Landmark versus ultrasound-guided insertion of femoral venous catheters in the pediatric intensive care unit: An efficacy and safety comparison study

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Estella, I. Saralegui, O. Rubio Sanchiz, A. Hernández-Tejedor, V. López Camps, M.C. Martín, L. Cabré Pericas, N. Masnou Burralló, M. Recuerda Nuñez, J.L. Monzón" "autores" => array:10 [ 0 => array:2 [ "nombre" => "Á." "apellidos" => "Estella" ] 1 => array:2 [ "nombre" => "I." "apellidos" => "Saralegui" ] 2 => array:2 [ "nombre" => "O." "apellidos" => "Rubio Sanchiz" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Hernández-Tejedor" ] 4 => array:2 [ "nombre" => "V." "apellidos" => "López Camps" ] 5 => array:2 [ "nombre" => "M.C." "apellidos" => "Martín" ] 6 => array:2 [ "nombre" => "L." "apellidos" => "Cabré Pericas" ] 7 => array:2 [ "nombre" => "N." "apellidos" => "Masnou Burralló" ] 8 => array:2 [ "nombre" => "M." "apellidos" => "Recuerda Nuñez" ] 9 => array:2 [ "nombre" => "J.L." 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Pietroboni, C.M. Carvajal, Y.I. Zuleta, P.L. Ortiz, Y.C. Lucero, M. Drago, B. vonDessauer" "autores" => array:7 [ 0 => array:4 [ "nombre" => "P.F." "apellidos" => "Pietroboni" "email" => array:1 [ 0 => "pietroboni@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "C.M." "apellidos" => "Carvajal" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Y.I." "apellidos" => "Zuleta" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "P.L." "apellidos" => "Ortiz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Y.C." "apellidos" => "Lucero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "M." "apellidos" => "Drago" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 6 => array:3 [ "nombre" => "B." "apellidos" => "vonDessauer" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Graduate School of Universidad de Chile, Pediatric Intensive Care, Specialization Program, Santiago, Chile" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Research Unit, Luis Calvo Mackenna Hospital, Santiago, Chile" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Inserción tradicional versus eco-dirigida de catéteres venosos femorales en la unidad de cuidados intensivos pediátricos: un estudio comparativo de eficacia y seguridad" ] ] "textoCompleto" => "IntroductionCentral venous cannulation is common and necessary in pediatric intensive care. However, this procedure is not without risks or complications. Although CVCs have classically been placed following anatomical landmarks, the use of ultrasound guidance has largely replaced the latter, given its better profile of efficacy and safety, clearly demonstrated at least in adult populations.<a class="elsevierStyleCrossRefs" href="#bib0110">1,2</a>The use of ultrasound is well-known and respected, however, there are not large well-designed studies in this setting and there is more evidence in adults compared with pediatric population.<a class="elsevierStyleCrossRefs" href="#bib0120">3–5</a> In critically-ill pediatric patients data shows advantage of ultrasound guidance in the insertion of central catheters via the internal jugular vein access<a class="elsevierStyleCrossRefs" href="#bib0130">5–7</a>; regarding femoral approach, there are published two randomized studies<a class="elsevierStyleCrossRefs" href="#bib0145">8,9</a> comparing the landmark technique vs. the ultrasounds guidance, with inconclusive evidence for supporting one method over the other.As part of the quality search process in patient care and given the lack of evidence in this area, we designed a randomized multicenter study in the pediatric critical care unit (PICU) comparing the landmark (LM) with real-time ultrasound guidance (US) for inserting central venous catheters via the femoral approach. Our primary outcome is the cannulation rate at the first attempt of the CVC in the femoral vein, and secondary outcomes include successful insertion, number of attempts and incidence of femoral artery puncture.This work is registered in ClinicalTrials.gov identifier NTC02318940. Available at: <a href="https://clinicaltrials.gov/ct2/show/NTC02318940?term=02318940">https://clinicaltrials.gov/ct2/show/NTC02318940?term=02318940</a>; in addition, it has financing of the Research Unit, Luis Calvo Mackenna's Hospital, and East Department of the University of Chile.MethodStudy designMulticenter randomized prospective study in the PICUs of the “Roberto Del Río” and “Exequiel González Cortés” Children's Hospitals. Patients entered the study between February 2015 and November 2015, after signing their informed consent by their parents or legal representative. This study was reviewed and approved by the local institutional review board (IRB).PatientsAll the newly admitted patients who met criteria for admission to the PICU and who needed a central venous access according to the criteria of treating physician were enrolled in this study. Children younger than 7 days and older than 15 years, those had local infection at the puncture site, known anatomical and/or functional vascular alterations were excluded.Subgroup analysis will be considered a priori in patients younger than 6 months.Sample sizePrevious studies report an average success rate of 50% at the first attempt using the LM method, both in children and adults.<a class="elsevierStyleCrossRefs" href="#bib0150">9–11</a> Sample size is determined to improve the success rate by 30% using US guidance. To obtain a power of 80% in relation to success at the first attempt and with a confidence level of 95%, a number of 50 patients per branch was determined.Randomization methodRandomization was performed by blocks for each center, with the Stata® 12.0 Software. They were stored in sealed envelopes available 24h a day in the unit. The selection of the vein was according to the attending physician, and patients selected for femoral CVC insertion were included consecutively.OperatorThe insertion, LM and US, was performed by a pediatric intensivist or by a resident of the pediatric intensive care university program at the PICUs of the hospitals involved in this study.To standardize knowledge in the placement of the CVC, intensivists were trained in ultrasound-guided cannulation by an expert pediatric intensivist, consisting in 2h of theory time and two hours of practice time: this was performed in phantoms specially designed for pediatric patients with small vessels and using Mindray® ultrasound machines.Insertion method<a class="elsevierStyleCrossRef" href="#bib0165">12</a><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">-LM technique: In the supine position with external rotation and abduction of the lower extremity, the femoral artery is located by palpation in the femoral triangle and is punctured medially in the direction of the navel until it has reflux of venous blood.</li><li class="elsevierStyleListItem" id="lsti0010">-US Guidance: Ultrasound was performed to verify the patency and position of the target vessel before cannulation, which was performed using and in-plane or an out-plane technique (based on operator preference). The transductor and cable were covered by sterile material.