International evidence-based recommendations for focused cardiac ultrasound

Organ dysfunction, injury and failure in acute heart failure: from pathophysiology to diagnosis and management. A review on behalf of the Acute Heart Failure Committee of the Heart Failure Association (HFA) of the European Society of Cardiology (ESC)

Organ injury and impairment are commonly observed in patients with acute heart failure (AHF), and congestion is an essential pathophysiological mechanism of impaired organ function. Congestion is the predominant clinical profile in most patients with AHF; a smaller proportion presents with peripheral hypoperfusion or cardiogenic shock. Hypoperfusion further deteriorates organ function. The injury and dysfunction of target organs (i.e. heart, lungs, kidneys, liver, intestine, brain) in the setting of AHF are associated with increased risk for mortality. Improvement in organ function after decongestive therapies has been associated with a lower risk for post-discharge mortality. Thus, the prevention and correction of organ dysfunction represent a therapeutic target of interest in AHF and should be evaluated in clinical trials. Treatment strategies that specifically prevent, reduce or reverse organ dysfunction remain to be identified and evaluated to determine if such interventions impact mortality, morbidity and patient-centred outcomes. This paper reflects current understanding among experts of the presentation and management of organ impairment in AHF and suggests priorities for future research to advance the field.

Curriculum Development and Evaluation of a Hemodynamic Critical Care Ultrasound: A Systematic Review of the Literature

OBJECTIVE

The application of ultrasound to assess a patient's cardiac function and volume status is becoming commonplace in the practice of critical care. These skills have been taught through varying curricula; however, no consensus on the optimal curriculum has been established. The purpose of this systematic review is to evaluate the literature regarding critical care ultrasound curriculum development and evaluation.

DATA SOURCES

Studies were identified using MEDLINE, Embase, CINAHL, PsycInfo, the Cochrane Center Register of Controlled Trials, and ERIC according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines through June 2014.

STUDY SELECTION

Included studies were limited to those that described adult (age, > 16 yr) cardiac or hemodynamic critical care ultrasound curricula for physicians. Two reviewers independently screened studies based on predetermined exclusion criteria, and disagreements were resolved by a third reviewer.

DATA EXTRACTION

Data were abstracted, and quality was assessed by two reviewers using the Newcastle-Ottawa Scale. Data abstracted from the studies included the learner population, examination type, duration, composition, and setting of the curriculum, means of evaluation, and outcomes.

DATA SYNTHESIS

The search yielded 654 studies; of which, 15 met inclusion criteria. All curricula used a combination of didactic and hands-on components. The highest agreement between novice and experts, coupled with the most time-efficient application, was achieved when the study was limited to a basic qualitative approach for the assessment of global function or contractility and assessment of inferior vena cava collapsibility. The mode of delivery seemed most efficient when a hybrid method was used, including online instruction. Minimum scanning competency may be achieved with 30 scans although more rigorous study on this element is necessary.

CONCLUSIONS

Assessment of cardiac function and volume assessment is becoming an essential skill in critical care medicine. Physicians can be taught bedside echocardiography in a time-effective manner with positive benefit to patients by applying a concise curriculum with limited content.

Expert consensus document: Echocardiography and lung ultrasonography for the assessment and management of acute heart failure

Echocardiography is increasingly recommended for the diagnosis and assessment of patients with severe cardiac disease, including acute heart failure. Although previously considered to be within the realm of cardiologists, the development of ultrasonography technology has led to the adoption of echocardiography by acute care clinicians across a range of specialties. Data from echocardiography and lung ultrasonography can be used to improve diagnostic accuracy, guide and monitor the response to interventions, and communicate important prognostic information in patients with acute heart failure. However, without the appropriate skills and a good understanding of ultrasonography, its wider application to the most acutely unwell patients can have substantial pitfalls. This Consensus Statement, prepared by the Acute Heart Failure Study Group of the ESC Acute Cardiovascular Care Association, reviews the existing and potential roles of echocardiography and lung ultrasonography in the assessment and management of patients with acute heart failure, highlighting the differences from established practice where relevant.

The impact of focused echocardiography using the Focused Intensive Care Echo protocol on the management of critically ill patients, and comparison with full echocardiographic studies by BSE-accredited sonographers

Introduction

Focused echocardiography is widely used to assist clinical decision-making in critically ill patients. In the UK, the Focused Intensive Care Echo protocol is recommended by the Intensive Care Society to ensure consistency of approach and guarantee training standards. Concerns remain about the reliability of information attained by non-expert clinicians in focused echocardiography, particularly when this is used to alter clinical management.

Methods

A prospective, observational evaluation of 60 consecutive patients undergoing Focused Intensive Care Echo studies in a single ICU.

Results

A complete Focused Intensive Care Echo study was possible in 43/60 scans (72%) and new diagnostic information obtained following 41/60 scans (68%), which lead to a change of clinical management in 28/60 (47%) of cases. In 24/60 (40%) of cases, a full transthoracic study was subsequently undertaken by a fully accredited sonographer. There were no cases where the results from the full study contradicted those from the limited Focused Intensive Care Echo study; additional diagnostic information was attained following 68% of full studies.

Conclusion

Focused echocardiography using the Focused Intensive Care Echo protocol is feasible and clinically useful in a high proportion of ICU patients. However, many still require additional expert echocardiographic assessment. Focused echocardiography delivered by non-experts is clinically useful in this setting but its limitations must be understood and access to expert assessment should be available.

