R1. Improvement of central vein ultrasound guided puncture success using a homemade needle guide. A simulation study

R1. Improvement of central vein ultrasound guided puncture success using a homemade needle guide. A simulation study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Short Report R1. Improvement of central vein ultrasound guided puncture success using a homemade needle guide. A simulation study Antoine Villa, Vladimir Hermand, Vincent Bonny, Gabriel Preda, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3286404/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Sep, 2023 Read the published version in Critical Care → Version 1 posted 7 You are reading this latest preprint version Abstract Background : Out-of-plane (OOP) approach is frequently used for ultrasound-guided insertion of central venous catheter (CVC) owing to its simplicity but does not avoid mechanical complication. In-plane (IP) approach might improve safety of insertion; however, it is less easy to master. We assessed, a homemade needle guide device aimed to improve CVC insertion using IP approach. Method : We evaluated in a randomized simulation trial, the impact of a homemade needle guide on internal jugular, subclavian and femoral vein puncture, using three approaches: out-of-plane free hand (OOP-FH), in-plane free hand (IP-FH), and in-plane needle guided (IP-NG). Success at first pass, the number of needle redirections and arterial punctures were recorded. Time elapsed (i) from skin contact to first skin puncture, (ii) from skin puncture to successful venous puncture and (iii) from skin contact to venous return were measured. Results : Thirty operators performed 270 punctures. IP-NG approach resulted in high success rate at first pass (jugular: 80%, subclavian: 95% and femoral: 100%) which was higher than success rate observed with OOP-FH and IP-FH regardless of the site (p=.01). Compared to IP-FH and OOP-FH, the IP-NG approach decreased the number of needle redirections at each site (p=.009) and arterial punctures (p=.001). Compared to IP-FH, the IP-NG approach decreased the total procedure duration for puncture at each site. Conclusion : In this simulation study, IP approach using a homemade needle guide for ultrasound-guided central vein puncture improved success rate at first pass, reduced the number of punctures/redirections and shortened the procedure duration compared to OOP and IP free-hand approaches. catheterization central venous catheter insertion ultrasonography Figures Figure 1 Introduction Current guidelines recommend ultrasound guidance for central venous catheter (CVC) insertion [1, 2] which, compared to landmark strategy, increases success cannulation rate and decreases the number of insertion attempts, time to cannulation, and complications such as arterial punctures or pneumothorax [3–5]. For optimal safety, ultrasound guided CVC insertion requires to visualize the vessel and the needle. Two approaches are available to visualize the needle: the out-of-plane (OOP) approach and the in-plane (IP) approach [6, 7] which are defined according to needle's position relative to the ultrasound beam. OOP is widely utilized and while safer compared to landmark, it still has potential for complications. During OOP approach, the needle is perpendicular to the ultrasound beam, and appears as a spot that represents its intersection with the ultrasound beam. With OOP approach, the operator does not continuously visualize the needle tip and faces risks of arterial injury or multiple sticks due to the need for redirection. Conversely, with IP approach, the needle is within the plane of the ultrasound beam and is tracked from skin's perforation to vessel penetration. As a result, IP approach might enhance safety by minimizing the risk of injury to adjacent structures. However, IP approach requires accurate needle alignment with the ultrasound beam making this approach highly demanding. Needle guiding devices or methods to facilitate IP approach are available but tend to be expensive (several hundred €), sometimes specific to particular probes, and remain poorly investigated so far [8–13]. Methods We designed an open-source 3D printed needle guide to facilitate IP-CVC insertion. The 7.5 MHz linear probe HFL38 available on the M-Turbo® device (Sonosite, Bothewell, MA) was scanned with an EinScan Pro 2X device. Printing process required two hours per model. We obtained the 3D mold of the probe. The needle guide made of Poly Lactic Acid was wrapped around the digitalized probe using Autodesk Fusion 360. A dedicated needle-guiding railway was incorporated into the mold along the narrow side of the probe. The railway must allow adjustments in needle angulation, while also maintaining tightly the needle in the ultrasound beam. Finally, the needle guide was 3D printed on a Prusa I3mkiiiS printer (Prusa Research, Praha, CZ). Six needle guide iterations were tested before obtaining the perfect fit for the probe. Design and conception took 26 hours for a cost of 1€. We conducted a prospective, randomized study among residents and board-certified physicians from either ICU or Emergency Department to assess the needle guide in the setting of central venous puncture performed on inanimate manikin. All the participants had received a training in ultrasound guided CVC insertion, but their proficiency was inhomogeneous. The participants were classified according on whether they had performed more or less than twenty CVCs insertion on patients. All participants were given a one-hour US-CVC lecture about US-guided IP and OOP approaches on simulator. Two simulators were used i) (the Blue Phantom II, CAE Healthcare St. Louis, MO) which allows internal jugular and subclavian puncture and ii) (the Gen II Femoral Vascular Access Ultrasound Training Model, CAE Healthcare St. Louis, MO) which permits femoral vein puncture. Blue fluid return confirmed venous puncture, whereas return of red fluid ruled in arterial puncture. Before the study, the participants were given a 10-minute session to the needle guide and the simulators. Each operator performed needle puncture of the jugular, subclavian and femoral veins on the simulators, with three different techniques, assigned in random order: Out-of-Plane Free Hand (OP-FH), In-Plane Free Hand (IP-FH) and