1
|
O'Brien EM, Guris RD, Quarshie W, Lin EE. The state of point-of-care ultrasound training in pediatric anesthesia fellowship programs in the United States: A survey assessment. Paediatr Anaesth 2024; 34:544-550. [PMID: 38358309 DOI: 10.1111/pan.14851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 11/20/2023] [Accepted: 01/24/2024] [Indexed: 02/16/2024]
Abstract
BACKGROUND Point-of-care ultrasound is an invaluable bedside tool for anesthesiologists and has been integrated into anesthesiology residency training and board certification in the United States. Little is known about point-of-care ultrasound training practices in pediatric anesthesia fellowship programs. AIMS To describe the current state of point-of-care ultrasound education in pediatric anesthesia fellowship programs in the United States. METHODS We conducted a cross-sectional survey study distributed to 60 American Accreditation Council for Graduate Medical Education-accredited pediatric anesthesia fellowship programs. Two programs were in their initial accreditation period and were excluded due to lack of historical data. Program directors or associate program directors were invited to complete this 23-item survey. RESULTS Thirty-three of fifty-eight programs (57%) completed the survey. Of those, 15 programs (45%) reported having a point-of-care ultrasound curriculum. Programs with ≤3 fellows per year were less likely to have an ultrasound curriculum compared to programs with ≥4 fellows per year (30% programs 0-3 fellows/year vs. 69% programs ≥4 fellows/year, odds ratio 0.19 [95% confidence intervals 0.04-0.87]; p = .03). Program directors and associate program directors rated point-of-care ultrasound training as highly valuable to fellows' education. Barriers to use most commonly included lack of experience (64%), lack of oversight/interpretive guidance (58%), and lack of time (45%). Programs without point-of-care ultrasound training had significantly higher odds of listing lack of ultrasound access as a primary barrier (50% programs without vs. 13% programs with, odds ratio 6.5, [95% confidence intervals 1.3-50]; p = .04). CONCLUSIONS This observational survey-based study suggests that fewer than half of pediatric anesthesia training programs in the United States offer point-of-care ultrasound education. Additional research is needed to optimize this education and training in pediatric anesthesia fellowship programs.
Collapse
Affiliation(s)
- Elizabeth M O'Brien
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Associate Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rodrigo Daly Guris
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - William Quarshie
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Elaina E Lin
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Anesthesiology and Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
2
|
Burnett G, Goldhaber-Fiebert S. The role of simulation training in patients' safety in anaesthesia and perioperative medicine. BJA Educ 2024; 24:7-12. [PMID: 38495746 PMCID: PMC10941098 DOI: 10.1016/j.bjae.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2023] [Indexed: 03/19/2024] Open
Affiliation(s)
- G.W. Burnett
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | |
Collapse
|
3
|
Shen J, Singh M, Tran TT, Bughrara NF, Vo C, Sigakis M, Nikravan S, Tone R, Sandhu CK, Kakazu C, Kumar V, Sharma A, Safa R, Byrne M, Subramani S, Pham N, Ramsingh D. Assessment of cardiopulmonary point-of-care ultrasound objective structured clinical examinations in graduating anesthesiology residents across multiple residency programs. J Clin Anesth 2023; 91:111260. [PMID: 37734197 DOI: 10.1016/j.jclinane.2023.111260] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 06/17/2023] [Accepted: 09/08/2023] [Indexed: 09/23/2023]
Abstract
STUDY OBJECTIVE To implement and assess a cardiopulmonary point-of-care ultrasound (POCUS) objective structured clinical examination (OSCE) in a large cohort of graduating anesthesia residents. DESIGN Observational cohort study. SETTING University-affiliated hospitals. SUBJECTS 150 graduating anesthesia residents in their last nine months of training. INTERVENTIONS A standardized cardiopulmonary OSCE was administered to each resident. MEASUREMENTS The cardiac views evaluated were parasternal long axis (PLAX), apical 4 chamber (A4C), and parasternal short axis (PSAX). The pulmonary views evaluated were pleural effusion (PLE) and pneumothorax (PTX). In addition, a pre- and post-exam survey scored on a 5-point Likert scale was administered to each resident. MAIN RESULTS A4C view (mean 0.7 ± 0.3) scored a lower mean, compared to PSAX (mean 0.8 ± 0.3) and PLAX (mean 0.8 ± 0.4). Residents performed well on the PTX exam (mean 0.9 ± 0.3) but more poorly on the PLE exam (mean 0.6 ± 0.4). Structural identification across cardiac and pulmonary views were mostly high (means >0.7), but advanced interpretive skills and maneuvers had lower mean scores. Pre- and post- OSCE survey results were positive with almost all questions scoring >4 on the Likert scale. CONCLUSION Our study demonstrates that a cardiopulmonary POCUS OSCE can be successfully implemented across multiple anesthesia training programs. While most residents were able to perform basic ultrasound views and identify structures, advanced interpretive skills and maneuvers performed lower.
Collapse
Affiliation(s)
- Jay Shen
- UC Irvine School of Medicine, Irvine, CA, USA.
| | | | | | | | | | | | | | - Ryan Tone
- Loma Linda University, Loma Linda, CA, USA
| | | | | | | | | | | | - Melissa Byrne
- University of Michigan Health System, Ann Arbor, MI, USA
| | | | - Nick Pham
- UC Irvine School of Medicine, Irvine, CA, USA
| | | |
Collapse
|
4
|
Richter E, Faloye A, Bhandary S, Hollon M. Pro: Does Every Anesthesiologist Need to Learn Point-of-Care Ultrasound? J Cardiothorac Vasc Anesth 2023; 37:2361-2365. [PMID: 36639259 DOI: 10.1053/j.jvca.2022.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Ellen Richter
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA.
| | - Abimbola Faloye
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA
| | - Sujatha Bhandary
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA
| | - McKenzie Hollon
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA
| |
Collapse
|
5
|
Bradley CA, Ma C, Hollon MM. Perioperative Point of Care Ultrasound for Hemodynamic Assessment: A Narrative Review. Semin Cardiothorac Vasc Anesth 2023; 27:208-223. [PMID: 36943777 DOI: 10.1177/10892532231165088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
While transesophageal echocardiography (TEE) has traditionally been used in perioperative care, there is growing evidence supporting point of care ultrasound (POCUS) for the anesthesiologist in guiding patient care. It is a quick way to non-invasively evaluate hemodynamically unstable patients and ascertain their state of shock, determine volume status, and guide resuscitation in cardiac arrest. In addition, through use of POCUS, the anesthesiologist is able to identify signs of chronic heart disease to provide a more tailored and safer approach to perioperative care.
Collapse
Affiliation(s)
- Caitlin A Bradley
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Chris Ma
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
| | - McKenzie M Hollon
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
| |
Collapse
|
6
|
Giron Arango L, Perlas A. Gastric point-of-care ultrasound: a diagnostic tool that is coming of age? Can J Anaesth 2023; 70:1291-1294. [PMID: 37380902 DOI: 10.1007/s12630-023-02524-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 01/12/2023] [Accepted: 01/12/2023] [Indexed: 06/30/2023] Open
Affiliation(s)
- Laura Giron Arango
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Anahi Perlas
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, Toronto, ON, Canada.
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
| |
Collapse
|
7
|
Sharkey A, Mitchell JD, Fatima H, Bose RR, Quraishi I, Neves SE, Isaak R, Wong VT, Mahmood F, Matyal R. National Delphi Survey on Anesthesiology Resident Training in Perioperative Ultrasound. J Cardiothorac Vasc Anesth 2022; 36:4022-4031. [PMID: 35999114 DOI: 10.1053/j.jvca.2022.07.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 07/06/2022] [Accepted: 07/17/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To establish agreement among nationwide experts through a Delphi process on the key components of perioperative ultrasound and the recommended minimum number of examinations that should be performed by a resident upon graduation. DESIGN A prospective cross-sectional study. SETTING A survey on multiinstitutional academic medical centers. PARTICIPANTS Anesthesiology residency program directors and/or experts in perioperative ultrasound. INTERVENTIONS A list of components and examinations recommended for anesthesiology resident training in perioperative ultrasound was developed based on guidelines and 2 survey rounds among a steering committee of 10 experts. A questionnaire asking for a rating of each component on a 5-point Likert scale subsequently was sent to an expert panel of 120 anesthesiology residency program directors across the United States. An agreement of at least 70% of participants, rating a component as 4 or 5, was compulsory to list a component as essential for anesthesiology resident training in perioperative ultrasound. MEASUREMENTS AND MAIN RESULTS The nationwide survey's response rate was 62.5%, and agreement was reached after 2 Delphi rounds. The final list included 44 essential components for basic ultrasound physics and knobology, cardiac ultrasound, lung ultrasound, and ultrasound-guided vascular access. Agreement was not reached for abdominal ultrasound, gastric ultrasound, and ultrasound-guided airway assessment. Agreement for the recommended minimum number of examinations that should be performed by a resident upon graduation included 50 each for transthoracic and transesophageal echocardiography, and 20 each for lung ultrasound, ultrasound-guided central line, and ultrasound-guided arterial line placements. CONCLUSIONS The recommendations outlined in this survey can be used to establish standardized training for perioperative ultrasound by anesthesiology residency programs.
