A COMPARATIVE STUDY OF RADIAL ARTERY CANNULATION BY ULTRASOUND GUIDANCE VERSUS
PALPATION TECHNIQUE IN ADULTS
Dissertation submitted to
THE TAMILNADU DR.M.G.R MEDICAL UNIVERSITY CHENNAI-600032
With partial fulfilment of the requirements for the award of M.D.DEGREE IN
ANAESTHESIOLOGY BRANCH X
COIMBATORE MEDICAL COLLEGE COIMBATORE
MAY 2019
DECLARATION
I Dr.S. Rakupathy, solemnly declare that the dissertation entitled “A COMPARATIVE STUDY OF RADIAL ARTERY CANNULATION BY ULTRASOUND GUIDANCE VERSUS PALPATION TECHNIQUE IN ADULTS” is a bonafide work done by me at Coimbatore Medical College Hospital during the year June2017 to May2018 under the guidance & supervision of Dr.K.Kalyanasundaram,M.D Associate Professor, Department of Anaesthesiology, Coimbatore Medical College & Hospital. The dissertation is submitted to Dr.MGR Medical University towards partial fulfilment of requirement for the award of MD degree branch X Anaesthesiology.
PLACE: Dr.S.Rakupathy
DATE
CERTIFICATE
This is to certify that the dissertation entitled “A COMPARATIVE STUDY OF RADIAL ARTERY CANNULATION BY ULTRASOUND GUIDANCE VERSUS PALPATION TECHNIQUE IN ADULTS” is a bonafide original work done by Dr.S . R a k u p a t h y , Post graduate student in the Department of Anaesthesiology, Coimbatore Medical College Hospital, Coimbatore under the guidance of Dr.K.Kalyanasundaram, M.D.,Associate Professor, Department of Anaesthesiology, Coimbatore Medical College Hospital, Coimbatore in partial fulfilment of the regulations for the Tamilnadu DR.M.G.R Medical University, Chennai towards the award of MD., degree (Branch X.) Anaesthesiology.
Date : GUIDE
Dr.K.Kalyanasundaram, M.D., Associate Professor,
Department of Anaesthesiology
Coimbatore Medical College and Hospital.
Date : Dr.K.Santha Arulmozhi, M.D., D.A.,
Professor and HOD,Department of Anaesthesiology Coimbatore Medical College and Hospital.
Date : Dr.B.Asokan, M.S., Mch.,
Dean,
Coimbatore Medical College and hospital, Coimbatore.
COPYRIGHT
Declaration by the Candidate
I here by declare that The Tamilnadu DR.M.G.R Medical University, Chennai shall have the rights to preserve, use and disseminate this dissertation / thesis in print or electronic format for academic / research purpose.
PLACE:COIMBATORE Dr.S.Rakupathy
DATE:
ACKNOWLEDGEMENT
I solicit my humble thanks to the Dean Dr.B.Asokan,M.S., Mch., Coimbatore Medical College Hospital, for allowing me to conduct the study in this hospital.
I am also immensely thankful to Prof.Dr.K.SanthaArulmozhi., M.D., D.A., Professor and HeadoftheDepartment,Anaesthesiology,forher invaluable guidance, motivationand helpthroughoutthestudy. I am deeply grateful to Associate Prof. Dr.K.Kalyanasundaram, M.D., for his valuable guidance in preparing this dissertation. I also thank my co-guide Dr.Sathisha Kumar., M.D., for helping and guiding me in conducting this study.
I am thankful to all assistant professors for their guidance and help. I am thankful to all my colleagues for the help rendered in carrying out this dissertation.
Dr.S.Rakupathy
TABLE OF CONTENTS
S.NO CONTENTS PAGE
1. INTRODUCTION 1
2. REVIEW OF LITERATURE 2
3. AIM AND OBJECTIVES OF THE STUDY 3
4. MATERIALS AND METHODS 28
5. OSBSERVATION AND RESULT 39
6. DISCUSSION 51
7. SUMMARY 59
8. CONCLUSION 60
9. BIBLIOGRAPHY 61
10. ANNEXURES 65
PROFORMA CONSENT FORM
KEY TO MASTER CHART MASTER CHART
LIST OF TABLES
SL.NO TABLES PAGE NO
1 VARIABLES AND THEIR STATISTICAL TESTS 38 2 FREQUENCY DISTRIBUTION OF AGE IN DP GROUP 39 3 FREQUENCY DISTRIBUTION OF FIRST ATTEMPT
SUCCESSFUL PLACEMENT IN DP GROUP 40 4 FREQUENCY OF SUCCESSFUL CANNULATION AT
SAME RADIAL ARTERY IN DP 41
5 FREQUENCY OF TOTAL NUMBER OF ATTEMPTS IN
DP GROUP 42
6 TIME TO SUCCESSFUL CANNULATION IN DP
GROUP 43
7 PERCENTAGE OF COMPLICATIONS IN DP GROUP 44 8 FREQUENCY DISTRIBUTION OF AGE IN US GROUP 45 9 FREQUENCY DISTRIBUTION OF FIRST ATTEMPT
SUCCESSFUL CANNULATION IN US GROUP 46 10 FREQUENCY OF SUCCESSFUL CANNULATION AT
SAME RADIAL ARTERY IN US GROUP 47
11 FREQUENCY OF TOTAL NUMBER OF ATTEMPTS IN
US GROUP 48
12 TIME TO SUCCESSFUL CANNULATION IN US
GROUP 49
13 PERCENTAGE OF COMPLICATIONS IN US GROUP 50 14 STATISTICAL COMPARISON BETWEEN BOTH THE
GROUPS 51
LIST OF FIGURES SL .
NO
FIGURE PAGE
NO.
1. COURSE OF BRACHIAL ARTERY AND ITS BRANCHES
7 2. CROSS SECTION OF WRIST JOINT
9 3. SUPERFICIAL AND DEEP PALMAR ARCH
10 4.
ARTERIAL CANNULA-VYGON ARTERIAL LEADER
CATHETER 11
5. ARTERIAL CANNULA-BD20G
12 6. ARTERIAL CANNULA-UTECH CATHETER
13 7. ARTERIAL CANNULA-BD VENFLON CATHETER
13
8. BASIC COMPONENTS OF TRANSDUCER
18
9. LINEAR TRANSDUCER
19
10. NORMAL ARTERIAL PRESSURE WAVEFORM
21
11. FOURIER WAVES
23
12. ARTERIAL PRESSURE DAMPENING
24
13.
ARTERIAL CATHETER TRANSDUCER-MONITORING
SET UP 25
14. SELDINGER TECHNIQUE
29
15.