</li></ul>Definitions<a class="elsevierStyleCrossRef" href="#bib0170">13</a><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015">-Successful cannulation: it was considered when the catheter is placed without difficulty in the femoral vein.</li><li class="elsevierStyleListItem" id="lsti0020">-Cannulation on the first attempt: it was considered when the CVC insertion is achieved at the first transcutaneous passage to the needle.</li><li class="elsevierStyleListItem" id="lsti0025">-Attempt of cannulation: it was considered an attempt to pass the needle without withdrawing or redirecting the needle with forward movement. Each successive removal or redirection with a forward movement was considered one separate attempt.</li><li class="elsevierStyleListItem" id="lsti0030">-Arterial puncture: The arterial puncture involves aspiration of pulsatile arterial blood for both methods, and also observing the needle in the artery in the US method.</li><li class="elsevierStyleListItem" id="lsti0035">-Rescue: After the fifth failed attempt in LM group, up to five attempts with ultrasound guidance were made in the same vein.</li></ul>Ultrasound machines and catheters<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0040">-US machine: For this study, a Sonosite® M-Turbo (Bothell, USA) equipped with a “7–10MHz” linear transducer (“Roberto del Río” Hospital) and a General Electric Vivid q (Bothell, USA) equipped with a 12MHz linear probe (“Exequiel Gonzales Cortes” Hospital) were used. Both US machines have software to improve the display of the needle.</li><li class="elsevierStyleListItem" id="lsti0045">-Catheter: the catheter was chosen based on patient size; 4 and 5F and 8cm length catheters were the most used.</li></ul>OutcomeThe main outcome was the insertion of the catheter at the first attempt; secondary outcome was the overall success in cannulation, number of attempts and, as a complication of the procedure, the rate of arterial puncture.Rescue was used after the 5th attempt in LM technique, changing to US Guidance.Failure to achieve access in both methods was considered as unsuccessful cannulation and the puncture site was change.Statistical analysisDescriptive analysis was performed for continuous variables with normal distribution using means and standard deviations, and continuous variables of not normal distribution and qualitative variables with medians and percentiles. For the primary outcome, proportions are compared for dichotomous variables using the Chi-square method. A value of p <0.05 will be considered significant. Stata® 12.0 Software will be used for statistical analysis.Multivariate Logistic Regression with Stepwise technique is performed in order to recognize independence of the method used in Outcome versus other variables that could be influencing the final result.ResultsNinety-nine patients were recruited, 50 in the US group and 49 in the LM group, one patient was lost during randomization. The characteristics of the patients were similar for both groups (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The success on the insertion of the catheter at the first attempt was significantly higher in the US group (US 42% vs. LM 18%, p 0.011) as well as overall cannulation success (US 84% vs. LM51% p <0.001) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). In relation to the number of attempts to achieve successful cannulation, again the ultrasound method was superior to the LM technique (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). While the protocol includes rescues, few of them were performed and thus a more thorough analysis cannot be performed<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>The multivariate logistic regression evaluates the participation of other variables contributing to the outcome, such as type of technique, operator experience, gender, age, nutritional status and the initial side chosen; among them, US Guidance was the only method predicting success in cannulation ((OR 5.04), 1.966–12.915, p 0.001).Regarding complications, femoral artery puncture was lower in the US group (5 patients) vs. 12 in LM group (p 0.056).DiscussionThis is the first randomized study conducted in general PICUs, with residents trained in vascular accesses guided by ultrasound, which is one of the strengths of this study.Similar to adults, the greatest risk factor for complications in children during venous catheterization is the number of attempts.<a class="elsevierStyleCrossRefs" href="#bib0175">14–16</a> The number of attempts is strongly associated with failure frequencies and complications. Mansfield et al.<a class="elsevierStyleCrossRef" href="#bib0190">17</a> observed that the complication rate at the first puncture is 4.3%, but in the second it increases to 24.0%. They recommend that if more than three attempts are required to cannulate the vein, a guidance method should be strongly considered since further attempts increases the risk of complications compared to successful cannulation in the first attempt.<a class="elsevierStyleCrossRefs" href="#bib0195">18,19</a>When comparing the results of our study with those published in femoral vein accesses,<a class="elsevierStyleCrossRefs" href="#bib0150">9,10,20,21</a> our success rate at the first attempt was low for both groups, especially in the LM technique. We believe that this is given by the strict definition of “cannulation attempt” since the fact of rearranging the needle in any direction means a new attempt, therefore the rate at the first attempt in the US is not so high either.Auoad et al.<a class="elsevierStyleCrossRef" href="#bib0150">9</a> shows success in cannulation of 95% in both methods, but the number of attempts reaches 8 in the US and 21 in the LM. In our work, it was limited to 5 attempts to reduce complications.The results obtained in our study reinforce what has already been demonstrated in the adult population,<a class="elsevierStyleCrossRefs" href="#bib0160">11,10,20</a> that the use of ultrasound increases the success rate and is associated with a lower risk of complications. When performing logistic regression, it is even more evident that the US method is associated with the success of the operator's independent installation, age, gender, nutritional status and the side chosen to be punctured.ConclusionsAccording to our results, the US-guidance insertion of CVCs via the femoral vein increases the likelihood of cannulation success, particularly at the first attempt and minimize the rate of arterial puncture. While it is intuitively recommended to incorporate this technology into the usual practice in the PICU, larger studies are needed to corroborate these findings, using the femoral vein as well as internal jugular and axillary-subclavian US-guidance approaches.Author's contributionPietro Pietroboni: Work design, protocol, supervision, execution, writing and sending documentsCristian Carvajal: Work design and protocol. Statistic analysisYuri Zuleta: Execution and translationPaula Ortiz: ExecutionBettina von Dessauer: DesignMichel Drago: ExecutionYalda Lucero: Design, revision and translationFinancial supportResearch Unit, Luis Calvo Mackenna Hospital.Conflict of interestsThe authors declare no conflict of interest." 