Collapse
Affiliation(s)
- Aidan Sharkey
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - John D Mitchell
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Huma Fatima
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Ruma R Bose
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Ibrahim Quraishi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sara E Neves
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Robert Isaak
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC
| | - Vanessa T Wong
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Feroze Mahmood
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Robina Matyal
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| |
Collapse
|
8
|
Hollon MM, Bradley C, McCullough I, Borgmeier E. Perioperative applications of focused cardiac ultrasound. Int Anesthesiol Clin 2022; 60:24-33. [PMID: 35670235 DOI: 10.1097/aia.0000000000000371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- McKenzie M Hollon
- Department of Anesthesiology, Emory University SOM, Atlanta, Georgia
| | - Caitlin Bradley
- Department of Anesthesiology, Emory University SOM, Atlanta, Georgia
| | - Ian McCullough
- Department of Anesthesiology, Emory University SOM, Atlanta, Georgia
| | - Emilee Borgmeier
- Department of Anesthesiology, University of Utah, Salt Lake City, Utah
| |
Collapse
|
9
|
Ma Q, Ji J, Shi X, Lu Z, Xu L, Hao J, Zhu W, Li B. Comparison of superior and inferior vena cava diameter variation measured with transthoracic echocardiography to predict fluid responsiveness in mechanically ventilated patients after abdominal surgery. BMC Anesthesiol 2022; 22:150. [PMID: 35581547 PMCID: PMC9112503 DOI: 10.1186/s12871-022-01692-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 04/22/2022] [Indexed: 11/29/2022] Open
Abstract
Background The volume status of patients after major abdominal surgery constantly varies owing to postoperative diverse issues comprising fluid loss or capillary leakage secondary to systemic inflammatory reaction syndrome, et.al, the precise fluid responsiveness assessment is crucial for those patients. The purpose of this study is to validate the transthoracic ultrasonographic measurement of superior and inferior vena cava variation in predicting fluid responsiveness of mechanically ventilated patients after surgery. Methods A total of 70 patients undergoing the scheduled major abdominal surgeries in the anesthesia ICU ward were included. The superior vena cava (SVC) collapsibility index (SVCCI), the inferior vena cava distensibility index (dIVC), SVC variation over the cardiac cycle (SVCV), and cardiac output (CO) were measured by transthoracic ultrasonography were recorded before and after fluid challenge test of 5 ml/kg crystalloid within 15 min. The responders were defined as a 15% or more increment in CO. Results Thirty patients (42.9%) responded to fluid challenge, while the remnant forty patients (57.1%) did not. The areas under the ROC curve (AUC) of SVCCI, dIVC and SVCV were 0.885 (95% CI, 0.786–0.949; P < 0.0001) and 0.727 (95% CI, 0.608–0.827; P < 0.001) and 0.751 (95% CI, 0.633–0.847; P < 0.0001), respectively. AUCdIVC and AUCSVCV were significantly lower when compared with AUCSVCCI (P < 0.05). The optimal cutoff values were 19% for SVCCI, 14% for dIVC, and 15% for SVCV. The gray zone for SVCCI was 20%-25% and included 15.7% of patients, while 7%-27% for dIVC including 62.9% of patients and 9%-21% for SVCV including 50% of patients. Conclusion Superior vena cava-related parameters measured by transthoracic ultrasound are reliable indices to predict fluid responsiveness. The accuracy of SVCCI in mechanically ventilated patients after abdominal surgery is better than that of dIVC and SVCV. Trial registration ChiCTR-INR-17013093. The initial registration date was 24/10/2017.
Collapse
Affiliation(s)
- Qian Ma
- Department of Anesthesiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Jingjing Ji
- Department of Anesthesiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Xueduo Shi
- Department of Anesthesiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Ziyun Lu
- Department of Anesthesiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Lu Xu
- Department of Anesthesiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Jing Hao
- Department of Anesthesiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Wei Zhu
- Department of Anesthesiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Bingbing Li
- Department of Anesthesiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China.
| |
Collapse
|
10
|
Stenberg Y, Rhodin Y, Lindberg A, Aroch R, Hultin M, Walldén J, Myrberg T. Pre-operative point-of-care assessment of left ventricular diastolic dysfunction, an observational study. BMC Anesthesiol 2022; 22:96. [PMID: 35382761 PMCID: PMC8981659 DOI: 10.1186/s12871-022-01642-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/30/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Left ventricular (LV) diastolic dysfunction is an acknowledged peri-operative risk factor that should be identified before surgery. This study aimed to evaluate a simplified echocardiographic method using e' and E/e' for identification and grading of diastolic dysfunction pre-operatively. METHODS Ninety six ambulatory surgical patients were consecutively included to this prospective observational study. Pre-operative transthoracic echocardiography was conducted prior to surgery, and diagnosis of LV diastolic dysfunction was established by comprehensive and simplified assessment, and the results were compared. The accuracy of e'-velocities in order to discriminate patients with diastolic dysfunction was established by calculating accuracy, efficiency, positive (PPV) and negative predictive (NPV) values, and area under the receiver operating characteristic curve (AUROC). RESULTS Comprehensive assessment established diastolic dysfunction in 77% (74/96) of patients. Of these, 22/74 was categorized as mild dysfunction, 43/74 as moderate dysfunction and 9/74 as severe dysfunction. Using the simplified method with e' and E/e', diastolic dysfunction was established in 70.8% (68/96) of patients. Of these, 8/68 was categorized as mild dysfunction, 36/68 as moderate dysfunction and 24/68 as severe dysfunction. To discriminate diastolic dysfunction of any grade, e'-velocities (mean < 9 cm s- 1) had an AUROC of 0.901 (95%CI 0.840-0.962), with a PPV of 55.2%, a NPV of 90.9% and a test efficiency of 0.78. CONCLUSIONS The results of this study indicate that a simplified approach with tissue Doppler e'-velocities may be used to rule out patients with diastolic dysfunction pre-operatively, but together with E/e' ratio the severity of diastolic dysfunction may be overestimated. TRIAL REGISTRATION Clinicaltrials.gov, Identifier: NCT03349593 . Date of registration 21/11/2017. https://clinicaltrials.gov .
Collapse
Affiliation(s)
- Ylva Stenberg
- Department of Surgical and Perioperative Sciences, Anaesthesiology and Intensive Care Medicine, (Sunderbyn), Umeå University, Umeå, Sweden
| | - Ylva Rhodin
- Department of Surgical and Perioperative Sciences, Anaesthesiology and Intensive Care Medicine, (Sunderbyn), Umeå University, Umeå, Sweden
| | - Anne Lindberg
- Department of Public Health and Clinical Medicine, Section of Medicine, Umeå University, Umeå, Sweden
| | - Roman Aroch
- Department of Surgical and Perioperative Sciences, Anaesthesiology and Intensive Care Medicine, (Umeå), Umeå University, Umeå, Sweden
| | - Magnus Hultin
- Department of Surgical and Perioperative Sciences, Anaesthesiology and Intensive Care Medicine, (Umeå), Umeå University, Umeå, Sweden
| | - Jakob Walldén
- Department of Surgical and Perioperative Sciences, Anaesthesiology and Intensive Care Medicine, (Sundsvall), Umeå University, Umeå, Sweden
| | - Tomi Myrberg
- Department of Surgical and Perioperative Sciences, Anaesthesiology and Intensive Care Medicine, (Sunderbyn), Umeå University, Umeå, Sweden. .,Department of Anaesthesiology and Critical Care, Sunderby Hospital, 971 80, Luleå, Sweden.
| |
Collapse
|
11
|
Clunie M, O'Brien J, Olszynski P, Bajwa J, Perverseff R. Competence of anesthesiology residents following a longitudinal point-of-care ultrasound curriculum. Can J Anaesth 2022; 69:460-471. [PMID: 34966971 PMCID: PMC8715842 DOI: 10.1007/s12630-021-02172-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 09/05/2021] [Accepted: 10/28/2021] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Point-of-care ultrasound (POCUS) facilitates diagnostic, procedural, and resuscitative applications in anesthesiology. Structured POCUS curricula improve learner satisfaction, test scores, and clinical management, but the learning curve towards competency and retention of skills over time remain unknown. METHODS We conducted a prospective observational study to determine when anesthesiology trainees enrolled in a POCUS curriculum achieve competency in POCUS skills. We also investigated the learning curve of trainees' competency using a POCUS-specific competency-based medical education assessment. The structured, longitudinal POCUS curriculum included online lectures, journal articles, live model scanning sessions, video review of cases, and a portfolio of supervised scans. Point-of-care ultrasound scanning sessions on standardized patients were conducted in the simulation lab for 2.5 hr a week and each resident completed eight sessions (20 hr) per academic year. At each scanning session, timed image acquisition scores were collected and POCUS skills entrustment scale evaluations were conducted. The primary outcome was the number of supervised scans and sessions required to achieve a mean entrustment score of 4 ("may use independently"). Secondary outcomes included image acquisition scores and retention of skills after six months. RESULTS The mean (standard deviation) number of supervised scans required for trainees (n = 29) to reach a mean entrustment score of ≥ 4 was 36 (10) scans over nine sessions for rescue echo. A mean entrustment score of ≥ 4 was observed for lung ultrasound after a mean (SD) of 8 (3) scans over two sessions. CONCLUSIONS Our study shows that anesthesiology residents can achieve competence in rescue echo and lung ultrasound through participation in a structured, longitudinal POCUS curriculum, and outlines the learning curve for progression towards competency.
Collapse
Affiliation(s)
- Michelle Clunie
- Department of Anesthesiology, Perioperative Medicine and Pain Management, Royal University Hospital, Room G525, 103 Hospital Drive, Saskatoon, SK, S7N 0W8, Canada.
| | - Jennifer O'Brien
- Department of Anesthesiology, Perioperative Medicine and Pain Management, Saskatoon, SK, Canada
| | - Paul Olszynski
- Department of Emergency Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | - Jagmeet Bajwa
- Department of Anesthesiology, Perioperative Medicine and Pain Management, Saskatoon, SK, Canada
| | - Rob Perverseff
- Department of Anesthesiology, Perioperative Medicine and Pain Management, Saskatoon, SK, Canada
| |
Collapse
|
12
|
Preoperative Point-of-Care Ultrasound to Identify Frailty and Predict Postoperative Outcomes: A Diagnostic Accuracy Study. Anesthesiology 2022; 136:268-278. [PMID: 34851395 PMCID: PMC9843825 DOI: 10.1097/aln.0000000000004064] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Frailty is increasingly being recognized as a public health issue, straining healthcare resources and increasing costs to care for these patients. Frailty is the decline in physical and cognitive reserves leading to increased vulnerability to stressors such as surgery or disease states. The goal of this pilot diagnostic accuracy study was to identify whether point-of-care ultrasound measurements of the quadriceps and rectus femoris muscles can be used to discriminate between frail and not-frail patients and predict postoperative outcomes. This study hypothesized that ultrasound could discriminate between frail and not-frail patients before surgery. METHODS Preoperative ultrasound measurements of the quadriceps and rectus femoris were obtained in patients with previous computed tomography scans. Using the computed tomography scans, psoas muscle area was measured in all patients for comparative purposes. Frailty was identified using the Fried phenotype assessment. Postoperative outcomes included unplanned intensive care unit admission, delirium, intensive care unit length of stay, hospital length of stay, unplanned skilled nursing facility admission, rehospitalization, falls within 30 days, and all-cause 30-day and 1-yr mortality. RESULTS A total of 32 patients and 20 healthy volunteers were included. Frailty was identified in 18 of the 32 patients. Receiver operating characteristic curve analysis showed that quadriceps depth and psoas muscle area are able to identify frailty (area under the curve-receiver operating characteristic, 0.80 [95% CI, 0.64 to 0.97] and 0.88 [95% CI, 0.76 to 1.00], respectively), whereas the cross-sectional area of the rectus femoris is less promising (area under the curve-receiver operating characteristic, 0.70 [95% CI, 0.49 to 0.91]). Quadriceps depth was also associated with unplanned postoperative skilled nursing facility discharge disposition (area under the curve 0.81 [95% CI, 0.61 to 1.00]) and delirium (area under the curve 0.89 [95% CI, 0.77 to 1.00]). CONCLUSIONS Similar to computed tomography measurements of psoas muscle area, preoperative ultrasound measurements of quadriceps depth shows promise in discriminating between frail and not-frail patients before surgery. It was also associated with skilled nursing facility admission and postoperative delirium. EDITOR’S PERSPECTIVE
Collapse
|
13
|
|
14
|
Krishnan S, Bronshteyn YS. Role of diagnostic point-of-care ultrasound in preoperative optimization: a narrative review. Int Anesthesiol Clin 2022; 60:64-68. [PMID: 34686645 DOI: 10.1097/aia.0000000000000343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Sundar Krishnan
- Department of Anesthesiology, Duke University School of Medicine, Duke University Medical Center
| | - Yuriy S Bronshteyn
- Department of Anesthesiology, Duke University School of Medicine, Duke University Medical Center
- Durham VA Health Care System, Durham, North Carolina
| |
Collapse
|
15
|
Liao Z, Feng S, Song H, Huang H. Continuous transthoracic echocardiographic monitoring for changes in maternal cardiac hemodynamics during cesarean section under combined epidural-spinal anesthesia: a prospective, observational study. J Clin Monit Comput 2021; 36:1387-1396. [PMID: 34743260 DOI: 10.1007/s10877-021-00777-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 11/01/2021] [Indexed: 02/05/2023]
Abstract
The change in maternal hemodynamics during cesarean section has not been well studied. Continuous transthoracic echocardiography can monitor cardiac function continuously. This study aimed to evaluate the effectiveness of maternal hemodynamic parameters monitoring during cesarean section using continuous transthoracic echocardiography. In this prospective, observational study, women with an uncomplicated singleton pregnancy scheduled for elective cesarean section at term under combined spinal-epidural anesthesia were enrolled. Maternal hemodynamic parameters were assessed by continuous transthoracic echocardiography at 11 pre-set time points. The image quality of continuous transthoracic echocardiography was evaluated before measurement was performed. Totally, one hundred parturients were recruited, and transthoracic echocardiography images with sufficient quality for further analysis were obtained in 72 women. Following anesthesia, maternal heart rate decreased by 11.18% and cardiac output decreased by 7.82%, but stroke volume remained stable. After delivery of the neonate and placenta, stroke volume and cardiac output increased by 21.09% and 22.33%, respectively. End-diastolic volume also increased significantly after delivery of the neonate, but end-systolic volume was unchanged. Following delivery of the neonate, fractional shortening increased till the end of the cesarean section while total peripheral resistance decreased significantly. In conclusion, continuous transthoracic echocardiographic monitoring revealed that there were significant changes in hemodynamic parameters during cesarean section after delivery of the newborn and placenta, which warranted further investigation.