PROBE POSITIONING DURING NEEDLE INSERTION
PICTORIAL 33
16.
PROBE POSITIONING DURING NEEDLE INSERTION
PHOTOGRAPHICAL 34
LIST OF GRAPHS
S.NO GRAPHS PAGE NO.
1. DISTRIBUTION OF GENDER BETWEEN TWO GROUPS 52
2. FREQUENCY OF COMPLICATIONS BETWEEN TWO GROUPS
53
3. FREQUENCY OF TOTAL NUMBER OD ATTEMPOTS IN DP GROUP
54
4. FREQUENCY OF TOTAL NUMBER OD ATTEMPOTS IN US GROUP
55
LIST OF ABBREVIATIONS
NIBP : Non Invasive Blood Pressure IBP : Invasive Blood Pressure RCT : Randomised Control Trial RR : Risk Ratio
CI : Confidence Interval ER : Emergency Room US : UltraSound
DP : DirectPalpation
1
INTRODUCTION
Arterial blood pressure is a basic vital sign routinely measured in all patients. Blood pressure can be measured either by non-invasive or invasive methods.
Non invasive measurement done manually by sphygmomanometer, automatically by non invasive blood pressure devices and invasively by arterial line pressure transducer.
Arterial line cannulations are generally performed in patients mainly for invasive blood pressure monitoring and arterial blood sampling for arterial blood gas analysis. Invasive blood pressure monitoring is essential in major surgical patients in operation theatres and critically ill patients in intensive care units. Arterial blood gas analysis is done for managing acid base disturbances in sick patients.
Invasive blood pressure monitoring helps to identify beat to beat variability in blood pressure during major fluid shifts. Non-invasive and invasive methods employ different techniques to measure blood pressure, resulting in varied values even during simultaneous measurements.
In this study, arterial cannulations weredone by ultrasound and palpation techniques, and their success rates and associated complications, are compared and evaluated in detail.
2
OBJECTIVES
The study is undertaken to compare ultrasound guided versus palpation technique of radial artery cannulation in patients aged above 18 years during invasive blood pressure monitoring in major surgeries with respect to the following parameters:
Successful cannulation at first attempt
Successful cannulation at same radial artery
Total number of attempts
Time taken for successful cannulation
Complications
3
REVIEW OF LITERATURE
HISTORY
Daniel Bernoullie, Swiss mathematician : The first person to study fluid mechanics.
Bernoullie and Euler : Research on fluid flow and its pressure.
(Technique: Pipe wall punctured with straw (with open end) - fluid height in straw-measure of pressure in pipe).
1733 - Stephen Hales: First person to measure blood pressure in arteries of horses.
1828 - Jean-Louis Poiseuille : Measured pressure at certain points in the aortawithU tube filled with mercury.
1876 - Tomlinson :Invention of strain gauge.
1947 - Lambert and Wood : Arterial blood pressure transduction through strain gauge.
1949 - Peterson et al : Catheter over needle technique-capacitance manometer.
1951 - Peirce: Used polyethylene catheters for large artery catheterisation (percutaneous) in animals and humans.
1953 - Sven Seldinger: Catheter-over-wire technique.
4
Cheryl Peters et al1,cja, 2015 evaluated 125 patients posted for cardiac surgery in a randomised control trial. They were randomly divided into two groups. First group (n=62) was catheterized by Direct Palpation (DP)guided radial artery catheterization. Second group (n=63) was catheterized by Ultrasound (US)guided radial artery catheterization. Time taken for placement (104seconds vs 104 seconds), number of redirects (2 vs. 3), number of reattempts (1 vs 1) were almost same in both the groups. Ultrasound group (71.4%) had more first attempt success rate than the direct palpation (56.4%) group. Rate of failure in direct palpation group was 21.0% and Ultrasound group was 12.7%. It was concluded that ultrasound guided radial arterial catheterization did not have a significant effect on duration taken to insert, the number of re-directs, or the number of attempts , first attempt success, failure, or hematoma formation.
AminaNasreenet al2, 2016 evaluated 100 patients posted for open heart surgery. In this study the patients were divided into two groups. Group 1 was cannulated by using ultrasound. Group 2 was cannulated by using palpation method. The mean time taken for first successful attempt was 72.4 ± 23.0 seconds in Group 1 versus 94.6 ± 13.7 seconds in Group II (p=0.001). The total number of cannulations at same radial artery was much lesser in the ultrasound group (1.4 ± 1.0) compared to the palpation group (2.0 ± 0.7) (p=0.001). Group 1 had 72% successful insertion at the first attempt (36 patients) compared to 64% patients in Group II(32 patients), but the difference was not significant statistically (p = 0.391).
5
Ali Amar et al3, 2016 studied hundred patients who were posted for surgery.
They did a randomised prospective study. The patients were divided into two groups. First group was cannulated by palpation technique. The second group was cannulated using ultrasound. First attempt success at insertion was 88% in the ultrasound group and 70% in the palpation group. The time taken for insertion during the first attempt was longer in the palpation group (95.46±15.53 sec) and shorter in the ultrasound group (77.68±7.98 sec).
MoussaPacha H et al4{June 2018,AHJ}conducted a meta analysis of 12 randomised controlled trials for radial artery access using ultrasound versus palpation method.They analysed 2432 adults posted mainly for hemodynamic monitoring.In ultrasound group, high First attempt success rate (risk ratio [RR]
1.35, 95% CI 1.16-1.57]) and decreased failure rate (RR 0.52, 95% CI 0.32- 0.87) compared to palpation group. Total time for successful placement had no statistical significance between two groups.Hence they emphasised the regular usage of ultrasound for radial artery cannulation.
BhattarcharjeeS et al5{2018,JCA} conducted a meta analysis of 10 studies and analysed 1895 patients .The successful cannulation was same between ultrasound and digital palpation groups [OR (95% CI) 2.01 (1.00, 4.06);
p = 0.05].First attempt success reate was higher in ultrasound group [OR (95% CI) 2.76 (186, 4.10); p < 0.001]. And time to cannulation and the number of attempts has no statistical significance.They concluded that the first attempt success rate may be increased with ultrasound,but not the overall successful placement when compared to digital palpation method.
6
Shiver S6, et al. AcadEmerg Med 2006 conducted a randomised study at level 1 urban ER department in 60 patients. They randomised 30 patients each for ultrasound group and palpation group. With respect to time to cannulation, 107 seconds for US group and 314 seconds for palpation group, difference of 207 seconds (p=0.0004). Number of attempts , US group was 1.2 and palpation 2.2, difference 1 (p=0.001). Number of access sites 1.1 vs 1.6, difference 0.5 (p=0.001). They found that ultrasound was associated with frequent success and decreased complications.