In-Plane with Needle Guide (IP-NG). The procedure was limited to venous puncture and did not include guide wire insertion. We recorded: success rate at first pass, number of needle redirections (and skin breaches) and duration of different parts of the puncture procedure i) from skin contact to first skin puncture, ii) from first skin puncture to successful venous puncture and iii) from skin contact to successful venous return (entire puncture procedure). Uncomplicated puncture was defined as puncture (with venous return) performed in less than 120 seconds without arterial puncture. Data are expressed as median [1st and 3rd interquartile]. Success rates are compared using Chi-2, Fisher exact test as required. The number of needle re-directions and the procedure time are compared using bilateral Wilcoxon matched pairs test. Significance is set for p less than 0.05. Results Thirty operators (age: 30 [27-37] years, female 20%) being board certified physicians (40%) or residents (60%) agreed to participate in the study. Twenty-four of the participants belonged to the ICU team, while the six remaining were physicians working in the Emergency Department. Sixteen operators (53%) reported clinical proficiency of more than 20 CVC insertions. All participants performed the nine scheduled catheter insertions for a total of 270 punctures. Utilizing NG-IP resulted in a high success rate at first pass (jugular: 80%, subclavian: 95% and femoral 100%) and was significantly higher than success rate at first pass observed with OOP-FH and IP-FH approaches whatever site (p<.001) (Figure 1). Analyzing data according to CVC insertion experience revealed similar trends (Figure 1). Compared to OOP-FH and IP-FH, IP-NG approach decreased the number of needle punctures (skin breaches) or redirections at all sites (p=.009) (Table 1). IP-NG use was associated with less arterial puncture than free hand approaches (2/90 vs 30/180, p=.002). Uncomplicated puncture occurred more frequently with NG-IP compared to IP-FH at subclavian site. Compared to IP-FH approach, IP-NG approach decreased the time elapsed between skin probe application and first needle puncture at each site (Table 1 Supplemental). Time from skin puncture to successful venous fluid return was shorter with the needle guide compared to the free hand techniques for subclavian and femoral punctures. Finally, compared to IP-FH approach, IP-NG approach decreased the duration of the total procedure from skin probe contact to successful venous return at all sites (Table 1 Supplemental). The duration of the total procedure using IP-NG approach was significantly lower compared to OOP-FH approach at subclavian and femoral sites (Table 1 Supplemental). IP-NG use resulted in significantly shorter total procedure duration compared to both IP-FH and OOP-FH at subclavian site whatever proficiency (18[13-33] vs 34 [17-133] and 33[18-114] p 20 CVC) and (25[21-45] vs 73 [38-94] and 50 [28-119] p<0.001, for operators having inserted < 20 CVC). Discussion Whereas guidelines actually recommend ultrasound use for CVC insertion some uncertainty remains for the best approach to use between OOP and IP [1, 7, 14]. Out-of-Plane approach is most often used for jugular and femoral CVC insertion owing to its convenience. However, it is associated with risk of injury of posterior venous wall [15, 16] and of adjacent structures during needle progression [16, 17]. This is why we designed a device aimed at making IP procedures easier with minimal risk of complications. We demonstrate here that, compared to IP-FH and OOP-FH, IP-NG approach significantly increases success rate at first pass in all sites. This is in keeping with previous studies reporting similar success rate with guiding system for jugular (82% and 81%) [18, 19] and subclavian puncture [20] even among inexperienced operators [19]. Accidental arterial puncture with the NG-IP approach was observed only once at the jugular and subclavian site and never at the femoral site. Using a different needle guiding system, Augoustides et al reported a rate of accidental arterial puncture at jugular site of 10%, similar to the rate observed with the landmark approach [16]. This could be due to the guiding device used in this study (based on OOP approach), which allows needle visibility only at the depth of the vein. The device we use in the present study places the needle in the ultrasound beam and visualizes the whole path of the needle. This design associated with the possibility to modify the angulation of the needle permits puncture whatever the depth of the vessel [20] without requiring supplemental accessories [16, 20]. The study reported here presents anyway several limits, the most important being that we should confirm our data in the clinical setting. We chose to include operators with limited proficiency considering that whether guide improves performance this would be true especially among operators with limited experience. Compared to IP-FH and OOP-FH, IP-NG translated in shorter total procedure duration only for subclavian puncture whatever proficiency. It should also be outlined that all IP-NG subclavian punctures (considered as the more complex puncture) performed by operators with the smallest experience were completed in less than 48 seconds. This confirms that needle-guiding interest is relevant especially for subclavian puncture [9]. This study presents the first ultrasound needle-guiding device for IP (CVC) insertion, constructed using an open-source and homemade method. The cost of production and ease of construction are noteworthy. This approach could allow every operator to obtain a guiding device that is adapted to his ultrasound probes. The online version contains supplementary material Movie of ultrasound subclavian vein catheterization performed using IP-NG approach Table 1: Needle redirections and needle passes (skin breaches), arterial puncture and uncomplicated puncture according to the different approaches at jugular, subclavian and femoral site. Site Approach Needle redirection/needles passes n Arterial puncture n (%) Uncomplicated puncture % Jugular IP-FH 2[1-3] 1 (3%) 97% OOP-FH 2[1-2] 2 (7%) 93% IP-NG 1[1-1]*£ 1 (3%) 93% Subclavian IP-FH 3[1-5] 6 (17%) 76% OOP-FH 3[1-4] 10 (33%) 83% IP-NG 1[1-1] *£ 1 (3%) £ 100% * Femoral IP-FH 1[1-3] 3 (10%) 93% OOP-FH 2[1-2] 8 (27%) 93% IP-NG 1[1-1]*£ 0 (0%) £ 97% Needle redirections and needle passes (skin breaches) are given for each puncture (median and IQR). Arterial puncture are defined by reflux of red fluid in the syringe reported at least once for a puncture (percentage). Uncomplicated puncture are defined as successful puncture completed in less than 120 seconds without arterial puncture (percentage) according to the different approaches at jugular, subclavian and femoral site. IP-FH: In-plane Free Hand, IP-NG: In-plane Needle Guided, OOP-FH Out-of-plane Free Hand.