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However, this procedure is not without risks or complications. Although CVCs have classically been placed following anatomical landmarks, the use of ultrasound guidance has largely replaced the latter, given its better profile of efficacy and safety, demonstrated at least in adult populations. ObjectivesTo compare the effectiveness and safety in the insertion of femoral central venous catheters guided by ultrasound (US) versus the anatomical method (LM) in critical care pediatric patients. Methods100 patients were randomized: 50 were assigned to the US group and 49 to the LM group. In the LM group the traditional method consisted in palpating the femoral artery pulse as a; in the US group the CVC was inserted using a real time technique. Success at the first attempt, overall success in cannulation, number of attempts and arterial puncture were the variables studied in both groups. ResultsSuccess at the first attempt and overall success in cannulation were significantly higher in the US group versus the LM (US 42% vs. LM 18%, p 0.011, US 84% vs. LM 51% p <0.001, respectively). The incidence of puncture of the femoral artery was lower in the US group (LM 12 vs. US 5, p 0.056) without achieving statistical significance. ConclusionsAccording to our results, the placement of central venous access via the femoral approach should be preferably performed under ultrasound guidance, however, further studies in larger populations are needed to confirm this findings." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objectives" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "AntecedentesLa instalación de un catéter venoso central (CVC) es una práctica común y necesaria en cuidados intensivos pediátricos. Sin embargo, dicho procedimiento no se encuentra carente de riesgos ni de complicaciones. Si bien clásicamente los CVC se han colocado siguiendo referencias anatómicas, el uso de la guía ecográfica ha reemplazado a este método, dado su mejor perfil de eficacia y seguridad, demostrado al menos en poblaciones adultas. ObjetivosComparar la efectividad y seguridad en la inserción de catéteres venosos centrales femorales guiados por ecografía (US) versus mediante el método anatómico (LM) en pacientes críticos pediátricos. MétodosSe aleatorizaron 100 pacientes: 50 se destinaron al grupo US y 49 al LM. En el grupo LM se usó el método tradicional palpando pulso femoral; en el grupo US se colocó el CVC guiado por ecografía en tiempo real. El éxito al primer intento, éxito global en la canulación, número de intentos y la punción arterial fueron las variables de estudio entre ambos grupos. ResultadosEl éxito al primer intento y el éxito global en la canulación fueron significativamente mayores en el grupo US versus LM (US 42% vs. LM 18%, p=0,011; US 84% vs. LM 51%, p<0,001, respectivamente). La incidencia de punción de la arteria femoral fue menor en el grupo US (LM 12 vs. US 5, p=0,056) sin lograr significación estadística. ConclusionesDe acuerdo con nuestros resultados, la colocación del acceso venoso central por vía femoral debiera realizarse bajo guía ecográfica, aunque se necesitan estudios en poblaciones más numerosas que confirmen dichos resultados." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivos" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "The research was done in the “Dr. Roberto del Río” and “Dr. Exequiel González Cortés” Children's Hospitals." ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "LM, landmark method.US real-time ultrasound guidance method.Data expressed in medians † and numbers ‡.There was no statistical difference between the two groups. Considering significant p-value <0.05." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">LM \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col">US \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n=49 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n=50 \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age (months)† \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Weight (kg)† \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Male (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">56 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nutritional E.‡</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Malnutrition \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Eutrophic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Overweight \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Obesity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2249792.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Patient characteristics." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "LM, landmark method.US real-time ultrasound guidance method.Data expressed in percentage.Considering significant p-value <0.05." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">LM \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">US \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p-Value \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cannulation on the first try (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.011 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Success in cannulation (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Arterial puncture (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.056 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2249793.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Outcomes." ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Test of homogeneity (equal odds): chi2=16.26. Pr>chi2=0.0027.Score test for trend of odds: chi2=10.59. Pr>chi2=0.0011.p<0.05 is considered clinically significant." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Number of attempts \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">LM \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">US \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Odds \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">IC-95% \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.333 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.06–5.09 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.500 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.52–13.29 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.666 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.18–2.36 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2249791.png" ] ] ] ] "descripcion" 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Landmark versus ultrasound-guided insertion of femoral venous catheters in the pediatric intensive care unit: An efficacy and safety comparison study