Advantages and pitfalls of pocket ultrasound vs daily chest radiography in the coronary care unit: A single-user experience

BACKGROUND

Pocket ultrasonography may enhance patient diagnosis and care. We sought to assess pocket ultrasound in detecting common conditions in the coronary care unit (CCU) compared to portable daily chest radiography (CXR) and conventional transthoracic echocardiography (TTE).

METHODS

An experienced pocket ultrasound user performed a pocket ultrasound examination for interstitial edema, pneumonia, central line seen in the right ventricle, pleural and pericardial effusions, left atrial enlargement, and cardiomegaly. Data were blindly compared to the radiologist CXR interpretation and cardiologist TTE interpretation.

RESULTS

A total of 102 CXR and pocket ultrasound examinations were performed in 66 patients. The most common CXR indication was "interval change" (37%) and finding central line (65%). Pocket ultrasound demonstrated overall good concordance with CXR ranging from 77% for pleural effusion to 92% for pneumonia. Additionally, the pocket ultrasound examination appeared to anticipate resolution of pulmonary edema prior to the CXR. Compared to TTE, pocket ultrasound had excellent sensitivity for cardiac findings with values ranging from 85% for left atrial enlargement to 100% for cardiomegaly, but limited specificity of cardiomegaly at just 51%.

CONCLUSION

In the CCU, bedside pocket ultrasound reliably diagnoses common conditions identified by CXR with the advantage of lack of ionizing radiation and the suggestion of detecting the resolution of pulmonary edema prior to CXR. Pitfalls include only modest concordance for pleural effusions and limited specificity for cardiomegaly. Larger, multicenter studies are needed to determine whether pocket ultrasound can reduce routine daily CXR in the CCU and other intensive care settings.

Ultrasound imaging in medical student education: Impact on learning anatomy and physical diagnosis

Ultrasound use has expanded dramatically among the medical specialties for diagnostic and interventional purposes, due to its affordability, portability, and practicality. This imaging modality, which permits real-time visualization of anatomic structures and relationships in vivo, holds potential for pre-clinical instruction of students in anatomy and physical diagnosis, as well as providing a bridge to the eventual use of bedside ultrasound by clinicians to assess patients and guide invasive procedures. In many studies, but not all, improved understanding of anatomy has been demonstrated, and in others, improved accuracy in selected aspects of physical diagnosis is evident. Most students have expressed a highly favorable impression of this technology for anatomy education when surveyed. Logistic issues or obstacles to the integration of ultrasound imaging into anatomy teaching appear to be readily overcome. The enthusiasm of students and anatomists for teaching with ultrasound has led to widespread implementation of ultrasound-based teaching initiatives in medical schools the world over, including some with integration throughout the entire curriculum; a trend that likely will continue to grow. Anat Sci Educ 10: 176-189. © 2016 American Association of Anatomists.

Appropriate use criteria for echocardiography in the Netherlands

Introduction

Appropriate use criteria (AUC) for echocardiography based on clinical scenarios were previously published by an American Task Force. We determined whether members of the Dutch Working Group on Echocardiography (WGE) would rate these scenarios in a similar way.

Methods

All 32 members of the WGE were invited to judge clinical scenarios independently using a blanked version of the previously published American version of AUC for echocardiography. During a face-to-face meeting, consensus about the final rating was reached by open discussion for each indication. For reasons of simplicity, the scores were reduced from a 9-point scale to a 3-point scale (indicating an appropriate, uncertain or inappropriate echo indication, respectively).

Results

Nine cardiologist members of the WGE reported their judgment on the echo cases (n = 153). Seventy-one indications were rated as appropriate, 35 were rated as uncertain, and 47 were rated as inappropriate. In 5% of the cases the rating was opposite to that in the original (appropriate compared with inappropriate and vice versa), whereas in 20% judgements differed by 1 level of appropriateness. After the consensus meeting, the appropriateness of 7 (5%) cases was judged differently compared with the original paper.

Conclusions

Echocardiography was rated appropriate when it is applied for an initial diagnosis, a change in clinical status or a change in patient management. However, in about 5% of the listed clinical scenarios, members of the Dutch WGE rated the AUC for echocardiography differently as compared with their American counterparts. Further research is warranted to analyse this decreased external validity.

Electronic supplementary material

The online version of this article (doi: 10.1007/s12471-017-0960-9) contains supplementary material, which is available to authorized users.

Vasopressors During Sepsis: Selection and Targets

Clinicians have greatly improved care for septic shock. Urgent resuscitation using intravenous fluids and vasopressors as well as rapid administration of broad spectrum antibiotics are probably the most basic and universally accepted interventions. Various trials have compared different types of vasopressors, associations of vasopressors and inotropes, and pressure targets. End goal-directed therapy algorithms are designed to optimize oxygen delivery by use of fluids, vasopressors, inotropes, and blood products. Patients who have a poor response to resuscitation and patients with known severe ventricular dysfunction might merit advanced hemodynamic monitoring. This review examines important vasopressor and septic shock trials.

Implementing point-of-care ultrasonography of the heart and lungs in an anesthesia department

BACKGROUND

Implementation of point-of-care ultrasonography (POCUS) of the heart and lungs requires image acquisition skills among providers. We aimed to determine the effect of POCUS implementation using a systematic education program on image acquisition skills and subsequent use and barriers in a department of anesthesiology.

