International evidence-based recommendations for focused cardiac ultrasound

A survey demonstrating that the procedural experience of residents in internal medicine, critical care and emergency medicine is poor: training in ultrasound is required to rectify this

BACKGROUND

Training in procedural skills is often suboptimal. The aim of this study was to quantify the needs of residents in internal medicine (IM), critical care (CC), and emergency medicine (EM) for instruction in ultrasound-guided procedures.

METHODS

All IM, EM and CC residents (n = 200) at King Abdulaziz Medical City, Riyadh, Saudi Arabia, were invited to participate in a questionnaire-based survey to identify skill and experience gaps. The contribution of procedural skills to patient care (i.e. applicability) and proficiency in the sterile technique required to perform ultrasound-guided procedures were rated on Likert scales. Data on training, accreditation, and experience with and without ultrasound were collected.

RESULTS

The overall response rate was 72% (IM 91%, CC 100%, EM 40%). Although the sample reported that procedural skills were very applicable, 19% (IM n = 25, EM n = 2) had not performed any procedures. However, five residents were accredited in point-of-care ultrasound, 61% of the sample had performed ultrasound-guided procedures and 65% had used landmark techniques. Whilst more internists had performed procedures using landmark techniques, CC and EM residents had performed more ultrasound-guided procedures. Whilst CC residents had not missed any opportunities to perform procedures because supervisors were less available, EM (6) and IM (89) residents had. Whilst skill gaps were only identified in the IM residency programme, experience gaps were present in all three residency programmes. The IM residency programme had larger experience gaps than the CC and EM programmes for all procedural skills.

DISCUSSION

Residents in IM, CC and EM perceive that ultrasound-guided procedures are relevant to their practice. However, the IM residents performed fewer procedures than CC residents and EM residents at least partly because internists also lack skills in ultrasound. Training in ultrasound-guided procedures may reduce the use of landmark techniques and improve patient safety. Residents in IM, CC and EM therefore require training in ultrasound-guided procedures.

[Special pathologies of pregnant patients in intensive care medicine]

Da die Inzidenz intensivtherapiepflichtiger Erkrankungen in Schwangerschaft oder Puerperium sehr niedrig ist, werden Intensivmediziner bei der Behandlung dieser Patientinnen vor eine Vielzahl von ungewohnten Herausforderungen gestellt. Die physiologischen und pathophysiologischen Veränderungen während einer Schwangerschaft bedingen einige Besonderheiten bezüglich der intensivmedizinischen Behandlung schwangerer oder kürzlich entbundener Patientinnen. Nachdem im ersten Beitrag dieser CME-Reihe die wichtigsten Prinzipien und aktuellen Empfehlungen zur Versorgung intensivtherapiebedürftiger schwangerer oder frisch entbundener Patientinnen behandelt wurden, fokussiert der zweite Beitrag auf Diagnostik und Therapie spezieller, ausgewählter Krankheitsbilder.

European Respiratory Society statement on thoracic ultrasound

Thoracic ultrasound is increasingly considered to be an essential tool for the pulmonologist. It is used in diverse clinical scenarios, including as an adjunct to clinical decision making for diagnosis, a real-time guide to procedures and a predictor or measurement of treatment response. The aim of this European Respiratory Society task force was to produce a statement on thoracic ultrasound for pulmonologists using thoracic ultrasound within the field of respiratory medicine. The multidisciplinary panel performed a review of the literature, addressing major areas of thoracic ultrasound practice and application. The selected major areas include equipment and technique, assessment of the chest wall, parietal pleura, pleural effusion, pneumothorax, interstitial syndrome, lung consolidation, diaphragm assessment, intervention guidance, training and the patient perspective. Despite the growing evidence supporting the use of thoracic ultrasound, the published literature still contains a paucity of data in some important fields. Key research questions for each of the major areas were identified, which serve to facilitate future multicentre collaborations and research to further consolidate an evidence-based use of thoracic ultrasound, for the benefit of the many patients being exposed to clinicians using thoracic ultrasound.

An email-based survey of practice regarding hemodynamic monitoring and management in children with septic shock in China

BACKGROUND

Understanding current hemodynamic monitoring (HM) practice patterns is essential to determine education and training strategies in China. The survey was to describe the practice of HM and management in children with septic shock in China.

METHODS

We conducted an Email-based survey of members of sub-association of pediatric intensive care physicians. The questionnaire consisted of 22 questions and gathered the following information: (I) general information on the hospitals, respective ICUs and participants, (II) the availability of technical equipment and parameters of HM and (III) management simulation of septic shock in three clinical case vignettes.

RESULTS

Surveys were received from 68 institutions (87.2%) and 368 questionnaires (response-rate 45.1%) were included. Basic HM (93-100%) were reported as the most utilized parameters, followed by advanced HM which included central venous pressure (CVP) (56.0%), cardiac output (53.5%), and central venous oxygen saturation (36.7%), 61.1% (225/368) of respondents stated the utilization of non-invasive HM equipment. The factors such as ICU specialist training center (P=0.003) and more than 30 cases of septic shock per year (P=0.002) were related to the utilization of non-invasive monitoring equipment. In the simulated case vignette, 49.7% (183/368) of respondents reported performing fluid responsiveness and volume status (FR-VS) assessment. Despite differences in training centers (P=0.005) and educational backgrounds (P=0.030), FR-VS assessment was not related to the volume expansion decision.

CONCLUSIONS

There is a large variability in use advanced HM parameters, an increasing awareness and acceptance of non-invasive HM devices and a potential need for hemodynamic education and training in pediatric intensive care medicine in China.

Retention of Point-of-Care Ultrasound Skills Among Practicing Physicians: Findings of the VA National POCUS Training Program

BACKGROUND

Point-of-care ultrasound (POCUS) use continues to increase in many specialties, but lack of POCUS training is a known barrier among practicing physicians. Many physicians are obtaining POCUS training through postgraduate courses, but the impact of these courses on skill retention and frequency of POCUS use post-course is unknown. The purpose of this study was to assess the change in POCUS knowledge, skills, and frequency of use after 6-9 months of participating in a brief training course.

METHODS

Course participants' POCUS knowledge and hands-on technical skills were tested pre-course using an online, 30-question knowledge test and a directly observed skills test, respectively. The same knowledge and skills tests were repeated immediately post-course and after 6-9 months using remote tele-ultrasound software. Course participants completed a survey on their POCUS use pre-course and after 6-9 months post-course.