Inserción tradicional versus eco-dirigida de catéteres venosos femorales en la unidad de cuidados intensivos pediátricos: un estudio comparativo de eficacia y seguridad

P.F. Pietrobonia,

Corresponding author

pietroboni@gmail.com

Corresponding author.

, C.M. Carvajala, Y.I. Zuletaa, P.L. Ortiza, Y.C. Lucerob, M. Dragoa, B. vonDessauera

a Graduate School of Universidad de Chile, Pediatric Intensive Care, Specialization Program, Santiago, Chile

b Research Unit, Luis Calvo Mackenna Hospital, Santiago, Chile

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Central venous cannulation is common and necessary in pediatric intensive care&#46; However&#44; this procedure is not without risks or complications&#46; Although CVCs have classically been placed following anatomical landmarks&#44; the use of ultrasound guidance has largely replaced the latter&#44; given its better profile of efficacy and safety&#44; clearly demonstrated at least in adult populations&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The use of ultrasound is well-known and respected&#44; however&#44; there are not large well-designed studies in this setting and there is more evidence in adults compared with pediatric population&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">3&#8211;5</span></a> In critically-ill pediatric patients data shows advantage of ultrasound guidance in the insertion of central catheters via the internal jugular vein access<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">5&#8211;7</span></a>&#59; regarding femoral approach&#44; there are published two randomized studies<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">8&#44;9</span></a> comparing the landmark technique vs&#46; the ultrasounds guidance&#44; with inconclusive evidence for supporting one method over the other&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">As part of the quality search process in patient care and given the lack of evidence in this area&#44; we designed a randomized multicenter study in the pediatric critical care unit &#40;PICU&#41; comparing the landmark &#40;LM&#41; with real-time ultrasound guidance &#40;US&#41; for inserting central venous catheters via the femoral approach&#46; Our primary outcome is the cannulation rate at the first attempt of the CVC in the femoral vein&#44; and secondary outcomes include successful insertion&#44; number of attempts and incidence of femoral artery puncture&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">This work is registered in ClinicalTrials&#46;gov identifier NTC02318940&#46; Available at&#58; <a href="https://clinicaltrials.gov/ct2/show/NTC02318940?term=02318940">https&#58;&#47;&#47;clinicaltrials&#46;gov&#47;ct2&#47;show&#47;NTC02318940&#63;term&#61;02318940</a>&#59; in addition&#44; it has financing of the Research Unit&#44; Luis Calvo Mackenna&#39;s Hospital&#44; and East Department of the University of Chile&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Method</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Study design</span><p id="par0025" class="elsevierStylePara elsevierViewall">Multicenter randomized prospective study in the PICUs of the &#8220;Roberto Del R&#237;o&#8221; and &#8220;Exequiel Gonz&#225;lez Cort&#233;s&#8221; Children&#39;s Hospitals&#46; Patients entered the study between February 2015 and November 2015&#44; after signing their informed consent by their parents or legal representative&#46; This study was reviewed and approved by the local institutional review board &#40;IRB&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Patients</span><p id="par0030" class="elsevierStylePara elsevierViewall">All the newly admitted patients who met criteria for admission to the PICU and who needed a central venous access according to the criteria of treating physician were enrolled in this study&#46; Children younger than 7 days and older than 15 years&#44; those had local infection at the puncture site&#44; known anatomical and&#47;or functional vascular alterations were excluded&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Subgroup analysis will be considered a priori in patients younger than 6 months&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Sample size</span><p id="par0040" class="elsevierStylePara elsevierViewall">Previous studies report an average success rate of 50&#37; at the first attempt using the LM method&#44; both in children and adults&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">9&#8211;11</span></a> Sample size is determined to improve the success rate by 30&#37; using US guidance&#46; To obtain a power of 80&#37; in relation to success at the first attempt and with a confidence level of 95&#37;&#44; a number of 50 patients per branch was determined&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Randomization method</span><p id="par0045" class="elsevierStylePara elsevierViewall">Randomization was performed by blocks for each center&#44; with the Stata&#174; 12&#46;0 Software&#46; They were stored in sealed envelopes available 24<span class="elsevierStyleHsp" style=""></span>h a day in the unit&#46; The selection of the vein was according to the attending physician&#44; and patients selected for femoral CVC insertion were included consecutively&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Operator</span><p id="par0050" class="elsevierStylePara elsevierViewall">The insertion&#44; LM and US&#44; was performed by a pediatric intensivist or by a resident of the pediatric intensive care university program at the PICUs of the hospitals involved in this study&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">To standardize knowledge in the placement of the CVC&#44; intensivists were trained in ultrasound-guided cannulation by an expert pediatric intensivist&#44; consisting in 2<span class="elsevierStyleHsp" style=""></span>h of theory time and two hours of practice time&#58; this was performed in phantoms specially designed for pediatric patients with small vessels and using Mindray&#174; ultrasound machines&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Insertion method<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">12</span></a></span><p id="par0060" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">LM technique</span>&#58; In the supine position with external rotation and abduction of