)
vers
us c
ontr
ol (
land
mar
k).
b Va
lues
are
sho
wn
as m
ean
± S
D, 3,
17 – 22
, 24, 28
, 30,
31, 34
med
ian
[int
erqu
artil
e ra
nge]
, 14, 15
, 27,
29, 32
, 35 m
ean
(ran
ge), 16
, 25 a
nd m
edia
n (r
ange
).23, 33
c Val
ues
are
show
n as
mea
n ±
SD,
3, 19
, 22, 24
, 30 m
edia
n [i
nter
quar
tile
rang
e], 14
, 15, 35
med
ian
(ran
ge), 17
, 18 a
nd m
edia
n.21
, 26
d Va
lues
are
sho
wn
as m
ean
± S
D, 3,
19, 21
, 22, 2
8, 31
med
ian
[int
erqu
artil
e ra
nge]
, 14, 15
, 32, 3
5 med
ian
(ran
ge), 17
, 18 m
ean
(ran
ge), 16
, 20 a
nd m
edia
n.26
, 27
TABL
E 1
Cont
inue
d
Other Outcomes
The time to success was reported in 17 studies.3, 14, 18 –20, 23 – 26, 28 – 35 Although the definition varied among articles, 8 revealed a significant reduction in time to success in the ultrasound groups, 3, 14, 23, 25, 30, 31, 34 8 studies revealed no difference between the techniques, 18, 19, 24, 26, 28, 32, 33, 35 and 1 revealed a shorter time to success in the landmark group.23 All 9 studies that assessed the attempts required
for success revealed a reduction with ultrasound assistance.‡
Regarding the complications, 3 studies revealed a significant reduction of hematomas in the ultrasound group, 14, 25, 29 whereas in 8 studies, no difference between the groups was observed.17, 20, 21, 27, 28, 30, 34, 35 In 1 study, a significant reduction in the occurrence of hemothorax was detected, 19 whereas another 2 studies
‡ Refs 3, 14, 16, 22, 25, 30, 31, 33, and 34.
revealed no difference between the groups.28, 34 None of the 6 studies that reported the occurrence of pneumothorax revealed a difference between the groups.14, 19, 20, 28, 34, 35 Moreover, no difference was found between the groups in the 2 studies in which researchers reported procedure-related infections.14, 22
Publication Bias
The assessment of publication bias performed by using the Egger et al13
DE SOUZA et al10
FIGURE 1Meta-analysis of the risk of cannulation failure between ultrasound-assistance versus anatomic landmark techniques. A, random sequence generation (selection bias); B, allocation concealment (selection bias); C, blinding of participants and personnel (performance bias); D, blinding of outcome assessment (detection bias); df, degrees of freedom; E, incomplete outcome data (attrition bias); F, selective reporting (reporting bias); G, other bias; IV, inverse variance.
test revealed a potential publication bias for cannulation failure among the 22 included studies (Egger’s test, P = .002; Begg’s test, P = .080). However, no publication bias was observed when analyzing only the subgroup RTUS versus landmark (RCTs) (Egger’s test, P = .113; Begg’s test, P = .761). The funnel plots for cannulation failure are shown in Supplemental Figs 8 and 9.
Neither the Begg and Mazumdar12 nor the Egger et al13 tests yielded evidence of significant publication bias for arterial puncture in the subgroup RTUS versus landmark (RCTs) (Egger’s test, P = .103; Begg’s test, P = .259). Nevertheless, a potential publication bias was observed when including all studies evaluating arterial punctures (Egger’s test, P = .038; Begg’s test,
P = .176). The funnel plot for arterial puncture is shown in Supplemental Figs 10 and 11.
DISCUSSION
This meta-analysis revealed that pediatric patients who require central venous catheterization can obtain significant benefits from ultrasound guidance techniques, whether that be RTUS guidance or ultrasound-assisted vein prelocation. In addition to updating evidence on the superiority of ultrasound guidance over the landmark technique, the overall pooled results of this meta-analysis revealed, for the first time, a statistically significant reduction of the incidence of arterial puncture in the ultrasound-guided
procedures. In fact, arterial puncture can be associated with several complications, such as major stroke, false aneurysm, and massive bleeding, that are serious events; when these complications occur, an endovascular approach may be required.36
However, some important considerations should be made regarding the results presented here. Similar to the authors of a previously published meta-analysis, 6 we decided to include nonrandomized studies in addition to RCTs. This decision was made to increase the amount of data for analysis because the number of published studies on this issue in pediatrics is low. The objective was achieved but not without cost.
PEDIATRICS Volume 142, number 5, November 2018 11
FIGURE 2Meta-analysis of the risk of failure of internal jugular vein cannulation between ultrasound assistance versus anatomic landmark techniques. A, random sequence generation (selection bias); B, allocation concealment (selection bias); C, blinding of participants and personnel (performance bias); D, blinding of outcome assessment (detection bias); df, degrees of freedom; E, incomplete outcome data (attrition bias); F, selective reporting (reporting bias); G, other bias; IV, inverse variance.
