Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil.
Emergency Medicine, Universidade Federal de São Paulo, São Paulo, Brazil.
Cochrane Database Syst Rev. 2021 Oct 12;10(10):CD013585. doi: 10.1002/14651858.CD013585.pub2.
Arterial vascular access is a frequently performed procedure, with a high possibility for adverse events (e.g. pneumothorax, haemothorax, haematoma, amputation, death), and additional techniques such as ultrasound may be useful for improving outcomes. However, ultrasound guidance for arterial access in adults is still under debate.
To assess the effects of ultrasound guidance for arterial (other than femoral) catheterisation in adults.
We searched CENTRAL, MEDLINE, Embase, LILACS, and CINAHL on 21 May 2021. We also searched IBECS, WHO ICTRP, and ClinicalTrials.gov on 16 June 2021, and we checked the reference lists of retrieved articles.
Randomised controlled trials (RCTs), including cross-over trials and cluster-RCTs, comparing ultrasound guidance, alone or associated with other forms of guidance, versus other interventions or palpation and landmarks for arterial (other than femoral) guidance in adults.
Two review authors independently performed study selection, extracted data, assessed risk of bias, and assessed the certainty of evidence using GRADE.
We included 48 studies (7997 participants) that tested palpation and landmarks, Doppler auditory ultrasound assistance (DUA), direct ultrasound guidance with B-mode, or any other modified ultrasound technique for arterial (axillary, dorsalis pedis, and radial) catheterisation in adults. Radial artery Real-time B-mode ultrasound versus palpation and landmarks Real-time B-mode ultrasound guidance may improve first attempt success rate (risk ratio (RR) 1.44, 95% confidence interval (CI) 1.29 to 1.61; 4708 participants, 27 studies; low-certainty evidence) and overall success rate (RR 1.11, 95% CI 1.06 to 1.16; 4955 participants, 28 studies; low-certainty evidence), and may decrease time needed for a successful procedure (mean difference (MD) -0.33 minutes, 95% CI -0.54 to -0.13; 4902 participants, 26 studies; low-certainty evidence) up to one hour compared to palpation and landmarks. Real-time B-mode ultrasound guidance probably decreases major haematomas (RR 0.35, 95% CI 0.23 to 0.56; 2504 participants, 16 studies; moderate-certainty evidence). It is uncertain whether real-time B-mode ultrasound guidance has any effect on pseudoaneurysm, pain, and quality of life (QoL) compared to palpation and landmarks (very low-certainty evidence). Real-time B-mode ultrasound versus DUA One study (493 participants) showed that real-time B-mode ultrasound guidance probably improves first attempt success rate (RR 1.35, 95% CI 1.11 to 1.64; moderate-certainty evidence) and time needed for a successful procedure (MD -1.57 minutes, 95% CI -1.78 to -1.36; moderate-certainty evidence) up to 72 hours compared to DUA. Real-time B-mode ultrasound guidance may improve overall success rate (RR 1.13, 95% CI 0.99 to 1.29; low-certainty evidence) up to 72 hours compared to DUA. Pseudoaneurysm, major haematomas, pain, and QoL were not reported. Real-time B-mode ultrasound versus