the lower extremity&#44; the femoral artery is located by palpation in the femoral triangle and is punctured medially in the direction of the navel until it has reflux of venous blood&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">US Guidance</span>&#58; Ultrasound was performed to verify the patency and position of the target vessel before cannulation&#44; which was performed using and in-plane or an out-plane technique &#40;based on operator preference&#41;&#46; The transductor and cable were covered by sterile material&#46;</p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Definitions<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">13</span></a></span><p id="par0075" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Successful cannulation</span>&#58; it was considered when the catheter is placed without difficulty in the femoral vein&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Cannulation on the first attempt</span>&#58; it was considered when the CVC insertion is achieved at the first transcutaneous passage to the needle&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Attempt of cannulation</span>&#58; it was considered an attempt to pass the needle without withdrawing or redirecting the needle with forward movement&#46; Each successive removal or redirection with a forward movement was considered one separate attempt&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Arterial puncture</span>&#58; The arterial puncture involves aspiration of pulsatile arterial blood for both methods&#44; and also observing the needle in the artery in the US method&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Rescue</span>&#58; After the fifth failed attempt in LM group&#44; up to five attempts with ultrasound guidance were made in the same vein&#46;</p></li></ul></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Ultrasound machines and catheters</span><p id="par0105" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">US machine</span>&#58; For this study&#44; a Sonosite&#174; M-Turbo &#40;Bothell&#44; USA&#41; equipped with a &#8220;7&#8211;10<span class="elsevierStyleHsp" style=""></span>MHz&#8221; linear transducer &#40;&#8220;Roberto del R&#237;o&#8221; Hospital&#41; and a General Electric Vivid q &#40;Bothell&#44; USA&#41; equipped with a 12<span class="elsevierStyleHsp" style=""></span>MHz linear probe &#40;&#8220;Exequiel Gonzales Cortes&#8221; Hospital&#41; were used&#46; Both US machines have software to improve the display of the needle&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Catheter</span>&#58; the catheter was chosen based on patient size&#59; 4 and 5F and 8<span class="elsevierStyleHsp" style=""></span>cm length catheters were the most used&#46;</p></li></ul></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Outcome</span><p id="par0120" class="elsevierStylePara elsevierViewall">The main outcome was the insertion of the catheter at the first attempt&#59; secondary outcome was the overall success in cannulation&#44; number of attempts and&#44; as a complication of the procedure&#44; the rate of arterial puncture&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Rescue was used after the 5th attempt in LM technique&#44; changing to US Guidance&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Failure to achieve access in both methods was considered as unsuccessful cannulation and the puncture site was change&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Statistical analysis</span><p id="par0135" class="elsevierStylePara elsevierViewall">Descriptive analysis was performed for continuous variables with normal distribution using means and standard deviations&#44; and continuous variables of not normal distribution and qualitative variables with medians and percentiles&#46; For the primary outcome&#44; proportions are compared for dichotomous variables using the Chi-square method&#46; A value of <span class="elsevierStyleItalic">p</span> &#60;0&#46;05 will be considered significant&#46; Stata&#174; 12&#46;0 Software will be used for statistical analysis&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Multivariate Logistic Regression with Stepwise technique is performed in order to recognize independence of the method used in Outcome versus other variables that could be influencing the final result&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Results</span><p id="par0145" class="elsevierStylePara elsevierViewall">Ninety-nine patients were recruited&#44; 50 in the US group and 49 in the LM group&#44; one patient was lost during randomization&#46; The characteristics of the patients were similar for both groups &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The success on the insertion of the catheter at the first attempt was significantly higher in the US group &#40;US 42&#37; vs&#46; LM 18&#37;&#44; <span class="elsevierStyleItalic">p</span> 0&#46;011&#41; as well as overall cannulation success &#40;US 84&#37; vs&#46; LM51&#37; <span class="elsevierStyleItalic">p</span> &#60;0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; In relation to the number of attempts to achieve successful cannulation&#44; again the ultrasound method was superior to the LM technique &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; While the protocol includes rescues&#44; few of them were performed and thus a more thorough analysis cannot be performed</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0150" class="elsevierStylePara elsevierViewall">The multivariate logistic regression evaluates the participation of other variables contributing to the outcome&#44; such as type of technique&#44; operator experience&#44; gender&#44; age&#44; nutritional status and the initial side chosen&#59; among them&#44; US Guidance was the only method predicting success in cannulation &#40;&#40;OR 5&#46;04&#41;&#44; 1&#46;966&#8211;12&#46;915&#44; <span class="elsevierStyleItalic">p</span> 0&#46;001&#41;&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Regarding complications&#44; femoral artery puncture was lower in the US group &#40;5 patients&#41; vs&#46; 12 in LM group &#40;<span class="elsevierStyleItalic">p</span> 0&#46;056&#41;&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Discussion</span><p id="par0160" class="elsevierStylePara elsevierViewall">This is the first