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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The use of ultrasound guidance reduces the number of punctures required for vascular access&#44; as well as the associated failure and complication rates&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> although requires considerable training&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">2</span></a> However&#44; the associated learning curve and technical preparation required for this procedure &#40;ultrasound equipment&#44; probe sterilization&#44; selection of suitable preset&#44; puncture plane&#44; previsualize&#44; etc&#46;&#41; often lead healthcare professionals to choose traditional &#8220;blind&#8221; cannulation despite its associated complications&#44; which frequently emerge in critical situations &#40;coagulopathy&#44; thrombocytopenia&#44; obesity&#41;&#44; especially in pediatric patients whose vessels are smaller and more superficial than those of adults&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Surprisingly&#44; non-human simulated models are scarcely used for training in invasive techniques such as ultrasound-guided vascular access&#46; Some training models may be expensive or scarcely available or transmit ultrasound poorly&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">3&#8211;5</span></a> Much like other recently adopted techniques&#44; few experimental models are available to simulate actual procedures&#46; Most of biologic models consist of chicken or turkey thighs&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a> and others &#40;sintetic models&#41; are performed by latex&#44; gelatin or silicone rubber models&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> where plastic structures simulating central vessels are inserted&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In this article&#44; we present&#58; &#40;a&#41; a low-cost reproducible training model that reliably simulates the central vascular structures of pediatric patients&#44; where different depth and diameter measures &#40;corresponding to children&#39;s vessels&#41; can be represented&#59; &#40;b&#41; the outcome of ecoguided puncture in the models and the useful tool for training in ultrasound-guided vascular cannulation&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Patients and method</span><p id="par0020" class="elsevierStylePara elsevierViewall">The training model consisted of&#58; &#40;a&#41; <span class="elsevierStyleItalic">Muscular component&#58;</span> a portion of avian chest muscle of approximately 7<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>7<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>cm &#40;long&#44; wide&#44; high&#41;&#44; which can be purchased in any food store&#46; &#40;b&#41; <span class="elsevierStyleItalic">Vascular component&#58;</span> a tube-like structure made of an elastic material &#40;latex free ballon&#41;&#44; filled-up with 10<span class="elsevierStyleHsp" style=""></span>ml of colored water using a syringe or manual pumping dispenser and sealed at both ends with knots&#46; Both components simulated the muscular and vascular structures of pediatric patients &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">A thoracic drainage cannula &#40;Argyle<span class="elsevierStyleSup">&#174;</span> 8 French &#8211; 2&#46;7<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>9<span class="elsevierStyleHsp" style=""></span>inch &#8211; 23<span class="elsevierStyleHsp" style=""></span>cm&#41; was inserted with a puncture trocar &#40;to different depths&#41; by longitudinally piercing the muscular component&#46; Then the trocar was removed while the plastic portion of the drainage cannula remained in the muscle&#46; The distal end of the drainage cannula was then sutured to the distal end of the elastic tube-like structure at the knot zone&#46; As the drainage cannula was pulled toward the opposite side&#44; the whole device was inserted into the muscular structure and could be used as a training model for training in ultrasound-guided vascular access &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; By fixing a clamp system at different lengths&#44; three different diameter ranges could be obtained&#44; similar to the blood vessel diameters of pediatric patients &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Puncture and cannulation were performed with a catheter Vigon<span class="elsevierStyleSup">&#174;</span> 3 French &#40;gauge&#41;<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>11<span class="elsevierStyleHsp" style=""></span>cm &#40;length&#41;&#44; a 30<span class="elsevierStyleHsp" style=""></span>cm radio-opaque guidewire and a 5&#46;5<span class="elsevierStyleHsp" style=""></span>mm needle&#46; The total cost of the model system was 3 Euros &#40;avian muscle 1&#8364;&#44; 15 elastic tube-like structures 1&#8364;&#44; fixing support and clamp 1&#8364;&#41;&#46; Every system could be used for more than 100 punctures&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Three different depth and diameter values were established on the basis of 300 central vessels measurements&#44; previously taken in 70 pediatrics patients of different weight and sizes after requesting the informed consent garents by the parents of the infants&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">24 punctures weekly were realized in the model during 18 weeks for each of operators in the three ultrasound scan axis more frequent&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The time required for successful wire insertion was calculated from the time that the skin was penetrated&#44; until the guidewire was successfully inserted&#46; The number of needle passes&#44; the success rate&#44; the number of cases with success achieved&#44; the time&#44; the visualization of the needle and the incidence of complications were