Collapse
Affiliation(s)
- Zhimin Liao
- Department of Anesthesiology and Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, 20#, 3rd Segment, Ren Min Nan Lu, Chengdu, 610041, Sichuan, People's Republic of China
| | - Shimiao Feng
- Department of Anesthesiology and Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, 20#, 3rd Segment, Ren Min Nan Lu, Chengdu, 610041, Sichuan, People's Republic of China
| | - Haibo Song
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Han Huang
- Department of Anesthesiology and Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, 20#, 3rd Segment, Ren Min Nan Lu, Chengdu, 610041, Sichuan, People's Republic of China.
| |
Collapse
|
16
|
Ranganna S, Kiefer JJ, Augoustides JG. Perioperative Transthoracic Echocardiography-Thoughtful Design and Delivery of Standardized Imaging Protocols for Anesthesiology Teams. J Cardiothorac Vasc Anesth 2021; 36:387-389. [PMID: 34922818 DOI: 10.1053/j.jvca.2021.10.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 10/25/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Shreyas Ranganna
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jesse J Kiefer
- Critical Care Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G Augoustides
- Cardiovascular and Thoracic Division, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| |
Collapse
|
17
|
Markin NW, Coker BJ, Tuck BC, Chacon MM. Focused Cardiac Ultrasound in the Operating Room-Another Important Tool for the Assessment of the Unstable Patient. Anesth Analg 2021; 133:848-851. [PMID: 34524984 DOI: 10.1213/ane.0000000000005487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Nicholas W Markin
- From the Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Bradley J Coker
- Department of Anesthesiology and Perioperative Medicine, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Benjamin C Tuck
- Department of Anesthesiology and Perioperative Medicine, The University of Alabama at Birmingham, Birmingham, Alabama
| | - M Megan Chacon
- From the Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska
| |
Collapse
|
18
|
Fatima H, Sharkey A, Qureshi N, Mahmood F, Mufarrih SH, Baribeau V, Matyal R, Bose RR. Three-Dimensional Transesophageal Echocardiography Simulator: New Learning Tool for Advanced Imaging Techniques. J Cardiothorac Vasc Anesth 2021; 36:2090-2097. [PMID: 34275733 DOI: 10.1053/j.jvca.2021.05.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/20/2021] [Accepted: 05/26/2021] [Indexed: 11/11/2022]
Abstract
The use of intraoperative three-dimensional (3D) transesophageal echocardiography (TEE) has grown exponentially in recent years. Three-dimensional TEE technology has evolved to allow for real-time display of 3D images and, thus, has become the standard of care for the evaluation of cardiac anatomy and function. Its use has provided a new dimension of clinical insight when managing patients for cardiac surgery or structural heart interventions. While the intraoperative utility of 3D TEE has expanded, there has been a slower advancement in the area of training and, specifically, simulator-based training in 3D TEE. This training is essential, as the skill set involved in acquiring 3D data sets differs from that of two-dimensional (2D) TEE and requires users to be able to appreciate how 3D anatomic display differs from that of tomographic cross-sectional 2D imaging. This added skill set requires mental reconstruction and spatial reorientation to appreciate the added elevational dimension in frustum-based imaging and is best achieved in a simulation environment rather than the busy operating room. In this review article, the authors evaluate the functionality of a 3D TEE simulator and how simulators such as this can establish preclinical proficiency in novices in the expanding area of advanced 3D TEE imaging.
Collapse
Affiliation(s)
- Huma Fatima
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA
| | - Aidan Sharkey
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA
| | - Nada Qureshi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA
| | - Feroze Mahmood
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA
| | - Syed Hamza Mufarrih
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA
| | - Vincent Baribeau
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA
| | - Robina Matyal
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA
| | - Ruma R Bose
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA.
| |
Collapse
|
19
|
Gomes SH, Simões AM, Nunes AM, Pereira MV, Teoh WH, Costa PS, Kristensen MS, Teixeira PM, Pêgo JM. Useful Ultrasonographic Parameters to Predict Difficult Laryngoscopy and Difficult Tracheal Intubation-A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2021; 8:671658. [PMID: 34124099 PMCID: PMC8193063 DOI: 10.3389/fmed.2021.671658] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 04/23/2021] [Indexed: 12/03/2022] Open
Abstract
Unexpected difficult airway management can cause significant morbidity and mortality in patients admitted for elective procedures. Ultrasonography is a promising tool for perioperative airway assessment, nevertheless it is still unclear which sonographic parameters are useful predictors of difficult laryngoscopy and tracheal intubation. To determine the ultrasonographic predictors of a difficult airway that could be applied for routine practice, a systematic review and meta-analysis was conducted. Literature search was performed on PubMED, Web of Science and Embase using the selected keywords. Human primary studies, published in English with the use of ultrasonography to prediction of difficult laryngoscopy or tracheal intubation were included. A total of 19 articles (4,570 patients) were analyzed for the systematic review and 12 articles (1,141 patients) for the meta-analysis. Standardized mean differences between easy and difficult laryngoscopy groups were calculated and the parameter effect size quantified. A PRISMA methodology was used and the critical appraisal tool from Joanna Briggs Institute was applied. Twenty-six sonographic parameters were studied. The overall effect of the distance from skin to hyoid bone (p = 0.02); skin to epiglottis (p = 0.02); skin to the anterior commissure of vocal cords (p = 0.02), pre-epiglottis space to distance between epiglottis and midpoint between vocal cords (p = 0.01), hyomental distance in neutral (p < 0.0001), and extended (p = 0.0002) positions and ratio of hyomental distance in neutral to extended (p = 0.001) was significant. This study shows that hyomental distance in the neutral position is the most reliable parameter for pre-operative airway ultrasound assessment. The main limitations of the study are the small sample size, heterogeneity of studies, and absence of a standardized ultrasonographic evaluation method [Registered at International prospective register of systematic reviews (PROSPERO): number 167931].
Collapse
Affiliation(s)
- Sara H. Gomes
- School of Medicine, Life and Health Sciences Research Institute (ICVS), University of Minho, Braga, Portugal
- ICVS/3B's - PT Government Associate Laboratory, Braga, Portugal
| | - Ana M. Simões
- School of Medicine, Life and Health Sciences Research Institute (ICVS), University of Minho, Braga, Portugal
- ICVS/3B's - PT Government Associate Laboratory, Braga, Portugal
| | - Andreia M. Nunes
- School of Medicine, Life and Health Sciences Research Institute (ICVS), University of Minho, Braga, Portugal
- ICVS/3B's - PT Government Associate Laboratory, Braga, Portugal
| | - Marta V. Pereira
- School of Medicine, Life and Health Sciences Research Institute (ICVS), University of Minho, Braga, Portugal
- ICVS/3B's - PT Government Associate Laboratory, Braga, Portugal
| | | | - Patrício S. Costa
- School of Medicine, Life and Health Sciences Research Institute (ICVS), University of Minho, Braga, Portugal
- ICVS/3B's - PT Government Associate Laboratory, Braga, Portugal
| | - Michael S. Kristensen
- Department of Anesthesia, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Pedro M. Teixeira
- School of Medicine, Life and Health Sciences Research Institute (ICVS), University of Minho, Braga, Portugal
- ICVS/3B's - PT Government Associate Laboratory, Braga, Portugal
| | - José Miguel Pêgo
- School of Medicine, Life and Health Sciences Research Institute (ICVS), University of Minho, Braga, Portugal
- ICVS/3B's - PT Government Associate Laboratory, Braga, Portugal
| |
Collapse
|
20
|
The Evaluation Point-of-Care Ultrasound in the Post-Anesthesia Unit-A Multicenter Prospective Observational Study. J Clin Med 2021; 10:jcm10112389. [PMID: 34071466 PMCID: PMC8198895 DOI: 10.3390/jcm10112389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 04/30/2021] [Accepted: 05/12/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction: Point-of-care ultrasound (POCUS) is the most rapidly growing imaging modality for acute care. Despite increased use, there is still wide variability and less evidence regarding its clinical utility for the perioperative setting compared to other acute care settings. This study sought to demonstrate the impact of POCUS examinations for acute hypoxia and hypotension occurring in the post-anesthesia care unit (PACU) versus traditional bedside examinations. Methods: This study was designed as a multi-center prospective observational study. Adult patients who experienced a reduced mean arterial blood pressure (MAP < 60mmHG) and/or a reduced oxygen saturation (SpO2 < 88%) in the PACU from 7AM to 4PM were targeted. POCUS was available or not for patient assessment based on PACU team training. All providers who performed POCUS exams received standardized training on cardiac and pulmonary POCUS. All POCUS exam findings were recorded on a standardized form and the number of suspected mechanisms to trigger the acute event were captured before and after the POCUS exam. PACU length of stay (minutes) across groups was the primary outcome. Results: In total, 128 patients were included in the study, with 92 patients receiving a POCUS exam. Comparison of PACU time between the POCUS group (median = 96.5 min) and no-POCUS groups (median = 120.5 min) demonstrated a reduction for the POCUS group, p = 0.019. Hospital length of stay and 30-day hospital readmission did not show a significant difference between groups. Finally, there was a reduction in the number of suspected diagnoses from before to after the POCUS examination for both pulmonary and cardiac exams, p-values < 0.001. Conclusions: Implementation of POCUS for assessment of acute hypotension and hypoxia in the PACU setting is associated with a reduced PACU length of stay and a reduction in suspected number of diagnoses.