* p<.05 IP-FH vs IP-NG, £ p<.05 IP-NG vs OOP-FH Declarations Ethical approval This simulation study was conducted on inanimate manikin and did not require ethical approval. Funding No funding for the present study. Availability of data and materials Datasets were collected on an Xcel file are stored by AV and EM and can be accessed upon request. Author Contributions Antoine Villa and Eric Maury made substantial contributions in conception, study design and data gathering. Vladimir Hermand performed the process of the 3D printing. Antoine Villa wrote the manuscript. All authors corrected and approved the final version of the manuscript. Conflicts of interest The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript. References Lamperti M, Bodenham AR, Pittiruti M, et al (2012) International evidence-based recommendations on ultrasound-guided vascular access. Intensive Care Med 38:1105–1117. https://doi.org/10.1007/s00134-012-2597-x Timsit JF, Baleine, Bernard, l et al (2020) Expert consensus-based clinical practice guidelines management of intravascular catheters in the intensive care unit. Ann Intensive Care 10:. https://doi.org/10.1186/s13613-020-00713-4 Fragou M, Gravvanis A, Dimitriou V, et al (2011) Real-time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients: a prospective randomized study. Crit Care Med 39:1607–1612. https://doi.org/10.1097/CCM.0b013e318218a1ae Brass P, Hellmich M, Kolodziej L, et al (2015) Ultrasound guidance versus anatomical landmarks for subclavian or femoral vein catheterization. Cochrane Database Syst Rev 1:CD011447. https://doi.org/10.1002/14651858.CD011447 Brass P, Hellmich M, Kolodziej L, et al (2015) Ultrasound guidance versus anatomical landmarks for internal jugular vein catheterization. Cochrane Database Syst Rev 1:CD006962. https://doi.org/10.1002/14651858.CD006962.pub2 Saugel B, Scheeren TWL, Teboul J-L (2017) Ultrasound-guided central venous catheter placement: a structured review and recommendations for clinical practice. Crit Care Lond Engl 21:225. https://doi.org/10.1186/s13054-017-1814-y Schmidt GA, Blaivas M, Conrad SA, et al (2019) Ultrasound-guided vascular access in critical illness. Intensive Care Med 45:434–446. https://doi.org/10.1007/s00134-019-05564-7 Bigé N, Dubée V, Alves M, et al (2017) Use of a needle-guided device to facilitate axillary vein cannulation. Minerva Anestesiol 83:102–103. https://doi.org/10.23736/S0375-9393.16.11398-7 Alves M, BIGè N, Pichereau C, et al (2016) Impact of AxotrackTM for ultrasound-guided central venous catheter insertion: a randomized controlled study conducted on inanimate manikin. Minerva Anestesiol 82:493–495 Gallo C, Foroughi P, Meagher E, et al (2020) Computer-assisted needle navigation for pediatric internal jugular central venous cannulation: A feasibility study. J Vasc Access 21:931–937. https://doi.org/10.1177/1129729820915035 Balaban O, Turgut M, Aydın T (2020) Ultrasound-guided supraclavicular brachiocephalic vein catheterization in children: Syringe-free in-plane technique with micro-convex probe. J Vasc Access 21:241–245. https://doi.org/10.1177/1129729819867221 Boulet N, Bobbia X, Gavoille A, et al (2021) Axillary vein catheterization using ultrasound guidance: A prospective randomized cross-over controlled simulation comparing standard ultrasound and new needle-pilot device. J Vasc Access 11297298211063704. https://doi.org/10.1177/11297298211063705 Chew SC, Beh ZY, Hakumat Rai VR, et al (2020) Ultrasound-guided central venous vascular access-novel needle navigation technology compared with conventional method: A randomized study. J Vasc Access 21:26–32. https://doi.org/10.1177/1129729819852057 Vezzani A, Manca T, Brusasco C, et al (2017) A randomized clinical trial of ultrasound-guided infra-clavicular cannulation of the subclavian vein in cardiac surgical patients: short-axis versus long-axis approach. Intensive Care Med 43:1594–1601. https://doi.org/10.1007/s00134-017-4756-6 Blaivas M, Adhikari S (2009) An unseen danger: frequency of posterior vessel wall penetration by needles during attempts to place internal jugular vein central catheters using ultrasound guidance. Crit Care Med 37:2345–2349; quiz 2359. https://doi.org/10.1097/CCM.0b013e3181a067d4 Augoustides JG, Horak J, Ochroch AE, et al (2005) A randomized controlled clinical trial of real-time needle-guided ultrasound for internal jugular venous cannulation in a large university anesthesia department. J Cardiothorac Vasc Anesth 19:310–315. https://doi.org/10.1053/j.jvca.2005.03.007 Slama M, Novara A, Safavian A, et al (1997) Improvement of internal jugular vein cannulation using an ultrasound-guided technique. Intensive Care Med 23:916–919. https://doi.org/10.1007/s001340050432 Denys BG, Uretsky BF, Reddy PS (1993) Ultrasound-assisted cannulation of the internal jugular vein. A prospective comparison to the external landmark-guided technique. Circulation 87:1557–1562. https://doi.org/10.1161/01.cir.87.5.1557 Airapetian N, Maizel J, Langelle F, et al (2013) Ultrasound-guided central venous cannulation is superior to quick-look ultrasound and landmark methods among inexperienced operators: a prospective randomized study. Intensive Care Med 39:1938–1944. https://doi.org/10.1007/s00134-013-3072-z Maecken T, Heite L, Wolf B, et al (2015) Ultrasound-guided catheterisation of the subclavian vein: freehand vs needle-guided technique. Anaesthesia 70:1242–1249. https://doi.org/10.1111/anae.13187 Additional Declarations No competing interests reported. Supplementary Files NeedleGuideShort1.mpeg supplemental21aoutR1.docx Cite Share Download PDF Status: Published Journal Publication published 30 Sep, 2023 Read the published version in Critical Care → Version 1 posted