randomized study conducted in general PICUs&#44; with residents trained in vascular accesses guided by ultrasound&#44; which is one of the strengths of this study&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Similar to adults&#44; the greatest risk factor for complications in children during venous catheterization is the number of attempts&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">14&#8211;16</span></a> The number of attempts is strongly associated with failure frequencies and complications&#46; Mansfield et al&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">17</span></a> observed that the complication rate at the first puncture is 4&#46;3&#37;&#44; but in the second it increases to 24&#46;0&#37;&#46; They recommend that if more than three attempts are required to cannulate the vein&#44; a guidance method should be strongly considered since further attempts increases the risk of complications compared to successful cannulation in the first attempt&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">18&#44;19</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">When comparing the results of our study with those published in femoral vein accesses&#44;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">9&#44;10&#44;20&#44;21</span></a> our success rate at the first attempt was low for both groups&#44; especially in the LM technique&#46; We believe that this is given by the strict definition of &#8220;cannulation attempt&#8221; since the fact of rearranging the needle in any direction means a new attempt&#44; therefore the rate at the first attempt in the US is not so high either&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Auoad et al&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">9</span></a> shows success in cannulation of 95&#37; in both methods&#44; but the number of attempts reaches 8 in the US and 21 in the LM&#46; In our work&#44; it was limited to 5 attempts to reduce complications&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">The results obtained in our study reinforce what has already been demonstrated in the adult population&#44;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">11&#44;10&#44;20</span></a> that the use of ultrasound increases the success rate and is associated with a lower risk of complications&#46; When performing logistic regression&#44; it is even more evident that the US method is associated with the success of the operator&#39;s independent installation&#44; age&#44; gender&#44; nutritional status and the side chosen to be punctured&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conclusions</span><p id="par0185" class="elsevierStylePara elsevierViewall">According to our results&#44; the US-guidance insertion of CVCs via the femoral vein increases the likelihood of cannulation success&#44; particularly at the first attempt and minimize the rate of arterial puncture&#46; While it is intuitively recommended to incorporate this technology into the usual practice in the PICU&#44; larger studies are needed to corroborate these findings&#44; using the femoral vein as well as internal jugular and axillary-subclavian US-guidance approaches&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Author&#39;s contribution</span><p id="par0190" class="elsevierStylePara elsevierViewall">Pietro Pietroboni&#58; Work design&#44; protocol&#44; supervision&#44; execution&#44; writing and sending documents</p><p id="par0195" class="elsevierStylePara elsevierViewall">Cristian Carvajal&#58; Work design and protocol&#46; Statistic analysis</p><p id="par0200" class="elsevierStylePara elsevierViewall">Yuri Zuleta&#58; Execution and translation</p><p id="par0205" class="elsevierStylePara elsevierViewall">Paula Ortiz&#58; Execution</p><p id="par0210" class="elsevierStylePara elsevierViewall">Bettina von Dessauer&#58; Design</p><p id="par0215" class="elsevierStylePara elsevierViewall">Michel Drago&#58; Execution</p><p id="par0220" class="elsevierStylePara elsevierViewall">Yalda Lucero&#58; Design&#44; revision and translation</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Financial support</span><p id="par0225" class="elsevierStylePara elsevierViewall">Research Unit&#44; Luis Calvo Mackenna Hospital&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Conflict of interests</span><p id="par0230" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Central venous cannulation &#40;CVC&#41; is common and necessary in pediatric intensive care&#46; However&#44; this procedure is not without risks or complications&#46; Although CVCs have classically been placed following anatomical landmarks&#44; the use of ultrasound guidance has largely replaced the latter&#44; given its better profile of efficacy and safety&#44; demonstrated at least in adult populations&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objectives</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To compare the effectiveness and safety in the insertion of femoral central venous catheters guided by ultrasound &#40;US&#41; versus the anatomical method &#40;LM&#41; in critical care pediatric patients&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">100 patients were randomized&#58; 50 were assigned to the US group and 49 to the LM group&#46; In the LM group the traditional method consisted in palpating the femoral artery pulse as a&#59; in the US group the CVC was inserted using a real time technique&#46; Success at the first attempt&#44; overall success in cannulation&#44; number of attempts and arterial puncture were the variables studied in both groups&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Success at the first attempt and overall success in cannulation were significantly higher in the US group versus the LM &#40;US 42&#37; vs&#46; LM 18&#37;&#44; <span class="elsevierStyleItalic">p</span> 0&#46;011&#44; US 84&#37; vs&#46; LM 51&#37; <span class="elsevierStyleItalic">p</span> &#60;0&#46;001&#44; respectively&#41;&#46; The incidence of puncture of the femoral artery was lower in the US group &#40;LM 12 vs&#46; US 5&#44; <span class="elsevierStyleItalic">p</span> 0&#46;056&#41; without achieving statistical significance&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">According to our results&#44; the placement of central venous access via the femoral approach should be preferably