The Use of POCUS to Manage ICU Patients With COVID-19

Critical Advances for Democratizing Ultrasound Diagnostics in Human and Veterinary Medicine

The democratization of ultrasound imaging refers to the process of making ultrasound technology more accessible. Traditionally, ultrasound imaging has been predominately used in specialized medical facilities by trained professionals. Advancements in technology and changes in the health-care landscape have inspired efforts to broaden the availability of ultrasound imaging to various settings such as remote and resource-limited areas. In this review, we highlight several key factors that have contributed to the ongoing democratization of ultrasound imaging, including portable and handheld devices, recent advancements in technology, and training and education. Examples of diagnostic point-of-care ultrasound (POCUS) imaging used in emergency and critical care, gastroenterology, musculoskeletal applications, and other practices are provided for both human and veterinary medicine. Open challenges and the future of POCUS imaging are presented, including the emerging role of artificial intelligence in technology development.

Muscle ultrasound and its application to point-of-care ultrasonography: a narrative review

Technological advances of hand-held ultrasound devices and educational programmes for their use, such as point-of-care ultrasonography (POCUS) training, have contributed to the increasing application of these devices in clinical practice. With the greater impact of frailty and sarcopenia in aging societies, attention is being focused on the use of ultrasound for skeletal muscle assessment. In this narrative review, we discuss how ultrasound can be applied to skeletal muscle assessment, especially that of the quadriceps muscle, in clinical practice. Muscle thickness by ultrasound has been shown to have good reliability and validity for the evaluation of muscle size, and echo intensity has been used to evaluate muscle quality. Muscle ultrasound has not only been useful to diagnose sarcopenia in various settings, but has also been validated to predict health-related outcomes such as death and functional disability. Recommended methods for muscle ultrasound was published recently, and the results of future studies are expected to be comparable. Although several challenging issues with muscle ultrasound remain, if it could be incorporated into educational programmes such as POCUS training, more clinicians may be able to use ultrasound for skeletal muscle assessment in the future.KEY MESSAGESThe evolution of hand-held ultrasound devices enables physicians to perform ultrasound at the bedside as part of regular medical examinations.Muscle ultrasound is considered an effective tool for evaluating muscle size and quality, and has been studied in various settings.More clinicians may be able to evaluate skeletal muscle assessment with the development of educational programmes on muscle ultrasound in the future.

Integrated Assessment of Heart, Lung and Lower Extremity Veins Using Hand-Held Ultrasound Device in COVID-19 Patients: Feasibility and Clinical Application

The emergence of the COVID-19 pandemic caused a significant shortage of medical personnel and the prioritization of life-saving procedures on internal medicine and cardiology wards. Thus, the cost- and time-effectiveness of each procedure proved vital. Implementing elements of imaging diagnostics into the physical examination of COVID-19 patients could prove beneficial to the treatment process, providing important clinical data at the moment of admission. Sixty-three patients with positive COVID-19 test results were enrolled into our study and underwent physical examination expanded with a handheld ultrasound device (HUD)-performed bedside assessment included: right ventricle measurement, visual and automated LVEF assessment, four-point compression ultrasound test (CUS) of lower extremities and lung ultrasound. Routine testing consisting of computed-tomography chest scanning, CT-pulmonary angiogram and full echocardiography performed on a high-end stationary device was completed in the following 24 h. Lung abnormalities characteristic for COVID-19 were detected in CT in 53 (84%) patients. The sensitivity and specificity of bedside HUD examination for detecting lung pathologies was 0.92 and 0.90, respectively. Increased number of B-lines had a sensitivity of 0.81, specificity 0.83 for the ground glass symptom in CT examination (AUC 0.82; p < 0.0001); pleural thickening sensitivity 0.95, specificity 0.88 (AUC 0.91, p < 0.0001); lung consolidations sensitivity 0.71, specificity 0.86 (AUC 0.79, p < 0.0001). In 20 patients (32%), pulmonary embolism was confirmed. RV was dilated in HUD examination in 27 patients (43%), CUS was positive in two patients. During HUD examination, software-derived LV function analysis failed to measure LVEF in 29 (46%) cases. HUD proved its potential as the first-line modality for the collection of heart-lung-vein imaging information among patients with severe COVID-19. HUD-derived diagnosis was especially effective for the initial assessment of lung involvement. Expectedly, in this group of patients with high prevalence of severe pneumonia, HUD-diagnosed RV enlargement had moderate predictive value and the option to simultaneously detect lower limb venous thrombosis was clinically attractive. Although most of the LV images were suitable for the visual assessment of LVEF, an AI-enhanced software algorithm failed in almost 50% of the study population.