ANATOMY
The brachial artery divides into radial and ulnar arteries at the level of radial head. The radial and ulnar artery provides the arterial supply of hand and wrist. The proximal two third of forearm is supplied by radial artery, which courses under supinator and brachioradialis. The distal part of radial artery is placed between flexor carpi radialis and supinator. It is also slightly wider in diameter in distal forearm compared to its origin. Around 5-7% of people have variationsin radial artery course.
7
Fig 1 :COURSE OF BRACHIAL ARTERY AND ITS BRANCHES
8
In distal forearm, the radial artery gives palmar carpal branch which anastamoses with palmar carpal branch of ulnar artery. Similarly dorsal carpal branch of radial artery anastamoses with its counterpart from ulnar artery to form dorsal carpal arch. The dorsal metacarpal arteries arises from dorsal carpal arch and anastamoses with palmar arches through perforating branches.
Deep palmar branch of ulnar artery anastamoses with the radial artery to form deep palmar arch which courses under the flexor tendons of forearm.
The ulnar artery terminates by forming superficial palmar arch with superficial palmar branch of radial artery. The superficial palmar arch lies superficial to flexor tendons. The deep palmar arch gives palmar metacarpal arteries which anastamoses with common palmar digital arteries arising from superficial palmar arch. The other two branches of radial artery are princepspollicis artery and radialisindicis artery which supplies thumb and lateral half of index finger.
The lateral half of index finger and third, fourth, fifth fingers are supplied by ulnar artery. In general, the superficial palmar arch is mainly formed by ulnarartery whereas the deep palmar arch is formed by radial artery.
The predominant four arterial anastamoses of the hand are 1. Superficial palmar arch
2. Deep palmar arch 3. Palmar carpal arch 4. Dorsal carpal arch
9
Superficial and deep palmar arches providethe major blood supply to the hand. These arches may be either interrupted or uninterrupted connections.
People with interrupted arches are prone to have ischemia of digits when either of the arterial supply is compromised.
Fig 2 :CROSS SECTION OF WRIST JOINT
10
Fig 3 :SUPERFICIAL AND DEEP PALMAR ARCH
11
ARTERIAL CANNULA
The cannula used in this study was VYGON ARTERIAL LEADER CATH Fig 4: ARTERIAL CANNULA-VYGON ARTERIAL LEADER
CATHETER
The cannulation kit consists of 1. Introducer needle 2. Guide wire
3. Catheter with winged hub.
12
SPECIFICATIONS :
20G size
80mm length
0.9mm outer diameter
24ml/min flow rate ADVANTAGES :
1. Introducer needle – naturally echogenic with triangular edge for precise insertion.
2. Guide wire – flexible, straight for safe entry into artery.
3. Catheter – transparent, X-ray contrast, pressure resistant material made of polyethylene, provides constant pressure signals and avoids damping of pressure waveforms.
4. Catheter hub – minimises catheter movement when safely secured within sterile dressing.
5. Latex free 6. Pyrogen free
13
The other arterial catheters widely used are 1. BD 20G arterial catheter
Fig 5 :ARTERIAL CANNULA-BD20G
2. UTECH Arterial catheter
Fig 6 :ARTERIAL CANNULA-UTECH CATHETER
14
3. BD 20G Venflon catheter
Fig 7 :ARTERIAL CANNULA-BD VENFLON CATHETER
INDICATIONS :
1. Continuous blood pressure monitoring 2. Blood sampling for arterial blood gas 3. Failure of NIBP
4. Additional details from waveform analysis ADVANTAGES OVER NIBP
1. Beat to beat variability-rapid intervention
2. Continuous NIBP monitoring-pain,petechiae,limbedema are avoided in IBP
3. Accurate and reliable
15
COMPLICATIONS OF ARTERIAL CANNULATION :
1. Distal ischemia 2. Hemorrhage
3. Arterial embolisation 4. Infection
5. Neuropathy 6. Equipment failure ULTRASONOGRAPHY
Ultrasonography is a non-invasive procedure using high frequency ultrasound waves to visualize the body structures.
PHYSICAL PROPERTIES
Sound waves are form of energy transmitted through a medium.
Frequency, velocity, wavelength explains the nature of a sound wave.
Frequency ( f )– number of cycles per second
Velocity ( v ) - the distance covered by a wave in unit time
Wavelength (λ) – Distance with which one wave cycle gets completed
Ultrasound uses (1 to 20 MHZ) high frequency waves which is well above the human ear limits (20,000 KHZ)
16
Frequency α 1 Wavelength Frequency α Resolution Frequency is independent of velocity
Frequency = Velocity Wavelength
17
PRINCIPLES:
1.Piezo Electric effect 2.Pulse Wave effect
In Piezo Electric effect, electric current is applied to the piezo electric crystals present in the transducer of ultrasound probe,which gets deformed and vibrate to generate ultrasound waves.The transducer crystals will determine the frequency of the waves
In Pulse wave effect the ultrasound waves are generated intermittently.
In between the pulses, the ultrasound wave which goes inside the patient comes back to the transducer and an image is produced.
ELECTRICAL CURRENT ELECTRICAL SIGNAL
ULTRASOUND PULSE
ECHO PULSE
REFLECTING SURFACE
I M A G E
18
TISSUE INTERACTION
.Atttenuation
Reflection
Scattering
Absorption
Refraction
Reflection :
The ultrasound waves that return from the patient towards the transducer produce the image.
Acoustic impedance of various adjacent structures will decide the proportion of the beam of ultrasound returning back from the tissue to the transducer.
Acoustic impedance = Sound wave’s Velocity × Density of the tissue
19
Scattering
Change in the direction of the ultrasound waves on hitting tiny structures which may be course or not smooth.
Frequency α Scattering
Refraction :
With variations in the density of tissues, the velocity of the ultrasound beam will change ,which in turn will lead to the bending of ultrasound beam causes refraction.This is noted as artefact
20
Attenuation It is the progressive decrease in the strength of the ultrasound wave as it courses into the patient
Absorption On entering the tissue a part of the sound energy is converted into heat energy
IMAGING MODES
A Mode (Amplitude)
B Mode (Brightness)
M Mode(Motion) A Mode (Amplitude)
In this mode the monitor shows the echoes that return in the form of spikes.
The amplitude of the wave is a direct measure of the height of the spike
B Mode (Brightness)
Here the waves are shown by dots on a line that generates an image
Brightness of the dots is a direct measure of the returned wave’s amplitude.
