BACKGROUND: The use of ultrasound (US) guidance for radial artery cannulation has been shown to improve first attempt success rate, reduce time to successful cannulation, and reduce complications. We sought to determine whether properly trained respiratory therapists (RTs) could utilize US guidance for the placement of radial artery catheters. Primary outcome measurements were successful cannulation and first attempt success rate. Secondary outcomes included the effect of systolic blood pressure, prior attempts, palpable pulse strength, and gender in relation to USguided radial artery cannulation success rates. METHODS: RTs certified in arterial catheter insertion were trained in radial artery catheterization using US by emergency medicine physicians. Subjects were enrolled based on the need for an arterial catheter placement. The catheters and US devices used were standardized. Data recorded included pulse strength, systolic and diastolic blood pressure, number of attempts, and successful/unsuccessful artery cannulation. All catheterization attempts were performed according to institutional policy and procedure. RESULTS: One hundred twenty-two radial artery catheter insertion attempts were made between December of 2008 and October of 2011, in patients in whom the treating physician requested RT radial artery cannulation. The overall success rate was 86.1%, whereas the first attempt success rate was 63.1%. There was no difference found between the overall mean success rate for weak or absent pulses, age, systolic blood pressure, gender, or prior attempts. Conclusion: RTs can effectively utilize US technology to place radial artery catheters. Systolic blood pressure, prior attempts, and gender are not reliable predictors of success for US-guided radial artery cannulation. Training on the use of US should be strongly encouraged for all practitioners who place radial artery catheters.
IMPORTANCE Inhaled nitric oxide (iNO) is commonly administered for selectively inhaled pulmonary vasodilation and prevention of oxidative injury after lung transplant (LT). Inhaled epoprostenol (iEPO) has been introduced worldwide as a cost-saving alternative to iNO without high-grade evidence for this indication.OBJECTIVE To investigate whether the use of iEPO will lead to similar rates of severe/grade 3 primary graft dysfunction (PGD-3) after adult LT when compared with use of iNO.DESIGN, SETTING, AND PARTICIPANTS This health system-funded, randomized, blinded (to participants, clinicians, data managers, and the statistician), parallel-designed, equivalence clinical trial included 201 adult patients who underwent single or bilateral LT between May 30, 2017, and March 21, 2020. Patients were grouped into 5 strata according to key prognostic clinical features and randomized per stratum to receive either iNO or iEPO at the time of LT via 1:1 treatment allocation.INTERVENTIONS Treatment with iNO or iEPO initiated in the operating room before lung allograft reperfusion and administered continously until cessation criteria met in the intensive care unit (ICU). MAIN OUTCOMES AND MEASURESThe primary outcome was PGD-3 development at 24, 48, or 72 hours after LT. The primary analysis was for equivalence using a two one-sided test (TOST) procedure (90% CI) with a margin of 19% for between-group PGD-3 risk difference. Secondary outcomes included duration of mechanical ventilation, hospital and ICU lengths of stay, incidence and severity of acute kidney injury, postoperative tracheostomy placement, and in-hospital, 30-day, and 90-day mortality rates. An intention-to-treat analysis was performed for the primary and secondary outcomes, supplemented by per-protocol analysis for the primary outcome.RESULTS A total of 201 randomized patients met eligibility criteria at the time of LT (129 men [64.2%]). In the intention-to-treat population, 103 patients received iEPO and 98 received iNO. The primary outcome occurred in 46 of 103 patients (44.7%) in the iEPO group and 39 of 98 (39.8%) in the iNO group, leading to a risk difference of 4.9% (TOST 90% CI, -6.4% to 16.2%; P = .02 for equivalence). There were no significant between-group differences for secondary outcomes.CONCLUSIONS AND RELEVANCE Among patients undergoing LT, use of iEPO was associated with similar risks for PGD-3 development and other postoperative outcomes compared with the use of iNO.
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