METHODS

Twenty-five anesthesiologists underwent a systematic education program in POCUS during the fall of 2012. A POCUS expert evaluated images from baseline and evaluation examinations performed on two healthy individuals as useful or not useful for clinical interpretation. In August 2016, anesthesiologists employed at the department answered a questionnaire regarding the use of POCUS and perceived barriers to its use.

RESULTS

The systematic education program increased the proportion of images useful for clinical interpretation from 0.70 (95% CI 0.65-0.75) to 0.98 (95% CI 0.95-0.99). This difference was significant when adjusted for prior cardiac ultrasonography courses, prior clinical cardiac ultrasonography experience, ultrasonography view, and ultrasound model (P < 0.001). After 3.5 years, 15/25 (60%) of perioperative medicine providers, 22/24 (92%) of intensive care providers, and 21/21 (100%) of pre-hospital care providers used POCUS either routinely, in selected patient groups, or sporadically.

CONCLUSION

Implementation of POCUS by a systematic education program increased image acquisition skills across anesthesiologists employed at the department. POCUS was used in the intensive care setting, the pre-hospital setting, and to a lesser extent in the perioperative setting. Educational strategies for obtaining images under difficult conditions, practical equipment and evidence for effect on patient outcomes are required for full implementation of POCUS.

[Emergency departments--2016 update]

Acute medical care in hospital emergency departments has experienced rapid development in recent years and gained increasing importance not only from a professional medical point of view but also from an economic and health policy perspective. The present article therefore provides an update on the situation of emergency departments in Germany. Care in emergency departments is provided with an increasing tendency to patients of all ages presenting with varying primary symptoms, complaints, illnesses and injury patterns. In the process, patients reach the emergency department by various routes and structural provision. Cross-sectional communication and cooperation, prioritization and organization of emergency management and especially medical staff qualifications increasingly play a decisive role in this process. The range of necessary knowledge and skills far exceeds the scope of prehospital medical emergency care and the working environment differs substantially. In addition to existing structural and economic problems, the latest developments, as well as future proposals for the design of in-hospital emergency medical care in interdisciplinary emergency departments are described.

4107 Limited Echocardiogram Examinations Performed by Intensivists: A Surgeon-Driven Multidisciplinary Program

Limited transthoracic echocardiogram (LTTE) has been introduced as a tool to direct resuscitation. At our institution, a multidisciplinary training program was instituted. Our hypothesis is that in spite all efforts for multidisciplinary training, certification, and credentialing, limited echocardiograms are under billed for. A training program was implemented in August 2010. This was followed by a process of credentialing and adding LTTE to the billing privileges for providers. Institutional Review Board approval was obtained to review all the studies performed from August 2010 to October 2014. About 4107 LTTEs were performed during the study period. Only 685 examinations were billed for (16.6%). The total amount billed for all the studies was $80,819.00. The number of studies billed for and performed in the emergency department (ED) were 342, and 343 studies were billed while performed in the intensive care unit (ICU). Our institution received payment at a higher rate when the studies were performed in the ICU (71.7%) versus ED (49.4%), P < 0.0001. The total actual reimbursement for the ED was $6487.29 and for the ICU was $8213.95 for a total of $14,701.24. The mean reimbursement amount was $35.59. If all of the studies were billed for and reimbursed at the average payment amount, the institution would have received $146,168.13. A multidisciplinary approach is pivotal for the success of intensivist-driven bedside echocardiogram programs. Education regarding credentialing and billing is a necessary addition to ensure sustainability of such efforts.

Point of Care Ultrasound: A WFUMB Position Paper

Over the last decade, the use of portable ultrasound scanners has enhanced the concept of point of care ultrasound (PoC-US), namely, "ultrasound performed at the bedside and interpreted directly by the treating clinician." PoC-US is not a replacement for comprehensive ultrasound, but rather allows physicians immediate access to clinical imaging for rapid and direct solutions. PoC-US has already revolutionized everyday clinical practice, and it is believed that it will dramatically change how ultrasound is applied in daily practice. However, its use and teaching are different from continent to continent and from country to country. This World Federation for Ultrasound in Medicine and Biology position paper discusses the current status and future perspectives of PoC-US. Particular attention is given to the different uses of PoC-US and its clinical significance, including within emergency and critical care medicine, cardiology, anesthesiology, rheumatology, obstetrics, neonatology, gynecology, gastroenterology and many other applications. In the future, PoC-US will be more diverse than ever and be included in medical student training.

Assessment of Image Quality of Repeated Limited Transthoracic Echocardiography After Cardiac Surgery

OBJECTIVES

The use of limited transthoracic echocardiography (TTE) has been restricted in patients after cardiac surgery due to reported poor image quality. The authors hypothesized that the hemodynamic state could be evaluated in a high proportion of patients at repeated intervals after cardiac surgery.

DESIGN

Prospective observational study.

SETTING

Tertiary university hospital.

PARTICIPANTS

The study comprised 51 patients aged 18 years or older presenting for cardiac surgery.

INTERVENTIONS

Patients underwent TTE before surgery and at 3 time points after cardiac surgery. Images were assessed offline using an image quality scoring system by 2 expert observers. Hemodynamic state was assessed using the iHeartScan protocol, and the primary endpoint was the proportion of limited TTE studies in which the hemodynamic state was interpretable at each of the 3 postoperative time points.