The location of the dots on the axis depends on the duration taken by each wave from the transducer to get transmitted and reflected back to the transducer.
B Mode is the most frequently used imaging mode
21
M Mode(Motion)
It uses single B mode line and the presence of dots in horizontal axis.
Commonly used in echocardiography to evaluate contractile function of heart
Transducers
Fig 8 :BASIC COMPONENTS OF TRANSDUCER
22
Linear probe
Linear arrangement of crystals-Rectangular image
High frequency sound waves
Better resolution
Poor penetration
CONTROLS
1.Gain control 2.Depth control
23
Gain control-
Uniform amplification of the intensity of ultrasound waves
Time gain control-Amplification of intensity at different depths
Seen as column of knobs
Arranged diagonally to generate desired image
Depth control-
To adjust the position of the desired structure in the image
ARTIFACTS
1.Acoustic shadowing
24
Acoustic shadowing occurs when the ultrasound beam enters gaseous or mineralised structure which prevents the entry of ultrasound waves, thereby creating anechoic shadow
2.Acoustic enhancement
Acoustic enhancement is the hyperechoic area distal to low attenuation structures.
3.Reverberation
Reverberation is the to and fro travel of ultrasound waves resulting in evenly spaced lines
+
25
ARTERIAL PRESSURE WAVEFORM
Arterial pressure wave is a longitudinal wave in which the particles move to and fro in the same direction and there is only transfer of energy.
Fig 9.1 : NORMAL ARTERIAL PRESSURE WAVEFORM-PARTS
26
Fig 9.2 : NORMAL ARTERIAL PRESSURE WAVEFORM-PHASES
27
ALTERNATIVE MONITORING SITES : 1. Ulnar artery
2. Brachial artery 3. Femoral artery
4. Less common sites are : 1.Dorsalispedis artery 2.Posteriortibial artery
3.Superficial temporal artery.
28
Fig 9.3 : NORMAL ARTERIAL PRESSURE WAVEFORM-IN VARIOUS ARTERIES
29
TRANSDUCER
Transducer is an instrument which changes electrical resistance in response to pressure change. It is placed in a circuit called Wheatstone bridge with three known resistances and the resistance change is converted into electrical voltage.
Fig.10.ARTERIAL PRESSURE TRANSDUCER
30
DYNAMIC PRESSURE MEASUREMENT
The arterial measurement system is compared to mass – spring harmonic oscillator.
The frequency at which the amplitude is maximum- resonant or natural frequency.
Amplitude α mass Friction
Optimal measurement of arterial waveform can have stiff tubings and short and small diameter tubings.
Natural frequency of commercial measurement systems is 10-15Hz, which is higher than the clinical heart rates.
The arterial waveform is not a sine wave. It is the addition of multiple harmonic sine waves called Fourier series.
31
Fig 11: FOURIER WAVES
Resonant frequency – 10 to 15 Hz
Damping coefficient – 0.4 to 0.5
Care should be taken to eliminate air bubbles as they increase friction.
Over damped pressure wave form-Increased damping co-efficient- decreased measured pressure.
Under damped pressure wave form-Low damping co-efficient-systolic pressure overshoot.
Damping co-efficient=amplitude ratio of successive peaks.
32
Fig 12. ARTERIAL PRESSURE DAMPENING
COMPONENTS
Arterial catheter
Extension tubing
Stop cock
Blood sampling set
Pressure transducer
Continuous flush device
33
Monitor
Stop cock-for blood sampling
Flush device -1 to 3 ml per hour to prevent thrombus formation in the catheter
Heparin 1 to 2 units per ml saline
Fig 13. ARTERIAL CATHETER TRANSDUCER-MONITORING SET UP
TRANSDUCER SET UP 1. Zeroing
2. Leveling
34
Zeroing
Flush the entire measurement tubing system with heparin saline, close the stop cock at patient end. Now expose the air fluid interface in the transducer to atmosphere, with continuous flushing of saline. Click the zeroing command on the monitor which ensures the pressure is equivalent to local atmospheric pressure.
Transducer calibration – improve the gain of measurement
Compare with manometer or non invasive pressure measurements.
2.Leveling
It is a process of equating zero reference to the patients body, where the measurements will start
Transducer Location:
At the level of heart or five cm posterior to sternum
Arterial pressure change with respect to transducer position:
1. When the position of the patient above the transducer –arterial pressure overshoots.
2. When the position of the patient below the transducer –arterial pressure underestimated.
35
Normal arterial pressure wave form 1. Upstroke
2. Peak
3. Dicrotic notch 4. Downstroke
Arterial pressure wave-Distal pulse amplification
When the pulse moves from heart towards periphery,systolic upstroke increases,dicrotic notch comes later,end diastole decreases which results in increase in pulse pressure.
36
MATERIALS AND METHODS
REQUIREMENTS :
1. Povidone iodine and chlorhexidine solution 2. Soft towel to keep under wrist
3. Strap to fix the fingers 4. Sterile towels and drapes 5. Sterile gloves
6. Local anaesthetic injection lignocaine 2% in 2ml syringe
7. Ultrasound machine with high frequency linear probe(8-10MHZ) in vascular mode[Mind Ray]
8. Tegaderm cover with gel
9. VYGON ARTERIAL LEADER CATH cannulation kit 10. Sterile gauges
11. Arterial pressure monitor with transducer- zeroed and kept ready 12. Extension tubings
13. Normal saline with heparin 14. Pressure bag
15. 10ml syringe for aspiration 16. Suture material.
37
TECHNIQUE OF ARTERIAL CANNULATION
SELDINGER TECHNIQUE
The arterial cannulation was done by conventional Seldinger technique in this study.In 1953, Sven IvarSeldinger, a Sweedish radiologist, introduced a technique for cannulation of medical devices into hollow organs and blood vessels and the procedure is named after him.
The Seldinger technique requires
1. Introducer needle 2. Guide wire 3. Catheter
Step 1 : Introduce the needle inside the vessel
Step 2 : Insert the guide wire into the hollow needle
Step 3 : Remove the needle with guide wire inside the vessel Step 4 : Thread catheter over the guide wire
Step 5 : Remove the guide wire out of the vessel
38
Fig 14: SELDINGER TECHNIQUE
39
TRANSFIXATION TECHNIQUE
The anterior and the posterior wall of the vessel is punctured intentionally. The needle withdrawn from the catheter,then the catheter is withdrawn until the pulsatile blood flow comes, and then advance the catheter into the vessel lumen.