Early Lung Ultrasound Findings in Patients With COVID-19 Pneumonia: A Retrospective Multicenter Study of 479 Patients

OBJECTIVES

Lung ultrasound (LUS) holds the promise of an accurate, radiation-free, and affordable diagnostic and monitoring tool in coronavirus disease 2019 (COVID-19) pneumonia. We sought to evaluate the usefulness of LUS in the diagnosis of patients with respiratory distress and suspicion of interstitial severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia, in comparison to other imaging modalities.

METHODS

This was a multicenter, retrospective study. LUS was performed, on Emergency Department (ED) arrival of patients presenting for possible COVID-19 evaluation, by trained emergency physicians, before undergoing conventional radiologic examination or while waiting for the report. Scans were performed using longitudinal transducer orientation of the lung regions. CXR was interpreted by radiologists staffing ED radiology. Subjects were divided into two group based on molecular test results. LUS findings were compared to COVID test results, nonlaboratory data, and other imaging for each patient. Categorical variables were expressed as percentages and continuous variables as median ± standard error.

RESULTS

A total of 479 patients were enrolled, 87% diagnosed with SARS-CoV-2 by molecular testing. COVID positive and COVID negative patients differed with respect to sex, presence of fever, and white blood cells count. Most common findings on lung point of care ultrasound (POCUS) for COVID-positive patients were B-lines, irregular pleural lines, and small consolidation. Normal chest X-ray was found in 17.89% of cases.

CONCLUSIONS

This 479 patient cohort, with COVID-19, found LUS to be noninferior to chest X-ray (CXR) for diagnostic accuracy. In this study, COVID-positive patients are most likely to show B lines and sub-pleural consolidations on LUS examination.

Point-of-Care Echocardiographic Characteristics of COVID-19 Patients with Pulmonary Embolism

Introduction: Thrombotic complications, such as pulmonary embolism, are common in COVID-19 patients. Point-of-care ultrasound is a highly recommended tool for orientation in critically ill patients with suspected or confirmed complications. Methods: An observational study was conducted on 32 consecutive patients with confirmed pulmonary embolism and COVID-19 infection treated in the Intensive Care Unit of the University Hospital Medical Center “Bežanijska kosa”, Belgrade, Serbia, between April 2021 and March 2022. Predictors of the need for oxygen support were determined, while point-of-care echocardiographic parameters and various anamnestic, laboratory, and clinically significant parameters were correlated with the Pulmonary Embolism Severity Index (PESI) score. Results: More than two-thirds of patients in our study had PE symptoms present at hospital admission (68.8%). The majority of patients had segmental pulmonary embolism (48.4%), with high to very high PESI score values in 31.3% of patients. Pneumonia was present in 68.8% of the study population. The PESI score was negatively correlated with diastolic blood pressure and SaO2 at the time of PE diagnosis, LV ejection fraction, and PVAT. A positive correlation was found between the PESI score, maximum CRP, and D-dimer at the time of PTE diagnosis. A larger right ventricular diameter was associated with a greater need for oxygen support. Conclusion: Point-of-care echocardiography is a valuable tool for the risk assessment of COVID-19 patients with pulmonary embolism. Right ventricular size stood out as a significant marker of disease severity.

Economic Evaluation of Ultrasound-guided Central Venous Catheter Confirmation vs Chest Radiography in Critically Ill Patients: A Labor Cost Model

INTRODUCTION

Despite evidence suggesting that point-of-care ultrasound (POCUS) is faster and non-inferior for confirming position and excluding pneumothorax after central venous catheter (CVC) placement compared to traditional radiography, millions of chest radiographs (CXR) are performed annually for this purpose. Whether the use of POCUS results in cost savings compared to CXR is less clear but could represent a relative advantage in implementation efforts. Our objective in this study was to evaluate the labor cost difference for POCUS-guided vs CXR-guided CVC position confirmation practices.

METHODS

We developed a model to evaluate the per patient difference in labor cost between POCUS-guided vs CXR-guided CVC confirmation at our local urban, tertiary academic institution. We used internal cost data from our institution to populate the variables in our model.

RESULTS

The estimated labor cost per patient was $18.48 using CXR compared to $14.66 for POCUS, resulting in a net direct cost savings of $3.82 (21%) per patient using POCUS for CVC confirmation.