RESULTS

There were 127 providers who completed the POCUS training course from October 2016 to November 2017. Knowledge test scores increased from a median of 60% to 90% immediately post-course followed by a slight decrease to 87% after 8 months post-course. Median skills test scores for 4 common POCUS applications (heart, lung, abdomen, vascular access) increased 36-74 points from pre-course to immediately post-course with a 2-7-point decrease after 8 months. Providers reported more frequent POCUS use post-course, which suggests application of their POCUS knowledge and skills in clinical practice. More frequent use of cardiac POCUS applications was associated with significantly greater retention of cardiac skills at 8 months.

CONCLUSIONS

Practicing physicians can retain POCUS knowledge and hands-on skills 8 months after participating in a 2.5-day POCUS training course, regardless of frequency of POCUS use post-course.

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

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.

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 I: clinical indications

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 (ASRA) commissioned this narrative review to provide recommendations for POCUS. The guidelines were written by content and educational experts and approved by the Guidelines Committee and the Board of Directors of the ASRA. In part I of this two-part series, clinical indications for POCUS in the perioperative and chronic pain setting are described. The clinical review addresses airway ultrasound, lung ultrasound, gastric ultrasound, the focus assessment with sonography for trauma examination and focused cardiac ultrasound for the regional anesthesiologist and pain physician. It also provides foundational knowledge regarding ultrasound physics, discusses the impact of handheld devices and finally, offers insight into the role of POCUS in the pediatric population.

Brain Ultrasonography Consensus on Skill Recommendations and Competence Levels Within the Critical Care Setting

BACKGROUND

To report a consensus on the different competency levels for the elaboration of skill recommendations in performing brain ultrasonography within the neurocritical care setting.

METHODS

Four brain ultrasound experts, supported by a methodologist, performed a preselection of indicators and skills based on the current literature and clinical expertise. An international panel of experts was recruited and subjected to web-based questionnaires according to a Delphi method presented in three separate rounds. A pre-defined threshold of agreement was established on expert subjective opinions, > 84% of votes was set to support a strong recommendation and > 68% for a weak recommendation. Below these thresholds, no recommendation reached.

RESULTS

We defined four different skill levels (basic, basic-plus, pre-advanced, advanced). Twenty-five experts participated to the full process. After four rounds of questions, two items received a strong recommendation in the basic skill category, three in the advanced, twelve in the basic-plus, and seven in the pre-advanced. Two items in the pre-advanced category received a weak recommendation and three could not be collocated and were excluded from the list.

CONCLUSIONS

Results from this consensus permitted stratification of the different ultrasound examination skills in four levels with progressively increasing competences. This consensus can be useful as a guide for beginners in brain ultrasonography and for the development of specific training programs within this field.

Point-of-Care Ultrasound (POCUS) for the Cardiothoracic Anesthesiologist

Point-of-Care Ultrasound (POCUS) is a valuable bedside diagnostic tool for a variety of expeditious clinical assessments or as guidance for a multitude of acute care procedures. Varying aspects of nearly all organ systems can be evaluated using POCUS and, with the increasing availability of affordable ultrasound systems over the past decade, many now refer to POCUS as the 21^st-century stethoscope. With the current available and growing evidence for the clinical value of POCUS, its utility across the perioperative arena adds enormous benefit to clinical decision-making. Cardiothoracic anesthesiologists routinely have used portable ultrasound systems for nearly as long as the technology has been available, making POCUS applications a natural extension of existing cardiothoracic anesthesia practice. This narrative review presents a broad discussion of the utility of POCUS for the cardiothoracic anesthesiologist in varying perioperative contexts, including the preoperative clinic, the operating room (OR), intensive care unit (ICU), and others. Furthermore, POCUS-related education, competence, and certification are addressed.

Point-of-care lung ultrasound for the assessment of pneumonia: a narrative review in the COVID-19 era

In the coronavirus disease-2019 (COVID-19) era, point-of-care lung ultrasound (LUS) has attracted increased attention. Prospective studies on LUS for the assessment of pneumonia in adult patients were extensively carried out for more than 10 years before this era. None of these prospective studies attempted to differentiate bacterial and viral pneumonia in adult patients using LUS. The majority of studies considered the LUS examination to be positive if sonographic consolidations or multiple B-lines were observed. Significant differences existed in the accuracy of these studies. Some studies revealed that LUS showed superior sensitivity to chest X-ray. These results indicate that point-of-care LUS has the potential to be an initial imaging modality for the diagnosis of pneumonia. The LUS diagnosis of ventilator-associated pneumonia in intensive care units is more challenging in comparison with the diagnosis of community-acquired pneumonia in emergency departments due to the limited access to the mechanically ventilated patients and the high prevalence of atelectasis. However, several studies have demonstrated that the combination of LUS findings with other clinical markers improved the diagnostic accuracy. In the COVID-19 era, many case reports and small observational studies on COVID-19 pneumonia have been published in a short period. Multiple B-lines were the most common and consistent finding in COVID-19 pneumonia. Serial LUS showed the deterioration of the disease. The knowledge and ideas on the application of LUS in the management of pneumonia that are expected to accumulate in the COVID-19 era may provide us with clues regarding more appropriate management.

Bedside Cardiac Pocus in Emergency Setting: A Practice Review

BACKGROUND

In the last years, ultrasound technology has entered clinical practice as a tank and today, it has also allowed no-cardiologists to extend their medical examination without needing to call the consultant and having a good profile of diagnostic accuracy. The ultrasound bedside does not replace the consultant, but it allows not to perform inappropriate consultations with more savings for hospitals.

OBJECTIVE

The aim was to review the recently published literature to inform the clinician about the most up to date management of use bedside echography in the emergency setting. In this short review, we focused on two types of syndromes, no traumatic- hypotension and dyspnea, common to the three holistic disciplines of medicine, showing the main and basic questions and answers that ultrasound can give us for rapid identification of the problems.

METHODS

We conducted a systematic review using Pubmed/Medline, Ovid/Willey and Cochrane Library, combining key terms such as "cardiac ultrasound, "cardiac diseases", "emergency medicine", "pocus", "dyspnea", " hypotension". We selected the most relevant clinical trials and review articles (excluding case reports) published in the last 19 years and in our opinion, 59 publications appeared to be the best choice according to the PRISMA statement. In additional papers identified from individual article reference lists were also included.

CONCLUSION

Recent studies have shown a promise in establishing best practices for evaluation of heart, lung abdomen and deep vessels At the moment, bedside US is widely used in an integrated ultrasound vision just like the holistic view have internal medicine, intensive care and emergency medicine and many medical schools in Europe and the USA are inserting ultrasonography into the core curriculum, but we still have to find a standard method for the training program for minimum competence acquisition.