Collapse
|
21
|
Fatima H, Amador Y, Walsh DP, Qureshi NQ, Chaudhary O, Mufarrih SH, Bose RR, Mahmood F, Matyal R. Simplified Algorithm for Evaluation of Perioperative Hypoxia and Hypotension (SALVATION): A Practical Echo-guided Approach Proposal. J Cardiothorac Vasc Anesth 2021; 35:2273-2282. [PMID: 34006466 DOI: 10.1053/j.jvca.2021.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 04/08/2021] [Accepted: 04/11/2021] [Indexed: 01/17/2023]
Abstract
Despite the valuable use of modern applications of perioperative ultrasound across multiple disciplines, there have been limitations to its implementation, restricting its impact on patient-based clinical outcomes. Point-of-care ultrasound evaluation of hypoxia and hypotension is an important tool to assess the underlying undifferentiated etiologies in a timely manner. However, there is a lack of consensus on the formal role of ultrasound during evaluation of perioperative hypoxia or hypotension. The previous ultrasound algorithms have adopted a complex technique that possibly ignore the pathophysiologic mechanisms underlying the conditions presenting in a similar fashion. The authors here propose a simple, sequential and focused multiorgan approach, applicable for the evaluation of perioperative hypotension and hypoxia in emergency scenarios. The authors believe this approach will enhance the care provided in the postanesthesia care unit, operating room, and intensive care unit.
Collapse
Affiliation(s)
- Huma Fatima
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA
| | - Yannis Amador
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA
| | - Daniel P Walsh
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA
| | - Nada Qaisar Qureshi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA
| | - Omar Chaudhary
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA
| | - Syed Hamza Mufarrih
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA
| | - Ruma R Bose
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA
| | - Feroze Mahmood
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA
| | - Robina Matyal
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA.
| |
Collapse
|
22
|
Bronshteyn YS, Anderson TA, Badakhsh O, Boublik J, Brady MBW, Charnin JE, Coker BJ, Deriy LB, Hardman HD, Haskins SC, Hollon M, Hsia HLJ, Neelankavil JP, Panzer OPF, Perlas A, Ramsingh D, Sharma A, Shore-Lesserson LJ, Zimmerman JM. Diagnostic Point-of-Care Ultrasound: Recommendations From an Expert Panel. J Cardiothorac Vasc Anesth 2021; 36:22-29. [PMID: 34059438 DOI: 10.1053/j.jvca.2021.04.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/28/2021] [Accepted: 04/10/2021] [Indexed: 12/31/2022]
Abstract
Diagnostic point-of-care ultrasound (PoCUS) has emerged as a powerful tool to help anesthesiologists guide patient care in both the perioperative setting and the subspecialty arenas. Although anesthesiologists can turn to guideline statements pertaining to other aspects of ultrasound use, to date there remains little in the way of published guidance regarding diagnostic PoCUS. To this end, in 2018, the American Society of Anesthesiologists chartered an ad hoc committee consisting of 23 American Society of Anesthesiologists members to provide recommendations on this topic. The ad hoc committee convened and developed a committee work product. This work product was updated in 2021 by an expert panel of the ad hoc committee to produce the document presented herein. The document, which represents the consensus opinion of a group of practicing anesthesiologists with established expertise in diagnostic ultrasound, addresses the following issues: (1) affirms the practice of diagnostic PoCUS by adequately trained anesthesiologists, (2) identifies the scope of practice of diagnostic PoCUS relevant to anesthesiologists, (3) suggests the minimum level of training needed to achieve competence, (4) provides recommendations for how diagnostic PoCUS can be used safely and ethically, and (5) provides broad guidance about diagnostic ultrasound billing.
Collapse
Affiliation(s)
- Yuriy S Bronshteyn
- Duke University School of Medicine, Duke University Health System, Durham Veterans Health Administration, Durham, NC.
| | | | - Orode Badakhsh
- University of California Davis Medical Center, Sacramento, CA
| | - Jan Boublik
- Stanford University School of Medicine, Stanford, CA
| | | | - Jonathan E Charnin
- Mayo Clinic, Rochester, MN, University of Alabama at Birmingham, Birmingham, AL
| | - Bradley J Coker
- Mayo Clinic, Rochester, MN, University of Alabama at Birmingham, Birmingham, AL
| | - Lev B Deriy
- Department of Anesthesiology and Critical Care, University of New Mexico, Albuquerque, NM
| | - H David Hardman
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Stephen C Haskins
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY; Department of Anesthesiology, Weill-Cornell Medical College, New York, NY
| | - McKenzie Hollon
- Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA
| | - Hung-Lun John Hsia
- Duke University School of Medicine, Duke University Health System, Durham Veterans Health Administration, Durham, NC
| | | | - Oliver P F Panzer
- Columbia University College of Physicians and Surgeons, New York, NY
| | - Anahi Perlas
- Department of Anesthesiology and Pain Management, Toronto Western Hospital, University of Toronto, Toronto, Canada
| | - Davinder Ramsingh
- Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA
| | - Archit Sharma
- University of Iowa Carver College of Medicine, Iowa City, IA
| | | | | | | |
Collapse
|
23
|
Abstract
BACKGROUND Graduate medical education is being transformed from a time-based training model to a competency-based training model. While the application of ultrasound in the perioperative arena has become an expected skill set for anesthesiologists, clinical exposure during training is intermittent and nongraduated without a structured program. We developed a formal structured perioperative ultrasound program to efficiently train first-year clinical anesthesia (CA-1) residents and evaluated its effectiveness quantitatively in the form of a proficiency index. METHODS In this prospective study, a multimodal perioperative ultrasound training program spread over 3 months was designed by experts at an accredited anesthesiology residency program to train the CA-1 residents. The training model was based on self-learning through web-based modules and instructor-based learning by performing perioperative ultrasound techniques on simulators and live models. The effectiveness of the program was evaluated by comparing the CA-1 residents who completed the training to graduating third-year clinical anesthesia (CA-3) residents who underwent the traditional ultrasound training in the residency program using a designed index called a "proficiency index." The proficiency index was composed of scores on a cognitive knowledge test (20%) and scores on an objective structured clinical examination (OSCE) to evaluate the workflow understanding (40%) and psychomotor skills (40%). RESULTS Sixteen CA-1 residents successfully completed the perioperative ultrasound training program and the subsequent evaluation with the proficiency index. The total duration of training was 60 hours of self-based learning and instructor-based learning. There was a significant improvement observed in the cognitive knowledge test scores for the CA-1 residents after the training program (pretest: 71% [0.141 ± 0.019]; posttest: 83% [0.165 ± 0.041]; P < .001). At the end of the program, the CA-1 residents achieved an average proficiency index that was not significantly different from the average proficiency index of graduating CA-3 residents who underwent traditional ultrasound training (CA-1: 0.803 ± 0.049; CA-3: 0.823 ± 0.063, P = .307). CONCLUSIONS Our results suggest that the implementation of a formal, structured curriculum allows CA-1 residents to achieve a level of proficiency in perioperative ultrasound applications before clinical exposure.
Collapse
|
24
|
Haskins SC, Bronshteyn Y, Perlas A, El-Boghdadly K, Zimmerman J, Silva M, Boretsky K, Chan V, Kruisselbrink R, Byrne M, Hernandez N, Boublik J, Manson WC, Hogg R, Wilkinson JN, Kalagara H, Nejim J, Ramsingh D, Shankar H, Nader A, Souza D, Narouze S. American Society of Regional Anesthesia and Pain Medicine expert panel recommendations on point-of-care ultrasound education and training for regional anesthesiologists and pain physicians-part II: recommendations. Reg Anesth Pain Med 2021; 46:1048-1060. [PMID: 33632777 DOI: 10.1136/rapm-2021-102561] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 02/04/2021] [Indexed: 12/21/2022]
Abstract
Point-of-care ultrasound (POCUS) is a critical skill for all regional anesthesiologists and pain physicians to help diagnose relevant complications related to routine practice and guide perioperative management. In an effort to inform the regional anesthesia and pain community as well as address a need for structured education and training, the American Society of Regional Anesthesia and Pain Medicine Society (ASRA) commissioned this narrative review to provide recommendations for POCUS. The recommendations were written by content and educational experts and were approved by the guidelines committee and the Board of Directors of the ASRA. In part II of this two-part series, learning goals and objectives were identified and outlined for achieving competency in the use of POCUS, specifically, airway ultrasound, lung ultrasound, gastric ultrasound, the focus assessment with sonography for trauma exam, and focused cardiac ultrasound, in the perioperative and chronic pain setting. It also discusses barriers to POCUS education and training and proposes a list of educational resources. For each POCUS section, learning goals and specific skills were presented in the Indication, Acquisition, Interpretation, and Medical decision-making framework.
