Ultrasound-Guided Drainage for Pediatric Soft Tissue Abscesses Decreases Clinical Failure Rates Compared to Drainage Without Ultrasound: A Retrospective Study

Impact of Didactic Instruction on the Utilization of Point-of-Care Ultrasound in Family Medicine Residents

Background and Objectives In 2014, the Council of Academic Family Medicine released recommendations for the education of family medicine residents in point-of-care ultrasound (POCUS) curricula for Family Medicine Residency programs. One barrier to resident education in POCUS is the lack of access to equipment. This pilot study evaluates whether introducing didactic education on POCUS within a Family Medicine Residency program, with limited access to equipment, correlated with increased utilization of ultrasound by residents. Methods Sixteen family medicine residents participated in the intervention, consisting of a four-hour didactic ultrasound session. Resident confidence in POCUS was evaluated utilizing a Likert scale. Resident utilization of POCUS in a clinical setting was also evaluated by review and analysis of resident procedure logs in the New Innovations database. Results The resident confidence in all skills increased immediately after the completion of the didactic teaching session. Residents demonstrated improved confidence in needle guidance immediately and six weeks after the session (p < 0.001). A review of resident activity two years after the intervention revealed a 9.6% increase in the proportion of resident ultrasounds performed compared to the academic year before the intervention. Conclusions Access to equipment is an ongoing barrier to Family Medicine Residency programs in providing education on POCUS. The results of this study indicate that introducing the basics of POCUS via a didactic teaching session not only increased resident confidence in basic ultrasound but also correlated with increased utilization of POCUS. This increased utilization occurred despite residents not having access to ultrasound in their home clinics.

Evaluation of a Novel Point-of-Care Ultrasound Curriculum for First-Year Pediatric Residents

OBJECTIVE

The aim of the study is to evaluate a novel point-of-care ultrasound (POCUS) educational curriculum for pediatric residents.

METHODS

The cohort study in graduate medical education was completed from January 2017 to March 2019. Postgraduate year 1 (PGY1) pediatric residents attended the educational curriculum that consisted of 3 half-day sessions over a 3-month period. Each session consisted of a lecture (introduction, extended focused assessment with sonography for trauma, soft tissue/musculoskeletal, cardiac, and resuscitative applications) followed by supervised hands-on scanning sessions. Group ratio was 3 learners to 1 machine/expert instructor. Main outcome measures included pre- and post-written test scores, as well as objective structured clinical examination (OSCE) scores.

RESULTS

Forty-nine PGY1 residents (78% women) completed the curriculum. The mean (SD) pretest score was 68% (8.5), and the mean posttest score was 83% (8.3) with a difference of 15 (95% confidence interval, 12.5-17.6; P < 0.001). Mean (SD) focused assessment with sonography for trauma OSCE score after the curriculum was 88.7% (11.9). The number of PGY1 pediatric residents that were comfortable performing POCUS examinations increased from pretraining to posttraining for soft tissue/musculoskeletal (14%-61%, P < 0.001), extended focused assessment with sonography for trauma (24%-90%, P < 0.001), and cardiac (18%-86%, P < 0.001). All participants found the curriculum useful, and 42 of 49 (86%) stated the curriculum increased their ability to acquire and interpret images.

CONCLUSIONS

Postgraduate year 1 pediatric residents learned the basics of POCUS through 3 brief educational sessions. The increase in posttest scores demonstrated improved POCUS knowledge, and the high OSCE score demonstrated their ability to acquire ultrasound images. Point-of-care ultrasound guidelines are needed for pediatric residency programs.

Integrated Multiorgan Bedside Ultrasound for the Diagnosis and Management of Sepsis and Septic Shock

Despite decades of research, the mortality rate of sepsis and septic shock remains unacceptably high. Delays in diagnosis, identification of an infectious source, and the challenge of providing patient-tailored resuscitation measures routinely result in suboptimal patient outcomes. Bedside ultrasound improves a clinician's ability to both diagnose and manage the patient with sepsis. Indeed, multiple point-of-care ultrasound (POCUS) protocols have been developed to evaluate and treat various subsets of critically ill patients. These protocols mostly target patients with undifferentiated shock and have been shown to improve clinical outcomes. Other studies have shown that POCUS can improve a clinician's ability to identify a source of infection. Once a diagnosis of septic shock has been made, serial POCUS exams can be used to continuously guide resuscitative efforts. In this review, we advocate that the patient with suspected sepsis or septic shock undergo a comprehensive POCUS exam in which sonographic information across organ systems is synthesized and used in conjunction with traditional data gleaned from the patient's history, physical exam, and laboratory studies. This harmonization of information will hasten an accurate diagnosis and assist with hemodynamic management.