MEASUREMENTS AND MAIN RESULTS

Hemodynamic state interpretability varied over time and was highest before surgery (90%) and lowest on the first postoperative day (49%) (p<0.01). This variation in interpretability over time was reflected in all 3 transthoracic windows, ranging from 43% to 80% before surgery and from 2% to 35% on the first postoperative day (p<0.01). Image quality scores were highest with the apical window, ranging from 53% to 77% across time points, and lowest with the subcostal window, ranging from 4% to 70% across time points (p< 0.01).

CONCLUSIONS

Hemodynamic state can be determined with TTE in a high proportion of cardiac surgery patients after extubation and removal of surgical drains.

Current status of emergency department attending physician ultrasound credentialing and quality assurance in the United States

BACKGROUND

The use of emergency ultrasonography (EUS) has gained much popularity in the past few decades, and is now a mainstay of diagnostic decision-making. This expanded use is now highlighting the substantial issue of individual hospitals in credentialing its emergency medicine attending physicians in EUS in the United States. This issue is also of importance as more hospitals are now requesting reimbursements for emergency ultrasounds. The objective of this study is to gain an understanding of how many emergency departments are currently credentialing its attending staff in EUS, what the internal structure and staffing are of these emergency departments, and how they are currently performing quality assurance of the ultrasounds performed.

METHODS

This was a cross-sectional, web-based survey sent to 160 ACGME-accredited EM residency programs from July 2013 to November 2013. The survey consisted of 23 questions regarding: (1) number of emergency medicine attendings on staff, (2) presence of an EUS fellowship, (3) quality assurance (QA) process, and (4) current US credentialing process.

RESULTS

There was a 50 % response rate. Fifty percent of the total respondents (n = 40) had an EUS fellowship program. Of the sites with an EUS fellowship, 36 had EUS fellowship-trained attendings. Of the sites without an EUS fellowship, 19 had EUS fellowship-trained faculty, p ≤ 0.0001. Sites with an EUS fellowship had a greater percentage of staff credentialed to perform EUS as compared to sites with no EUS fellowship, p = 0.0161. All sites with an EUS fellowship had EUS-credentialed attendings. In sites with an EUS fellowship, 35 conducted a formal QA of ED performed EUS scans versus 22 at sites without an EUS fellowship, p = 0.003.

CONCLUSIONS

The survey results support hiring emergency attendings that have completed postgraduate training in emergency ultrasonography to aid in credentialing staff. This also seems to be helpful in completing a timelier QA of all ED ultrasounds.

Learning process and improvement of point-of-care ultrasound technique for subxiphoid visualization of the inferior vena cava

BACKGROUND

Medical residents' training in ultrasonography usually follows the recommendations of the American College of Emergency Physicians (ACEP), even though these do not provide specific technical guidelines. Adequate training is considered to require 25 practical iterations in the majority of ultrasound procedures. However, the effectiveness of this approach has not been verified experimentally. We set out to determine the number of repetitions required for an acceptable ultrasound procedure of the inferior vena cava (IVC), as an important and emerging ultrasound procedure in cardiology.

METHODS

Using three human models, each of eight medical residents in the Emergency Medicine (EM) Program at the Universidad del Rosario performed 25 iterations of the recommended procedure, with image quality evaluation by an EM physician expert in the technique. Logistic regression analysis was used to determine the lowest number of repetitions required to achieve an adjusted probability of success of 80 and 90 %, respectively.

RESULTS

We obtained 200 ultrasound images. The percentage success by each resident ranged from 52 to 96 %. There was no statistical significance in the relation between gender and success (p = 0.83), but there was an association between year of residency and success (p < 0.001). The average time taken for each procedure was 17.3 s (SD 8.1); there was no association between the time taken and either repetition number or image quality. We demonstrate that eleven repetitions are required to achieve acceptable image quality in 80 %, and that 21 repetitions are required to achieve acceptable image quality in 90 %.

CONCLUSIONS

This is the first study to formally evaluate the effectiveness of recommended training in ultrasound techniques. Our findings demonstrate that training comprising 25 procedural repetitions is easily sufficient to achieve optimal image quality, and they also provide empiric knowledge toward elucidating the times and minimum repetitions needed to acquire and improve ultrasonographic technique in novice operators to a level which fulfills quality requirements for interpretation.

Pediatric emergency medicine point-of-care ultrasound: summary of the evidence

The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers.  To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed "how to" and description of individual point-of-care ultrasound examinations.  Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.

Point-of-Care Ultrasonography for Primary Care Physicians and General Internists

Point-of-care ultrasonography (POCUS) is a safe and rapidly evolving diagnostic modality that is now utilized by health care professionals from nearly all specialties. Technological advances have improved the portability of equipment, enabling ultrasound imaging to be executed at the bedside and thereby allowing internists to make timely diagnoses and perform ultrasound-guided procedures. We reviewed the literature on the POCUS applications most relevant to the practice of internal medicine. The use of POCUS can immediately narrow differential diagnoses by building on the clinical information revealed by the traditional physical examination and refining clinical decision making for further management. We describe 2 common patient scenarios (heart failure and sepsis) to highlight the impact of POCUS performed by internists on efficiency, diagnostic accuracy, resource utilization, and radiation exposure. Using POCUS to guide procedures has been found to reduce procedure-related complications, along with costs and lengths of stay associated with these complications. Despite several undisputed advantages of POCUS, barriers to implementation must be considered. Most importantly, the utility of POCUS depends on the experience and skills of the operator, which are affected by the availability of training and the cost of ultrasound devices. Additional system barriers include availability of templates for documentation, electronic storage for image archiving, and policies and procedures for quality assurance and billing. Integration of POCUS into the practice of internal medicine is an inevitable change that will empower internists to improve the care of their patients at the bedside.