noted&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The quantitative variables were expressed in averages and standard deviation and the qualitative variables in percentages&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">The structure &#40;vascular and muscular&#41; in the training model was visualized with a Philips HD 7<span class="elsevierStyleSup">&#174;</span> ultrasound equipment with a linear multi-frequency probe L12-5&#44; selecting &#8220;preset vascular&#8221; and 2<span class="elsevierStyleHsp" style=""></span>cm depth &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">By ultrasound visualization&#44; the depth and diameter of the elastic tubular vessel-like structure could be measured&#46; Three different depth and diameter values were established on the basis of 300 central vessels depth and diameter measurements previously taken in pediatric patients of different weights and sizes&#46; The averaged measurements &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; determined 9 depth and diameter ranges for the vessel in the training model &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Ultrasound-guided vessel puncture and cannulation in the model could be conducted in the three more frequently used axes in vascular access&#58; transverse out-of-plane axis&#44; oblique in-plane axis and longitudinal axis &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">The training model also allowed visualizing the needle in the selected ultrasound axes as well as the probe inserted for vessel cannulation&#44; which made it possible to maneuver the probe or the needle to avoid difficulties that could possibly be encountered during the cannulation procedure&#44; thus facilitating vessel catheterization &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">864 ecoguided punctures was realized in the model at different vessel depth and gauge measures were simulated&#44; for two medical operators with different degree of experience&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The average depth and diameter of vessel cannulated were 1&#46;16 &#40;0&#46;42&#41;<span class="elsevierStyleHsp" style=""></span>cm and 0&#46;43 &#40;0&#46;1&#41;<span class="elsevierStyleHsp" style=""></span>cm&#44; respectively&#46; The average number of attempts was of 1&#46;22 &#40;0&#46;62&#41;&#46; The percentage of visualization of the needle was 74&#37;&#46; The most frequent maneuver used for the correct location&#44; was the modification of the angle of the needle and the relocation of the guidewire in 24&#37; of the cases&#46; The average time for the correct cannulations was 41 &#40;35&#46;8&#41;<span class="elsevierStyleHsp" style=""></span>s&#46; The more frequent complications were the vascular perforation &#40;11&#46;9&#37;&#41; and the correct vascular puncture without possibility of introducing the guidewire &#40;1&#46;2&#37;&#41;&#46; The rate of success was 96&#37;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Discussion</span><p id="par0080" class="elsevierStylePara elsevierViewall">Although whole-body ultrasound examination was mainly developed for adults&#44; in pediatric patients it may help evaluating cardiac function and volemia&#44; performing cardiopulmonary resuscitation &#40;protocol FEER&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a> monitoring and guiding endotracheal intubation &#40;protocol TRUE&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a> assessing pleural and pulmonary involvement&#44; detecting free fluid in the peritoneum &#40;protocol FAST&#41;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a> and guiding invasive procedures such as vascular access&#44; thoracocentesis&#44; pericardiocentesis&#44; endotracheal intubation or lumbar puncture&#44; in a safer and easier way at the bedside&#46; Advances in vascular visualization lead to a more widespread use of vascular ultrasound as a helpful tool for central vascular access in critical pediatric patients&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Cannulation of central vessels in critical pediatric patients is a usual technique in Pediatric Intensive Care&#44; Anestesiology and Emergency Services&#46; In general&#44; &#8220;blind&#8221; vascular access is performed&#44; which is not free of complications&#44; even for most experienced profesionals&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a> It is widely accepted that ultrasound-guided central vascular access is associated with higher success and lower complication rates&#44; as well as higher quality and safety for pediatric patients in the Intensive Care Unit&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">11&#8211;13</span></a> Actually&#44; the &#8220;Guidelines on the use of ultrasound guidance for vascular access&#8221; recommended that cannulation of the internal jugular vein and the femoral vein in pediatric patients should be performed under ultrasound guidance&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a> and other consensus document for training in ultrasound-guided vascular access have recently been published&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">14&#8211;18</span></a> The Agency for Healthcare Research and Quality confirmed that training in central vessel cannulation&#44; both &#8220;blind&#8221; or ultrasound-guided&#44; reduces the required number of vessel punctures and the associated complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1&#44;15</span></a> Compared with performing ultrasound-guided puncture directly to the patient at the bedside&#44; training with an experimental model is less stressful and risky and offers an opportunity to improve ultrasound use&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a> All of this contributes to the safety of invasive procedures in critical pediatric patients&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Our model obtain similar