The radial artery is used in this study because 1. Presence of collateral circulation
2. Easier landmark identification for palpation technique 3. Accessibility during surgery
4. Reliable straight course ALLEN’S TEST
Allen’s test is performed in patients prior to arterial cannulation to assess the adequacy of collateral circulation in hand. The patient is asked to make a fist of his/her hand desired for cannulation. After 5 minutes, both radial and ulnar arteries are occluded. When the patient opens his/her fisted hand, it appears blanched. Subsequently the occlusion over ulnar artery is released, and the time taken for reperfusion of hand is noted.
40
If <5 seconds - Allen’s test negative Adequacy of collateral circulation If >5 seconds – Allen’s test positive Collateral circulation inadequate – arterial cannulation not to be done in that artery.
The modified Allen’s test is done using pulse oximeter Fig 15: Modified Allen’s test
41
PREPARATION
1. Informed written consent.
2. Positioning the patient.
The Patient is placed in supine position,with upper limbs at right angles to the torso, resting on arm board.
A soft pad is kept under the wrist to dorsiflex the wrist joint.
The fingers are strapped to the arm board.
PALPATION TECHNIQUE :
1. The desired radial artery site is painted and draped.
2. The course of the radial artery is identified by palpation.
3. Local anaesthetic is injected intradermally and subcutaneously after negative aspiration for blood.
4. Arterial catheterisation is performed with guide wire catheter assembly.
42
ULTRASOUND TECHNIQUE
1. The patient is positioned in the same way.
2. Gel is placed over the ultrasound probe which is covered with tegaderm and disposable cover .
3. The field is painted and draped and the ultrasound probe is kept over the field with the help of assistant.
4. The probe is fixed at 70-80 degree angle in transverse view and the visualisation of radial artery in cross section is optimized.
5. The introducer needle is introduced into the radial artery and visualized at the centre of the lumen of the vessel.
6. When the needle is placed in optimal position within the lumen, the probe is tilted to longitudinal axis and the course of the radial artery is made out.
7. The catheter is advanced using Seldinger technique under real time ultrasound guidance.
43
Fig 16.1 : PROBE POSITIONING DURING NEEDLE INSERTION PICTORIAL
44
Fig 16.2 : PROBE POSITIONING DURING NEEDLE INSERTION PHOTOGRAPHICAL
45
METHODOLOGY
In this study, totally 100 patients were selected. They were randomly divided into two groups
1. Direct palpation group (DP) 2.Ultrasound group (US)
By using sealed envelope method.
All patients were above 18 years of age.
It is a prospective randomised controlled study.
The patients were explained about the procedure regarding advantages and complications associated with arterial pressure monitoring.
Informed written consent was obtained from all patients.
The patients were posted for major onco-surgeries, neurological procedures and open cardiothoracic procedures.
The study was started on July 4th, 2017 and completed on September 30th , 2018.
INCLUSION CRITERIA
- Adult patients aged above 18 years posted for major neurosurgeries,cardiac and oncosurgeries
- Weight 40-80kg
46
EXCLUSION CRITERIA - Patient refusal - Infection at the site - Bleeding disorders
- Patient not capable of giving consent (psychiatric patients) - Raynaud’s phenomenon
- Positive Modified Allen’s test
Patients were shifted inside the operating theatre on the day of surgery.
They were asked to lie on supine position on the operating table. The patients’
hands were placed on the arm boards. Standard monitors like non invasive blood pressure cuff, pulse oximeter, electrocardiographic leads were attached and baseline values recorded for all patients.
Patients were given premedication with anxiolytics.
The patients’ arms were positioned with dorsiflexion at the wrist joint and the hand is fixed to the arm board for arterial cannulation.
The desired site was painted and drapped. Under strict aseptic precautions, the course of the radial artery was identified by either direct palpation or by using ultrasound machine. After identification of the course of
47
artery, local anaesthetic drug injection lignocaine 2% was infiltrated at the local site intradermally and sub cutaneously after negative aspiration for blood.
Stop clock was started at the time of insertion of cannula and the time taken for cannulation attempts were noted. One cannulation time is taken as the duration from the insertion of the cannula to the successful placement of the catheter inside the radial artery.
The successful cannulation at first attempt was noted. If the first attempt failed, then the total number of attempts for successful cannulation were noted.
All patients were tried with left radial artery in the first attempt. The other radial artery was attempted when there was failure on the left side.
Complications like bleeding, haematoma, vasospasm, ischaemia, if any was noted.
All the variables were analysed using SPSS 20.0software.
48
Table 1.Variables and their Statistical Tests
S.NO VARIABLES STATISTICAL TEST
1 Successful cannulation at first attempt Fishers Exact test
2
Successful cannulation at same radial artery
Chi square test
3 Total number of attempts Fishers Exact test 4 Time to successful cannulation Paired –t-test
5 Complications Fishers Exact test
The parameters noted in this study were analysed using the above mentioned statistical tests, in order to compare both groups and to find out if the difference was statistically significant.
49
RESULTS
DIRECT PALPATION GROUP Table 2 Frequency Distribution of Age in DPGroup
Among the fifty patients in the DP group,the 75years and 25 years were the maximum and minimum ages respectively .The mean age in the DP group was 53.34
DIRECT PALPATION AGE (in years)
N 50
Maximum age 75
Minimum age 25
Range 50
Mean + SD 53.34 + 10.91
50
Table.3. Frequency distribution of successful cannulation at first attempt in DP Group
Successful cannulation at the first attempt was possible in 34% of the patients(n=17) in the DP group.Cannulation at first attempt was unsuccessful in 66% ot the patients(n=33) in the DP group.
SUCCESSFUL CANNULATION AT FIRST ATTEMPT
FREQUENCY(n) PERCENTAGE(%)
UNSUCCESSFUL 33 66.0
SUCCESSFUL 17 34.0
TOTAL 50 100.0
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Table.4.Frequency distribution of successful cannulation at same radial artery in DP Group
Successful cannulation at the same radial artery was possible in 76% of the patients (n=38) in DP group and the other radial artery had to be cannulated in 24% of patients(n=12)in the DP group.
SUCCESSFUL CANNULATION AT SAME RADIAL ARTERY
FREQUENCY(n) PERCENTAGE(%)
UNSUCCESSFUL 12 24.0
SUCCESSFUL 38 76.0
TOTAL 50 100.0
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Table 5.Frequency distribution of total number of attempts in DP Group
In the DP group 14% of the patients(n=7) needed more than three attempts for successful cannulation.