Collapse
Affiliation(s)
- Stephen C Haskins
- Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA .,Anesthesiology, Weill Cornell Medical College, New York, New York, USA
| | - Yuriy Bronshteyn
- Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Anahi Perlas
- Anesthesia and Pain Management, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Joshua Zimmerman
- Anesthesiology, University of Utah Health, Salt Lake City, Utah, USA
| | - Marcos Silva
- Anesthesia and Pain Management, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Karen Boretsky
- Anesthesiology, Critical Care and Pain Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Vincent Chan
- Anesthesia and Pain Management, Toronto Western Hospital, Toronto, Ontario, Canada
| | | | - Melissa Byrne
- Anesthesiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Nadia Hernandez
- Anesthesiology, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jan Boublik
- Anesthesiology, Stanford Hospital and Clinics, Stanford, California, USA
| | - William Clark Manson
- Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Rosemary Hogg
- Anaesthesia, Belfast Health and Social Care Trust, Belfast, UK
| | - Jonathan N Wilkinson
- Intensive Care and Anaesthesia, Northampton General Hospital, Northampton, Northamptonshire, UK
| | | | - Jemiel Nejim
- Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, New York, USA.,Anesthesiology, Weill Cornell Medical College, New York, New York, USA
| | - Davinder Ramsingh
- Anesthesiology, Loma Linda University Medical Center, Loma Linda, California, USA
| | - Hariharan Shankar
- Anesthesiology, Clement Zablocki VA Medical Center/Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Antoun Nader
- Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Dmitri Souza
- Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
| | - Samer Narouze
- Center for Pain Medicine, Western Reserve Hospital, Cuyahoga Falls, Ohio, USA
| |
Collapse
|
25
|
Buesing J, Weng Y, Kugler J, Wang L, Blaha O, Hom J, Ahuja N, Kumar A. Handheld Ultrasound Device Usage and Image Acquisition Ability Among Internal Medicine Trainees: A Randomized Trial. J Grad Med Educ 2021; 13:76-82. [PMID: 33680304 PMCID: PMC7901629 DOI: 10.4300/jgme-d-20-00355.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/10/2020] [Accepted: 09/25/2020] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND There is insufficient knowledge about how personal access to handheld ultrasound devices (HUDs) improves trainee learning with point-of-care ultrasound (POCUS). OBJECTIVE To assess whether HUDs, alongside a yearlong lecture series, improved trainee POCUS usage and ability to acquire images. METHODS Internal medicine intern physicians (n = 47) at a single institution from 2017 to 2018 were randomized 1:1 to receive personal HUDs (n = 24) for patient care/self-directed learning vs no-HUDs (n = 23). All interns received a repeated lecture series on cardiac, thoracic, and abdominal POCUS. Main outcome measures included self-reported HUD usage rates and post-intervention assessment scores using the Rapid Assessment of Competency in Echocardiography (RACE) scale between HUD and no-HUD groups. RESULTS HUD interns reported performing POCUS assessments on patients a mean 6.8 (SD 2.2) times per week vs 6.4 (SD 2.9) times per week in non-HUD arm (P = .66). There was no relationship between the number of self-reported examinations per week and a trainee's post-intervention RACE score (rho = 0.022, P = .95). HUD interns did not have significantly higher post-intervention RACE scores (median HUD score 17.0 vs no-HUD score 17.8; P = .72). Trainee confidence with cardiac POCUS did not correlate with RACE scores. CONCLUSIONS Personal HUDs without direct supervision did not increase the amount of POCUS usage or improve interns' acquisition abilities. Interns who reported performing more examinations per week did not have higher RACE scores. Improved HUD access and lectures without additional feedback may not improve POCUS mastery.
Collapse
|
26
|
Lammers S, Hong C, Tepper J, Moore C, Baston C, Dolin CD. Use of point-of-care ultrasound to diagnose spontaneous rupture of fibroid in pregnancy. POCUS JOURNAL 2021; 6:16-21. [PMID: 36895497 PMCID: PMC9979928 DOI: 10.24908/pocus.v6i1.14757] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background: Complications of fibroids in pregnancy are well known, including postpartum hemorrhage, labor dystocia, and cesarean delivery. Outside of pregnancy and labor, the rare occurrence of spontaneous fibroid rupture has been documented. Case: The current case report involves a woman who presented with acute abdominal pain in the third trimester of pregnancy and was found to have spontaneous rupture of a fibroid before the onset of labor. Her initial presentation, diagnosis through use of point-of-care ultrasound, acute surgical management, and postoperative course are described. Conclusion: When assessing acute abdominal pain in a pregnant patient, fibroid rupture should be considered despite the absence of prior uterine surgery. Bedside point-of-care ultrasonography is a useful tool for assessment of abdominal pain in the third trimester of pregnancy.
Collapse
Affiliation(s)
- Stephen Lammers
- Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine Philadelphia, PA
| | - Christopher Hong
- Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine Philadelphia, PA
| | - Jared Tepper
- Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine Philadelphia, PA
| | - Christy Moore
- Department of Emergency Medicine, University of Pennsylvania Philadelphia, PA
| | - Cameron Baston
- Department of Medicine, University of Pennsylvania Philadelphia, PA
| | - Cara D Dolin
- Department of Obstetrics & Gynecology, University of Pennsylvania Perelman School of Medicine Philadelphia, PA
| |
Collapse
|
27
|
Dong L, Yang L, Li Z, Wang X. Application of PBL Mode in a Resident-Focused Perioperative Transesophageal Echocardiography Training Program: A Perspective of MOOC Environment. ADVANCES IN MEDICAL EDUCATION AND PRACTICE 2020; 11:1023-1028. [PMID: 33380858 PMCID: PMC7767642 DOI: 10.2147/amep.s282320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 11/21/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Massive open online courses (MOOCs) is a new teaching technology based on a network platform, which can provide more students with the possibility of systematic and repeated learning. Due to the complexity of transesophageal echocardiography (TEE), the wide range of knowledge involved, and many knowledge points being difficult to understand, it is difficult to meet the teaching needs of this content with the traditional teaching mode. This study aimed to discuss the application of lecture based learning (LBL) and problem based learning (PBL) in the training of perioperative TEE in the context of MOOCs. METHODS Sixty residents were randomly divided into two groups to participate in a 5-day perioperative TEE training program. The web-based PBL mode was used in the observation group and the LBL mode was used in the control group, with 30 residents in each group. The teaching effect of the web-based PBL mode was compared with the LBL mode by basic theory test, practice examination, image interpretation and questionnaire. RESULTS The image interpretation score and the total test score were higher in the observation group than in the control group with statistically significant differences (P<0.001). The results of the questionnaire show that the residents were more satisfied with the web-based PBL mode than the LBL mode (P<0.001). CONCLUSION The web-based PBL method has obvious advantages over the LBL mode in the training of perioperative TEE.
Collapse
Affiliation(s)
- Lini Dong
- Department of Geriatrics, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Lin Yang
- Department of Anesthesiology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
- Anesthesia Medical Research Center of Central South University, Changsha, Hunan, China
| | - Zhijian Li
- Department of Anesthesiology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
- Anesthesia Medical Research Center of Central South University, Changsha, Hunan, China
| | - Xin Wang
- Department of Anesthesiology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
- Anesthesia Medical Research Center of Central South University, Changsha, Hunan, China
| |
Collapse
|
28
|
Affiliation(s)
- Emily Methangkool
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles
| | - Daniel J Cole
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles
| |
Collapse
|
29
|
Kars MS, Gomez Morad A, Haskins SC, Boublik J, Boretsky K. Point-of-care ultrasound for the pediatric regional anesthesiologist and pain specialist: a technique review. Reg Anesth Pain Med 2020; 45:985-992. [DOI: 10.1136/rapm-2020-101341] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 08/04/2020] [Accepted: 08/08/2020] [Indexed: 01/11/2023]
Abstract
Point-of-care ultrasound (PoCUS) has been well described for adult perioperative patients; however, the literature on children remains limited. Regional anesthesiologists have gained interest in expanding their clinical repertoire of PoCUS from regional anesthesia to increasing numbers of applications. This manuscript reviews and highlights emerging PoCUS applications that may improve the quality and safety of pediatric care.In infants and children, lung and airway PoCUS can be used to identify esophageal intubation, size airway devices such as endotracheal tubes, and rule in or out a pulmonary etiology for clinical decompensation. Gastric ultrasound can be used to stratify aspiration risk when nil-per-os compliance and gastric emptying are uncertain. Cardiac PoCUS imaging is useful to triage causes of undifferentiated hypotension or tachycardia and to determine reversible causes of cardiac arrest. Cardiac PoCUS can assess for pericardial effusion, gross ventricular systolic function, cardiac volume and filling, and gross valvular pathology. When PoCUS is used, a more rapid institution of problem-specific therapy with improved patient outcomes is demonstrated in the pediatric emergency medicine and critical care literature.Overall, PoCUS saves time, expedites the differential diagnosis, and helps direct therapy when used in infants and children. PoCUS is low risk and should be readily accessible to pediatric anesthesiologists in the operating room.
Collapse
|
30
|
Deshpande R, Karnik R, Baer C, Kurup V. Resource Utilization in Implementation of a Point of Care Ultrasound Curriculum for Resident Training in Anesthesiology. THE YALE JOURNAL OF BIOLOGY AND MEDICINE 2020; 93:423-427. [PMID: 32874148 PMCID: PMC7448394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Purpose: Point of care ultrasound (POCUS) brings high-quality patient care to the bedside but continues to be an expensive training to implement in a residency program. There are multiple resources available to train providers in ultrasound, but they are all associated with significant cost. The Accreditation Council for Graduate Medical Education (ACGME) mandates anesthesiology residents to be competent in diagnostic and therapeutic uses of ultrasound. In this paper, we describe how an academic anesthesiology department implemented a POCUS curriculum for resident training. Methods: An anesthesiologist intensivist directed program was created to train residents in POCUS. We started by training a group of seven critical care trained anesthesiologists with the guidance of cardiologists. These anesthesiologists participated in the training of our anesthesiology residents. A hybrid curriculum consisting of a simulator as well as hands-on scanning of patients was created. We recorded the time that personnel spent in the training program as well as the money spent in acquiring equipment. Results: Seven faculty utilized a total of 270 hours of scanning and teaching time to train 48 residents who rotated through the ICU between July 2017 and June 2018. Simulation technicians used 48 hours to guide residents through simulation scenarios. The education administrator used 24 hours to coordinate sessions for residents. The technician and coordinator were both employees of the department with no additional cost for their responsibilities. The cost of equipment, including the ultrasound machine and simulator, was $45,000. An additional charge of $3500 was incurred for technician training time. Conclusion: Implementing a robust, sustainable POCUS curriculum requires a significant investment of time and money. Simulators and e-learning can allow efficiency in resource allocation and control cost in orienting new students to ultrasound. Having residents go through the simulator decreased the time that faculty would otherwise have spent going over basics with the students while allowing students to master these skills at their own pace. Advances in ultrasound technology have created newer, more affordable machines which can decrease cost considerably. It would serve departments well to consider alternatives and plan for resources when deciding to implement POCUS curriculum for resident training.