Assessing congestion in acute heart failure using cardiac and lung ultrasound - a review

Introduction: Acute heart failure (AHF) is one of the leading causes of hospital admissions and is characterized by systemic and pulmonary congestion, which often precedes the overt clinical signs and symptoms. Echocardiography in the management of chronic HF is well described; however, there are less evidence regarding echocardiography and lung ultrasound (LUS) in the acute setting.Areas covered: We have summarized current evidence regarding the use of echocardiography and LUS for assessing congestion in patients with AHF. We discuss the value and reliability of handheld/pocketsize ultrasound devices in AHF.Expert opinion: Echocardiography is an essential tool for the diagnostic work up in patients with AHF. No individual parameter reliably detects congestion, thus the physician must integrate several measurements from the right and left heart. Novel methods and advances in cardiac imaging and clinical chemistry make it possible to detect congestion at an early stage. LUS is particularly helpful in assessing congestion, and it has demonstrated diagnostic, therapeutic, and prognostic value in AHF. LUS is relatively easy to learn and allows for quick assessment of the presence of pulmonary congestion and pleural effusion. We recommend integration of LUS for routine management of patients with AHF.

Inferior vena cava dilation predicts global cardiac dysfunction in acute respiratory distress syndrome: A strain echocardiographic study

PURPOSE

Limited data exist on the utility of ultrasonographic evaluation of inferior vena cava (IVC) in acute respiratory distress syndrome (ARDS). We studied the value of IVC diameter in assessing cardio-circulatory performance in ARDS using strain echocardiography.

MATERIALS AND METHODS

Retrospective cross-sectional analysis of Doppler echocardiograms of patients with moderate-severe ARDS was performed. Right ventricle (RV) parameters, IVC diameter, and left ventricle (LV) systolic and diastolic parameters were collected. RV free wall strain (RVFWS) and LV global longitudinal strain (LVGLS) were calculated.

RESULTS

Fifty-one patients were dichotomized into two groups: with IVC > 2.1 cm (dilated) and with IVC ≤ 2.1 cm (nondilated). The dilated IVC group presented worse hypoxemic profile, hypotension, and poor perfusion markers. No significant associations with positive end-expiratory pressure or lung mechanics were observed. Dilated IVC was associated with impaired RV function, high central venous pressure, elevated pulmonary artery pressure, and LV systolic and diastolic dysfunctions. Strongest predictors of a dilated IVC were RVFWS, LVGLS, and tissue Doppler mitral annular early diastolic velocity. Dilated IVC predicted a global cardiac dysfunction defined by strain echocardiography (GCDS) with high sensitivity and specificity.

CONCLUSIONS

In ARDS, strain echocardiography analyses demonstrated that a dilated IVC is associated with GCDS and impaired hemodynamics independent of lung mechanics. A dilated IVC should be considered a marker of circulatory distress, signaling the potential necessity for improved hemodynamic optimization.

Diagnosis and management of acute aortic syndromes in the emergency department

Acute aortic syndromes (AASs) are deadly cardiovascular emergencies involving the thoracic aorta. AASs are relatively rare conditions, have unspecific signs and symptoms (including truncal pain, syncope, neurologic deficit and limb ischemia) and require contrast-enhanced tomography angiography (CTA) of the chest and abdomen for conclusive diagnosis and subsequent therapeutic planning. In the Emergency Department (ED), most patients with potential signs/symptoms of AASs are finally found affected by other alternative diagnoses. Hence, misdiagnosis and delayed diagnosis of AASs are major concerns. In critically ill patients, decision to perform CTA is usually straightforward, as exam benefits largely outweigh risks. In patients with ST-tract elevation on ECG, suspected primary ischemic stroke and in stable patients (representing the most prevalent ED scenarios), proper selection of patients necessitating CTA is cumbersome, due to concurrent risks of misdiagnosis and over-testing. Available studies support an algorithm integrating clinical probability assessment, bedside echocardiography and D-dimer (if the clinical probability is not high). Therapeutic management includes medical therapy for all patients including an opioid and anti-impulse drugs (a beta-blocker and a vasodilator), targeting a heart rate of 60 bpm and systolic blood pressure of 100-120 mmHg. Patients with AASs involving the ascending aorta are likely candidate for urgent surgery, and complicated type B AASs (severe aortic dilatation, impending or frank rupture, organ malperfusion, refractory pain, severe hypertension) necessitate evaluation for urgent endovascular treatment. For uncomplicated type B AASs, optimal medical therapy is the current standard of care.

Simple echocardiographic scoring in screening aortic stenosis with focused cardiac ultrasonography in the emergency department

BACKGROUND

No established methodology exists for diagnosis of aortic stenosis (AS) using focused cardiac ultrasound (FOCUS). We evaluated the diagnostic accuracy of our developed visual AS score for screening AS in an emergency department.

METHODS

Seventy-two emergency outpatients with suspected cardiovascular disease were studied. Emergency physicians assessed the visual AS score in addition to conducting the standard FOCUS, and then the aortic valve area index (AVAI) was measured by expert sonographers in the echocardiography laboratory. AVAI values >0.85 cm²/m², 0.6-0.85 cm²/m², and <0.6 cm²/m² were defined as no or mild AS, moderate AS, and severe AS, respectively.

RESULTS

Seventeen (24%) patients had moderate or severe AS. Visual AS scores assessed by emergency physicians and by expert sonographers showed excellent agreement (κ = 0.93), and a strong association was noted between the visual AS score assessed by emergency physicians and the AVAI assessed by expert sonographers (R = -0.71, p < 0.0001). A visual AS score ≥3 assessed by emergency physicians had a sensitivity of 82%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 95% for diagnosing moderate or severe AS. The prevalence of new-onset AS-related events during hospitalization was higher in patients with visual AS score ≥3 assessed by emergency physicians than in the remaining patients [7 (50%) vs. 2 (3%), p < 0.0001].

CONCLUSION

The visual AS score is a useful AS screening tool for emergency physicians who are not expert cardiologists.

Multi-organ point-of-care ultrasound for COVID-19 (PoCUS4COVID): international expert consensus

COVID-19 has caused great devastation in the past year. Multi-organ point-of-care ultrasound (PoCUS) including lung ultrasound (LUS) and focused cardiac ultrasound (FoCUS) as a clinical adjunct has played a significant role in triaging, diagnosis and medical management of COVID-19 patients. The expert panel from 27 countries and 6 continents with considerable experience of direct application of PoCUS on COVID-19 patients presents evidence-based consensus using GRADE methodology for the quality of evidence and an expedited, modified-Delphi process for the strength of expert consensus. The use of ultrasound is suggested in many clinical situations related to respiratory, cardiovascular and thromboembolic aspects of COVID-19, comparing well with other imaging modalities. The limitations due to insufficient data are highlighted as opportunities for future research.