Editorial decision: Major revision 29 Aug, 2023 Reviews received at journal 27 Aug, 2023 Reviewers agreed at journal 27 Aug, 2023 Reviewers invited by journal 27 Aug, 2023 Submission checks completed at journal 23 Aug, 2023 Editor assigned by journal 23 Aug, 2023 First submitted to journal 22 Aug, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3286404","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Short Report","associatedPublications":[],"authors":[{"id":228341534,"identity":"7d814de8-6584-46f4-951b-60c1f05f0bde","order_by":0,"name":"Antoine Villa","email":"","orcid":"","institution":"Hôpital Saint Antoine, Assistance Publique -Hôpitaux de Paris","correspondingAuthor":false,"prefix":"","firstName":"Antoine","middleName":"","lastName":"Villa","suffix":""},{"id":228341536,"identity":"7274827a-2f1a-4591-842f-d172d21da3ab","order_by":1,"name":"Vladimir Hermand","email":"","orcid":"","institution":"Learning Planet 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15:14:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3286404/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3286404/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13054-023-04661-w","type":"published","date":"2023-09-30T15:00:57+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":42258897,"identity":"23ff3a41-a7ed-4453-868e-c5a57adacdfb","added_by":"auto","created_at":"2023-08-28 17:57:04","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":80204,"visible":true,"origin":"","legend":"\u003cp\u003eshowing\u003cstrong\u003e \u003c/strong\u003esuccess rate at first pass according to the site where the puncture was performed, and the approach used in all operators (upper panel) and among operators having performed more than 20 CVC insertions (lower panel A) or less than 20 CVC insertions (lower panel B). Success was defined by syringe filling by blue liquid. IP-FH: In-plane Free Hand, IP-NG: In-plane Needle Guided, OOP-FH: Out-of-plane Free Hand. * p\u0026lt;.05 Chi-2 test.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3286404/v1/4f88df725da1c76bebd0ea1e.jpg"},{"id":43974739,"identity":"0d17d975-75b7-4cf3-a972-359005bada2f","added_by":"auto","created_at":"2023-10-02 15:09:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":315522,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3286404/v1/b24f338f-27d8-4e09-b1ad-f226d1d75f8a.pdf"},{"id":42258898,"identity":"6f18b489-cd20-4fc9-8250-81d3723d5314","added_by":"auto","created_at":"2023-08-28 17:57:10","extension":"mpeg","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":111917162,"visible":true,"origin":"","legend":"","description":"","filename":"NeedleGuideShort1.mpeg","url":"https://assets-eu.researchsquare.com/files/rs-3286404/v1/85987c1246d379333770c290.mpeg"},{"id":42259198,"identity":"88684f2b-0915-4192-9a99-741d6c760840","added_by":"auto","created_at":"2023-08-28 18:05:04","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":14001,"visible":true,"origin":"","legend":"","description":"","filename":"supplemental21aoutR1.docx","url":"https://assets-eu.researchsquare.com/files/rs-3286404/v1/86239225a418ab3cd7c7c287.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"R1. Improvement of central vein ultrasound guided puncture success using a homemade needle guide. A simulation study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCurrent guidelines recommend ultrasound guidance for central venous catheter (CVC) insertion\u0026nbsp;[1, 2]\u0026nbsp;which, compared to landmark strategy, increases success cannulation rate and decreases the number of insertion attempts, time to cannulation, and complications such as arterial punctures or pneumothorax\u0026nbsp;[3\u0026ndash;5].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor optimal safety, ultrasound guided CVC insertion requires to visualize the vessel and the needle. Two approaches are available to visualize the needle: the out-of-plane (OOP) approach and the in-plane (IP) approach\u0026nbsp;[6, 7]\u0026nbsp;which are defined according to needle\u0026apos;s position relative to the ultrasound beam. OOP is widely utilized and while safer compared to landmark, it still has potential for complications. During OOP approach, the needle is perpendicular to the ultrasound beam, and appears as a spot that represents its intersection with the ultrasound beam. With OOP approach, the operator does not continuously visualize the needle tip and faces risks of arterial injury or multiple sticks due to the need for redirection. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConversely, with IP approach, the needle is within the plane of the ultrasound beam and is tracked from skin\u0026apos;s perforation to vessel penetration. As a result, IP approach might enhance safety by minimizing the risk of injury to adjacent structures. However, IP approach requires accurate needle alignment with the ultrasound beam making this approach highly demanding. Needle guiding devices or methods to facilitate IP approach are available but tend to be expensive (several hundred \u0026euro;), sometimes specific to particular probes, and remain poorly investigated so far [8\u0026ndash;13].\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe designed an open-source 3D printed needle guide to facilitate IP-CVC insertion. The 7.5 MHz linear probe HFL38 available on the M-Turbo\u0026reg; device (Sonosite, Bothewell, MA) was scanned with an EinScan Pro 2X device. Printing process required two hours per model. We obtained the 3D mold of the probe. The needle guide made of Poly Lactic Acid was wrapped around the digitalized probe using Autodesk Fusion 360. A dedicated needle-guiding railway was incorporated into the mold along the narrow side of the probe. The railway must allow adjustments in needle angulation, while also maintaining tightly the needle in the ultrasound beam. Finally, the needle guide was 3D printed on a Prusa I3mkiiiS printer (Prusa Research, Praha, CZ). Six needle guide iterations were tested before obtaining the perfect fit for the probe. Design and conception took 26 hours for a cost of 1\u0026euro;.