Collapse
Affiliation(s)
- Ranjit Deshpande
- Department of Anesthesiology, Yale School of Medicine,
New Haven, CT,To whom all correspondence should be addressed:
Ranjit Deshpande M.B.B.S., Assistant Professor of Anesthesiology, Yale School of
Medicine, 333 Cedar Street, TMP-3, New Haven, CT 06511; Tel: 203-785-2802, Fax:
203-785-6664, , ORCID iD: https://orcid.org/0000-0001-7348-194X
| | - Ruchika Karnik
- Department of Pediatrics, Yale School of Medicine, New
Haven, CT
| | - Christine Baer
- Department of Anesthesiology, Yale School of Medicine,
New Haven, CT
| | - Viji Kurup
- Department of Anesthesiology, Yale School of Medicine,
New Haven, CT
| |
Collapse
|
31
|
Point-of-care ultrasound in pediatric anesthesia: perioperative considerations. Curr Opin Anaesthesiol 2020; 33:343-353. [PMID: 32324662 DOI: 10.1097/aco.0000000000000852] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To review the perioperative applications of point-of-care ultrasound (POCUS). RECENT FINDINGS The role of point-of-care ultrasonography for perioperative care is expanding with respect to perioperative application. The imaging approach can complement the physical exam and provide additional information for decision-making in pediatric perioperative medicine. This review will focus on applications in the following organ systems: airway, cardiac, pulmonary and gastric. Specifically, POCUS of the airway has been used to optimize endotracheal tube depth, aid in tube size selection and predict difficulty with laryngoscopy and intubation. Lung POCUS has been used to assess for causes hypoxemia as well as to optimize ventilatory mechanics. Cardiac POCUS has been used for assessment of hemodynamics, valvular and ventricular function. Gastric ultrasound has emerged as an evaluative mechanism of gastric content in the setting of fasting as well as to confirm placement of gastric tubes. The applications of POCUS in the perioperative setting continue to evolve as a reliable diagnostic tool that can assist in timely diagnosis, improve procedural safety and has the potential to improve patient outcomes. SUMMARY The utility of perioperative POCUS has been well demonstrated, specifically for examination of the airway, stomach and cardiopulmonary system. It is advisable for the novice sonographer to perform POCUS within the guidelines set by the American Society of Echocardiography regarding basic POCUS. As with all diagnostic modalities, understanding the limitations of ultrasound and POCUS as well as continuous self-assessment is crucial.
Collapse
|
32
|
Subramaniam K, Boisen ML, Yehushua L, Esper SA, Philips DP, Howard-Quijano K. Perioperative Transthoracic Echocardiography Practice By Cardiac Anesthesiologists-Report of a "Start-Up" Experience. J Cardiothorac Vasc Anesth 2020; 35:222-232. [PMID: 32888802 DOI: 10.1053/j.jvca.2020.06.046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 06/10/2020] [Accepted: 06/12/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVE In this paper, the authors report their experience of perioperative transthoracic echocardiography (TTE) practice and its impact on perioperative patient management. DESIGN Retrospective case series. SETTING Single institution, tertiary university hospital. PARTICIPANTS A total of 101 adult ASA II-V male and female patients >18 years old who were scheduled for or having surgery were included in this retrospective case series. INTERVENTIONS All patients underwent a focused perioperative TTE exam performed by cardiac anesthesiologists with significant TTE experience, and further clinical management was based on echocardiography findings discussed with the anesthesia care team. MEASUREMENTS Significant echocardiographic findings and changes in patient management were reported. Step-up management was a new intervention that was executed based on echocardiographic findings (volume infusion, inotropic therapy, cardiology consultation, and other interventions), and step-down management was avoidance of an unnecessary intervention based on echocardiographic findings (proceeding to surgery without cancellation, delay, cardiology consultation, and additional investigations/interventions). MAIN RESULTS Fifty-three percent of TTEs were performed in the preoperative setting, 34% were intra-operative, and 13% were postoperative. No significant findings were detected in 38 patients, leading to step-down management in all of them. Among patients with positive findings, left ventricular dysfunction (12.8%), hypovolemia (10.8%), and right ventricular dysfunction (7.9%) were the most common. Step-up therapy included inotropic/vasopressor therapy (24.8%), intensive care admission after surgery for further management (13.8%), volume infusion (12.8%), and other interventions (additional monitoring, surgical delay, cardiology consultation, and modification of surgical technique). CONCLUSION Perioperative focused TTE examination is useful in the diagnosis of new cardiac conditions for anesthesia management (intraoperative monitoring and hemodynamic therapy) and postoperative care (intensive care unit admissions). Perioperative TTE performed by anesthesiologists can also help avoid procedural delays and unnecessary consults.
Collapse
Affiliation(s)
- Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, UPMC (University of Pittsburgh Medical Center), Pittsburgh, PA.
| | - Michael L Boisen
- Department of Anesthesiology and Perioperative Medicine, UPMC (University of Pittsburgh Medical Center), Pittsburgh, PA
| | - Liora Yehushua
- Department of Anesthesiology and Perioperative Medicine, UPMC (University of Pittsburgh Medical Center), Pittsburgh, PA
| | - Stephen A Esper
- Department of Anesthesiology and Perioperative Medicine, UPMC (University of Pittsburgh Medical Center), Pittsburgh, PA
| | - Dennis P Philips
- Department of Anesthesiology and Perioperative Medicine, UPMC (University of Pittsburgh Medical Center), Pittsburgh, PA
| | - Kimberly Howard-Quijano
- Department of Anesthesiology and Perioperative Medicine, UPMC (University of Pittsburgh Medical Center), Pittsburgh, PA
| |
Collapse
|
33
|
Vernieuwe L, Van de Putte P, Deen J, Bouchez S. Focus on PoCUS or hocus pocus? Integrating point-of-care ultrasound into residency and clinical practice. ACTA ANAESTHESIOLOGICA BELGICA 2020. [DOI: 10.56126/71.2.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Point-of care ultrasound (PoCUS) is a new clinical diagnostic paradigm that plays an instrumental role in the ongoing anesthesiologist’s evolving role towards a perioperative physician. Currently, there are few approved curricula that incorporate a PoCUS program into anesthesia residency. This article examines relevant PoCUS applications for anesthesiologists, presents an overview of existing international guidelines for education and training, and reflects on the need for specialty-wide standards. We present a possible framework, that could offer a first move towards a structured PoCUS pathway for Belgian anesthesia residents and facilitate its incorporation into national anesthesia practice.
Collapse
|
34
|
Brouillette MA, Aidoo AJ, Hondras MA, Boateng NA, Antwi-Kusi A, Addison W, Singh S, Laughlin PT, Johnson B, Pakala SR. Regional anesthesia training model for resource-limited settings: a prospective single-center observational study with pre-post evaluations. Reg Anesth Pain Med 2020; 45:528-535. [PMID: 32447288 DOI: 10.1136/rapm-2020-101550] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 04/28/2020] [Accepted: 05/02/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND OBJECTIVES Educational initiatives are a sustainable means to address provider shortages in resource-limited settings (RLS), yet few regional anesthesia curricula for RLS have been described. We sought to design a reproducible training model for RLS called Global Regional Anesthesia Curricular Engagement (GRACE), implement GRACE at an RLS hospital in Ghana, and measure training and practice-based outcomes associated with GRACE implementation. METHODS Fourteen of 15 physician anesthesiologists from the study location and three from an outside orthopedic specialty hospital consented to be trainees and trainers, respectively, for this prospective single-center observational study with pre-post evaluations. We conducted an initial needs assessment to determine current clinical practices, participants' learning preferences, and available resources. Needs assessment findings, expert panel recommendations, and investigator consensus were then used to generate a site-specific curriculum that was implemented during two 3-week periods. We evaluated trainee satisfaction and changes in knowledge, clinical skill, and peripheral nerve block (PNB) utilization using the Kirkpatrick method. RESULTS The curriculum consisted of didactic lectures, simulations, and clinical instruction to teach ultrasound-guided PNB for limb injuries. Pre-post evaluations showed trainees were satisfied with GRACE, median knowledge examination score improved from 62.5% (15/24) to 91.7% (22/24) (p<0.001), clinical examination pass rate increased from 28.6% (4/14) to 85.7% (12/14) (p<0.01), and total PNB performed in 3 months grew from 48 to 118. CONCLUSIONS GRACE applied in an RLS hospital led to the design, implementation, and measurement of a regional anesthesia curriculum tailored to institutional specifications that was associated with positive Kirkpatrick outcomes.
Collapse
Affiliation(s)
- Mark A Brouillette
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA .,Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| | - Alfred J Aidoo
- Directorate of Anaesthesia and Intensive Care, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Maria A Hondras
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Nana A Boateng
- Directorate of Anaesthesia and Intensive Care, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Akwasi Antwi-Kusi
- Directorate of Anaesthesia and Intensive Care, Komfo Anokye Teaching Hospital, Kumasi, Ghana.,School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - William Addison
- Directorate of Anaesthesia and Intensive Care, Komfo Anokye Teaching Hospital, Kumasi, Ghana.,School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Sanjeev Singh
- Directorate of Anaesthesia and Intensive Care, Komfo Anokye Teaching Hospital, Kumasi, Ghana.,School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Patrick T Laughlin
- Department of Anesthesiology, US Anesthesia Partners, Denver, Colorado, USA
| | - Benjamin Johnson
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Swetha R Pakala
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
| |
Collapse
|
35
|
Li C, Wang J, Ma Z, Li B, Kang K, Wei L, Zhang W. Ultrasound versus manipulation to determine an intercostal space for single-port thoracoscopy surgery: a diagnostic accuracy study. World J Surg Oncol 2020; 18:103. [PMID: 32446300 PMCID: PMC7245900 DOI: 10.1186/s12957-020-01870-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 05/04/2020] [Indexed: 11/10/2022] Open
Abstract
Background Malposition of the intercostal space used for single-port thoracoscopy surgery can lead to problems. This study was to assess the accuracy of point-of-care ultrasound in verifying the position of intercostal space. Methods A total of 200 patients, ASA (American Society of Anesthesiologists) physical status I or II, who underwent single-port thoracoscopic lobectomy, were enrolled. After the induction of anesthesia, a thoracic team confirmed the incision position. Firstly, the intercostal space was located by a young resident thoracic surgeon by ultrasound. Secondly, the intercostal space was located by an experienced thoracic surgeon by manipulation. Finally, the investigator verified the location of the intercostal space under direct vision through thoracoscopy, which was recognized as standard method. The time required by ultrasound and manipulation were recorded. Results The inter-relationships between ultrasound and the standard method and between manipulation and the standard method were consistent. Manipulation positioning showed a sensitivity of 90.6% and specificity of 30% while ultrasound positioning showed a sensitivity of 87.1% and specificity of 60%. The specificity of ultrasound positioning was higher than that of manipulation position. The time required by ultrasound was shorter than that required by manipulation. Conclusions Compared with the manipulation method, the ultrasound-guided method could accurately locate the intercostal space. Ultrasound requires less time than manipulation. Trial registration ISRCTN10722758. Registered 04 June 2019
Collapse
Affiliation(s)
- Chenxi Li
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People's Hospital, No. 7, Weiwu Road, Zhengzhou City, 450003, Henan Province, China
| | - Jianjun Wang
- Department of Thoracic Surgery, Henan Provincial People's Hospital, No. 7, Weiwu Road, Zhengzhou City, Henan Province, China
| | - Zeheng Ma
- Department of Thoracic Surgery, Henan Provincial People's Hospital, No. 7, Weiwu Road, Zhengzhou City, Henan Province, China
| | - Bing Li
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People's Hospital, No. 7, Weiwu Road, Zhengzhou City, 450003, Henan Province, China
| | - Kang Kang
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People's Hospital, No. 7, Weiwu Road, Zhengzhou City, 450003, Henan Province, China
| | - Li Wei
- Department of Thoracic Surgery, Henan Provincial People's Hospital, No. 7, Weiwu Road, Zhengzhou City, Henan Province, China
| | - Wei Zhang
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People's Hospital, No. 7, Weiwu Road, Zhengzhou City, 450003, Henan Province, China.
| |
Collapse
|
36
|
Abstract
This clinical focus review targets all anesthesiologists and seeks to highlight the following aspects of perioperative point-of-care ultrasound: clinical utility, technology advancements, training/certification, education, reporting/billing, and limitations.
