Ultrasound-guided central venous catheter placement: a structured review and recommendations for clinical practice.
Saugel B , Scheeren TWL, Teboul JL | Crit Care.  2017 Aug 28;21(1):225
DOI: https://doi.org/10.1186/s13054-017-1814-y  | Télécharger l'article au format  
Keywords: Central venous access; Femoral vein; In plane; Internal jugular vein; Long axis; Out of plane; Short axis; Subclavian vein; Ultrasound

Review

Editorial : The use of ultrasound (US) has been proposed to reduce the number of complications and to increase the safety and quality of central venous catheter (CVC) placement. In this review, we describe the rationale for the use of US during CVC placement, the basic principles of this technique, and the current evidence and existing guidelines for its use. In addition, we recommend a structured approach for US-guided central venous access for clinical practice. Static and real-time US can be used to visualize the anatomy and patency of the target vein in a short-axis and a long-axis view. US-guided needle advancement can be performed in an "out-of-plane" and an "in-plane" technique. There is clear evidence that US offers gains in safety and quality during CVC placement in the internal jugular vein. For the subclavian and femoral veins, US offers small gains in safety and quality. Based on the available evidence from clinical studies, several guidelines from medical societies strongly recommend the use of US for CVC placement in the internal jugular vein. Data from survey studies show that there is still a gap between the existing evidence and guidelines and the use of US in clinical practice. For clinical practice, we recommend a six-step systematic approach for US-guided central venous access that includes assessing the target vein (anatomy and vessel localization, vessel patency), using real-time US guidance for puncture of the vein, and confirming the correct needle, wire, and catheter position in the vein. To achieve the best skill level for CVC placement the knowledge from anatomic landmark techniques and the knowledge from US-guided CVC placement need to be combined and integrated.

Conclusion : US guidance can improve patient safety and procedural quality during CVC placement in the IJV, FV, and SV. Based on evidence from clinical studies, several guide- lines of medical societies strongly recommend the use of US for CVC placement in the IJV. Data from survey studies show that there is still a gap between the existing evidence and guidelines and the use of US in clinical practice. We recommend a six-step systematic approach for US-guided central venous access. To achieve the best skill level for CVC placement the knowledge from ana- tomic landmark techniques and the knowledge from US-guided CVC placement need to be combined and integrated.

Conclusion (proposition de traduction) : Le guidage par échographie peut améliorer la sécurité du patient et la qualité de la procédure lors de la mise en place d'un cathéter veineux central dans la veine jugulaire interne, la veine fémorale et la veine sous-clavière.
Sur la base des résultats d'études cliniques, plusieurs recommandations de sociétés médicales recommandent fortement l'utilisation de l'échographie pour le placement du cathéter veineux central dans la veine jugulaire interne. Les données d’enquêtes montrent qu’il existe toujours un écart entre les preuves et les recommandations existantes et l’utilisation de l’échographie dans la pratique clinique.
Nous recommandons une approche systématique en six étapes pour la mise en place d'un l'accès veineux central guidé par échographie. Pour obtenir le meilleur niveau de compétence pour le placement du cathéter veineux central, il est nécessaire de combiner et d'intégrer les connaissances acquises grâce aux techniques de repérage anatomique et les connaissances acquises lors de la mise en place d'un cathéter veineux central guidé par échographie.

Commentaire : Revue intéressante et bien documentée qui propose un protocole en six points pour le guidage échographique de la pose d'un cathéter veineux central

Severe Hyperkalemia: Can the Electrocardiogram Risk Stratify for Short-term Adverse Events?.
Durfey N , Lehnhof B, Bergeson A, Durfey SNM, Leytin V, McAteer K, Schwam E, Valiquet J | West J Emerg Med.  2017 Aug;18(5):963-971
DOI: https://doi.org/10.5811/westjem.2017.6.33033  | Télécharger l'article au format  
Keywords: Aucun

Critical Care

Introduction : The electrocardiogram (ECG) is often used to identify which hyperkalemic patients are at risk for adverse events. However, there is a paucity of evidence to support this practice. This study analyzes the association between specific hyperkalemic ECG abnormalities and the development of short-term adverse events in patients with severe hyperkalemia.

Méthode : We collected records of all adult patients with potassium (K+) ≥6.5 mEq/L in the hospital laboratory database from August 15, 2010, through January 30, 2015. A chart review identified patient demographics, concurrent laboratory values, ECG within one hour of K+ measurement, treatments and occurrence of adverse events within six hours of ECG. We defined adverse events as symptomatic bradycardia, ventricular tachycardia, ventricular fibrillation, cardiopulmonary resuscitation (CPR) and/or death. Two emergency physicians blinded to study objective independently examined each ECG for rate, rhythm, peaked T wave, PR interval duration and QRS complex duration. Relative risk was calculated to determine the association between specific hyperkalemic ECG abnormalities and short-term adverse events.

Résultats : We included a total of 188 patients with severe hyperkalemia in the final study group. Adverse events occurred within six hours in 28 patients (15%): symptomatic bradycardia (n=22), death (n=4), ventricular tachycardia (n=2) and CPR (n=2). All adverse events occurred prior to treatment with calcium and all but one occurred prior to K+-lowering intervention. All patients who had a short-term adverse event had a preceding ECG that demonstrated at least one hyperkalemic abnormality (100%, 95% confidence interval [CI] [85.7-100%]). An increased likelihood of short-term adverse event was found for hyperkalemic patients whose ECG demonstrated QRS prolongation (relative risk [RR] 4.74, 95% CI [2.01-11.15]), bradycardia (HR<50) (RR 12.29, 95%CI [6.69-22.57]), and/or junctional rhythm (RR 7.46, 95%CI 5.28-11.13). There was no statistically significant correlation between peaked T waves and short-term adverse events (RR 0.77, 95% CI [0.35-1.70]).

Conclusion : Our findings support the use of the ECG to risk stratify patients with severe hyperkalemia for short-term adverse events.

Conclusion (proposition de traduction) : Nos résultats appuient l'utilisation de l'ECG pour stratifier les patients présentant une hyperkaliémie grave pour les événements indésirables à court terme.

Commentaire : Il est intéressant de noter que tous les patients qui avaient une tachycardie ventriculaire ou une bradycardie extrême et qui ont bénéficié du gluconate de calcium, ont été améliorés et n’ont pas eu d’événements indésirables graves.