Ensuring competency in focused cardiac ultrasound: a systematic review of training programs

BACKGROUND

Focused cardiac ultrasound (FoCUS) is a valuable skill for rapid assessment of cardiac function and volume status. Despite recent widespread adoption among physicians, there is limited data on the optimal training methods for teaching FoCUS and metrics for determining competency. We conducted a systematic review to gain insight on the optimal training strategies, including type and duration, that would allow physicians to achieve basic competency in FoCUS.

METHODS

Embase, PubMed, and Cochrane Library databases were searched from inception to June 2020. Included studies described standardized training programs for at least 5 medical students or physicians on adult FoCUS, followed by an assessment of competency relative to an expert. Data were extracted, and bias was assessed for each study.

RESULTS

Data were extracted from 23 studies on 292 learners. Existing FoCUS training programs remain varied in duration and type of training. Learners achieved near perfect agreement (κ > 0.8) with expert echocardiographers on detecting left ventricular systolic dysfunction and pericardial effusion with 6 h each of didactics and hands-on training. Substantial agreement (κ > 0.6) on could be achieved in half this time.

CONCLUSION

A short training program will allow most learners to achieve competency in detecting left ventricular systolic dysfunction and pericardial effusion by FoCUS. Additional training is necessary to ensure skill retention, improve efficiency in image acquisition, and detect other pathologies.

Diagnostic accuracy of inferior vena cava ultrasound for heart failure in patients with acute dyspnoea: a systematic review and meta-analysis

BACKGROUND

Dyspnoea is the most common sign of heart failure (HF). Patients accessing the ED for HF-related symptoms require fast diagnosis and early treatment. Transthoracic echocardiography has a crucial role in HF diagnosis, but requires qualified staff and adequate time for execution. The measurement of inferior vena cava (IVC) diameter has been recently proposed as a rapid, simple and reliable marker of volume overload. The aim of this systematic review was to assess the accuracy of IVC-ultrasound as a stand-alone test for HF diagnosis in patients presenting to the ED with acute dyspnoea.

METHODS

Studies evaluating the diagnostic accuracy of the inferior vena cava collapsibility index (IVC-CIx) for HF diagnosis were systematically searched in the EMBASE and MEDLINE databases (up to January 2018). Quality Assessment of Diagnostic Accuracy Studies 2 tool was used for the quality assessment of the primary studies. A bivariate random-effects regression approach was used for summary estimates of both sensitivity and specificity.

RESULTS

Seven studies, for a total of 591 patients, were included. Three studies were at low-risk of bias. All studies used a proper reference test. Weighted mean prevalence of HF was 49.3% at random-effect model (I² index for heterogeneity=74.7%). IVC-CIx bivariate weighted mean sensitivity was 79.1% (95% CI 68.5% to 86.8%) and bivariate weighted mean specificity was 81.8% (95% CI 75.0% to 87.0%).

CONCLUSIONS

Our findings suggest that the sensitivity and specificity of IVC-CIx are suboptimal to rule in or rule out HF diagnosis in patients with acute dyspnoea in the ED setting. Therefore, IVC-CIx is not advisable as a stand-alone test, but may be useful when integrated in a specific diagnostic algorithm for the differential diagnosis of acute dyspnoea.

Point-of-care ultrasound: Closing guideline gaps in screening for valvular heart disease

BACKGROUND

A linear increase in the number of valvular heart disease is expected due to the aging population, yet most patients with severe valvular heart disease remain undiagnosed.

HYPOTHESIS

POCUS can serve as a screening tool for valvular heart disease.

METHODS

We reviewed the literature to assess the strengths and limitations of POCUS in screening and diagnosing valvular heart disease.

RESULTS

POCUS is an accurate, affordable, accessible, and comprehensive tool. It has a fast learning curve and can prevent unnecessary and more expensive imaging. Challenges include training availability, lack of simplified screening protocols, and reimbursement. Large scale valvular screening data utilizing POCUS is not available.

CONCLUSION

POCUS can serve as a screening tool and guide the management of patients with valvular heart disease. More data is needed about its efficacy and cost-effectiveness in the screening of patients with valvular heart disease.

Feasibility of using a handheld ultrasound device to detect and characterize shunt and deep vein thrombosis in patients with COVID-19: an observational study

BACKGROUND

Coronavirus disease 2019 (COVID-19) causes an atypical acute respiratory distress syndrome associated with thromboembolism and high shunt fraction. Shunt may be intrapulmonary, or extrapulmonary. Handheld devices are increasingly being used for point-of-care ultrasound, but their use to characterize shunt has not been reported.

OBJECTIVES

Determine the feasibility of using handheld ultrasound to detect and characterize anatomical substrates of hypoxia and deep vein thrombosis (DVT) in patients with COVID-19 suspected to have severe shunt.

METHODS

A handheld ultrasound device (iQ, Butterfly, USA) was used to perform lung ultrasound, vascular assessment for DVT, and limited transthoracic echocardiography (TTE) with color Doppler and saline microbubble contrast in patients with COVID-19 suspected to have severe shunt. Images were reassessed by an independent reviewer.

RESULTS

After screening 40 patients, six patients who fulfilled the inclusion criteria were identified. Two were excluded because palliation had been initiated. So, four patients were studied. Interpretable images were obtained in all cases. Interobserver agreement was good. All patients had abnormal lung ultrasound (lung ultrasound score range 17-22). Identified lung pathology included interstitial syndrome with light beams and small peripheral consolidation (4), lobar consolidation (1), and pleural effusion (1). Abnormal echocardiographic findings included interatrial shunt (2), intrapulmonary shunt (1), and dilated right ventricle with tricuspid valve regurgitation (1). Significant DVT was not detected.

CONCLUSION

Use of handheld ultrasound to perform combined lung ultrasound, DVT ultrasound, and limited TTE with color Doppler and saline microbubble contrast is feasible, and may be able to characterize shunt in critically hypoxic patients. Serial studies could be used to monitor changes in shunt. Further studies are required to determine whether this can guide treatment to improve the outcomes of patients with refractory hypoxia.

Perioperative Point-of-Care Ultrasound in Children

Anesthesiologists and other acute care physicians perform and interpret portable ultrasonography-point-of-care ultrasound (POCUS)-at a child's bedside, in the perioperative period. In addition to the established procedural use for central line and nerve block placement, POCUS is being used to guide critical clinical decisions in real-time. Diagnostic point-of-care applications most relevant to the pediatric anesthesiologist include lung ultrasound for assessment of endotracheal tube size and position, pneumothorax, pleural effusion, pneumonia, and atelectasis; cardiac ultrasound for global cardiac function and hydration status, and gastric ultrasound for aspiration risk stratification. This article reviews and discusses select literature regarding the use of various applications of point-of-care ultrasonography in the perioperative period.