Collapse
|
37
|
Li L, Yong RJ, Kaye AD, Urman RD. Perioperative Point of Care Ultrasound (POCUS) for Anesthesiologists: an Overview. Curr Pain Headache Rep 2020; 24:20. [DOI: 10.1007/s11916-020-0847-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
|
38
|
Rashid MM, Lahaye LA, Riley CL, Liebman S, Murphy WP, Shah PR. Longitudinal Competency-Based Point-of-Care Ultrasound Curriculum in Anesthesiology. A A Pract 2020; 14:155-165. [DOI: 10.1213/xaa.0000000000001147] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
39
|
Tomasi R, Stark K, Scheiermann P. Efficacy of a certified modular ultrasound curriculum. Anaesthesist 2020; 69:192-197. [PMID: 32055882 PMCID: PMC7056694 DOI: 10.1007/s00101-020-00730-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 11/13/2019] [Accepted: 12/26/2019] [Indexed: 11/16/2022]
Abstract
Background In recent years, ultrasound (US) has become more incorporated into anesthesia and intensive care medicine. The German Anesthesia Society established a modular curriculum to teach US skills. Until now, the efficacy of this modular curriculum has not been validated. Objective The main objective of this study was to determine whether there is an increase of knowledge and of psychomotor skills for the trainees in this curriculum. Material and methods After ethical committee approval, 41 anesthesia physicians were enrolled. To determine the increase of knowledge and of practical skills theoretical and practical tests performed were evaluated before and after two different US courses. Results Comparing before and after course tests, the participants showed significant improvement in theoretical multiple choice tests (p = 0.008). Regarding psychomotor skills following course 1, the trainees improved significantly in the time needed to perform the two practical tests (p = 0.03), but not in the performance of the test. Better needle visualization during simulated US-guided vessel puncture (p = 0.52) and better identification of the anatomical structures in the axillary region (p = 0.56) could not be achieved. Conclusion This study shows that although this US course curriculum has positively enhanced the trainees’ theoretical knowledge of US practice, it does not enhance the practical application of that theoretical knowledge. To improve this curriculum, a supervised clinically practical training should follow the course. Electronic supplementary material The online version of this article (10.1007/s00101-020-00730-9) provides the two questionnaires in German. The article and additional material are available at www.springermedizin.de. Please enter the title of the article in the search field, the additional material can be found under “Ergänzende Inhalte”. ![]()
Collapse
Affiliation(s)
- R Tomasi
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
| | - K Stark
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - P Scheiermann
- Department of Anesthesiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| |
Collapse
|
40
|
Kumar A, Weng Y, Wang L, Bentley J, Almli M, Hom J, Witteles R, Ahuja N, Kugler J. Portable Ultrasound Device Usage and Learning Outcomes Among Internal Medicine Trainees: A Parallel-Group Randomized Trial. J Hosp Med 2020; 15:e1-e6. [PMID: 32118565 DOI: 10.12788/jhm.3351] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 11/03/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Little is known about how to effectively train residents with point-of-care ultrasonography (POCUS) despite increasing usage. OBJECTIVE This study aimed to assess whether handheld ultrasound devices (HUDs), alongside a year-long lecture series, improved trainee image interpretation skills with POCUS. METHODS Internal medicine intern physicians (N = 149) at a single academic institution from 2016 to 2018 participated in the study. The 2017 interns (n = 47) were randomized 1:1 to receive personal HUDs (n = 24) for patient care vs no-HUDs (n = 23). All 2017 interns received a repeated lecture series regarding cardiac, thoracic, and abdominal POCUS. Interns were assessed on their ability to interpret POCUS images of normal/abnormal findings. The primary outcome was the difference in end-of-the-year assessment scores between interns randomized to receive HUDs vs not. Secondary outcomes included trainee scores after repeating lectures and confidence with POCUS. Intern scores were also compared with historical (2016, N = 50) and contemporaneous (2018, N = 52) controls who received no lectures. RESULTS Interns randomized to HUDs did not have significantly higher image interpretation scores (median HUD score: 0.84 vs no-HUD score: 0.84; P = .86). However, HUD interns felt more confident in their abilities. The 2017 cohort had higher scores (median 0.84), compared with the 2016 historical control (median 0.71; P = .001) and 2018 contemporaneous control (median 0.48; P < .001). Assessment scores improved after first-time exposure to the lecture series, while repeated lectures did not improve scores. CONCLUSIONS Despite feeling more confident, personalized HUDs did not improve interns' POCUS-related knowledge or interpretive ability. Repeated lecture exposure without further opportunities for deliberate practice may not be beneficial for mastering POCUS.
Collapse
Affiliation(s)
- Andre Kumar
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Yingjie Weng
- Quantitative Science Unit, Stanford University School of Medicine, Stanford, California
| | - Libo Wang
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Jason Bentley
- Quantitative Science Unit, Stanford University School of Medicine, Stanford, California
| | - Marta Almli
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Jason Hom
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Ronald Witteles
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Neera Ahuja
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - John Kugler
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| |
Collapse
|
41
|
Learners and Luddites in the Twenty-first Century: Bringing Evidence-based Education to Anesthesiology. Anesthesiology 2020; 131:908-928. [PMID: 31365369 DOI: 10.1097/aln.0000000000002827] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Anesthesiologists are both teachers and learners and alternate between these roles throughout their careers. However, few anesthesiologists have formal training in the methodologies and theories of education. Many anesthesiology educators often teach as they were taught and may not be taking advantage of current evidence in education to guide and optimize the way they teach and learn. This review describes the most up-to-date evidence in education for teaching knowledge, procedural skills, and professionalism. Methods such as active learning, spaced learning, interleaving, retrieval practice, e-learning, experiential learning, and the use of cognitive aids will be described. We made an effort to illustrate the best available evidence supporting educational practices while recognizing the inherent challenges in medical education research. Similar to implementing evidence in clinical practice in an attempt to improve patient outcomes, implementing an evidence-based approach to anesthesiology education may improve learning outcomes.
Collapse
|
42
|
Singh M, Tuteja A, Wong DT, Goel A, Trivedi A, Tomlinson G, Chan V. Point-of-Care Ultrasound for Obstructive Sleep Apnea Screening: Are We There Yet? A Systematic Review and Meta-analysis. Anesth Analg 2019; 129:1673-1691. [PMID: 31743189 DOI: 10.1213/ane.0000000000004350] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Perioperative diagnosis of obstructive sleep apnea (OSA) has important resource implications as screening questionnaires are overly sensitive, and sleep studies are expensive and time-consuming. Ultrasound (US) is a portable, noninvasive tool potentially useful for airway evaluation and OSA screening in the perioperative period. The objective of this systematic review was to evaluate the correlation of surface US with OSA diagnosis and to determine whether a point-of-care ultrasound (PoCUS) for OSA screening may help with improved screening in perioperative period. METHODS A search of all electronic databases including Medline, Embase, and Cochrane Database of Systematic Reviews was conducted from database inception to September 2017. Inclusion criteria were observational cohort studies and randomized controlled trials of known or suspected OSA patients undergoing surface US assessment. Article screening, data extraction, and summarization were conducted by 2 independent reviewers with ability to resolve conflict with supervising authors. Diagnostic properties and association between US parameters (index test) and OSA diagnosis using sleep study (reference standard) were evaluated. The US parameters were divided into airway and nonairway parameters. A random-effects meta-analysis was planned, wherever applicable. RESULTS Of the initial 3865 screened articles, 21 studies (7 airway and 14 nonairway) evaluating 3339 patients were included. Majority of studies were conducted in the general population (49%), respirology (23%), and sleep clinics (12%). No study evaluated the use of US for OSA in perioperative setting. Majority of included studies had low risk of bias for reference standard and flow and timing. Airway US parameters having moderate-good correlation with moderate-severe OSA were distance between lingual arteries (DLAs > 30 mm; sensitivity, 0.67; specificity, 0.59; 1 study/66 patients); mean resting tongue thickness (>60 mm; sensitivity, 0.85; specificity, 0.59; 1 study/66 patients); tongue base thickness during Muller maneuver (MM; sensitivity, 0.59; specificity, 0.78; 1 study/66 patients); and a combination of neck circumference and retropalatal (RP) diameter shortening during MM (sensitivity, 1.0; specificity, 0.65; 1 study/104 patients). Nonairway US parameters having a low-moderate correlation with moderate-severe OSA were carotid intimal thickness (pooled correlation coefficient, 0.444; 95% confidence interval [CI], 0.320-0.553; P value = .000, 8 studies/727 patients) and plaque presence (sensitivity, 0.24-0.75; specificity, 0.13-1.0; 4 studies/1183 patients). CONCLUSIONS We found that a number of airway and nonairway parameters were identified with moderate to good correlation with OSA diagnosis in the general population. In future studies, it remains to be seen whether PoCUS screening for a combination of these parameters can address the pitfalls of OSA screening questionnaires.