outcomes than others publications in pediatrics patients or in training models of ecoguided vascular access at the time of correct location&#44; though his rate of success is 100&#37; as in another model of training&#44; but in this one the mean diameter of the vessels was 8<span class="elsevierStyleHsp" style=""></span>mm&#44; bigger than that of our model&#46; The number of attempts ranges between 1 and 3 similar to our study and the maneuver to facilitate the location of the catheter is the replacement of the needle and the guide&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">19&#8211;20</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The here-presented training model is low cost and readily available to any service of critical patient transfer&#44; anesthesiology&#44; intensive care or emergency care with an ultrasound equipment and suitable probe for vascular puncture&#44; where vascular access is regularly performed and whose personnel need training&#46; Additionally&#44; this model is helpful to improve ultrasound use and probe sterilization and protection skills&#44; as well as &#8220;eye-hand&#8221; coordination&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a> Furthermore&#44; the puncture and cannulation procedures can be repeated many times and several operators can work on a model system&#44; since several tube-like structures can be placed&#44; as necessary&#46; Though the model this one designed for pediatric patients&#44; can apply without problems in adult patients fitting the depths &#40;1&#46;50&#8211;1&#46;75<span class="elsevierStyleHsp" style=""></span>cm&#41; and vascular diameters &#40;0&#46;8&#8211;1<span class="elsevierStyleHsp" style=""></span>cm&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Several synthetic &#40;silicone&#44; gelatin&#44; latex&#41; and tissue models &#40;chicken&#44; turkey or pork thigh &#8211; &#8220;pork belly&#8221;&#41;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">3&#44;6&#44;16</span></a> are commercially available for training in ultrasound-guided vascular access&#46; However&#44; unlike other models where semi-rigid plastic structures &#40;cannulae or probes&#41; are used to simulate the vessels&#44; in our model the feeling is closely similar to that of puncturing pediatric patients on the usual zones &#40;cervical&#44; infraclavicular&#44; brachial or inguinal&#41;&#44; both in the muscular and vascular structures&#46; Furthermore&#44; the path of the needle is not marked and vascular fluid extravasation does not affect visualization&#44; as it happens in synthetic models&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">One of the limitations of the model &#8211; just like other mentioned models &#8211; is the fact that the anatomical structure &#40;avian chest muscle&#41; does not vary&#44; whereas the structures of real pediatric patients may vary in size&#44; location &#40;cervical&#44; inguinal&#44; brachial&#41;&#44; mobility or restlessness &#40;except in sedated patients&#41;&#46; Moreover&#44; unlike real pediatric patients&#44; the model remains motionless&#44; which facilitates ultrasound visualization and guidance of vascular cannulation&#46; However&#44; in our opinion the model is a helpful training tool&#44; both for physicians experienced in the traditional &#8220;blind&#8221; technique and residents who are starting with vascular access&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conclusions</span><p id="par0110" class="elsevierStylePara elsevierViewall">The here-presented experimental model for ultrasound-guided vascular access is rather similar to the vascular structures of pediatric patients in terms of vessel anatomy&#44; depth and diameter in relation to body weight&#46; It also facilitates ultrasound-guided vascular cannulation and supports the learning curve to acquire the required skills&#46; Furthermore&#44; the model allows for needle path visualization and correction when necessary&#46; On the basis of these conclusions&#44; we postulate that our experimental model may be considered and used as reliably as other available models&#44; such as the &#8220;pork belly&#8221;&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a> for training in ultrasound-guided vascular access&#46; In future studies&#44; we expect to collect data to confirm whether training with this experimental model reduces the complication rates associated with vascular access in critical pediatric patients&#44; thus enhancing children safety&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conflicts of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors report no conflicts of interest&#46;</p></span></span>"
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    "fechaRecibido" => "2015-10-17"
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            1 => "Vascular access"
            2 => "Pediatric tissue model"
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          "palabras" => array:5 [
            0 => "Ultrasonidos"
            1 => "Accesos vasculares"
            2 => "Modelos tisulares pedi&#225;tricos"
            3 => "Entrenamiento"