Rapid, Single-View Speckle-Tracking-Based Method for Examining Left Ventricular Systolic and Diastolic Function in Point of Care Ultrasound

OBJECTIVES

A rapid, reliable quantitative assessment of left ventricular systolic and diastolic function is important for patient treatment in urgent and dynamic settings. Quantification of annular velocities based on a single 2-dimensional image loop, rather than on Doppler velocities, could be useful in point-of-care or focused cardiac ultrasound. We hypothesized that novel speckle-tracking-based mitral annular velocities would correlate with reference standard tissue Doppler imaging (TDI) velocities in a focused cardiac ultrasound-esque setting.

METHODS

Two echocardiographers each performed transthoracic echocardiographic measurements before and after induction of anesthesia in supine patients undergoing cardiac surgery. Speckle-tracking echocardiography (STE)-based systolic (S'_STE ) and diastolic (E'_STE and A'_STE ) velocities were compared to TDI and global longitudinal strain/strain rate. We also compared mitral annular displacement by speckle tracking with M-mode imaging.

RESULTS

Twenty-five patients were included and examined in both preinduction and postinduction states. Speckle-tracking-based velocities correlated with TDI measurements in both states (S', r = 0.73 and 0.76; E', r = 0.87 and 0.65; and A', r = 0.65 and 0.73), showing a mean bias of 25% to 30% of the reference standard measurement. The correlation of S'_STE with strain and the strain rate (S-wave) and E'_STE with the strain rate (E-wave) was good in awake, spontaneously breathing patients but was less strong in the ventilated state. Similarly, displacement by speckle tracking correlated with M-mode measurements in both states (r = 0.91 and 0.84). Measurements required medians of 31 and 34 seconds; reproducibility was acceptable for S'_STE and E'_STE .

CONCLUSIONS

Speckle-tracking-based mitral annular velocities and displacement correlate well with conventional measures as well as with deformation imaging. They may be clinically useful in rapidly assessing both systolic and diastolic function from a single 2-dimensional image loop.

[German recommendations on lung and thoracic ultrasonography in patients with COVID-19]

Lung and chest ultrasound are further examination modalities in addition to computed tomography and laboratory diagnostics in patients with COVID-19. It extends the clinical-physical examination because it can examine lung surface sensitively. Lung surface pattern changes have been found in sonograms of patients with COVID-19 pneumonia and during the course of the disease. German specialist societies of clinical acute, emergency and intensive care medicine as well as imaging, which are concerned with the care of patients with SARS-CoV‑2 infection and COVID-19, have coordinated recommendations for lung and thorax sonography. This document has been created within a transparent process, led by the German Society of Interdisciplinary Emergency and Acute Medicine e. V. (DGINA), and worked out by an expert panel and delegates from the societies. Sources of the first 200 cases were summarized. Typical thorax sonographic findings are presented. International sources or standards that were available in PubMed until May 24, 2020 were included. Using case studies and multimedia content, the document is intended to not only support users but also demonstrate quality features and the potential of chest and lung sonography. The German Society for Ultrasound in Medicine (DEGUM) is carrying out a multicenter study (study coordination at the TU Munich).

Point-of-Care Ultrasound Training: An Assessment of Interns' Needs and Barriers to Training

Background and objective The use of point-of-care ultrasound (POCUS) is generally on the rise worldwide. However, as the epidemiology of diseases and the approach to their management vary internationally, POCUS may not be universally applicable. The resources available for medical education are generally limited. Thus, when considering the development of a training program during the internship year, we sought to determine interns' perceptions of the applicability of POCUS to clinical practice, the current skill gaps, and barriers to training. Methods  A validated questionnaire was distributed to the interns of the College of Medicine, King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh to determine their proficiency in POCUS, and their opinions on its applicability on a 5-point Likert scale. Each skill gap was calculated by subtracting self-reported proficiency in POCUS from its perceived applicability. Results Of the 300 total interns (male: 200, female: 100), 229 participated [response rate: 76%; male: 136 (68%), female: 93 (93%)]. The use of POCUS to detect abdominal free fluid was perceived to be the most applicable use (mean: 3.9 ±1.1); scanning for consolidation was the least applicable (mean: 3.0 ±1.2). Knowledge and proficiency among the sample were generally poor. The skill gap was greatest for the assessment of inferior vena cava collapsibility (mean: 1.4 ±1.3) and least for the identification of pneumothorax (mean: 0.5 ±1.5). Although three-quarters of the participants (170) agreed that POCUS was an essential skill, 36 (16%) stated that they had no interest in it, and nearly half (101) believed that they did not have time to learn POCUS. Conclusions  While POCUS is applicable to medical interns in Saudi Arabia, significant skill gaps exist. However, our sample's perception of the applicability of POCUS was less favorable than that of internal medicine (IM) residents in Canada. Thus, initiating POCUS training during the internship year may yield suboptimal results. Interns must prioritize medical licensing examinations and applications for residency training. Indeed, many interns believe that they do not have enough time to learn POCUS. Thus, prioritizing the training of residents in POCUS may be a more effective use of the finite resources available for medical education.

Point-of-care ultrasonography in nephrology: a cross-sectional national survey among Brazilian nephrologists

Introduction:

Point-of-care ultrasonography (US) (POCUS) has been used in several specialties, particularly in medical emergency. Despite the confirmation of its numerous benefits, the use of POCUS is still timid in nephrology. In the present study, we aim to investigate the use of POCUS by Brazilian nephrologists.

Methods:

A survey carried out among the members of the Brazilian Society of Nephrology, through institutional e-mail, using the SurveyMonkey platform. We included 12 self-administered questions, which answers were given anonymously.

Results:

It was evident that the majority (64%) of the participants did not have the opportunity to practice US during their nephrological training in their residency, specialization, or even in internships; those with experience with US use the method mainly for implanting central vascular accesses (68%), performing a renal biopsy (58%) and evaluating renal morphology (50%); and the main barriers for nephrologists who do not yet use US are the high price of US machines (26%) and the lack of time to learn about US (23%). Also, POCUS use for examinations of other organs, such as the lung (31%) and heart (18%), which are fundamental in the cardiovascular and volume assessment of patients with kidney diseases, is even more limited. However, 95% of the participants expressed an interest in learning POCUS for use in their medical practice.

Conclusion:

Most of the Brazilian nephrologists interviewed were not trained in US; however, almost all of the research participants expressed an interest in learning to use POCUS in nephrological practice.

Integration of transthoracic focused cardiac ultrasound in the diagnostic algorithm for suspected acute aortic syndromes

AIMS

The diagnosis of acute aortic syndromes (AASs) is challenging and requires integrated strategies. Transthoracic focused cardiac ultrasound (FoCUS) is endorsed by guidelines as a first-line/triage tool allowing rapid bedside assessment of the aorta. However, the performance of FoCUS in the European Society of Cardiology-recommended workup of AASs awaits validation.