performed under ultrasound guidance&#44; however&#44; further studies in larger populations are needed to confirm this findings&#46;</p></span>"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Antecedentes</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La instalaci&#243;n de un cat&#233;ter venoso central &#40;CVC&#41; es una pr&#225;ctica com&#250;n y necesaria en cuidados intensivos pedi&#225;tricos&#46; Sin embargo&#44; dicho procedimiento no se encuentra carente de riesgos ni de complicaciones&#46; Si bien cl&#225;sicamente los CVC se han colocado siguiendo referencias anat&#243;micas&#44; el uso de la gu&#237;a ecogr&#225;fica ha reemplazado a este m&#233;todo&#44; dado su mejor perfil de eficacia y seguridad&#44; demostrado al menos en poblaciones adultas&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivos</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Comparar la efectividad y seguridad en la inserci&#243;n de cat&#233;teres venosos centrales femorales guiados por ecograf&#237;a &#40;US&#41; versus mediante el m&#233;todo anat&#243;mico &#40;LM&#41; en pacientes cr&#237;ticos pedi&#225;tricos&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">M&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se aleatorizaron 100 pacientes&#58; 50 se destinaron al grupo US y 49 al LM&#46; En el grupo LM se us&#243; el m&#233;todo tradicional palpando pulso femoral&#59; en el grupo US se coloc&#243; el CVC guiado por ecograf&#237;a en tiempo real&#46; El &#233;xito al primer intento&#44; &#233;xito global en la canulaci&#243;n&#44; n&#250;mero de intentos y la punci&#243;n arterial fueron las variables de estudio entre ambos grupos&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">El &#233;xito al primer intento y el &#233;xito global en la canulaci&#243;n fueron significativamente mayores en el grupo US versus LM &#40;US 42&#37; vs&#46; LM 18&#37;&#44; p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#61;</span><span class="elsevierStyleHsp" style=""></span>0&#44;011&#59; US 84&#37; vs&#46; LM 51&#37;&#44; p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;001&#44; respectivamente&#41;&#46; La incidencia de punci&#243;n de la arteria femoral fue menor en el grupo US &#40;LM 12 vs&#46; US 5&#44; p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#61;</span><span class="elsevierStyleHsp" style=""></span>0&#44;056&#41; sin lograr significaci&#243;n estad&#237;stica&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">De acuerdo con nuestros resultados&#44; la colocaci&#243;n del acceso venoso central por v&#237;a femoral debiera realizarse bajo gu&#237;a ecogr&#225;fica&#44; aunque se necesitan estudios en poblaciones m&#225;s numerosas que confirmen dichos resultados&#46;</p></span>"
        "secciones" => array:5 [
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          2 => array:2 [
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            "titulo" => "M&#233;todos"
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          3 => array:2 [
            "identificador" => "abst0045"
            "titulo" => "Resultados"
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          4 => array:2 [
            "identificador" => "abst0050"
            "titulo" => "Conclusiones"
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      ]
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">The research was done in the &#8220;Dr&#46; Roberto del R&#237;o&#8221; and &#8220;Dr&#46; Exequiel Gonz&#225;lez Cort&#233;s&#8221; Children&#39;s Hospitals&#46;</p>"
      ]
    ]
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">LM&#44; landmark method&#46;</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">US real-time ultrasound guidance method&#46;</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Data expressed in medians &#8224; and numbers &#8225;&#46;</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">There was no statistical difference between the two groups&#46; Considering significant <span class="elsevierStyleItalic">p</span>-value &#60;0&#46;05&#46;</p>"
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                  <table border="0" frame="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col">LM&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9&#46;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">55&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">56&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Nutritional E&#46;&#8225;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Malnutrition&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Obesity&nbsp;\t\t\t\t\t\t\n
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                  <table border="0" frame="\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Cannulation on the first try &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">18&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">42&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Success in cannulation &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#60;0&#46;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Arterial puncture &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">25&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
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                      "titulo" => "Guidance on the use of ultrasound locating devices for placing central venous catheters&#46; Technology Appraisal Guidance &#8211; No&#46;49"
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                          "etal" => true
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                            2 => "J&#46;L&#46; Apfelbaum"
                            3 => "R&#46;A&#46; Caplan"
                            4 => "R&#46;T&#46; Connis"
                            5 => "K&#46;B&#46; Domino"
                            6 => "L&#46;A&#46; Fleisher"
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                            3 => "J&#46; Wang"
                            4 => "M&#46;X&#46; Xu"
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                            2 => "A&#46; Mittnacht"
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                      "Revista" => array:6 [
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Article information