CONCLUSION

In this study comparing the labor costs of two approaches for CVC confirmation, the more efficient alternative (POCUS-guided) is not more expensive than traditional CXR. Performing an economic analysis framed in terms of labor costs and work efficiency may influence stakeholders and facilitate earlier adoption of POCUS for CVC confirmation.

A Call for Development of Point-of-Care Ultrasound Training Recommendations in Obstetrics and Gynecology Residency

Point-of-care ultrasound (POCUS) skillsets are now taught throughout training levels from medical school through fellowship given the broad utility in assisting with bedside procedures and triaging clinical presentations for expedited workup. This is reflected in training curricula for emergency medicine, internal medicine, and general surgery residencies. However, these skillsets are not formally taught or required in obstetrics and gynecology residency. We present the opinion that these skillsets and curricula should be developed for obstetrics and gynecology trainees given their exposure to patients with similar clinical presentations in which the clinical management would be aided by POCUS.

Multi-organ point-of-care ultrasound for detection of pulmonary embolism in critically ill COVID-19 patients - A diagnostic accuracy study

Purpose

Critically ill COVID-19 patients have an increased risk of developing pulmonary embolism (PE). Diagnosis of PE by point-of-care ultrasound (POCUS) might reduce the need for computed tomography pulmonary angiography (CTPA), while decreasing time-to-diagnosis.

Materials & methods

This prospective, observational study included adult ICU patients with COVID-19. Multi-organ (lungs, deep vein, cardiac) POCUS was performed within 24 h of CTPA, looking for subpleural consolidations, deep venous thrombosis (DVT), and right ventricular strain (RVS). We reported the scan time, and calculated diagnostic accuracy measures for these signs separately and in combination.

Results

70 consecutive patients were included. 23 patients (32.8%) had a PE. Median scan time was 14 min (IQR 11–17). Subpleural consolidations' diagnostic accuracy was: 42.9% (95%CI [34.1–52.0]). DVT's and RVS' diagnostic accuracy was: 75.6% (95%CI [67.1–82.9]) and 74.4% (95%CI [65.8–81.8]). Their sensitivity was: 24.0% (95%CI [9.4–45.1]), and 40.0% (95%CI [21.3–61.3]), while their specificity was: 88.8% (95%CI [80.8–94.3]), and: 83.0% (95%CI [74.2–89.8]), respectively. Multi-organ POCUS sensitivity was: 87.5% (95%CI [67.6–97.3]), and specificity was: 25% (95%CI [16.9–34.7]).

Conclusions

Multi-organ rather than single-organ POCUS can be of aid in ruling out PE in critically ill COVID-19 and help select patients for CTPA. In addition, finding RVS can make PE more likely, while a DVT would preclude the need for a CTPA.

Registration: www.trialregister.nl: NL8540.

Value of standard echocardiography at the bedside for COVID-19 patients in intensive care units: a Japanese single-center analysis

PURPOSE

In the era of COVID-19, those special settings or indications for which standard transthoracic echocardiography (TTE) can safely produce benefits or advantages over minimized ultrasound imaging procedures need to be identified. Thus, the purpose of this study was to conduct a retrospective analysis with offline comprehensive conventional measurement of bilateral heart function and develop an appropriate prognostic model for in-hospital death.

METHODS

We performed a retrospective analysis of 37 consecutive patients with COVID-19, confirmed by real-time reverse-transcriptase polymerase chain reaction assay, who had undergone clinically indicated standard two-dimensional echocardiographic studies in intensive care wards. Offline comprehensive measurement was also performed. We further integrated the echocardiographic findings as paired evidence of vital organ involvement (possible respiratory distress assessed using right ventricular functional parameters, possible myocardial injury assessed using increased wall thickness, effusion or asynergy) and circulatory failure (suspected low flow status assessed using stroke volume index, suspected congestion assessed using elevated right or left atrial pressure). We evaluated its value for in-hospital death along with other echocardiographic findings.

RESULTS

The most common features included a normal-sized left atrium and left ventricle with preserved left ventricular ejection fraction, despite deteriorated left ventricular flow volume. Less frequent findings, such as abnormalities in the right heart and left ventricular abnormalities suggesting myocarditis, were observed. Although the single echocardiographic parameters failed to show predictive values for in-hospital death, integration of the echocardiographic findings suggested predictive value (p = 0.04, odds ratio: 12.28).

CONCLUSION

Standard TTE at the bedside with offline comprehensive conventional measurement may provide prognostic information that is valuable for the management of patients with COVID-19.