METHODS AND RESULTS

This was a prespecified subanalysis of the ADvISED multicentre prospective study. Patients with suspected AAS underwent FoCUS for detection of direct/indirect signs of AAS. Clinical probability assessment was performed with the aortic dissection detection risk score (ADD-RS). Case adjudication was based on advanced imaging, surgery, autopsy, or 14-day follow-up. An AAS was diagnosed in 146 (17.4%) of 839 patients. Presence of direct FoCUS signs had a sensitivity and specificity of 45.2% [95% confidence interval (CI) 37-53.6%] and 97.4% (95% CI 95.9-98.4%), while presence of any FoCUS sign had a sensitivity and specificity of 89% (95% CI 82.8-93.6%) and 74.5% (95% CI 71-77.7%) for AAS. The additive value of FoCUS was most evident within low clinical probability (ADD-RS ≤1). Herein, direct FoCUS signs were identified in 40 (4.8%) patients (P < 0.001), including 29 with AAS. ADD-RS ≤1 plus negative FoCUS for AAS rule-out had a sensitivity of 93.8% (95% CI 88.6-97.1%) and a failure rate of 1.9% (95% CI 0.9-3.6%). Addition of negative D-dimer led to a failure rate of 0% (95% CI 0-1.2%).

CONCLUSION

FoCUS has additive value in the workup of AASs. Direct FoCUS signs can rapidly identify patients requiring advanced imaging despite low clinical probability. In integrated bundles, negative FoCUS is useful for rule-out of AASs.

Teaching vs learning: Impact of deliberate practice and formative feedback on developing point of care ultrasound skills

PURPOSE

The study investigators hypothesized that Point of Care Ultrasound (POCUS) training through bolus didactic and workshop experiences may be sufficient for trainees to learn the cognitive aspects, while an extended period of exposure with formative feedback is responsible for developing the psychomotor skills critical for POCUS.

METHODS

The investigators studied trainees over the course of an academic year. They compared trainees' performance on written (cognitive) and observed image acquisition (psychomotor) exams at baseline and at each subsequent quarter, using a stepped-wedge design. They performed linear regression analysis to determine which variables contributed to knowledge and psychomotor skill development.

RESULTS

Twenty-six trainees met the study requirements and participated in the POCUS curriculum. Participating in a POCUS rotation was consistently associated with an increase in psychomotor scores. There was no consistent variable to predict an increase in trainee's score on written knowledge assessments.

CONCLUSIONS

Extended exposure to POCUS over a 4-week rotation with direct and indirect formative feedback can explain difference in scores on psychomotor skills assessments. Trainees scored similarly on the written assessment with or without a POCUS rotation. Training through didactic and workshop experiences may be sufficient to learn the cognitive aspects, but not psychomotor skills required for POCUS.

Point-of-Care Ultrasound

Purpose of the Review

Point-of-care ultrasound using small ultrasound devices has expanded beyond emergency and critical care medicine to many other subspecialties. Awareness of the strengths and limitations of the technology and knowledge of the appropriate settings and common indications for point-of-care ultrasound is important.

Recent Findings

Point-of-care ultrasound is widely embraced as an extension of the physical exam and is employed in acute care and medical education settings. Echocardiography laboratories involved in education must individualize training to the intended scope of practice of the user. Advances in artificial intelligence may assist in image acquisition and interpretation by novice users.

Summary

Point-of-care ultrasound is widely available in a variety of clinical settings. The field has advanced substantially in the past 2 decades and will likely continue to expand with advancement in technology, reduced cost, and improved opportunities to assist new users.

Point-of-care ultrasound for the pediatric regional anesthesiologist and pain specialist: a technique review

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.

Ultrasonography in the Critical Care Unit

Purpose of Review

This article summarizes the utility and evidence supporting the use of ultrasound exams in the intensive care unit.

Recent Findings

Point-of-care ultrasonography (POCUS) is widely used by intensivists managing critically ill patients whereby they can accurately and rapidly assess for many pathologies such as pneumothorax, pulmonary edema, hydronephrosis, hemoperitoneum, and deep vein thrombosis among others. Basic and advanced critical care echocardiography, including transesophageal echocardiography, are routinely performed to determine the etiology of hemodynamic instability in undifferentiated shock and to guide subsequent therapy. The use of POCUS in the assessment of volume status is controversial with studies demonstrating that respiratory variation of the IVC is not reliable and with analysis of aortic blood flow velocity after passive leg raising maneuvers being the most promising.

Summary

Point-of-care ultrasonography allows frontline clinicians to make real-time diagnoses and treatment decisions. This article will provide the reader with a broad overview of this important topic.

Electronic supplementary material

The online version of this article (10.1007/s11886-020-01393-z) contains supplementary material, which is available to authorized users.

Building focused cardiac ultrasound capacity in a lower middle-income country: A single centre study to assess training impact

Background

In low- and middle-income countries (LMICs) where echocardiography experts are in short supply, training non-cardiologists to perform Focused Cardiac Ultrasound (FoCUS) could minimise diagnostic delays in time-critical emergencies. Despite advocacy for FoCUS training however, opportunities in LMICs are limited, and the impact of existing curricula uncertain. The aim of this study was to assess the impact of FoCUS training based on the Focus Assessed Transthoracic Echocardiography (FATE) curriculum. Our primary objective was to assess knowledge gain. Secondary objectives were to evaluate novice FoCUS image quality, assess inter-rater agreement between expert and novice FoCUS and identify barriers to the establishment of a FoCUS training programme locally.

Methods

This was a pre-post quasi-experimental study at a tertiary hospital in Nairobi, Kenya. Twelve novices without prior echocardiography training underwent FATE training, and their knowledge and skills were assessed. Pre- and post-test scores were compared using the Wilcoxon signed-rank test to establish whether the median of the difference was different than zero. Inter-rater agreement between expert and novice scans was assessed, with a Cohen's kappa >0.6 indicative of good inter-rater agreement.

Results

Knowledge gain was 37.7%, with a statistically significant difference between pre-and post-test scores (z = 2.934, p = 0.001). Specificity of novice FoCUS was higher than sensitivity, with substantial agreement between novice and expert scans for most FoCUS target conditions. Overall, 65.4% of novice images were of poor quality. Post-workshop supervised practice was limited due to scheduling difficulties.

Conclusions

Although knowledge gain is high following a brief training in FoCUS, image quality is poor and sensitivity low without adequate supervised practice. Substantial agreement between novice and expert scans occurs even with insufficient practice when the prevalence of pathology is low. Supervised FoCUS practice is challenging to achieve in a real-world setting in LMICs, undermining the effectiveness of training initiatives.