            4 => "Seguridad del paciente"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Central vascular cannulation is not a risk-free procedure&#44; especially in pediatric patients&#46; Newborn and infants are small and low-weighted&#44; their vascular structures have high mobility because of tissue laxity and their vessels are superficial and with small diameter&#46; These characteristics&#44; together with the natural anatomical variability and poor collaboration of small children&#44; make this technique more difficult to apply&#46; Therefore&#44; ultrasound imaging is increasingly being used to locate vessels and guide vascular access in this population&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">&#40;a&#41; To present a model that simulates the vascular system for training ultrasound-guided vascular access in pediatrics patients&#59; &#40;b&#41; to ultrasound-guided vascular cannulation in the model&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The model consisted of two components&#58; &#40;a&#41; muscular component&#58; avian muscle&#44; &#40;b&#41; vascular component&#58; elastic tube-like structure filled with fluid&#46; 864 ecoguided punctures was realized in the model at different vessel depth and gauge measures were simulated&#44; for two medical operators with different degree of experience&#46; The average depth and diameter of vessel cannulated were 1&#46;16 &#40;0&#46;42&#41;<span class="elsevierStyleHsp" style=""></span>cm and 0&#46;43 &#40;0&#46;1&#41;<span class="elsevierStyleHsp" style=""></span>cm&#44; respectively&#46; The average number of attempts was of 1&#46;22 &#40;0&#46;62&#41;&#46; The percentage of visualization of the needle was 74&#37;&#46; The most frequent maneuver used for the correct location&#44; was the modification of the angle of the needle and the relocation of the guidewire in 24&#37; of the cases&#46; The average time for the correct cannulations was 41 &#40;35&#46;8&#41;<span class="elsevierStyleHsp" style=""></span>s&#46; The more frequent complications were the vascular perforation &#40;11&#46;9&#37;&#41; and the correct vascular puncture without possibility of introducing the guidewire &#40;1&#46;2&#37;&#41;&#46; The rate of success was 96&#37;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The model simulates the anatomy &#40;vascular and muscular structures&#41; of a pediatric patient&#46; It is cheap models&#44; easily reproducible and a useful tool for training in ultrasound-guided puncture and cannulation&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La canalizaci&#243;n vascular central es una t&#233;cnica no exenta de riesgos sobretodo en la poblaci&#243;n de los pacientes pedi&#225;tricos&#46; El tama&#241;o y peso de los pacientes m&#225;s peque&#241;os &#40;reci&#233;n nacidos y lactantes&#41;&#44; la mayor movilidad de algunas de sus estructuras vasculares&#44; la posici&#243;n m&#225;s superficial y di&#225;metros m&#225;s peque&#241;os de sus vasos&#44; la variabilidad anat&#243;mica que pueden presentar&#44; asociado a la poca colaboraci&#243;n que presentan estos pacientes&#44; hace m&#225;s dif&#237;cil la realizaci&#243;n de esta t&#233;cnica&#46; A pesar de ello la ecograf&#237;a est&#225; instaur&#225;ndose para asistir a la realizaci&#243;n de la punci&#243;n vascular en dichos pacientes&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Objetivo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">a&#41; Dise&#241;ar un modelo experimental que permita la simulaci&#243;n vascular&#44; la punci&#243;n vascular ecodirigida y que sirva como m&#233;todo de aprendizaje y entrenamiento para la canalizaci&#243;n ecoguiada de los vasos sangu&#237;neos de los pacientes pedi&#225;tricos&#46; b&#41; Realizar la punci&#243;n ecoguiada en el modelo&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se presenta un modelo compuesto por una porci&#243;n muscular aviar a la que se introduce un sistema tubular el&#225;stico&#46; Se simulan distintas profundidades del vaso as&#237; como diferentes di&#225;metros de los mismos&#46; Se realizaron 864 punciones ecoguiadas en el modelo con diferentes niveles de profundidad y de di&#225;metro vascular por dos operadores con distinto grado de experiencia&#46; La media de profundidad y di&#225;metro de los vasos canalizados fue de 1&#44;6 &#40;0&#44;42&#41; cm y de 0&#44;43 &#40;0&#44;1&#41; cm respectivamente&#46; El n&#250;mero medio de intentos fue de 1&#44;22 &#40;0&#44;62&#41;&#46; El porcentaje de visualizaci&#243;n de la aguja fue del 74&#37;&#46; La maniobra m&#225;s frecuentemente utilizada para la correcta canalizaci&#243;n fue la recolocaci&#243;n de la aguja y la gu&#237;a en el 24&#37; de los casos&#46; El tiempo medio hasta la correcta canalizaci&#243;n fue de 41 &#40;35&#44;8&#41; segundos&#46; La complicaci&#243;n m&#225;s frecuente fue la perforaci&#243;n vascular &#40;11&#44;9&#37;&#41; y la adecuada punci&#243;n sin conseguir la introducci&#243;n de la gu&#237;a&#46; La tasa de &#233;xito fue del 96&#37;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El modelo presentado simula la anatom&#237;a &#40;estructuras vasculares y musculares&#41; del paciente pedi&#225;trico&#59; es barato&#44; f&#225;cilmente reproducible&#59; permite la canalizaci&#243;n y el aprendizaje de la t&#233;cnica de la punci&#243;n ecoguiada&#46;</p></span>"
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">P1&#58; 0&#46;5&#8211;1&#46;0<span class="elsevierStyleHsp" style=""></span>cm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">D1&#58; 0&#46;51&#8211;0&#46;65<span class="elsevierStyleHsp" style=""></span>cm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">P2&#58; 1&#46;01&#8211;1&#46;50<span class="elsevierStyleHsp" style=""></span>cm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">D2&#58; 0&#46;36&#8211;0&#46;50<span class="elsevierStyleHsp" style=""></span>cm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">P3&#58; 1&#46;51&#8211;2&#46;0<span class="elsevierStyleHsp" style=""></span>cm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">D3&#58; 0&#46;20&#8211;0&#46;35<span class="elsevierStyleHsp" style=""></span>cm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Depth ranges &#40;P1-3&#41; and diameter ranges &#40;D1-3&#41; used in the training model&#46;</p>"
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Design and application of model for training ultrasound-guided vascular cannulation in pediatric patients
Diseño y aplicación de un modelo de entrenamiento para la canalización vascular ecoguiada en pacientes pediátricos
O. Pérez-Quevedoa, J.M. López-Álvareza,
Corresponding author
jmloal@hotmail.com

Corresponding author.