Does Point-of-Care Ultrasound Affect Outcomes in Pediatric Patients with Skin and Soft Tissue Infections?

OBJECTIVE

There is increasing evidence for the use of point-of-care ultrasound (POCUS) in pediatric patients with skin and soft tissue infections (SSTI), but there is a lack of sufficient data on its impact on SSTI outcomes. The objective of this study was to determine whether POCUS use is associated with fewer complications after discharge from the pediatric emergency department.

METHODS

This was a prospective cohort study in patients presenting to the emergency department with SSTI between the ages of 2 months and 19 years old. Adverse outcomes included hospitalization after discharge, change in antibiotics, subsequent procedures, or reevaluation by a medical professional. Outcome information was obtained 1 week later. Descriptive statistics and χ² tests were used.

RESULTS

Of 456 patients screened, 250 were enrolled. POCUS was performed on 113 (45%) patients. The median age was 5 years, with more females in the non-POCUS group compared with the POCUS group (58% vs. 52%). Cellulitis without abscess was more commonly diagnosed in the POCUS group than in the non-POCUS group (26% vs 14%, P = 0.02.) The patients in the non-POCUS group were more likely to undergo incision and drainage than those in the POCUS group (62% vs 45%, P = 0.008). Overall, a greater number of patients in the POCUS group did not undergo any procedure (45% vs 27%, P = 0.003). The outcomes at 1 week did not differ significantly between the two groups.

CONCLUSIONS

POCUS use may lead to fewer procedures, but it does not lead to significantly better outcomes. Large randomized controlled trials are needed to confirm or refute our findings.

Point-of-care ultrasound in primary care: a systematic review of generalist performed point-of-care ultrasound in unselected populations

BACKGROUND

Both the interest and actual extent of use of point-of-care ultrasound, PoCUS, among general practitioners or family physicians are increasing and training is also increasingly implemented in residency programs. However, the amount of research within the field is still rather limited compared to what is seen within other specialties in which it has become more established, such as in the specialty of emergency medicine. An assumption is made that what is relevant for emergency medicine physicians and their populations is also relevant to the general practitioner, as both groups are generalists working in unselected populations. This systematic review aims to examine the extent of use and to identify clinical studies on the use of PoCUS by either general practitioners or emergency physicians on indications that are relevant for the former, both in their daily practice and in out-of-hours services.

METHODS

Systematic searches were done in PubMed/MEDLINE using terms related to general practice, emergency medicine, and ultrasound.

RESULTS

On the extent of use, we identified 19 articles, as well as 26 meta-analyses and 168 primary studies on the clinical use of PoCUS. We found variable, but generally low, use among general practitioners, while it seems to be thoroughly established in emergency medicine in North America, and increasingly also in the rest of the world. In terms of clinical studies, most were on diagnostic accuracy, and most organ systems were studied; the heart, lungs/thorax, vessels, abdominal and pelvic organs, obstetric ultrasound, the eye, soft tissue, and the musculoskeletal system. The studies found in general either high sensitivity or high specificity for the particular test studied, and in some cases high total accuracy and superiority to other established diagnostic imaging modalities. PoCUS also showed faster time to diagnosis and change in management in some studies.

CONCLUSION

Our review shows that generalists can, given a certain level of pre-test probability, safely use PoCUS in a wide range of clinical settings to aid diagnosis and better the care of their patients.

Point-of-Care Ultrasound for the Pediatric Hospitalist's Practice

Point-of-care ultrasound (POCUS) has the potential to provide real-time valuable information that could alter diagnosis, treatment, and management practices in pediatric hospital medicine. We review the existing pediatric POCUS literature to identify potential clinical applications within the scope of pediatric hospital medicine. Diagnostic point-of-care applications most relevant to the pediatric hospitalist include lung ultrasound for pneumothorax, pleural effusion, pneumonia, and bronchiolitis; cardiac ultrasound for global cardiac function and hydration status; renal or bladder ultrasound for nephrolithiasis, hydronephrosis, and bladder volumes; soft tissue ultrasound for differentiating cellulitis from abscess; and procedural-guidance applications, including line placement, lumbar puncture, and abscess incision and drainage. We discuss POCUS applications with reviews of major pathologic findings, research gaps, the integration of POCUS into practice, and barriers to implementation.