Ultrasound findings in critical care patients: the "liver sign" and other abnormal abdominal air patterns

In critical care patients, point of care abdominal ultrasound examination, although it has been practiced for over 30 years, is not as widespread as its cardiac or pulmonary counterparts. We report two cases in which detection of air during abdominal ultrasound allowed the early detection of life-threatening pathologies. In the first case, a patient with severe Clostridium difficile was found to have portal venous gas but its significance was confounded by a recent surgery. Serial ultrasonographic exams triggered a surgical intervention. In the second case, we report what we call the "liver sign" a finding in patients with pneumoperitoneum. These findings, all obtained prior to conventional abdominal imaging, had immediate clinical impact and avoided unnecessary delays and radiation. Detection of abdominal air should be part of the routine-focused ultrasonographic exam and for critically ill patients an algorithm is proposed.

Common pitfalls in point-of-care ultrasound: a practical guide for emergency and critical care physicians

BACKGROUND

Point-of-care ultrasonography (POCUS) is a widely used tool in emergency and critical care settings, useful in the decision-making process as well as in interventional guidance. While having an impressive diagnostic accuracy in the hands of highly skilled operators, inexperienced practitioners must be aware of some common misinterpretations that may lead to wrong decisions at the bedside.

OBJECTIVES

This article provides a revision list of common POCUS misdiagnoses usually found in practice and offers useful tips to recognize and avoid them.

DISCUSSION

The following aspects were selected and reviewed: pericardial effusion vs. pleural vs. ascites vs. epicardial fat; right ventricle dilation in acute pulmonary embolism and inferior vena cava for volume status assessment in cardiac ultrasound; lung point and lung pulse misinterpretations and mirror artifacts vs. lung consolidations in lung ultrasound; peritoneal fluid vs. the stomach and a critical appraisal of gallbladder signs of acute cholecystitis in abdominal ultrasound; the rouleaux phenomenon vs. deep vein thrombosis or acute right strain in vascular ultrasound.

CONCLUSIONS

Following some rules in technique and interpretation, and always integrating POCUS findings into the broader clinical context, most POCUS misdiagnosis can be avoided, and thus patients' safety can be enhanced. Being aware of a list of common pitfalls may help to avoid misdiagnoses.

A novel semiquantitative assessment of right ventricular systolic function with a modified subcostal echocardiographic view

OBJECTIVES

The tricuspid annular plane systolic excursion (TAPSE) is a validated measure of right ventricular function; however, the apical echocardiographic window varies and has limitations in intensive care unit (ICU) patients receiving mechanical ventilation or those with underlying disease and air entrapment. We aimed to evaluate the subcostal echocardiographic assessment of tricuspid annular kick (SEATAK) as an alternative to TAPSE in critically ill patients.

METHODS

To measure SEATAK, we obtained the subcostal inferior vena cava view and used M-mode to measure excursion of the tricuspid annulus (kick). Analysis was performed with JMP for Bland-Altman and Spearman correlations.

RESULTS

We evaluated 45 patients, 26 (57.8%) of whom were women, with a mean age of 60.8 years. We were not able to obtain the apical view to measure TAPSE in 8.9% of the patients. In contrast, SEATAK was measured in all patients. The mean SEATAK and TAPSE were 1.62 cm and 1.93 cm, respectively, with a mean pairwise difference of -0.26 cm (95% CI: -0.19 to -0.35), with the SEATAK value being lower than TAPSE. The overall correlation was strong and significant (ρ = .86, P=.03). The graphical correlation was maintained between TAPSE and SEATAK and the degree of RVF.

CONCLUSION

In patients presenting with RVF in the ICU (or in situations where the apical echocardiographic view is suboptimal for tricuspid annular assessment), SEATAK can be an alternative to TAPSE. Further research is needed to validate and determine the sensitivity and specificity of SEATAK for RVF prognostication.

Focused ultrasound examination of the chest on patients admitted with acute signs of respiratory problems: a study protocol for a pragmatic randomised controlled multicentre trial

INTRODUCTION

Patients with acute respiratory problems poses a diagnostic challenge because similar symptoms can be caused by various pathological conditions. Focused ultrasound examination (f-US) of the heart and lungs has proven to increase the diagnostic accuracy in these patients. In this protocol of a randomised multicentre trial, we study the effect of f-US of the heart and lungs in patients with respiratory problems performed by emergency physicians (EP) as soon as the patient arrives to the emergency department (ED). The primary outcome is the number of patients with a correct presumptive diagnosis at 4 hours from admission.

METHODS AND ANALYSIS

This is a semiblinded randomised prospective study. 288 patients will be included and randomised into the control or intervention group. All patients receive a standard diagnostic evaluation by the EP to assess the primary presumptive diagnosis. Investigators are EP, with varying degrees of experience in f-US, who perform an f-US of the heart and lungs in patients in both treatment arms. f-US results in the intervention group are non-blinded to the treating EP to be included in the assessment of the 4-hour presumptive diagnosis. As standard for correct diagnosis, we perform a blinded journal audit after discharge. As primary analysis, we use the intention-to-treat analysis.