Collapse
Affiliation(s)
- Mandeep Singh
- From the Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Toronto Sleep and Pulmonary Centre, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Management, Women's College Hospital, Toronto, Ontario, Canada
| | - Arvind Tuteja
- From the Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - David T Wong
- From the Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Akash Goel
- From the Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Aditya Trivedi
- Department of Chemistry, McMaster University, Hamilton, ON, Canada
| | - George Tomlinson
- Department of Medicine, University Health Network and Mt Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Vincent Chan
- From the Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
43
|
Ramsingh D, Ma M, Le DQ, Davis W, Ringer M, Austin B, Ricks C. Feasibility Evaluation of Commercially Available Video Conferencing Devices to Technically Direct Untrained Nonmedical Personnel to Perform a Rapid Trauma Ultrasound Examination. Diagnostics (Basel) 2019; 9:diagnostics9040188. [PMID: 31739422 PMCID: PMC6963664 DOI: 10.3390/diagnostics9040188] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 11/08/2019] [Accepted: 11/11/2019] [Indexed: 01/23/2023] Open
Abstract
Introduction: Point-of-care ultrasound (POCUS) is a rapidly expanding discipline that has proven to be a valuable modality in the hospital setting. Recent evidence has demonstrated the utility of commercially available video conferencing technologies, namely, FaceTime (Apple Inc, Cupertino, CA, USA) and Google Glass (Google Inc, Mountain View, CA, USA), to allow an expert POCUS examiner to remotely guide a novice medical professional. However, few studies have evaluated the ability to use these teleultrasound technologies to guide a nonmedical novice to perform an acute care POCUS examination for cardiac, pulmonary, and abdominal assessments. Additionally, few studies have shown the ability of a POCUS-trained cardiac anesthesiologist to perform the role of an expert instructor. This study sought to evaluate the ability of a POCUS-trained anesthesiologist to remotely guide a nonmedically trained participant to perform an acute care POCUS examination. Methods: A total of 21 nonmedically trained undergraduate students who had no prior ultrasound experience were recruited to perform a three-part ultrasound examination on a standardized patient with the guidance of a remote expert who was a POCUS-trained cardiac anesthesiologist. The examination included the following acute care POCUS topics: (1) cardiac function via parasternal long/short axis views, (2) pneumothorax assessment via pleural sliding exam via anterior lung views, and (3) abdominal free fluid exam via right upper quadrant abdominal view. Each examiner was given a handout with static images of probe placement and actual ultrasound images for the three views. After a brief 8 min tutorial on the teleultrasound technologies, a connection was established with the expert, and they were guided through the acute care POCUS exam. Each view was deemed to be complete when the expert sonographer was satisfied with the obtained image or if the expert sonographer determined that the image could not be obtained after 5 min. Image quality was scored on a previously validated 0 to 4 grading scale. The entire session was recorded, and the image quality was scored during the exam by the remote expert instructor as well as by a separate POCUS-trained, blinded expert anesthesiologist. Results: A total of 21 subjects completed the study. The average total time for the exam was 8.5 min (standard deviation = 4.6). A comparison between the live expert examiner and the blinded postexam reviewer showed a 100% agreement between image interpretations. A review of the exams rated as three or higher demonstrated that 87% of abdominal, 90% of cardiac, and 95% of pulmonary exams achieved this level of image quality. A satisfaction survey of the novice users demonstrated higher ease of following commands for the cardiac and pulmonary exams compared to the abdominal exam. Conclusions: The results from this pilot study demonstrate that nonmedically trained individuals can be guided to complete a relevant ultrasound examination within a short period. Further evaluation of using telemedicine technologies to promote POCUS should be evaluated.
Collapse
Affiliation(s)
- Davinder Ramsingh
- Department of Anesthesiology, Loma Linda University Health, 11234 Anderson St. MC-2532, Loma Linda, CA 92354, USA
- Correspondence:
| | - Michael Ma
- Department of Anesthesiology, UCI Medical Center, Orange, CA 92868, USA; (M.M.); (C.R.)
| | - Danny Quy Le
- David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA;
| | - Warren Davis
- Department of Anesthesiology, St. Joseph Medical Center, 7601 Osler Drive, Towson, MD 21204, USA;
| | - Mark Ringer
- Loma Linda University School of Medicine, Loma Linda, CA 92350, USA;
| | - Briahnna Austin
- Department of Anesthesiology, Loma Linda University Health, 11234 Anderson St. MC-2532, Loma Linda, CA 92354, USA
| | - Cameron Ricks
- Department of Anesthesiology, UCI Medical Center, Orange, CA 92868, USA; (M.M.); (C.R.)
| |
Collapse
|
44
|
Ramsingh D, Runyon A, Gatling J, Dorotta I, Lauer R, Wailes D, Yang J, Alschuler M, Austin B, Stier G, Martin R. Improved diagnostic accuracy of pathology with the implementation of a perioperative point-of-care ultrasound service: quality improvement initiative. Reg Anesth Pain Med 2019; 45:95-101. [DOI: 10.1136/rapm-2019-100632] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 05/29/2019] [Indexed: 11/04/2022]
Abstract
IntroductionThe utility of perioperative point-of-care ultrasound (P-POCUS) is rapidly growing. The successful implementation of a comprehensive P-POCUS curriculum, Focused PeriOperative Risk Evaluation Sonography Involving Gastro-abdominal, Hemodynamic, and Trans-thoracic Ultrasound (FORESIGHT), has been demonstrated. This project sought to further evaluate the utility of P-POCUS with the following aims: (1) to assess the ability to train the FORESIGHT curriculum via a free, open-access, online platform; (2) to launch a P-POCUS clinical service as a quality improvement (QI) initiative; (3) to evaluate the diagnostic accuracy of the P-POCUS examinations to formal diagnostic studies; and (4) to compare the P-POCUS diagnostic accuracy with the diagnostic accuracy of traditional assessment (TA).MethodsThis study was launched as a QI project for the implementation of a P-POCUS service. A group of attending and resident anesthesiologists completed P-POCUS training supported by an online curriculum. After training, a P-POCUS service was launched. The P-POCUS service was available for any perioperative event, and specific triggers were also identified. All examinations were documented on a validated datasheet. The diagnostic accuracy of the two index tests, P-POCUS and TA, were compared with formal diagnostic testing. TA was defined as a combination of the anesthesiologist’s bedside assessment and physical examination. The primary outcome marker was a comparison in the accuracy of new diagnosis detected by P-POCUS service versus the TA performed by the primary anesthesiologist.ResultsA total of 686 P-POCUS examinations were performed with 466 examinations having formal diagnostic studies for comparison. Of these, 92 examinations were detected as having new diagnoses. Performance for detection of a new diagnosis demonstrated a statistically higher sensitivity for the P-POCUS examinations (p<0.0001). Performance comparison of all P-POCUS examinations that were matched to formal diagnostic studies (n=466) also demonstrated a significantly higher sensitivity. These findings were consistent across cardiovascular, pulmonary and abdominal P-POCUS categories (p<0.01). Additionally, multiple pathologies demonstrated complete agreement between the P-POCUS examination and the formal study.ConclusionA P-POCUS service can be developed after training facilitated by an online curriculum. P-POCUS examinations can be performed by anesthesiologists with a high degree of accuracy to formal studies, which is superior to TA.
Collapse
|
45
|
Boublik J, Haskins SC. One small step for mankind, a big step for PoCUS. Reg Anesth Pain Med 2019; 45:93-94. [DOI: 10.1136/rapm-2019-100800] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 09/20/2019] [Accepted: 09/23/2019] [Indexed: 01/24/2023]
|
46
|
Nasr VG, Gottlieb EA, Adler AC, Evans MA, Sawardekar A, DiNardo JA, Mossad EB, Mittnacht AJ. Selected 2018 Highlights in Congenital Cardiac Anesthesia. J Cardiothorac Vasc Anesth 2019; 33:2833-2842. [DOI: 10.1053/j.jvca.2019.03.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 03/05/2019] [Indexed: 01/19/2023]
|
47
|
Pulton D, Feinman J. Hocus POCUS: Making Barriers to Perioperative Point-of-Care Ultrasound Disappear. J Cardiothorac Vasc Anesth 2019; 33:2419-2420. [DOI: 10.1053/j.jvca.2019.05.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 05/20/2019] [Indexed: 01/04/2023]
|
48
|
Denault A, Shaaban Ali M, Couture EJ, Beaubien-Souligny W, Bouabdallaoui N, Brassard P, Mailhot T, Jacquet-Lagrèze M, Lamarche Y, Deschamps A. A Practical Approach to Cerebro-Somatic Near-Infrared Spectroscopy and Whole-Body Ultrasound. J Cardiothorac Vasc Anesth 2019; 33 Suppl 1:S11-S37. [DOI: 10.1053/j.jvca.2019.03.039] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
49
|
Adler AC, Brown KA, Conlin FT, Thammasitboon S, Chandrakantan A. Cardiac and lung point-of-care ultrasound in pediatric anesthesia and critical care medicine: Uses, pitfalls, and future directions to optimize pediatric care. Paediatr Anaesth 2019; 29:790-798. [PMID: 31211472 DOI: 10.1111/pan.13684] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 06/09/2019] [Accepted: 06/10/2019] [Indexed: 12/20/2022]
Abstract
Point-of-care ultrasound (POCUS) has found many relevant applications in pediatric anesthesia and critical care medicine. Specifically, the cardiac and pulmonary POCUS examinations provide a wealth of information from physical examination assistance to diagnostic evaluation and assessment of treatment response. However, as with any adjunct, potentially dangerous pitfalls exist when POCUS is performed, interpreted, and applied by the novice sonographer. Using case illustrations, we highlight the clinical application of POCUS in addition to potential dangers. Additionally, suggestions for learning POCUS, assessing competency and credentialing are reviewed.
Collapse
Affiliation(s)
- Adam C Adler
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Houston, Texas.,Section of Pediatric Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Houston, Texas
| | - Kyle A Brown
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Houston, Texas.,Baylor College of Medicine, Houston, Texas
| | - Frederick T Conlin
- Department of Anesthesiology and Pain Medicine, Baystate Medical Center, Springfield, Massachusetts.,University of Massachusetts School of Medicine, Worcester, Massachusetts
| | - Satid Thammasitboon
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Houston, Texas.,Baylor College of Medicine, Houston, Texas
| | - Arvind Chandrakantan
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Houston, Texas.,Section of Pediatric Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Houston, Texas
| |
Collapse
|
50
|
Denault A, Canty D, Azzam M, Amir A, Gebhard CE. Whole body ultrasound in the operating room and intensive care unit. Korean J Anesthesiol 2019; 72:413-428. [PMID: 31159535 PMCID: PMC6781205 DOI: 10.4097/kja.19186] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 05/23/2019] [Indexed: 12/14/2022] Open
Abstract
Whole body ultrasound can be used to improve the speed and accuracy of evaluation of an increasing number of organ systems in the critically ill. Cardiac and abdominal ultrasound can be used to identify the mechanisms and etiology of hemodynamic instability. In hypoxemia or hypercarbia, lung ultrasound can rapidly identify the etiology of the condition with an accuracy that is equivalent to that of computed tomography. For encephalopathy, ocular ultrasound and transcranial Doppler can identify elevated intracranial pressure and midline shift. Renal and bladder ultrasound can identify the mechanisms and etiology of renal failure. Ultrasound can also improve the accuracy and safety of percutaneous procedures and should be currently used routinely for central vein catheterization and percutaneous tracheostomy.
Collapse
Affiliation(s)
- André Denault
- Department of Anesthesiology and Critical Care Medicine, Faculté de Médecine, Université de Montréal, Institut de Cardiologie de Montréal, and Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - David Canty
- Department of Surgery, University of Melbourne, Australia.,Department of Medicine, Monash Medical Centre, Monash University, Clayton, Melbourne, and Department of Anesthesia, Monash Medical Centre and Royal Melbourne Hospital, Victoria, Australia
| | - Milène Azzam
- Department of Anesthesiology, Jewish General Hospital, McGill University Faculty of Medicine, Montreal, QC, Canada
| | - Alexander Amir
- Department of Anesthesiology, Montreal General Hospital, McGill University Faculty of Medicine, Montreal, QC, Canada
| | - Caroline E Gebhard
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Basel, Basel, Switzerland
| |
Collapse
|