This meta-analysis has the largest amount of data analyzed on the issue in pediatric patients; however, we included more studies with a high risk of bias. Therefore, the data from RCTs and nonrandomized studies were carefully analyzed in different subgroups.
Even among RCTs, serious problems were observed regarding the risk of bias. These include the lack of detail in the number and profile of the operators evaluated. These are important considerations because we cannot extrapolate the conclusions associated with studies that involved experienced operators to those that involved resident physicians and vice versa. In addition, even operators with similar experience may have different skill levels. Thus, studies in which researchers do not describe the number of operators or those involving a single operator should be interpreted with caution. Meta-analyses such as this are important owing to the gathering of data from multiple operators; however, it would be of great value to stratify
the analysis by operator experience or training. Moreover, similar to conclusions not being extrapolatable to different operators, the same holds true for different patient profiles. Only 2 randomized studies evaluated children who were critically ill and admitted to the PICU.14, 25 Finally, it is essential to emphasize that the puncture technique is not identical for all sites. Nevertheless, researchers in some nonrandomized studies presented results obtained from punctures performed at different sites, whereas Bruzoni et al28 evaluated different sites in each group in their RCT. It might be more appropriate to analyze the data obtained from the punctures of the jugular, femoral, and subclavian veins separately.
Despite the limitations on the evidence cited above, many professional organizations and governmental agencies have long supported the systematic use of ultrasound in deep vein punctures. The Agency for Healthcare Research and Quality in the United States
was the first to announce its recommendation in 2001, 37 followed in 2002 by the National Institute for Health and Care Excellence in the United Kingdom.38 The same was done in 2010 by the American College of Surgeons.39 These efforts seem successful. A survey conducted in the United Kingdom in 2006 revealed that 85% of pediatric anesthetists had access to ultrasound, but only 27% used it routinely.40 This study also revealed that 62% of respondents believed that ultrasound was unnecessary. Almost 10 years later, similar research in Nordic countries revealed that 80% of pediatric anesthetists used ultrasound regularly for central venous cannulation.41 However, even in developed countries, the use of the ultrasound guidance technique has had low adherence rates. In 2015, only 23% of the pediatric surgeons in the United States admitted to using ultrasound regardless of the puncture site.2
After all, why is the ultrasound guidance technique not completely
DE SOUZA et al12
FIGURE 3Meta-analysis of the risk of failure of femoral vein cannulation between ultrasound assistance versus anatomic landmark techniques. A, random sequence generation (selection bias); B, allocation concealment (selection bias); C, blinding of participants and personnel (performance bias); D, blinding of outcome assessment (detection bias); df, degrees of freedom; E, incomplete outcome data (attrition bias); F, selective reporting (reporting bias); G, other bias; IV, inverse variance.
diffused among all practitioners? It is reasonable to consider that the limitations in the evidence cited above may contribute to this fact and may be used to explain why 38% of the interviewed members of the American Pediatric Surgical Association were convinced that the use of ultrasound is unnecessary for deep vein punctures.2 However, this is probably not the greatest barrier to the diffusion of the ultrasound guidance technique. The lack of formal training in ultrasonography
and the unavailability of the device were indicated as the primary causes for not using the ultrasound for CVC in children.2, 41 It is surprising that only 19% of the pediatric anesthetists and 24% of the pediatric surgeons interviewed received formal ultrasound training.2, 41 These problems can be even more serious in low-income countries, especially with regard to the availability of ultrasound machines. However, a cost-effectiveness analysis revealed favorable results on the ultrasound
guidance technique in the central venous catheterization of adults.42
CONCLUSIONS
The current meta-analysis reveals that ultrasound-guided techniques are associated with a reduced incidence of failure and inadvertent arterial puncture in pediatric central venous cannulation when compared with the anatomic landmark technique. However, results should be interpreted
PEDIATRICS Volume 142, number 5, November 2018 13
FIGURE 4Meta-analysis of the risk of arterial punctures between ultrasound assistance versus anatomic landmark techniques. A, random sequence generation (selection bias); B, allocation concealment (selection bias); C, blinding of participants and personnel (performance bias); D, blinding of outcome assessment (detection bias); df, degrees of freedom; E, incomplete outcome data (attrition bias); F, selective reporting (reporting bias); G, other bias; IV, inverse variance.
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ACKNOWLEDGMENT
Thank you to Carolina Grotta Ramos Télio for her review of the article.
DE SOUZA et al14
supervised data collection and critically reviewed the manuscript for important intellectual content; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
This trial has been registered with the PROSPERO Register (identifier CRD42018091333).
DOI: https:// doi. org/ 10. 1542/ peds. 2018- 1719
Accepted for publication Aug 1, 2018
Address correspondence to Tiago Henrique de Souza, MD, Division of Pediatric Critical Care, Department of Pediatrics, 126 Tessália Vieira de Camargo St, Campinas, São Paulo 13083-887, Brazil. E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2018 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
ABBREVIATIONS
CI: confidence intervalCVC: central venous catheterOR: odds ratioRCT: randomized controlled
trialRTUS: real-time ultrasound
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