I Will Be at Your (Bed)Side - The Role of Bedside Echocardiography for Non-Cardiologists

As the availability of portable echocardiographic equipment is becoming more and more widespread, physicians can add a powerful tool to their bedside examination skills, thus helping them to more effectively face the growing complexity of patients admitted to internal medicine departments or the emergency room. Focused cardiac ultrasound (FoCUS) can be defined as a goal-directed, simplified, qualitative examination performed at the bedside using portable echocardiographic devices. FoCUS is not meant to be a substitute for a standard 2D color Doppler echocardiographic examination. Nevertheless, it can provide rapid and reliable information when limited to basic questions, even when performed by non-cardiologists with brief training. Furthermore, a focused cardiac ultrasound examination maximizes its diagnostic role when integrated with an ultrasonographic assessment of the lung, abdomen and deep veins, in a multisystem approach that is particularly dear to internists. In this article, we will focus on the specific targets of a focused cardiac ultrasound examination, as well as the most common pitfalls that can be encountered in ultrasonographic practice. We will also address the application of FoCUS in the management of two typical scenarios in clinical practice, such as dyspnea and non-post-traumatic hypotension.

To Swan or Not to Swan: Indications, Alternatives, and Future Directions

The pulmonary artery catheter (PAC) has revolutionized bedside assessment of preload, afterload, and contractility using measured pulmonary capillary wedge pressure, calculated systemic vascular resistance, and estimated cardiac output. It is placed percutaneously by a flow-directed balloon-tipped technique through the venous system and the right heart to the pulmonary artery. Interest in the hemodynamic variables obtained from PACs paved the way for the development of numerous less-invasive hemodynamic monitors over the past 3 decades. These devices estimate cardiac output using concepts such as pulse contour and pressure analysis, transpulmonary thermodilution, carbon dioxide rebreathing, impedance plethysmography, Doppler ultrasonography, and echocardiography. Herein, the authors review the conception, technologic advancements, and modern use of PACs, as well as the criticisms regarding the clinical utility, reliability, and safety of PACs. The authors comment on the current understanding of the benefits and limitations of alternative hemodynamic monitors, which is important for providers caring for critically ill patients. The authors also briefly discuss the use of hemodynamic monitoring in goal-directed fluid therapy algorithms in Enhanced Recovery After Surgery programs.

Training and Accreditation Pathways in Critical Care and Perioperative Echocardiography

In recent years, there has been a dramatic rise in the use of echocardiography in perioperative and critical care medicine. It is now recommended widely as a first-line diagnostic tool when approaching patients in shock, due to its ability to identify shock etiology and response to treatment noninvasively. To match the increasing training demand, and to ensure maintenance of high-quality and reproducible scanning, several accreditation pathways have been developed worldwide. Critical care echocardiography training pathways can include both transthoracic and transesophageal scanning and range from basic focused protocols to advanced comprehensive scans. The complexity of each individual training program is reflected in its accreditation process. While basic accreditations may require only course attendance and a relatively brief logbook, comprehensive accreditations often require extensive logbooks and written and practical examinations. Currently, the use of transoesophageal echocardiography remains restricted largely to cardiothoracic anesthesia and critical care; however, its use in the general intensive care setting is growing. This narrative review summarizes the most common training pathways, their curricula, and accreditation requirements. The authors initially focus on echocardiography training in the United Kingdom, and then go on to describe similar international accreditations available in Europe, North America, and Australasia.

Offshore telementored ultrasound: a quality assessment study

Background

Telementored ultrasound (US) connects experts to novices through various types of communication and network technologies with the overall aim to bridge the medical imaging gap between patients’ diagnostic needs and on-site user experience. The recurrent theme in previous research on remote telementored US is the limited access to US machines and experienced users. This study was conducted to determine whether telementored US was feasible in a remote offshore setting. The aim was to assess if an onshore US expert can guide an offshore nurse through focused US scanning protocols by connecting an US machine to existing videoconference units at the offshore hospitals and to evaluate the diagnostic quality of the images and cineloops procured.

Results

The diagnostic quality of cineloops was scored on a five-point scale. The percentage of cineloops suitable for interpretation (score 3 ≥) for the FATE and e-FAST protocols was 96.4 and 79.1. Lung sliding and seashore sign could be identified in all volunteers. The scan time for the FAST protocol (n = four scanning positions), FATE protocol (n = six scanning positions) and both lungs (n = two scanning positions) was 1 min 20 s, 4 min 15 s and 32 s, respectively.

Conclusion

A novice US user can be guided by a remote expert through focused US protocols within an acceptable time frame and with good diagnostic quality using existing communication and network systems found onboard offshore oil rigs.

Development of a Focused Cardiac Ultrasound Image Acquisition Assessment Tool

Background: Focused cardiac ultrasound (FCU) is widely used by healthcare providers to answer specific questions about cardiac structure and function at the bedside. Currently, no widely accepted FCU image acquisition checklist exists to assess learners with varying skill levels from different specialties.

Objective: The primary objective of this project was to develop a consensus-based FCU image acquisition checklist using a multispecialty group of point-of-care ultrasound (POCUS) experts.

Methods: The essential components of an FCU examination were identified on the basis of published recommendations from echocardiography and international ultrasound societies. A checklist of the essential components of an FCU examination was drafted. A panel of POCUS experts from different medical specialties in the United States and Canada was convened to vote on each checklist item by answering two questions: 1) Is this item important to include in a checklist of essential FCU skills applicable to any medical specialty? and 2) Should the learner be required to successfully complete this item to be considered competent? A modified Delphi approach was used to assess the level of agreement for each checklist item during four rounds of voting. Checklist items that achieved an agreement of 80% or greater were included in the final checklist.

Results: Thirty-one POCUS experts from seven different medical specialties voted on sixty-five items to be included in the FCU image acquisition assessment tool. The majority of POCUS experts (61%) completed all four rounds of voting. During the first round of voting, 59 items reached consensus, and after revision and revoting, an additional 3 items achieved 80% or greater consensus. A total of 62 items were included in the final checklist, and 57 items reached consensus as a requirement for demonstration of competency.

Conclusion: We have developed a multispecialty, consensus-based FCU image acquisition checklist that may be used to assess the skills of learners from different specialties. Future steps include studies to develop additional validity evidence for the use of the FCU assessment tool and to evaluate its utility for the translation of skills into clinical practice.

Point-of-care ultrasound in pediatric anesthesia: perioperative considerations

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.