, J.M. Limiñana-Cañalb, J.F. Loro-Ferrerc
a Unidad de Medicina Intensiva Pediátrica, Complejo Hospitalario Universitario Insular Materno-Infantil, Las Palmas de Gran Canaria, Spain
b Unidad de Investigación, Complejo Hospitalario Universitario Insular Materno-Infantil, Las Palmas de Gran Canaria, Spain
c Departamento de Ciencias Clínicas, Universidad de Las Palmas de Gran Canaria, Spain
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which frequently emerge in critical situations &#40;coagulopathy&#44; thrombocytopenia&#44; obesity&#41;&#44; especially in pediatric patients whose vessels are smaller and more superficial than those of adults&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Surprisingly&#44; non-human simulated models are scarcely used for training in invasive techniques such as ultrasound-guided vascular access&#46; Some training models may be expensive or scarcely available or transmit ultrasound poorly&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">3&#8211;5</span></a> Much like other recently adopted techniques&#44; few experimental models are available to simulate actual procedures&#46; Most of biologic models consist of chicken or turkey thighs&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a> and others &#40;sintetic models&#41; are performed by latex&#44; gelatin or silicone rubber models&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> where plastic structures simulating central vessels are inserted&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In this article&#44; we present&#58; &#40;a&#41; a low-cost reproducible training model that reliably simulates the central vascular structures of pediatric patients&#44; where different depth and diameter measures &#40;corresponding to children&#39;s vessels&#41; can be represented&#59; &#40;b&#41; the outcome of ecoguided puncture in the models and the useful tool for training in ultrasound-guided vascular cannulation&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Patients and method</span><p id="par0020" class="elsevierStylePara elsevierViewall">The training model consisted of&#58; &#40;a&#41; <span class="elsevierStyleItalic">Muscular component&#58;</span> a portion of avian chest muscle of approximately 7<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>7<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>cm &#40;long&#44; wide&#44; high&#41;&#44; which can be purchased in any food store&#46; &#40;b&#41; <span class="elsevierStyleItalic">Vascular component&#58;</span> a tube-like structure made of an elastic material &#40;latex free ballon&#41;&#44; filled-up with 10<span class="elsevierStyleHsp" style=""></span>ml of colored water using a syringe or manual pumping dispenser and sealed at both ends with knots&#46; Both components simulated the muscular and vascular structures of pediatric patients &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">A thoracic drainage cannula &#40;Argyle<span class="elsevierStyleSup">&#174;</span> 8 French &#8211; 2&#46;7<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>9<span class="elsevierStyleHsp" style=""></span>inch &#8211; 23<span class="elsevierStyleHsp" style=""></span>cm&#41; was inserted with a puncture trocar &#40;to different depths&#41; by longitudinally piercing the muscular component&#46; Then the trocar was removed while the plastic portion of the drainage cannula remained in the muscle&#46; The distal end of the drainage cannula was then sutured to the distal end of the elastic tube-like structure at the knot zone&#46; As the drainage cannula was pulled toward the opposite side&#44; the whole device was inserted into the muscular structure and could be used as a training model for training in ultrasound-guided vascular access &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; By fixing a clamp system at different lengths&#44; three different diameter ranges could be obtained&#44; similar to the blood vessel diameters of pediatric patients &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; Puncture and cannulation were performed with a catheter Vigon<span class="elsevierStyleSup">&#174;</span> 3 French &#40;gauge&#41;<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>11<span class="elsevierStyleHsp" style=""></span>cm &#40;length&#41;&#44; a 30<span class="elsevierStyleHsp" style=""></span>cm radio-opaque guidewire and a 5&#46;5<span class="elsevierStyleHsp" style=""></span>mm needle&#46; The total cost of the model system was 3 Euros &#40;avian muscle 1&#8364;&#44; 15 elastic tube-like structures 1&#8364;&#44; fixing support and clamp 1&#8364;&#41;&#46; Every system could be used for more than 100 punctures&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Three different depth and diameter values were established on the basis of 300 central vessels measurements&#44; previously taken in 70 pediatrics patients of different weight and sizes after requesting the informed consent garents by the parents of the infants&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">24 punctures weekly were realized in the model during 18 weeks for each of operators in the three ultrasound scan axis more frequent&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The time required for successful wire insertion was calculated from the time that the skin was penetrated&#44; until the guidewire was successfully inserted&#46; The number of needle passes&#44; the success rate&#44; the number of cases with success achieved&#44; the time&#44; the visualization of the needle and the incidence