modified real-time B-mode ultrasound Real-time B-mode ultrasound guidance may decrease first attempt success rate (RR 0.68, 95% CI 0.55 to 0.84; 153 participants, 2 studies; low-certainty evidence), may decrease overall success rate (RR 0.93, 95% CI 0.86 to 1.01; 153 participants, 2 studies; low-certainty evidence), and may lead to no difference in time needed for a successful procedure (MD 0.04 minutes, 95% CI -0.01 to 0.09; 153 participants, 2 studies; low-certainty evidence) up to one hour compared to modified real-time B-mode ultrasound guidance. It is uncertain whether real-time B-mode ultrasound guidance has any effect on major haematomas compared to modified real-time B-mode ultrasound (very low-certainty evidence). Pseudoaneurysm, pain, and QoL were not reported. In-plane versus out-of-plane B-mode ultrasound In-plane real-time B-mode ultrasound guidance may lead to no difference in overall success rate (RR 1.00, 95% CI 0.96 to 1.05; 1051 participants, 8 studies; low-certainty evidence) and in time needed for a successful procedure (MD -0.06 minutes, 95% CI -0.16 to 0.05; 1134 participants, 9 studies; low-certainty evidence) compared to out-of-plane B-mode ultrasound up to one hour. It is uncertain whether in-plane real-time B-mode ultrasound guidance has any effect on first attempt success rate or major haematomas compared to out-of-plane B-mode ultrasound (very low-certainty evidence). Pseudoaneurysm, pain, and QoL were not reported. DUA versus palpation and landmarks DUA may lead to no difference in first attempt success rate (RR 1.01, 95% CI 0.90 to 1.14; 666 participants, 2 studies; low-certainty evidence) or overall success rate (RR 0.99, 95% CI 0.92 to 1.07; 666 participants, 2 studies; low-certainty evidence) and probably increases time needed for a successful procedure (MD 0.45 minutes, 95% CI 0.20 to 0.70; 500 participants, 1 study; moderate-certainty evidence) up to 72 hours compared to palpation and landmarks. Pseudoaneurysm, major haematomas, pain, and QoL were not reported. Oblique-axis versus long-axis in-plane B-mode ultrasound Oblique-axis in-plane B-mode ultrasound guidance may increase overall success rate (RR 1.27, 95% CI 1.05 to 1.53; 215 participants, 2 studies; low-certainty evidence) up to 72 hours compared to long-axis in-plane B-mode ultrasound. It is uncertain whether oblique-axis in-plane B-mode ultrasound guidance has any effect on first attempt success rate, time needed for a successful procedure, and major haematomas compared to long-axis in-plane B-mode ultrasound. Pseudoaneurysm, pain, and QoL were not reported. We are uncertain about effects in the following comparisons due to very low-certainty evidence and unreported outcomes: real-time B-mode ultrasound versus palpation and landmarks (axillary and dorsalis pedis arteries), real-time B-mode ultrasound versus near-infrared laser (radial artery), and dynamic versus static out-of-plane B-mode ultrasound (radial artery).