\u003c/p\u003e \u003cp\u003eWe conducted a prospective, randomized study among residents and board-certified physicians from either ICU or Emergency Department to assess the needle guide in the setting of central venous puncture performed on inanimate manikin. All the participants had received a training in ultrasound guided CVC insertion, but their proficiency was inhomogeneous. The participants were classified according on whether they had performed more or less than twenty CVCs insertion on patients. All participants were given a one-hour US-CVC lecture about US-guided IP and OOP approaches on simulator.\u003c/p\u003e \u003cp\u003eTwo simulators were used i) (the Blue Phantom II, CAE Healthcare St. Louis, MO) which allows internal jugular and subclavian puncture and ii) (the Gen II Femoral Vascular Access Ultrasound Training Model, CAE Healthcare St. Louis, MO) which permits femoral vein puncture. Blue fluid return confirmed venous puncture, whereas return of red fluid ruled in arterial puncture. Before the study, the participants were given a 10-minute session to the needle guide and the simulators. Each operator performed needle puncture of the jugular, subclavian and femoral veins on the simulators, with three different techniques, assigned in random order: Out-of-Plane Free Hand (OP-FH), In-Plane Free Hand (IP-FH) and In-Plane with Needle Guide (IP-NG). The procedure was limited to venous puncture and did not include guide wire insertion.\u003c/p\u003e \u003cp\u003eWe recorded: success rate at first pass, number of needle redirections (and skin breaches) and duration of different parts of the puncture procedure i) from skin contact to first skin puncture, ii) from first skin puncture to successful venous puncture and iii) from skin contact to successful venous return (entire puncture procedure). Uncomplicated puncture was defined as puncture (with venous return) performed in less than 120 seconds without arterial puncture.\u003c/p\u003e \u003cp\u003eData are expressed as median [1st and 3rd interquartile]. Success rates are compared using Chi-2, Fisher exact test as required. The number of needle re-directions and the procedure time are compared using bilateral Wilcoxon matched pairs test. Significance is set for p less than 0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThirty operators (age: 30 [27-37] years, female 20%) being board certified physicians (40%) or residents (60%) agreed to participate in the study. Twenty-four of the participants belonged to the ICU team, while the six remaining were physicians working in the Emergency Department. Sixteen operators (53%) reported clinical proficiency of more than 20 CVC insertions. All participants performed the nine scheduled catheter insertions for a total of 270 punctures.\u003c/p\u003e\n\u003cp\u003eUtilizing NG-IP resulted in a high success rate at first pass (jugular: 80%, subclavian: 95% and femoral 100%) and was significantly higher than success rate at first pass observed with OOP-FH and IP-FH approaches whatever site (p\u0026lt;.001) (Figure 1). \u0026nbsp;Analyzing data according to CVC insertion experience revealed similar trends (Figure 1).\u003c/p\u003e\n\u003cp\u003eCompared to OOP-FH and IP-FH, IP-NG approach decreased the number of needle punctures (skin breaches) or redirections at all sites (p=.009) (Table 1). IP-NG use was associated with less arterial puncture than free hand approaches (2/90 vs 30/180, p=.002). Uncomplicated puncture occurred more frequently with NG-IP compared to IP-FH at subclavian site.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompared to IP-FH approach, IP-NG approach decreased the time elapsed between skin probe application and first needle puncture at each site (Table 1 Supplemental). Time from skin puncture to successful venous fluid return was shorter with the needle guide compared to the free hand techniques for subclavian and femoral punctures. Finally, compared to IP-FH approach, IP-NG approach decreased the duration of the total procedure from skin probe contact to successful venous return at all sites (Table 1 Supplemental).\u003c/p\u003e\n\u003cp\u003eThe duration of the total procedure using IP-NG approach was significantly lower compared to OOP-FH approach at subclavian and femoral sites (Table 1 Supplemental).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIP-NG use resulted in significantly shorter total procedure duration compared to both IP-FH and OOP-FH at subclavian site whatever proficiency (18[13-33] vs 34 [17-133] and 33[18-114] p\u0026lt;0.001, for operators having inserted \u0026gt; 20 CVC) and (25[21-45] vs 73 [38-94] and 50 [28-119] p\u0026lt;0.001, for operators having inserted \u0026lt; 20 CVC).\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWhereas guidelines actually recommend ultrasound use for CVC insertion \u0026nbsp;some uncertainty remains for the best approach to use between OOP and IP\u0026nbsp;[1, 7, 14].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOut-of-Plane approach is most often used for jugular and femoral CVC insertion owing to its convenience. However, it is associated with risk of injury of posterior venous wall [15, 16] and of adjacent structures during needle progression [16, 17]. This is why we designed a device aimed at making IP procedures easier with minimal risk of complications.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe demonstrate here that, compared to IP-FH and OOP-FH, IP-NG approach significantly increases success rate at first pass in all sites. This is in keeping with previous studies reporting similar success rate with guiding system for jugular (82% and 81%) [18, 19] and subclavian puncture [20] even among inexperienced operators [19]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAccidental arterial puncture with the NG-IP approach was observed only once at the jugular and subclavian site and never at the femoral site. \u0026nbsp;Using a different needle guiding system, Augoustides et al reported a rate of accidental arterial puncture at jugular site of 10%, similar to the rate observed with the landmark approach [16]. This could be due to the guiding device used in this study (based on OOP approach), which allows needle visibility only at the depth of the vein. The device we use in the present study places the needle in the ultrasound beam and visualizes the whole path of the needle. This design associated with the possibility to modify the angulation of the needle permits puncture whatever the depth of the vessel [20] without requiring supplemental accessories [16, 20].