of complications were noted&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The quantitative variables were expressed in averages and standard deviation and the qualitative variables in percentages&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Results</span><p id="par0050" class="elsevierStylePara elsevierViewall">The structure &#40;vascular and muscular&#41; in the training model was visualized with a Philips HD 7<span class="elsevierStyleSup">&#174;</span> ultrasound equipment with a linear multi-frequency probe L12-5&#44; selecting &#8220;preset vascular&#8221; and 2<span class="elsevierStyleHsp" style=""></span>cm depth &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">By ultrasound visualization&#44; the depth and diameter of the elastic tubular vessel-like structure could be measured&#46; Three different depth and diameter values were established on the basis of 300 central vessels depth and diameter measurements previously taken in pediatric patients of different weights and sizes&#46; The averaged measurements &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41; determined 9 depth and diameter ranges for the vessel in the training model &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Ultrasound-guided vessel puncture and cannulation in the model could be conducted in the three more frequently used axes in vascular access&#58; transverse out-of-plane axis&#44; oblique in-plane axis and longitudinal axis &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">The training model also allowed visualizing the needle in the selected ultrasound axes as well as the probe inserted for vessel cannulation&#44; which made it possible to maneuver the probe or the needle to avoid difficulties that could possibly be encountered during the cannulation procedure&#44; thus facilitating vessel catheterization &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">864 ecoguided punctures was realized in the model at different vessel depth and gauge measures were simulated&#44; for two medical operators with different degree of experience&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The average depth and diameter of vessel cannulated were 1&#46;16 &#40;0&#46;42&#41;<span class="elsevierStyleHsp" style=""></span>cm and 0&#46;43 &#40;0&#46;1&#41;<span class="elsevierStyleHsp" style=""></span>cm&#44; respectively&#46; The average number of attempts was of 1&#46;22 &#40;0&#46;62&#41;&#46; The percentage of visualization of the needle was 74&#37;&#46; The most frequent maneuver used for the correct location&#44; was the modification of the angle of the needle and the relocation of the guidewire in 24&#37; of the cases&#46; The average time for the correct cannulations was 41 &#40;35&#46;8&#41;<span class="elsevierStyleHsp" style=""></span>s&#46; The more frequent complications were the vascular perforation &#40;11&#46;9&#37;&#41; and the correct vascular puncture without possibility of introducing the guidewire &#40;1&#46;2&#37;&#41;&#46; The rate of success was 96&#37;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Discussion</span><p id="par0080" class="elsevierStylePara elsevierViewall">Although whole-body ultrasound examination was mainly developed for adults&#44; in pediatric patients it may help evaluating cardiac function and volemia&#44; performing cardiopulmonary resuscitation &#40;protocol FEER&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a> monitoring and guiding endotracheal intubation &#40;protocol TRUE&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a> assessing pleural and pulmonary involvement&#44; detecting free fluid in the peritoneum &#40;protocol FAST&#41;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">9</span></a> and guiding invasive procedures such as vascular access&#44; thoracocentesis&#44; pericardiocentesis&#44; endotracheal intubation or lumbar puncture&#44; in a safer and easier way at the bedside&#46; Advances in vascular visualization lead to a more widespread use of vascular ultrasound as a helpful tool for central vascular access in critical pediatric patients&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Cannulation of central vessels in critical pediatric patients is a usual technique in Pediatric Intensive Care&#44; Anestesiology and Emergency Services&#46; In general&#44; &#8220;blind&#8221; vascular access is performed&#44; which is not free of complications&#44; even for most experienced profesionals&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a> It is widely accepted that ultrasound-guided central vascular access is associated with higher success and lower complication rates&#44; as well as higher quality and safety for pediatric patients in the Intensive Care Unit&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">11&#8211;13</span></a> Actually&#44; the &#8220;Guidelines on the use of ultrasound guidance for vascular access&#8221; recommended that cannulation of the internal jugular vein and the femoral vein in pediatric patients should be performed under ultrasound guidance&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a> and other consensus document for training in ultrasound-guided vascular access have recently been published&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">14&#8211;18</span></a> The Agency for Healthcare Research and Quality confirmed that training in central vessel cannulation&#44; both &#8220;blind&#8221; or ultrasound-guided&#44; reduces the required number of vessel punctures and the associated complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1&#44;15</span></a> Compared with performing ultrasound-guided puncture directly to the patient at the bedside&#44; training with an experimental model is less stressful and risky and offers an opportunity to improve ultrasound use&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a> All of this contributes to the safety of invasive procedures in critical pediatric patients&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Our model obtain similar outcomes than others publications in pediatrics patients or in training models of ecoguided vascular access at the time of correct location&#44; though his rate of success is 100&#37; as in another model of training&#44; but in this one the mean diameter of the vessels was 8<span class="elsevierStyleHsp" style=""></span>mm&#44; bigger than that of our model&#46; The number of attempts ranges between 1 and 3 similar to our study and the maneuver to facilitate the location of the catheter is the replacement of the needle and the guide&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">19&#8211;20</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The here-presented training model is low cost and readily available to any service of critical patient transfer&#44; anesthesiology&#44; intensive care or emergency care with an ultrasound equipment and suitable probe for vascular puncture&#44; where vascular access is regularly performed and whose personnel need training&#46; Additionally&#44; this model is helpful to improve ultrasound use and probe sterilization and protection skills&#44; as well as &#8220;eye-hand&#8221; coordination&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a> Furthermore&#44; the puncture and cannulation procedures can be repeated many times and several operators can work on a model system&#44; since several tube-like structures can be placed&#44; as necessary&#46; Though the model this one designed for pediatric patients&#44; can apply without problems in adult patients fitting the depths &#40;1&#46;50&#8211;1&#46;75<span class="elsevierStyleHsp" style=""></span>cm&#41; and vascular diameters &#40;0&#46;8&#8211;1<span class="elsevierStyleHsp" style=""></span>cm&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Several synthetic &#40;silicone&#44; gelatin&#44; latex&#41; and tissue models &#40;chicken&#44; turkey or pork thigh &#8211; &#8220;pork belly&#8221;&#41;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">3&#44;6&#44;16</span></a> are commercially available for training in ultrasound-guided vascular access&#46; However&#44; unlike other models where semi-rigid plastic structures &#40;cannulae or probes&#41; are used to simulate the vessels&#44; in our model the feeling is closely similar to that of puncturing pediatric patients on the usual zones &#40;cervical&#44; infraclavicular&#44; brachial or inguinal&#41;&#44; both in the muscular and vascular structures&#46; Furthermore&#44; the path of the needle is not marked and vascular fluid extravasation does not affect visualization&#44; as it happens in synthetic models&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">One of the limitations of the model &#8211; just like other mentioned models &#8211; is the fact that the anatomical structure &#40;avian chest muscle&#41; does not vary&#44; whereas the structures of real pediatric patients may vary in size&#44; location &#40;cervical&#44; inguinal&#44; brachial&#41;&#44; mobility or restlessness &#40;except in sedated patients&#41;&#46; Moreover&#44; unlike real pediatric patients&#44; the model remains motionless&#44; which facilitates ultrasound visualization and guidance of vascular cannulation&#46; However&#44; in our opinion the model is a helpful training tool&#44; both for physicians experienced in the traditional &#8220;blind&#8221; technique and residents who are starting with vascular access&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conclusions</span><p id="par0110" class="elsevierStylePara elsevierViewall">The here-presented experimental model for ultrasound-guided vascular access is rather similar to the vascular structures of pediatric patients in terms of vessel anatomy&#44; depth and diameter in relation to body weight&#46; It also facilitates ultrasound-guided vascular cannulation and supports the learning curve to acquire the required skills&#46; Furthermore&#44; the model allows for needle path visualization and correction when necessary&#46; On the basis of these conclusions&#44; we postulate that our experimental model may be considered and used as reliably as other available models&#44; such as the &#8220;pork belly&#8221;&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a> for training in ultrasound-guided vascular access&#46; In future studies&#44; we expect to collect data to confirm whether training with this experimental model reduces the complication rates associated with vascular access in critical pediatric patients&#44; thus enhancing children safety&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conflicts of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors report no conflicts of interest&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Central vascular cannulation is not a risk-free procedure&#44; especially in pediatric patients&#46; Newborn and infants are small and low-weighted&#44; their vascular structures have high mobility because of tissue laxity and their vessels are superficial and with small diameter&#46; These characteristics&#44; together with the natural