CONCLUSIONS

This study is the first multicentre trial in EDs to investigate whether f-US, in the hands of the EP, increases the proportion of correct diagnosis at 4 hours after arrival when performed on patients with respiratory problems.

ETHICS AND DISSEMINATION

This trial is conducted in accordance with the Helsinki II Declaration and approved by the Danish Data Protection Agency and the Committee on Biomedical Research Ethics for the Region of Southern Denmark. Results will be published in accordance with the CONSORT statement in a peer-reviewed scientific journal regardless of the outcome.

TRIAL REGISTRATION NUMBER

NCT02550184; Pre-results.

Transthoracic echocardiography in the perioperative setting

PURPOSE OF REVIEW

A need for further assessment of patients in the perioperative setting and an increasing availability of ultrasonography equipment have facilitated the diffusion of ultrasonography and lately focused transthoracic echocardiography (TTE) in anesthesiology practice. This review will discuss the possible use of focused TTE in the perioperative setting and provides an update on present and future perspectives.

RECENT FINDINGS

Several studies focusing on patient management and diagnostic accuracy of perioperative, focused TTE, have been published recently. Several multidisciplinary guidelines addressing use and educational aspects of focused ultrasonography are available, yet guidelines focusing solely on the use in the perioperative setting are lacking.

SUMMARY

Hemodynamically significant cardiac disease or pathophysiology can be disclosed using TTE. Focused TTE is feasible for perioperative patient management and monitoring and will be an inevitable and indispensable tool for the anesthetist. Future research should focus on the outcome of perioperative TTE performed by anesthetists, using rigorous study designs and patient-centered outcomes such as mortality and morbidity.

Clinically integrated multi-organ point-of-care ultrasound for undifferentiated respiratory difficulty, chest pain, or shock: a critical analytic review

Rapid and accurate diagnosis and treatment are paramount in the management of the critically ill. Critical care ultrasound has been widely used as an adjunct to standard clinical examination, an invaluable extension of physical examination to guide clinical decision-making at bedside. Recently, there is growing interest in the use of multi-organ point-of-care ultrasound (MOPOCUS) for the management of the critically ill, especially in the early phase of resuscitation. This article will review the role and utility of symptom-based and sign-oriented MOPOCUS in patients with undifferentiated respiratory difficulty, chest pain, or shock and how it can be performed in a timely, effective, and efficient manner.

Make it SIMPLE: enhanced shock management by focused cardiac ultrasound

BACKGROUND

Shock is a spectrum of circulatory failure that, if not properly managed, would lead to high mortality. Special diagnostic and treatment strategies are essential to save lives. However, clinical and laboratory findings are always non-specific, resulting in clinical dilemmas.

MAIN CONTENT

Focused cardiac ultrasound (FoCUS) has emerged as one of the power tools for clinicians to answer simple clinical questions and guide subsequent management in hypotensive patients. This article will review the development and utility of FoCUS in different types of shock. The sonographic features and ultrasound enhanced management of hypotensive patients by a de novo "SIMPLE" approach will be described. Current evidence on FoCUS will also be reviewed.

CONCLUSION

Focused cardiac ultrasound provides timely and valuable information for the evaluation of shock. It helps to improve the diagnostic accuracy, narrow the possible differential diagnoses, and guide specific management. SIMPLE is an easy-to-remember mnemonic for non-cardiologists or novice clinical sonographers to apply FoCUS and interpret the specific sonographic findings when evaluating patients in shock.

Role of Simulation in Perioperative Echocardiography Training

Echocardiography plays a major role in the diagnosis and management of hemodynamic compromise during the perioperative period. Both transthoracic and transesophageal echocardiography have been shown to improve outcomes after cardiac and noncardiac surgery. Teaching basic echocardiographic skills to perioperative physicians remains a challenging task. Thus far, simulation-based medical education has been proven useful in teaching specific procedural skills and management of infrequent catastrophic events. Simulation-based echocardiography education has the potential to facilitate clinical training in echocardiography. Several small studies have shown the benefits of echocardiographic simulation on developing psychomotor and cognitive echocardiography skills. Future research should focus on the impact of simulation on actual clinical echocardiographic performance in the operating room and ultimately, patient outcomes.

Echocardiography and Focused Cardiac Ultrasound

OBJECTIVES

The following review will describe the use of focused cardiac ultrasound performed by noncardiologists and its role as an acute hemodynamic monitoring tool in pediatric cardiac critical care.

DATA SOURCE

MEDLINE and PubMed.

CONCLUSION

The use of focused cardiac ultrasound has grown tremendously over recent years, and is increasingly being performed and interpreted by intensivists, anesthesiologists, and emergency medicine physicians. These imaging techniques are useful in establishing etiologies of cardiac dysfunction and should compliment the physical examination and standard hemodynamic monitoring.

Stable patients and patients with advanced disease: consensus definitions to support sustained scale up of antiretroviral therapy

OBJECTIVE

As guidelines are evolving towards recommending starting antiretroviral therapy (ART) in all HIV-positive individuals irrespective of clinical and immunological status, HIV programmes will be challenged to manage an increasingly diverse set of patient needs. To support global guideline recommendations for differentiated service delivery, WHO developed consensus definitions for two distinct patient populations: patients presenting with advanced disease and patients who are stable on ART.