\u003c/p\u003e\n\u003cp\u003eThe study reported here presents anyway several limits, the most important being that we should confirm our data in the clinical setting.\u003c/p\u003e\n\u003cp\u003eWe chose to include operators with limited proficiency considering that whether guide improves performance this would be true especially among operators with limited experience. Compared to IP-FH and OOP-FH, IP-NG translated in shorter total procedure duration only for subclavian puncture whatever proficiency. \u0026nbsp;It should also be outlined that all IP-NG subclavian punctures (considered as the more complex puncture) performed by operators with the smallest experience were completed in less than 48 seconds. This confirms that needle-guiding interest is relevant especially for subclavian puncture [9]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study presents the first ultrasound needle-guiding device for IP (CVC) insertion, constructed using an open-source and homemade method. The cost of production and ease of construction are noteworthy. This approach could allow every operator to obtain a guiding device that is adapted to his ultrasound probes.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe online version contains supplementary material\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMovie of ultrasound subclavian vein catheterization performed using IP-NG approach\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1:\u003c/strong\u003e Needle redirections and needle passes (skin breaches), arterial puncture and uncomplicated puncture according to the different approaches at jugular, subclavian and femoral site.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"623\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.987179487179485%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eSite\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.384615384615385%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eApproach\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.67948717948718%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNeedle redirection/needles passes\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.237179487179485%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eArterial puncture\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.71153846153846%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eUncomplicated puncture\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.987179487179485%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eJugular\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.384615384615385%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eIP-FH\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.67948717948718%\" valign=\"top\"\u003e\n \u003cp\u003e2[1-3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.237179487179485%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.71153846153846%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;97%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.987179487179485%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.384615384615385%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eOOP-FH\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.67948717948718%\" valign=\"top\"\u003e\n \u003cp\u003e2[1-2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.237179487179485%\" valign=\"top\"\u003e\n \u003cp\u003e2 (7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.71153846153846%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;93%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.987179487179485%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.384615384615385%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eIP-NG\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.67948717948718%\" valign=\"top\"\u003e\n \u003cp\u003e1[1-1]*\u0026pound;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.237179487179485%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.71153846153846%\" valign=\"top\"\u003e\n \u003cp\u003e93%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.987179487179485%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eSubclavian\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.384615384615385%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eIP-FH\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.67948717948718%\" valign=\"top\"\u003e\n \u003cp\u003e3[1-5]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.237179487179485%\" valign=\"top\"\u003e\n \u003cp\u003e6 (17%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.71153846153846%\" valign=\"top\"\u003e\n \u003cp\u003e76%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.987179487179485%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.384615384615385%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eOOP-FH\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.67948717948718%\" valign=\"top\"\u003e\n \u003cp\u003e3[1-4]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.237179487179485%\" valign=\"top\"\u003e\n \u003cp\u003e10 (33%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.71153846153846%\" valign=\"top\"\u003e\n \u003cp\u003e83%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.987179487179485%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.384615384615385%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eIP-NG\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.67948717948718%\" valign=\"top\"\u003e\n \u003cp\u003e1[1-1] *\u0026pound;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.237179487179485%\" valign=\"top\"\u003e\n \u003cp\u003e1 (3%) \u0026pound;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.71153846153846%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;100% *\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.987179487179485%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eFemoral\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.384615384615385%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eIP-FH\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.67948717948718%\" valign=\"top\"\u003e\n \u003cp\u003e1[1-3]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.237179487179485%\" valign=\"top\"\u003e\n \u003cp\u003e3 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.71153846153846%\" valign=\"top\"\u003e\n \u003cp\u003e93%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.987179487179485%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.384615384615385%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eOOP-FH\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.67948717948718%\" valign=\"top\"\u003e\n \u003cp\u003e2[1-2]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.237179487179485%\" valign=\"top\"\u003e\n \u003cp\u003e8 (27%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.71153846153846%\" valign=\"top\"\u003e\n \u003cp\u003e93%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.987179487179485%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.384615384615385%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003eIP-NG\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"24.67948717948718%\" valign=\"top\"\u003e\n \u003cp\u003e1[1-1]*\u0026pound;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.237179487179485%\" valign=\"top\"\u003e\n \u003cp\u003e0 (0%) \u0026pound;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"19.71153846153846%\" valign=\"top\"\u003e\n \u003cp\u003e97%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNeedle redirections and needle passes (skin breaches) are given for each puncture (median and IQR). Arterial puncture are defined by reflux of red fluid in the syringe reported at least once for a puncture (percentage). Uncomplicated puncture are defined as successful puncture completed in less than 120 seconds without arterial puncture (percentage) according to the different approaches at jugular, subclavian and femoral site.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;IP-FH: In-plane Free Hand, IP-NG: In-plane Needle Guided, OOP-FH Out-of-plane Free Hand.* p\u0026lt;.05 IP-FH vs IP-NG, \u0026pound; p\u0026lt;.05 IP-NG vs OOP-FH\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis simulation study was conducted on inanimate manikin and did not require ethical approval.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding for the present study.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDatasets were collected on an Xcel file are stored by AV and EM and can be accessed upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAntoine Villa and Eric Maury made substantial contributions in conception, study design and data gathering. Vladimir Hermand performed the process of the 3D printing. Antoine Villa wrote the manuscript. All authors corrected and approved the final version of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLamperti M, Bodenham AR, Pittiruti M, et al (2012) International evidence-based recommendations on ultrasound-guided vascular access. Intensive Care Med 38:1105\u0026ndash;1117. https://doi.org/10.1007/s00134-012-2597-x\u003c/li\u003e\n\u003cli\u003eTimsit JF, Baleine, Bernard, l et al (2020) Expert consensus-based clinical practice guidelines management of intravascular catheters in the intensive care unit. Ann Intensive Care 10:. https://doi.org/10.1186/s13613-020-00713-4\u003c/li\u003e\n\u003cli\u003eFragou M, Gravvanis A, Dimitriou V, et al (2011) Real-time ultrasound-guided subclavian vein cannulation versus the landmark method in critical care patients: a prospective randomized study. Crit Care Med 39:1607\u0026ndash;1612. https://doi.org/10.1097/CCM.0b013e318218a1ae\u003c/li\u003e\n\u003cli\u003eBrass P, Hellmich M, Kolodziej L, et al (2015) Ultrasound guidance versus anatomical landmarks for subclavian or femoral vein catheterization. Cochrane Database Syst Rev 1:CD011447. https://doi.org/10.1002/14651858.CD011447\u003c/li\u003e\n\u003cli\u003eBrass P, Hellmich M, Kolodziej L, et al (2015) Ultrasound guidance versus anatomical landmarks for internal jugular vein catheterization. Cochrane Database Syst Rev 1:CD006962. https://doi.org/10.1002/14651858.CD006962.pub2\u003c/li\u003e\n\u003cli\u003eSaugel B, Scheeren TWL, Teboul J-L (2017) Ultrasound-guided central venous catheter placement: a structured review and recommendations for clinical practice. Crit Care Lond Engl 21:225. https://doi.org/10.1186/s13054-017-1814-y\u003c/li\u003e\n\u003cli\u003eSchmidt GA, Blaivas M, Conrad SA, et al (2019) Ultrasound-guided vascular access in critical illness. Intensive Care Med 45:434\u0026ndash;446. https://doi.org/10.1007/s00134-019-05564-7\u003c/li\u003e\n\u003cli\u003eBig\u0026eacute; N, Dub\u0026eacute;e V, Alves M, et al (2017) Use of a needle-guided device to facilitate axillary vein cannulation. Minerva Anestesiol 83:102\u0026ndash;103. https://doi.org/10.23736/S0375-9393.16.11398-7\u003c/li\u003e\n\u003cli\u003eAlves M, BIG\u0026egrave; N, Pichereau C, et al (2016) Impact of AxotrackTM for ultrasound-guided central venous catheter insertion: a randomized controlled study conducted on inanimate manikin. Minerva Anestesiol 82:493\u0026ndash;495\u003c/li\u003e\n\u003cli\u003eGallo C, Foroughi P, Meagher E, et al (2020) Computer-assisted needle navigation for pediatric internal jugular central venous cannulation: A feasibility study. J Vasc Access 21:931\u0026ndash;937. https://doi.org/10.1177/1129729820915035\u003c/li\u003e\n\u003cli\u003eBalaban O, Turgut M, Aydın T (2020) Ultrasound-guided supraclavicular brachiocephalic vein catheterization in children: Syringe-free in-plane technique with micro-convex probe. J Vasc Access 21:241\u0026ndash;245. https://doi.org/10.1177/1129729819867221\u003c/li\u003e\n\u003cli\u003eBoulet N, Bobbia X, Gavoille A, et al (2021) Axillary vein catheterization using ultrasound guidance: A prospective randomized cross-over controlled simulation comparing standard ultrasound and new needle-pilot device. J Vasc Access 11297298211063704. https://doi.org/10.1177/11297298211063705\u003c/li\u003e\n\u003cli\u003eChew SC, Beh ZY, Hakumat Rai VR, et al (2020) Ultrasound-guided central venous vascular access-novel needle navigation technology compared with conventional method: A randomized study. J Vasc Access 21:26\u0026ndash;32. https://doi.org/10.1177/1129729819852057\u003c/li\u003e\n\u003cli\u003eVezzani A, Manca T, Brusasco C, et al (2017) A randomized clinical trial of ultrasound-guided infra-clavicular cannulation of the subclavian vein in cardiac surgical patients: short-axis versus long-axis approach. Intensive Care Med 43:1594\u0026ndash;1601. https://doi.org/10.1007/s00134-017-4756-6\u003c/li\u003e\n\u003cli\u003eBlaivas M, Adhikari S (2009) An unseen danger: frequency of posterior vessel wall penetration by needles during attempts to place internal jugular vein central catheters using ultrasound guidance. Crit Care Med 37:2345\u0026ndash;2349; quiz 2359. https://doi.org/10.1097/CCM.0b013e3181a067d4\u003c/li\u003e\n\u003cli\u003eAugoustides JG, Horak J, Ochroch AE, et al (2005) A randomized controlled clinical trial of real-time needle-guided ultrasound for internal jugular venous cannulation in a large university anesthesia department. J Cardiothorac Vasc Anesth 19:310\u0026ndash;315. https://doi.org/10.1053/j.jvca.2005.03.007\u003c/li\u003e\n\u003cli\u003eSlama M, Novara A, Safavian A, et al (1997) Improvement of internal jugular vein cannulation using an ultrasound-guided technique. Intensive Care Med 23:916\u0026ndash;919. https://doi.org/10.1007/s001340050432\u003c/li\u003e\n\u003cli\u003eDenys BG, Uretsky BF, Reddy PS (1993) Ultrasound-assisted cannulation of the internal jugular vein. A prospective comparison to the external landmark-guided technique. Circulation 87:1557\u0026ndash;1562. https://doi.org/10.1161/01.cir.87.5.1557\u003c/li\u003e\n\u003cli\u003eAirapetian N, Maizel J, Langelle F, et al (2013) Ultrasound-guided central venous cannulation is superior to quick-look ultrasound and landmark methods among inexperienced operators: a prospective randomized study. Intensive Care Med 39:1938\u0026ndash;1944. https://doi.org/10.1007/s00134-013-3072-z\u003c/li\u003e\n\u003cli\u003eMaecken T, Heite L, Wolf B, et al (2015) Ultrasound-guided catheterisation of the subclavian vein: freehand vs needle-guided technique. Anaesthesia 70:1242\u0026ndash;1249. https://doi.org/10.1111/anae.13187\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"critical-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cric","sideBox":"Learn more about [Critical Care](http://ccforum.biomedcentral.com/)","snPcode":"13054","submissionUrl":"https://submission.nature.com/new-submission/13054/3","title":"Critical Care","twitterHandle":"@Crit_Care","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"catheterization, central venous catheter insertion, ultrasonography","lastPublishedDoi":"10.21203/rs.3.rs-3286404/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3286404/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: Out-of-plane (OOP) approach is frequently used for ultrasound-guided insertion of central venous catheter (CVC) owing to its simplicity but does not avoid mechanical complication. In-plane (IP) approach might improve safety of insertion; however, it is less easy to master. We assessed, a homemade needle guide device aimed to improve CVC insertion using IP approach.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod\u003c/strong\u003e: We evaluated in a randomized simulation trial, the impact of a homemade needle guide on internal jugular, subclavian and femoral vein puncture, using three approaches: out-of-plane free hand (OOP-FH), in-plane free hand (IP-FH), and in-plane needle guided (IP-NG). Success at first pass, the number of needle redirections and arterial punctures were recorded. Time elapsed (i) from skin contact to first skin puncture, (ii) from skin puncture to successful venous puncture and (iii) from skin contact to venous return were measured.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Thirty operators performed 270 punctures. IP-NG approach resulted in high success rate at first pass (jugular: 80%, subclavian: 95% and femoral: 100%) which was higher than success rate observed with OOP-FH and IP-FH regardless of the site (p=.01). Compared to IP-FH and OOP-FH, the IP-NG approach decreased the number of needle redirections at each site (p=.009) and arterial punctures (p=.001). Compared to IP-FH, the IP-NG approach decreased the total procedure duration for puncture at each site.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: In this simulation study, IP approach using a homemade needle guide for ultrasound-guided central vein puncture improved success rate at first pass, reduced the number of punctures/redirections and shortened the procedure duration compared to OOP and IP free-hand approaches.\u003c/p\u003e","manuscriptTitle":"R1. Improvement of central vein ultrasound guided puncture success using a homemade needle guide. A simulation study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-08-28 17:56:59","doi":"10.21203/rs.3.rs-3286404/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-08-29T07:54:59+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-08-27T21:34:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"1180afbb-b4af-4156-acef-0708bbcde06a","date":"2023-08-27T20:27:31+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-08-27T10:57:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-08-23T08:47:54+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-08-23T08:47:54+00:00","index":"","fulltext":""},{"type":"submitted","content":"Critical Care","date":"2023-08-22T15:04:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"critical-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cric","sideBox":"Learn more about [Critical Care](http://ccforum.biomedcentral.com/)","snPcode":"13054","submissionUrl":"https://submission.nature.com/new-submission/13054/3","title":"Critical Care","twitterHandle":"@Crit_Care","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"af105c74-abad-4ff7-9bd5-23551693db4a","owner":[],"postedDate":"August 28th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-02T15:07:55+00:00","versionOfRecord":{"articleIdentity":"rs-3286404","link":"https://doi.org/10.1186/s13054-023-04661-w","journal":{"identity":"critical-care","isVorOnly":false,"title":"Critical Care"},"publishedOn":"2023-09-30 15:00:57","publishedOnDateReadable":"September 30th, 2023"},"versionCreatedAt":"2023-08-28 17:56:59","video":"","vorDoi":"10.1186/s13054-023-04661-w","vorDoiUrl":"https://doi.org/10.1186/s13054-023-04661-w","workflowStages":[]},"version":"v1","identity":"rs-3286404","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3286404","identity":"rs-3286404","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}