TOTAL NUMBER OFATTEMPTS
FREQUENCY(n) PERCENTAGE(%)
1 17 34.0
2 20 40.0
3 6 12.0
4 7 14.0
TOTAL 50 100.0
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Table 6.Time to successful cannulation in DP Group
The maximum time taken for successful cannulation in the DP group was 110 seconds and the minimum time taken for cannulation was 55 seconds. The mean time taken being 76.32 seconds.
TIME TO SUCCESFUL CANNULATION(in seconds)
Time(seconds)
N 50
Maximum time 110
Minimum time 55
Range 55
Mean + SD 76.32 +14.78
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Table 7.Percentage of complications in DP Group
Complications such as vasospasm and haematoma were present in 30%(n=15) and 2%(n=1) of the patients respectively, in the DP group.There was no complications at all in 68%(n=34) of the patients in this group
COMPLICATIONS FREQUENCY(n) PERCENTAGE(%)
NONE 34 68.0
VASOSPASM 15 30.0
HAEMATOMA 1 2.0
TOTAL 50 100.0
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ULTRASOUND GROUP
Table8.Frequency distribution of age in US Group
Among the fifty patients in the US group, 75years and 19 years were the maximum and minimum ages respectively .The mean age in the US group was 51.16.
US GROUP AGE (in years)
N 50
Maximum age 75
Minimum age 19
Range 56
Mean 51.16 + 11.89
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Table.9. Frequency distribution of successful cannulation at first attempt in US Group
Successful cannulation at the first attempt was possible in 60%of the patients(n=30) in the US group.Cannulation at first attempt was unsuccessful in 40% of the patients(n=20) in the US group
FIRST ATTEMPT SUCCESSFUL PLACEMENT
FREQUENCY (n)
PERCENTAGE (%)
UNSUCCESSFUL 20 40.0
SUCCESSFUL 30 60.0
TOTAL 50 100.0
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Table .10.Frequency distribution of successful cannulation at same radial artery in USGroup
SUCCESSFUL PLACEMENT AT SAME RADIAL ARTERY
FREQUENCY (n)
PERCENTAGE (%)
UNSUCCESSFUL 4 8.0
SUCCESSFUL 46 92.0
TOTAL 50 100.0
Successful cannulation at the same radial artery was possible in 92% of the patients (n=46) in US group and the other radial artery had to be cannulated in 8% of patients(n=4)in the US group.
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Table 11.Frequency distribution of total number of attempts in USGroup
Inthe US group 2% of the patients(n=1) needed more than three attempts for successful cannulation.
TOTAL NUMBER OFATTEMPTS
FREQUENCY (n)
PERCENTAGE (%)
1 30 60.0
2 14 28.0
3 5 10.0
4 1 2.0
TOTAL 50 100.0
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Table 12.Time to successful cannulation in US Group
The maximum time taken for successful cannulation in the US group was 95 seconds and the minimum time taken for cannulation was 55 seconds.
The mean time taken being 78.02 seconds.
TIME TO SUCCESFUL PLACEMENT(in seconds)
Time(seconds)
N 50
Maximum time 95
Minimum time 55
Range 40
Mean + SD 78.02 +10.88
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Table 13.Percentage of complications in US Group
Complications such as vasospasm was present in 12% of the patients(n=6) in the US group.There was no complications at all in 88% of the patients(n=44) in this group
COMPLICATIONS FREQUENCY(n) PERCENTAGE (%)
NONE 44 88.0
VASOSPASM 6 12.0
TOTAL 50 100.0
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DISCUSSION
Table.14.Statistical comparison of variables in DP versus US Groups
VARIABLE DIRECT PALPATION GROUP
ULTRASOUND
GROUP p value
MEAN AGE(in years) 53.34 51.16 0.34
SUCCESSFUL CANNULATION AT FIRST ATTEMPPT
17(34%) 30(60%) 0.015
SUCCESSFUL
CANNULATION AT SAME RADIAL ARTERY
38(76%) 46(92%) 0.029
MORE >3 ATTEMPTS 7(26%) 1(12%) 0.059
TIME TO SUCCESSFUL CANNULATION(in
seconds)
76.32 78.02 0.435
NO COMPLICATIONS 34(68%) 44(88%) 0.028
* p value <0.05 is considered statistically significant
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GRAPH 1:DISTRIBUTION OF GENDER BETWEEN THE TWO GROUPS
Gender distribution between both the groups was similar with 50% of the patients in the study being males and 50% being females in both the groups.
25 (50) 25 (50) 25 (50) 25 (50)
0 5 10 15 20 25 30
DP GROUP US GROUP
MALE n(%) FEMALE n(%)
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GRAPH 2 : FREQUENCY OF COMPLICATIONS BETWEEN THE TWO GROUPS
There were lesser complications in the US Group when compared with the DP Group.
44(88)
6(12)
1 34(68)
15(30)
1(2) 0
5 10 15 20 25 30 35 40 45 50
0 1(vasospasm) 2(haematoma)
DP Group n(%) US Group n(%)2
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GRAPH 3: PERCENTAGE OF SUCCESSFUL CANNULATION AT FIRST ATTEMPT IN DP GROUP
Successful cannulation at the first attempt was possible in 34% of the patients(n=17) in the DP group.Cannulation at first attempt was unsuccessful in 66% ot the patients(n=33) in the DP group.
17(34%) 33(66%)
successful cannulation at first attempt in DP Group
successful
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GRAPH 4: PERCENTAGE OF SUCCESSFUL CANNULATION AT SAME RADIAL ARTERY IN DP GROUP
Successful cannulation at the same radial artery was possible in 76% of the patients (n=38) in DP group and the other radial artery had to be cannulated in 24% of patients(n=12)in the DP group.
38(76%) 12(24%)
successful cannulation at same radial artery in DP Group
successful unsuccessful
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GRAPH 5: TIME TAKEN FOR SUCCESSFUL CANNULATION IN BOTH THE GROUPS
110 95
55 55
55
78.02
0 20 40 60 80 100 120
DP US
TIME TAKEN FOR PLACEMENT (IN SECONDS)
GROUPS
TIME TAKEN FOR SUCCESSFUL CANNULATION IN DP AND US GROUP
mean minimum time maximum time
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GRAPH 6: PERCENTAGE OF SUCCESSFUL CANNULATION AT FIRST ATTEMPT IN US GROUP
Successful cannulation at the first attempt was possible in 60%of the patients(n=30) in the US group.Cannulation at first attempt was unsuccessful in 40% of the patients(n=20) in the US group
30(60%) 20(40%)
0 0
successful cannulation at first attempt in US Group
successful unsuccessful
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GRAPH 7: PERCENTAGE OF SUCCESSFUL CANNULATION AT SAME RADIAL ARTERY IN US GROUP
Successful cannulation at the same radial artery was possible in 92% of the patients (n=46) in US group and the other radial artery had to be cannulated in 8% of patients(n=4)in the US group.