METHODS

An expert panel consisting of 73 respondents from 28 countries across all six WHO regions supported the development of these definitions. The panel included clinicians, researchers, programme managers, technical advisors and patient group representatives.

RESULTS

Patients presenting with advanced disease at presentation to care were defined as CD4 count <200 CD4 cells/mm(3) or WHO Stage III & IV defining illness. Patients stable on ART were defined as those who were receiving ART for at least 1 year with no adverse drug reactions requiring regular monitoring, no current illnesses or pregnancy, a good understanding of lifelong adherence, and evidence of treatment success. Treatment success was defined as two consecutive undetectable viral load measures or, in the absence of viral load monitoring, rising CD4 counts or CD4 counts above 200 cells/mm(3) and an objective adherence measure.

CONCLUSIONS

Patients who are stable on ART should be offered a less intensive care package that can lead to improved outcomes while saving resources, including less frequent clinic visits, out-of-clinic drug refills and reduced laboratory monitoring. This will allow for clinic resources to be directed towards reducing morbidity and mortality among patients presenting with advanced disease.

Image-based resuscitation of the hypotensive patient with cardiac ultrasound: An evidence-based review

This article is a detailed review of the literature regarding the use of cardiac ultrasound for the resuscitation of hypotensive patients. In addition, figures regarding windows and description of how to perform the test are included.

Use of Targeted Neonatal Echocardiography and Focused Cardiac Sonography in Tertiary Neonatal Intensive Care Units: Time to Embrace It?

Focused cardiac sonography and targeted neonatal echocardiography refer to goal-directed cardiac imaging using ultrasound, typically by noncardiologic specialists. Although the former consists of a rapid qualitative assessment of cardiac function, which is usually performed by acute care practitioners, the latter refers to detailed functional echocardiography to obtain quantitative and qualitative indexes of pulmonary and systemic hemodynamics in sick neonates and is typically performed by neonatologists. Although the use of these modalities is increasing, they still remain unavailable in most North American centers providing acute care to neonates, partly because of limited data regarding their direct impact on patient care. Here we present a series of 5 cases from a large perinatal unit in which immediate availability of relevant expertise led to important and arguably life-saving clinical interventions. In 4 of these cases, focused cardiac sonography was sufficient to make the diagnosis, whereas in 1 case, clinical integration of detailed systemic hemodynamics measured on target neonatal echocardiography was required.

Transthoracic and transoesophageal echocardiography: a systematic review of feasibility and impact on diagnosis, management and outcome after cardiac surgery

Transthoracic and transoesophageal echocardiography are increasingly used as tools to improve clinical assessment following cardiac surgery. However, most physicians are not trained in echocardiography, and there is no widespread agreement on the feasibility, indications or effect on outcome of transthoracic or transoesophageal echocardiography for patients after cardiac surgery. We performed a systematic review of electronic databases for focused transthoracic and transoesophageal echocardiography after cardiac surgery which revealed 15 full-text articles. They consistently reported that echocardiography is feasible, whether performed by a novice or expert, and frequently resulted in important changes in diagnosis of cardiac abnormalities and their management. However, most were observational studies and there were no well-designed trials investigating the impact of echocardiography on outcome. We conclude that both transthoracic and transoesophageal echocardiography are useful following cardiac surgery.

Focused cardiopulmonary ultrasound for assessment of dyspnea in a resource-limited setting

BACKGROUND

The diagnosis and management of acutely dyspneic patients in resource-limited developing world settings poses a particular challenge. Focused cardiopulmonary ultrasound (CPUS) may assist in the emergency diagnosis and management of patients with acute dyspnea by identifying left ventricular systolic dysfunction, pericardial effusion, interstitial pulmonary edema, and pleural effusion. We sought to assess the accuracy of emergency providers performing CPUS after a training intervention in a limited-resource setting; a secondary objective was to assess the ability of CPUS to affect change of clinician diagnostic assessment and acute management in patients presenting with undifferentiated dyspnea.

METHODS AND RESULTS

After a training intervention for Haitian emergency providers, patients with dyspnea presenting urgently to a regional referral center in Haiti underwent a rapid CPUS examination by the treating physician. One hundred seventeen patients (median age of 36 years, 56 % female) were prospectively evaluated with a standardized CPUS exam. Blinded expert review of ultrasound images was performed by two board certified cardiologists and one ultrasound fellowship trained emergency physician. Inter-observer agreement was determined using an agreement coefficient (kappa). Sensitivity and Specificity with confidence intervals were calculated. Pre-test and post-test clinician impressions and management plans were compared to assess for a change. We enrolled 117 patients with undifferentiated dyspnea. Upon expert image review, prevalence of left ventricular systolic dysfunction was 40.2 %, and in those with systolic dysfunction, the average EF was 14 % (±9 %). The parasternal long axis (PLAX) single view was predictive of an overall abnormal echo with PPV of abnormal PLAX 95 % and NPV 93 % of normal PLAX. Weighted kappa for pericardial effusion between the Haitian physicians and two cardiology reviewers was 0.81 (95 % CI 0.75-0.87, p value <0.001) and for ejection fraction was 0.98 (95 % CI 0.98-0.99, p value <0.001). For lung ultrasound, a kappa statistic assessing agreement between the Haitian physician and the EP for pleural effusion was 0.73, and for interstitial syndrome was 0.49. Detailed test characteristics are detailed in Table 3. Overall, there was a change in treating clinician impression in 15.4 % (95 % CI 9-22 %) and change in management in 19.6 % (95 % CI 12-27 %) of patients following CPUS. A significant structural heart disease was common: 48 % of patients were noted to have abnormal right ventricular systolic function, 36 % had at least moderate mitral regurgitation, and 7.7 % had a moderate to large pericardial effusion.