anatomical variability and poor collaboration of small children&#44; make this technique more difficult to apply&#46; Therefore&#44; ultrasound imaging is increasingly being used to locate vessels and guide vascular access in this population&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">&#40;a&#41; To present a model that simulates the vascular system for training ultrasound-guided vascular access in pediatrics patients&#59; &#40;b&#41; to ultrasound-guided vascular cannulation in the model&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The model consisted of two components&#58; &#40;a&#41; muscular component&#58; avian muscle&#44; &#40;b&#41; vascular component&#58; elastic tube-like structure filled with fluid&#46; 864 ecoguided punctures was realized in the model at different vessel depth and gauge measures were simulated&#44; for two medical operators with different degree of experience&#46; The average depth and diameter of vessel cannulated were 1&#46;16 &#40;0&#46;42&#41;<span class="elsevierStyleHsp" style=""></span>cm and 0&#46;43 &#40;0&#46;1&#41;<span class="elsevierStyleHsp" style=""></span>cm&#44; respectively&#46; The average number of attempts was of 1&#46;22 &#40;0&#46;62&#41;&#46; The percentage of visualization of the needle was 74&#37;&#46; The most frequent maneuver used for the correct location&#44; was the modification of the angle of the needle and the relocation of the guidewire in 24&#37; of the cases&#46; The average time for the correct cannulations was 41 &#40;35&#46;8&#41;<span class="elsevierStyleHsp" style=""></span>s&#46; The more frequent complications were the vascular perforation &#40;11&#46;9&#37;&#41; and the correct vascular puncture without possibility of introducing the guidewire &#40;1&#46;2&#37;&#41;&#46; The rate of success was 96&#37;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The model simulates the anatomy &#40;vascular and muscular structures&#41; of a pediatric patient&#46; It is cheap models&#44; easily reproducible and a useful tool for training in ultrasound-guided puncture and cannulation&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La canalizaci&#243;n vascular central es una t&#233;cnica no exenta de riesgos sobretodo en la poblaci&#243;n de los pacientes pedi&#225;tricos&#46; El tama&#241;o y peso de los pacientes m&#225;s peque&#241;os &#40;reci&#233;n nacidos y lactantes&#41;&#44; la mayor movilidad de algunas de sus estructuras vasculares&#44; la posici&#243;n m&#225;s superficial y di&#225;metros m&#225;s peque&#241;os de sus vasos&#44; la variabilidad anat&#243;mica que pueden presentar&#44; asociado a la poca colaboraci&#243;n que presentan estos pacientes&#44; hace m&#225;s dif&#237;cil la realizaci&#243;n de esta t&#233;cnica&#46; A pesar de ello la ecograf&#237;a est&#225; instaur&#225;ndose para asistir a la realizaci&#243;n de la punci&#243;n vascular en dichos pacientes&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Objetivo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">a&#41; Dise&#241;ar un modelo experimental que permita la simulaci&#243;n vascular&#44; la punci&#243;n vascular ecodirigida y que sirva como m&#233;todo de aprendizaje y entrenamiento para la canalizaci&#243;n ecoguiada de los vasos sangu&#237;neos de los pacientes pedi&#225;tricos&#46; b&#41; Realizar la punci&#243;n ecoguiada en el modelo&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se presenta un modelo compuesto por una porci&#243;n muscular aviar a la que se introduce un sistema tubular el&#225;stico&#46; Se simulan distintas profundidades del vaso as&#237; como diferentes di&#225;metros de los mismos&#46; Se realizaron 864 punciones ecoguiadas en el modelo con diferentes niveles de profundidad y de di&#225;metro vascular por dos operadores con distinto grado de experiencia&#46; La media de profundidad y di&#225;metro de los vasos canalizados fue de 1&#44;6 &#40;0&#44;42&#41; cm y de 0&#44;43 &#40;0&#44;1&#41; cm respectivamente&#46; El n&#250;mero medio de intentos fue de 1&#44;22 &#40;0&#44;62&#41;&#46; El porcentaje de visualizaci&#243;n de la aguja fue del 74&#37;&#46; La maniobra m&#225;s frecuentemente utilizada para la correcta canalizaci&#243;n fue la recolocaci&#243;n de la aguja y la gu&#237;a en el 24&#37; de los casos&#46; El tiempo medio hasta la correcta canalizaci&#243;n fue de 41 &#40;35&#44;8&#41; segundos&#46; La complicaci&#243;n m&#225;s frecuente fue la perforaci&#243;n vascular &#40;11&#44;9&#37;&#41; y la adecuada punci&#243;n sin conseguir la introducci&#243;n de la gu&#237;a&#46; La tasa de &#233;xito fue del 96&#37;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El modelo presentado simula la anatom&#237;a &#40;estructuras vasculares y musculares&#41; del paciente pedi&#225;trico&#59; es barato&#44; f&#225;cilmente reproducible&#59; permite la canalizaci&#243;n y el aprendizaje de la t&#233;cnica de la punci&#243;n ecoguiada&#46;</p></span>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Performance of training model for ultrasound-guided vascular cannulation&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Vessel diameters &#40;D1&#8211;D3&#41; according to the degree of stretching with location clamps &#40;arrows&#41; of the elastic structure and their corresponding ultrasound image&#46;</p>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;65<span class="elsevierStyleHsp" style=""></span>cm &#40;0&#46;14&#41;&nbsp;\t\t\t\t\t\t\n
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
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