Monitoring patients with acute dyspnoea with a serial focused ultrasound of the heart and the lungs (MODUS): a protocol for a multicentre, randomised, open-label, pragmatic and controlled trial

INTRODUCTION

Among patients admitted to an emergency department, dyspnoea is one of the most common symptoms. Patients with dyspnoea have high mortality and morbidity. Therefore, novel methods to monitor the patients are warranted. The aim is to investigate whether therapy guided by monitoring patients with acute dyspnoea with serial ultrasound examinations of the heart and the lungs together with standard care can change the severity of dyspnoea compared with treatment guided by standard monitoring alone.

METHODS AND ANALYSIS

The study will be conducted as a multicentre, randomised, pragmatic, open-label and controlled trial where patients admitted with acute dyspnoea to an emergency ward will be randomised into a standard care group and a serial ultrasound group with 103 patients in each. All patients will be examined with an ultrasound of the heart and the lungs upfront. In addition, the patients in the serial ultrasound group will be examined with an ultrasound of the heart and lungs two more times to guide further therapy during the admittance. The primary outcome is a change in dyspnoea on a verbal scale. After discharge, the patients are followed for 1 year to assess the number of readmissions, death and length of hospital stay.

ETHICS AND DISSEMINATION

The trial is conducted in accordance with the Declaration of Helsinki and approved by The Regional Committee on Health Research Ethics for Region Zealand, Denmark (identifier SJ-744). Data handling agreement with participating centres has been made (identifier REG-056-2019). The General Data Protection Regulation and the Danish Data Protection Act will be respected. The results of the trial will be reported in peer-reviewed scientific journals regardless of the outcomes.

TRIAL REGISTRATION NUMBER

NCT04091334.

Transesophageal echocardiography instead or in addition to transthoracic echocardiography in evaluating haemodynamic problems in intubated critically ill patients

Background

Transesophageal echocardiography (TEE) performed by intensivists is increasingly used in critically ill patients. However, TEE is usually not the preferred monitoring tool, especially when transthoracic echocardiography (TTE) appears to have addressed the clinical problems. As a result, it remains largely unknown whether TEE is a clinically valuable replacement or supplement for TTE as a primary tool in evaluating haemodynamic problems in critically ill surgical patients. The purpose of this study was to assess the diagnostic and therapeutic value of TEE instead or in addition to TTE in critically ill surgical patients with hemodynamic instability.

Methods

A prospective observational study was conducted. A total of 68 consecutive patients were enrolled from December 2016 to February 2018. TEE was routinely performed in addition to TTE, and the imaging data from TTE and TEE were successively disclosed to two different primary physicians, who reported any resulting changes in management. The two physicians were required to reach a consensus if there was any disagreement. The results of the additional TEE examination were compared with the clinical findings and TTE information. The image quality of TTE views was classified as a good (score 2), suboptimal (score 1) or poor view (score 0). According to the scores of TTE images, the patients were divided into two groups: patients with adequate TTE views (score ≥6) and inadequate TTE views (score <6).

Results

The results of additional TEE examination were classified into four categories. TEE failed to provide additional information about the initial diagnosis and therapy (class 1) in 26 patients (38.2%). Of the remaining 42 patients (61.8%), TEE instead or in addition to TTE revealed new findings or led to significant changes in therapy, as TTE supplied inadequate information. TEE used in addition to TTE led to a new diagnosis without therapeutic implications (class 2) in 11 patients (16.2%) and made a major clinical contribution leading to a therapeutic change (class 3) in 23 patients (33.8%). TEE used instead of TTE determined the diagnosis and therapy in 8 patients (11.8%) whose haemodynamic problems could not be addressed by TTE (class 4). In total, TEE had critical therapeutic benefits (class 3 and 4) that was not provided by TTE in 31 patients (45.6%). Of particular concern was that TEE had a higher proportion of therapeutic benefits to patients with inadequate TTE views than those with adequate TTE views (54.3% vs. 27.3%, P=0.036).

Conclusions

TEE as a feasible clinical tool is useful for critically ill surgical patients with hemodynamic instability, especially for the patients with inadequate TTE views. TEE instead or in addition to TTE could provide valuable information for diagnosis, which may bring significant therapeutic benefits.

Point-of-care ultrasound in the preoperative setting

Point-of-care ultrasound (POCUS) is a widely used diagnostic tool, especially in emergency and critical care medicine, and it is increasingly being used in the perioperative setting. Its specific role in preoperative assessment of patients, however, has not yet been defined. While some data show innovative use of the technique in the preoperative setting, higher-level evidence to underscore potential advantages is still limited. We review and discuss a range of POCUS examinations which can potentially help anaesthesiologists in the preoperative clinic decide whether to perform additional testing, can assist in selecting the best anaesthetic approach, and can support perioperative and postoperative monitoring.

Focused Cardiac Ultrasound during Amniotic Fluid Embolism

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General Pediatric Clinical Applications of POCUS: Part 2

The use of point-of-care ultrasound (POCUS) performed by non-radiologists has become more widespread and is entering new arenas of clinical care, particularly in the world of pediatrics. Children are prime candidates for ultrasound because they are more at risk to the harmful effects of ionizing radiation than adults. This is the second part of a two-part article reviewing 10 uses of POCUS that pediatricians can apply to their practice in both inpatient and outpatient settings. [Pediatr Ann. 2020;49(4):e196-e200.].

Lung Ultrasound in Emergency and Critically Ill Patients

Background

Lung ultrasound is increasingly used in critically ill patients as an alternative to bedside chest radiography, but the best training method remains uncertain. This study describes a training curriculum allowing trainees to acquire basic competence.

Methods

This multicenter, prospective, and educational study was conducted in 10 Intensive Care Units in Brazil, China, France and Uruguay. One hundred residents, respiratory therapists, and critical care physicians without expertise in transthoracic ultrasound (trainees) were trained by 18 experts. The main study objective was to determine the number of supervised exams required to get the basic competence, defined as the trainees’ ability to adequately classify lung regions with normal aeration, interstitial–alveolar syndrome, and lung consolidation. An initial 2-h video lecture provided the rationale for image formation and described the ultrasound patterns commonly observed in critically ill and emergency patients. Each trainee performed 25 bedside ultrasound examinations supervised by an expert. The progression in competence was assessed every five supervised examinations. In a new patient, 12 pulmonary regions were independently classified by the trainee and the expert.

Results

Progression in competence was derived from the analysis of 7,330 lung regions in 2,562 critically ill and emergency patients. After 25 supervised examinations, 80% of lung regions were adequately classified by trainees. The ultrasound examination mean duration was 8 to 10 min in experts and decreased from 19 to 12 min in trainees (after 5 vs. 25 supervised examinations). The median training duration was 52 (42, 82) days.

Conclusions

A training curriculum including 25 transthoracic ultrasound examinations supervised by an expert provides the basic skills for diagnosing normal lung aeration, interstitial–alveolar syndrome, and consolidation in emergency and critically ill patients.

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