46(92%) 4(8%)
successful cannulation at same radial artery in DP Group
successful unsuccessful
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GRAPH 8:FREQUENCY DISTRIBUTION OF AGE IN DP AND US GROUPS
75 75
25 19
53.34 51.16
0 10 20 30 40 50 60 70 80
DP US
AGE (in years)
GROUPS
FREQUENCY DISTRIBUTION OF AGE IN DP AND US GROUPS
mean minimum age maximum age
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GRAPH 9: FREQUENCY DISTRIBUTION OF NUMBER OF ATTEMPTS AMONG THE DP GROUP
Successful cannulation at the first attempt was possible in less than half of the patients(n= 17) in the US Group.
17
20 6
7
DIGITAL PALPATION n
1st attempt 2nd attempt 3rd attempt 4th attempt
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GRAPH 10 : FREQUENCY DISTRIBUTION TOTAL NUMBER OF ATTEMPTS AMONG THE US GROUP
Successful cannulation at the first attempt was possible in more than half of the patients(n= 30) in the US Group
30 14
5 1
US GROUP n
1st attempt 2nd attempt 3rd attempt 4th attempt
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The patients mean ages were similar in both the direct palpation and ultrasound group. (p = 0.34)
First attempt successful placement was possible in 30 patients (60%) in the ultrasound group and 17 patients(34%) in the direct palpation group.
The analysis was done by Fishers Exact test.(p = 0.015). Hence the difference in first attempt successful placement between both the groups is statistically significant.
Successful placement at the same radial artery was possible in 46(92%) patients in the ultrasound group and 38( 76%)patients in the palpation group. The analysis was done by Chi square test (p=0.029).Hence the difference in successful placement at the same radial artery between DP and US groups is statistically significant
Only in 1(12%) patient there was more than three attempts in the ultrasound group whereas it was 7(26%)patients in the palpation group.
The analysis was done by Fishers Exact test. (p=0.059).Thus there is a statistically significant difference in the number of attempts in both the groups.
These end results shows that the cannulation was much easier and more successful with ultrasound guidance.
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The time to successful placement was 76.32 seconds in the palpation group and 78.02 seconds in the ultrasound group. The analysis was done by Paired-t-test. (p=0.435)This shows that there was no statistical significance between the total timefor successful placement in both the groups.
Regarding the complications, only 6(12%) of the patients had vasospasm in ultrasound group whereas 16(32%) of the patients in palpation group had vasospasm and hematoma. There were no complications in 44(88%) patients in the US group .While in the DP group only 34(68%) patients had no complications. The analysis was done by Fisher exact test. (p=0.028). Hence it can be inferred that ultrasound cannulation is associated with statistically significant lesser complications.Ultrasound guided arterial cannulation increases the success rate and decreases associated complications compared to direct palpation method as concluded by most of the studies.Ultrasound
guided cannulation is useful in high BMI
group,oldage,peripheraledema,hypotension and abnormal course of vessels.
Sites et al ,showed that there is difficulty in imaging the artery during cannulation.Hansen et al sorted this out by using dynamic needle positioning through continuos imaging of the needle tip and observing the tip into the artery.Most of the studies found successful cannulation at
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first attempt was 60 %to 90%.In our study the rate of successful cannulation at first attempt was 60%.
Doppler guided radial artery cannulation is done by detecting the change in Doppler tone when the introducer needle enters the blood vessel.Experienced clinicians had 90% success rate with this technique.
LIMITATIONS
1. Sample size is inadequate due to time constraints.
2. Observer bias in recording the time.
3. Inexperience of the observer.
4. Modified Allen’s test need to be supplemented by Doppler method prior to cannulation.
.
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CONCLUSION
This study shows that ultrasound guidance for radial artery cannulation has advantages like successful cannulation at first attempt (p=0.0158),Successful cannulation at the same radial artery(p=0.029) and lesser complications(p=0.028) compared to the direct palpation technique,which are statistically significant. However ultrasound has no statistically significant advantage(p=0.435) in total time taken for cannulation compared to the direct palpation technique.
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SUMMARY
This is a randomised prospective study in which hundred patients were evaluated for radial artery cannulation during major surgeries.They were divided into two groups of fifty each,the first group was cannulated by direct palpation technique and the second group with ultrasound technique.The parameters evaluated in the study were successful cannulation at first attempt (p=0.015),successful cannulation at the same radial artery(p=0.029), total number of attempts(p=0.05), complications(p=0.028),which are statistically significant.Time taken for successful cannulation(p=0.435) which was not statistically significant. This study shows that ultrasound has definitive advantage over palpation technique in terms of efficacy and lesser complications.
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BIBLIOGRAPHY
.
1.Ultrasound guidance versus direct palpation for radial artery catheterization b y expert operators: a randomized trial among Canadian cardiac anesthesiologists.Peters C1,2, Schwarz SK3,4, Yarnold CH1,2, Kojic K1,2, Kojic S1,2, Head SJ1,2.Can J Anaesth. 2015 Nov;62(11):1161-8. doi:
10.1007/s12630-015-0426-8. Epub 2015 Jul
2.A randomized comparison of ultrasound guided versus direct palpation method of radial artery cannulation techniques in adult patients undergoing open heart surgery Amina Nasreen1 , Amin M. Khuwaja1 , Parveen Akhtar1 , Najma Amjad1 , ZahidAkhtarRao.Anaesthesia,Pain& Intensive cre Vol20(1)JAn-Mar2016
3.A Randomised comparison of ultrasound guided versus blindly placed radial arterial catheters. Ali Ammar1 , Liaqat Ali2 , Aamir Furqan3. JPMI Vol 31, no.1
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4.Ultrasound-guided versus palpation-guided radial artery catheterization in adult population: A systematic review and meta-analysis of randomized controlled trialsMoussaPacha H1, Alahdab F2, Al-Khadra Y3, Idris A4, Rabbat F5, Darmoch F3, Soud M1, Zaitoun A6, Kaki A7, Rao SV8, Kwok CS9, Mamas MA9, Alraies MC
5. A Prospective Comparison of Ultrasound-guided and Blindly Placed Radial Arterial Catheters.Shiver S, Blaivas M, Lyon M.AcadEmerg Med 2006;
13:1275
6.Comparison between ultrasound guided technique and digital palpation technique for radial artery cannulation in adult patients: An updated meta- analysis of randomized controlled trials.Bhattacharjee S1, Maitra S2, Baidya DK
7.A Practical Training Program for Peripheral Radial Artery Catheterization in Adult Patients: A Prospective, Randomized Controlled Trial.Nakayama Y1, Inagaki Y, Nakajima Y, Sessler DI, Mukai N, Ogawa S, Mizobe T, Sawa T.
