Laser-assisted Pediatric Radial Artery Cannulation: Comment

We have read with great interest the article by Hou et al.1 in the May issue of Anesthesiology. They used laser-assisted ultrasound guidance to project the path of the target artery onto the skin surface, improving the speed and the first-attempt success rate of radial artery cannulation in children less than 2 yr old.1 Although their findings have potential clinical implications, we observed several unaddressed issues in their study.First, the authors assert that using this method leads to decreased time to success during the first attempt (31 vs. 46 s), second attempt (32 vs. 49 s), and overall arterial puncture (32 vs. 48 s), indicating improved efficiency and time savings compared to traditional ultrasound-guided cannulation. However, it is worth noting that preparing and setting up this laser device must take time. Although the authors stated that the position time and preparation time of the laser device was mostly within 10 s and 30 s (40 s in total), we have reservations that this may outweigh the clinical time savings reported. In fact, the authors took more than 20 s (Supplemental Video File, https://links.lww.com/ALN/D94; 4:22 to 4:46) to set the device in place.Second, the study lacks adequate description of laser safety. High-intensity laser light may cause damage to the skin of the patient and the retina of the anesthesiologist.2,3 The severity of the damage depends on various factors, including laser power, exposure duration, and specific wavelength.4 Prolonged exposure to the laser environment may occur during difficult radial artery cannulation, leading to more severe damage. Furthermore, children’s skin is more sensitive to laser-induced damage.Third, the probe is clamped by the manipulator arm, which is fixed to the ultrasound machine, restricting the operator’s ability to easily tilt the angle of the probe left and right. Accordingly, the operator must adjust the laser direction to ensure that the laser beam becomes the superficial projection of the underlying anatomical path of the artery, making the dynamic needle tip–positioning step more difficult due to the inflexibility of the probe. In addition, when the surgical drapes and instruments are applied to pediatric patients, the laser device’s accessibility to the cannulation site may be limited, complicating the placement of the ultrasound machine in a space-constrained operating room.Fourth, the authors used a dynamic needle tip–positioning, short-axis, out-of-plane approach in this study. However, recent literature5 suggests that a modified long-axis in-plane approach offers additional benefits with a lower incidence (5%) of posterior wall puncture than reported (10%) in this study.1 We believe that a combined short- and modified long-axis approach would yield optimal success.The authors declare no competing interests.