ISSN: 21735727
Original language: English

DOI:10.1016/j.medine.2019.07.006

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Year/Month	Html	Pdf	Total

2024 November	3	5	8
2024 October	60	66	126
2024 September	58	46	104
2024 August	63	62	125
2024 July	58	41	99
2024 June	56	57	113
2024 May	49	43	92
2024 April	42	40	82
2024 March	41	34	75
2024 February	32	40	72
2024 January	40	51	91
2023 December	31	42	73
2023 November	37	44	81
2023 October	38	38	76
2023 September	26	47	73
2023 August	22	19	41
2023 July	33	36	69
2023 June	21	17	38
2023 May	33	33	66
2023 April	35	22	57
2023 March	74	42	116
2023 February	45	35	80
2023 January	34	20	54
2022 December	55	32	87
2022 November	70	39	109
2022 October	45	40	85
2022 September	30	39	69
2022 August	37	36	73
2022 July	32	42	74
2022 June	31	26	57
2022 May	49	35	84
2022 April	34	43	77
2022 March	33	45	78
2022 February	47	29	76
2022 January	36	31	67
2021 December	35	49	84
2021 November	29	35	64
2021 October	53	69	122
2021 September	31	25	56
2021 August	22	27	49
2021 July	22	22	44
2021 June	33	18	51
2021 May	43	48	91
2021 April	112	81	193
2021 March	85	29	114
2021 February	44	25	69
2021 January	56	29	85
2020 December	32	25	57
2020 November	37	21	58
2020 October	13	12	25
2020 July	18	8	26
2020 June	18	12	30
2020 May	22	12	34
2020 April	22	13	35

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