8.Ultrasound guidance versus direct palpation for radialartery catheterization b y expert operators: a randomized trial among Canadian cardiac anesthesiologists.Peters C1,2, Schwarz SK3,4, Yarnold CH1,2, Kojic K1,2, Kojic S1,2, Head SJ1
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9 A randomized comparison of ultrasound guided versus direct palpation method of radial artery cannulation techniques in adult patients undergoing open heart surgery..Nasreen A, Khuwaja AM, Akhtar P, Amjad N, Rao ZA.Anaesth Pain Inten Care 2016; 20:38-42.
10. Gender disparity in radial and femoral arterial size: an ultrasound study.
Minami T, Eisen LA, Berger JS, Sekiguchi H, Mayo PH, NarasimhanM.Intensive care Med 2007; 33:552-3.
11Clinical review: complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive care medicine..Scheer B, Perel A, Pfeiffer UJ.Crit Care 2002; 6:199-204.
12. Ultrasound-guided radial artery cannulation in adult and paediatric populations: a systematic review and meta-analysis.White L, Halpin A, Turner M, Wallace L. Br J Anaesth 2016; 116:610-7.
13. Ultrasound guidance facilitates radial artery catheterization: a meta-analysis with trial sequential analysis of randomized controlled trials.Gu 0W-J, Wu XD, Wang F, Ma ZL, Gu XP. Chest 2016;149:166-79.
14. Use of ultrasonography as a rescue technique for failed radial artery cannulation.Sandhu NS, Patel B. J ClinAnesth 2006; 18:138-41.
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15. Ultrasound-guided catheterization of the radial artery: a systematic review and meta-analysis of randomized controlled trials.Shiloh AL, Savel RH, Paulin LM, Eisen LA. Chest 2011; 139:524-9.
16.. The learning curve associated with a simulated ultrasound-guided interventional task by inexperienced anesthesia residents.Sites BD, Gallagher JD, Cravero J, Lundberg J, Blike GRegAnesth Pain Med 2004; 29:544-8.
17. Ultrasonography-guided radial artery catheterization is superior compared with the traditional palpation technique.Hansen MA, Juhi-Olsen P, Thorn S, Frederiksen C, Sloth E.ActaAnaesthesiolScand 2014; 58:446-52
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PROFORMA
“A COMPARATIVE STUDY OF RADIAL ARTERY CANNULATION BY ULTRASOUND GUIDANCE VERSUS PALPATION TECHNIQUE IN ADULTS”
NAME:
AGE:
SEX:
I.P NUMBER:
PROPOSED SURGERY:
1.ARTERIAL CANNULATION PROCEDURE FOLLOWED
1.ULTRASOUND GUIDED
2.DIRECT PALPATION
2.WAS THE ARTERIAL CANNULA SUCCESSFULLY PLACED IN THE FIRST ATTEMPT
1.YES
2.NO
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3.WAS SUCCESSFUL PLACEMENT MADE AT THE SAME RADIAL ARTERY
1.YES 2.NO
4.TOTAL NUMBER OF ATTEMPTS TAKEN FOR
CANNULATION
1.LESS THAN OE EQUAL TO THREE(< 3) 2.MORE THAN THREE
5.TIME TAKEN FOR SUCCESSFUL PLACEMENT(in
seconds)=______
6.IF COMPLICATIONS WERE ASSOCIATED WITH
CANNULATION
1.YES 2.NO
7.IF YES FOR ABOVE QUESTION,WHAT WAS THE COMPLICATION
83
CONSENT FORM FOR PROCEDURE
“A COMPARATIVE STUDY OF RADIAL ARTERY CANNULATION BY ULTRASOUND GUIDANCE VERSUS PALPATION TECHNIQUE IN ADULTS”
You are requested to participate in this study byDr.S.Rakupathy,Final year postgraduatre student of,Anaesthesiology,Coimbatore Medical College The purpose of this study is to find out the advantages and disadvantages of ultrasound guided arterial cannulation versus direct palpation method of arterial cannulation.
Your participation in this study involves your consent for arterial cannulation followed by arterial cannulation at the time of surgery(either ultrasound guided or by direct palpation).There are certain complications
associated with arterial cannulation such as
vasospasm,hematomaformation.This study will benefit in better monitoring of your vitals during the procedure and it would ultimately help us in better understanding of the benefit and risk of ultrasound guided cannulation versus direct palpation.
Study participants identity will not be revealed in any publication resulting from this study.Protection of patients confidentiality to the maximum extent is hereby assured.
84
Participation in this study is voluntary. You may choose to withdraw your consent to participatein the study at any time.
I..., ...(M/F), ...YEARS.,I.P NUMBER..., in my full senses hereby give complete consent for arterial cannulation ,which is needed for invasive blood pressure monitoring during ...surgery under anaesthesia deemed fit.The nature and risk involved in the procedure have been explained to me to my satisfaction..I thereby give my consent for being a patient in this study.
Date:
Signature/Thumb impression of patient
Name:
Address:
85
xg]g[jy] gotk]
ெசய ைற இண த ப வ
அர ேகாைவம வ க ய மய க வ ய ம வ ைறய ப டேம ப பய மாணவ ம வ ர பதிஅவ க ேம ெகா
“அ ராச வழிகா த ல தமன ய ழா ெச த
ம ேநர த ல தமன ய ழா ெச த இைடய லானஒ ப ”ப றியஆ வ ெச ைறம
அைன வ ள க கைள ேக ெகா
என ச ேதக கைளெதள ப தி ெகா ேட எ பைதெத வ ெகா கிேற .
இ தஆ வ எ ைடயஅைன வ வர க பா கா க ப வ ட இத க ஆ கள
ெவள ய ட ப வதி ஆ ேசபைனஇ ைலஎ ப
ைதெத வ ெகா கிேற .
எ தேநர தி இ தஆ வ இ வ லகி ெகா
ளஎன உ ைமஉ எ பைத அறிேவ
நா :ேநாயாள ைகெயா ப / ைனயஈ
ெபய : கவ
86
KEY TO MASTER CHART
I.P No : In Patient Number M : Male
F : Female
F.A : Successful Cannulation at First Attempt S.R.A : Successful Cannulation at Same Radial Artery No.A : Number of Attempts
Time : Time taken for cannulation(in seconds) COP : Complication