CONCLUSIONS

A focused training intervention in CPUS was sufficient for providers in a limited-resource setting to accurately identify left ventricular systolic dysfunction, pericardial effusion, evidence of interstitial syndrome, and pleural effusions in dyspneic patients. Clinicians were able to integrate CPUS into their clinical impressions and management plans and reported a high level of confidence in their ultrasound findings.

Practice of hemodynamic monitoring and management in German, Austrian, and Swiss intensive care units: the multicenter cross-sectional ICU-CardioMan Study

BACKGROUND

Hemodynamic instability is frequent and outcome-relevant in critical illness. The understanding of complex hemodynamic disturbances and their monitoring and management plays an important role in treatment of intensive care patients. An increasing number of treatment recommendations and guidelines in intensive care medicine emphasize hemodynamic goals, which go beyond the measurement of blood pressures. Yet, it is not known to which extent the infrastructural prerequisites for extended hemodynamic monitoring are given in intensive care units (ICUs) and how hemodynamic management is performed in clinical practice. Further, it is still unclear which factors trigger the use of extended hemodynamic monitoring.

METHODS

In this multicenter, 1-day (November 7, 2013, and the preceding 24 h) cross-sectional study, we retrieved data on patient monitoring from ICUs in Germany, Austria, and Switzerland by means of a web-based case report form. One hundred and sixty-one intensive care units contributed detailed information on availability of hemodynamic monitoring. In addition, detailed information on hemodynamic monitoring of 1789 patients that were treated on due date was collected, and independent factors triggering the use of extended hemodynamic monitoring were identified by multivariate analysis.

RESULTS

Besides basic monitoring with electrocardiography (ECG), pulse oximetry, and blood pressure monitoring, the majority of patients received invasive arterial (77.9 %) and central venous catheterization (55.2 %). All over, additional extended hemodynamic monitoring for assessment of cardiac output was only performed in 12.3 % of patients, while echocardiographic examination was used in only 1.9 %. The strongest independent predictors for the use of extended hemodynamic monitoring of any kind were mechanical ventilation, the need for catecholamine therapy, and treatment backed by protocols. In 71.6 % of patients in whom extended hemodynamic monitoring was added during the study period, this extension led to changes in treatment.

CONCLUSIONS

Extended hemodynamic monitoring, which goes beyond the measurement of blood pressures, to date plays a minor role in the surveillance of critically ill patients in German, Austrian, and Swiss ICUs. This includes also consensus-based recommended diagnostic and monitoring applications, such as echocardiography and cardiac output monitoring. Mechanical ventilation, the use of catecholamines, and treatment backed by protocol could be identified as factors independently associated with higher use of extended hemodynamic monitoring.

Incremental value of thoracic ultrasound in intensive care units: Indications, uses, and applications

Emergency physicians are required to care for unstable patients with life-threatening conditions, and thus must make decisions that are both quick and precise about unclear clinical situations. There is increasing consensus in favor of using ultrasound as a real-time bedside clinical tool for clinicians in emergency settings alongside the irreplaceable use of historical and physical examinations. B-mode sonography is an old technology that was first proposed for medical applications more than 50 years ago. Its application in the diagnosis of thoracic diseases has always been considered limited, due to the presence of air in the lung and the presence of the bones of the thoracic cage, which prevent the progression of the ultrasound beam. However, the close relationship between air and water in the lungs causes a variety of artifacts on ultrasounds. At the bedside, thoracic ultrasound is based primarily on the analysis of these artifacts, with the aim of improving accuracy and safety in the diagnosis and therapy of the various varieties of pulmonary pathologic diseases which are predominantly “water-rich” or “air-rich”. The indications, contraindications, advantages, disadvantages, and techniques of thoracic ultrasound and its related procedures are analyzed in the present review.

Focused cardiac and lung ultrasonography: implications and applicability in the perioperative period

Focused ultrasonography in anesthesia (FUSA) can be a procedural and diagnostic tool, as well as potentially a tool for monitoring, and can facilitate the perioperative management of surgical patients. Its utilization is proposed within the anesthesiologist and/or intensivist scope of practice. However, there are significant barriers to more generalized use, but evidence continues to evolve that might one day make this practice a standard of care in the perioperative period. Currently, the most widely used applications of FUSA include the guidance and characterization of perioperative shock (acute cor pulmonale, left ventricular dysfunction, cardiac tamponade, and hypovolemia) and acute respiratory failure (pneumothorax, acute pulmonary edema, large pleural effusion, major atelectasis, and consolidation). Increased diagnostic accuracy of all of these clinical conditions makes FUSA valuable in the perioperative period. Furthermore, FUSA can be applied to other anesthesiology fields, such as airway management and evaluation of gastric content in surgical emergencies.