AUTHORS' CONCLUSIONS: Real-time B-mode ultrasound guidance may improve first attempt success rate, overall success rate, and time needed for a successful procedure for radial artery catheterisation compared to palpation, or DUA. In addition, real-time B-mode ultrasound guidance probably decreases major haematomas compared to palpation. However, we are uncertain about the evidence on major haematomas and pain for other comparisons due to very low-certainty evidence and unreported outcomes. We are also uncertain about the effects on pseudoaneurysm and QoL for axillary and dorsalis pedis arteries catheterisation. Given that first attempt success rate and pseudoaneurysm are the most relevant outcomes for people who underwent arterial catheterisation, future studies must measure both. Future trials must be large enough to detect effects, use validated scales, and report longer-term follow-up.
动脉血管通路是一项经常进行的操作，有发生不良事件（例如气胸、血胸、血肿、截肢、死亡）的高可能性，并且超声等附加技术可能有助于改善结果。然而，超声引导在成人动脉（除股动脉外）置管中的应用仍存在争议。
评估超声引导成人（除股动脉外）动脉导管插入术的效果。
我们于 2021 年 5 月 21 日在 CENTRAL、MEDLINE、Embase、LILACS 和 CINAHL 上进行了检索。我们还于 2021 年 6 月 16 日在 IBECS、WHO ICTRP 和 ClinicalTrials.gov 上进行了检索，并检查了检索到的文章的参考文献列表。
随机对照试验（RCT），包括交叉试验和整群 RCT，比较了超声引导与其他形式的引导（包括单独使用和与其他形式联合使用）与其他干预措施或触诊和地标定位在成人（除股动脉外）动脉（腋动脉、足背动脉和桡动脉）置管中的效果。
两位综述作者独立进行了研究选择、数据提取、风险偏倚评估，并使用 GRADE 评估了证据的确定性。
我们纳入了 48 项研究（7997 名参与者），这些研究测试了触诊和地标定位、多普勒超声辅助（DUA）、实时 B 型超声直接引导或任何其他改良超声技术在成人（腋动脉、足背动脉和桡动脉）动脉置管中的应用。桡动脉实时 B 型超声与触诊和地标定位实时 B 型超声引导相比，可能提高首次尝试成功率（RR 1.44，95%CI 1.29 至 1.61；4708 名参与者，27 项研究；低质量证据）和总体成功率（RR 1.11，95%CI 1.06 至 1.16；4955 名参与者，28 项研究；低质量证据），并可能降低成功操作所需的时间（MD -0.33 分钟，95%CI -0.54 至 -0.13；4902 名参与者，26 项研究；低质量证据），与触诊和地标定位相比，可达 1 小时。实时 B 型超声引导可能降低主要血肿的发生率（RR 0.35，95%CI 0.23 至 0.56；2504 名参与者，16 项研究；中等质量证据）。与触诊和地标定位相比，实时 B 型超声引导对假性动脉瘤、疼痛和生活质量（QoL）可能没有影响（极低质量证据）。实时 B 型超声与 DUA 一项研究（493 名参与者）显示，实时 B 型超声引导可能提高首次尝试成功率（RR 1.35，95%CI 1.11 至 1.64；中等质量证据）和成功操作所需的时间（MD -1.57 分钟，95%CI -1.78 至 -1.36；中等质量证据），与 DUA 相比，可达 72 小时。实时 B 型超声引导可能提高总体成功率（RR 1.13，95%CI 0.99 至 1.29；低质量证据），与 DUA 相比，可达 72 小时。假性动脉瘤、主要血肿、疼痛和 QoL 没有报告。实时 B 型超声与改良实时 B 型超声 实时 B 型超声引导可能降低首次尝试成功率（RR 0.68，95%CI 0.55 至 0.84；153 名参与者，2 项研究；低质量证据），可能降低总体成功率（RR 0.93，95%CI 0.86 至 1.01；153 名参与者，2 项研究；低质量证据），并可能导致与改良实时 B 型超声引导相比，成功操作所需的时间没有差异（MD 0.04 分钟，95%CI 0.01 至 0.09；153 名参与者，2 项研究；低质量证据），可达 1 小时。与改良实时 B 型超声相比，我们不确定实时 B 型超声引导对主要血肿是否有影响（极低质量证据）。假性动脉瘤、疼痛和 QoL 没有报告。平面内与平面外 B 型超声 平面内实时 B 型超声引导可能导致总体成功率（RR 1.00，95%CI 0.96 至 1.05；1051 名参与者，8 项研究；低质量证据）和成功操作所需的时间（MD -0.06 分钟，95%CI -0.16 至 0.05；1134 名参与者，9 项研究；低质量证据）与平面外 B 型超声相比没有差异，可达 1 小时。与平面外 B 型超声相比，我们不确定平面内实时 B 型超声引导对首次尝试成功率或主要血肿是否有影响（极低质量证据）。假性动脉瘤、疼痛和 QoL 没有报告。DUA 与触诊和地标定位 DUA 可能导致首次尝试成功率（RR 1.01，95%CI 0.90 至 1.14；666 名参与者，2 项研究；低质量证据）或总体成功率（RR 0.99，95%CI 0.92 至 1.07；666 名参与者，2 项研究；低质量证据）没有差异，并且可能增加成功操作所需的时间（MD 0.45 分钟，95%CI 0.20 至 0.70；500 名参与者，1 项研究；中等质量证据），与触诊和地标定位相比，可达 72 小时。假性动脉瘤、主要血肿、疼痛和 QoL 没有报告。斜轴与长轴平面内 B 型超声 斜轴平面内 B 型超声引导可能提高总体成功率（RR 1.27，95%CI 1.05 至 1.53；215 名参与者，2 项研究；低质量证据），与长轴平面内 B 型超声相比，可达 72 小时。我们不确定斜轴平面内 B 型超声引导对首次尝试成功率、成功操作所需的时间和主要血肿是否有影响，与长轴平面内 B 型超声相比。假性动脉瘤、疼痛和 QoL 没有报告。由于极低质量证据和未报告的结局，我们对以下比较的效果不确定：实时 B 型超声与触诊和地标定位（腋动脉和足背动脉）、实时 B 型超声与近红外激光（桡动脉）、动态与静态平面外 B 型超声（桡动脉）。
与触诊或 DUA 相比，实时 B 型超声引导可能提高桡动脉置管的首次尝试成功率、总体成功率和成功操作所需的时间，并且可能降低主要血肿的发生率。然而，我们不确定其他比较中主要血肿和疼痛的证据，因为这是极低质量证据和未报告的结局。我们对腋动脉和足背动脉置管的假性动脉瘤和 QoL 影响也不确定。鉴于首次尝试成功率和假性动脉瘤是接受动脉置管术的人最相关的结局，未来的研究必须测量这两个结局。未来的试验必须足够大，以检测到效果，使用经过验证的量表，并报告更长期的随访。
