Basic ultrasound head-to-toe skills for intensivists in the general and neuro intensive care unit population: consensus and expert recommendations of the European Society of Intensive Care Medicine

Operator independent continuous ultrasound monitoring of diaphragm excursion predicts successful weaning from mechanical ventilation: a prospective observational study

BACKGROUND

In mechanically ventilated patients, diaphragm ultrasound can identify diaphragm weakness and predict weaning failure. We evaluated whether a novel operator-independent ultrasound-based medical device allowing continuous monitoring of the diaphragm (CUSdi) could reliably (1) measure diaphragm excursion (EXdi) and peak contraction velocity (PCVdi), (2) predict weaning outcome, and (3) approximate transdiaphragmatic pressure (Pdi).

METHODS

In 49 mechanically ventilated patients, CUSdi was recorded during a 30-min spontaneous breathing trial (SBT), and EXdi and PCVdi were measured. In subgroups of patients, standard ultrasound measurement of EXdi and PCVdi was performed (n = 36), and Pdi derived parameters (peak and pressure time product, n = 30) were measured simultaneously.

RESULTS

The agreement bias between standard ultrasound and CUSdi for EXdi was 0.1 cm (95% confidence interval -0.7-0.9 cm). The regression of Passing-Bablok indicated a lack of systematic difference between EXdi measured with standard ultrasound and CUSdi, which were positively correlated (Rho = 0.84, p < 0.001). Weaning failure was observed in 54% of patients. One, two and three minutes after the onset of the SBT, EXdi was higher in the weaning success group than in the failure group. Two minutes after the onset of the SBT, an EXdi < 1.1 cm predicted weaning failure with a sensitivity of 0.83, a specificity of 0.68, a positive predictive value of 0.76, and a negative predictive value of 0.24. There was a weak correlation between EXdi and both peak Pdi (r = 0.22, 95% confidence interval 0.15 - 0.28) and pressure time product (r = 0.13, 95% confidence interval 0.06 - 0.20). Similar results were observed with PCVdi.

CONCLUSIONS

Operator-independent continuous diaphragm monitoring quantifies EXdi reliably and can predict weaning failure with an identified cut-off value of 1.1 cm. Trial registration clinicaltrial.gov, NCT04008875 (submitted 12 April 2019, posted 5 July 2019) and NCT03896048 (submitted 27 March 2019, posted 29 March 2019).

Renal and Genitourinary Ultrasound Evaluation in Emergency and Critical Care: An Overview

Renal and genitourinary ultrasound are fundamental resources employed by emergency and critical care healthcare providers to make prompt diagnoses and perform ultrasound-guided procedures. At the bedside, ultrasound can aid in the diagnosis of relevant pathologies, such as post-renal obstruction or kidney stones, and life-threatening conditions such as aortic dissection or hemoperitoneum. A narrative overview was performed, providing an updated review of renal and genitourinary ultrasound for emergency and critical care healthcare providers, emphasizing its advantages and the latest advances in the field. A thorough summary that can be utilized as a guide for emergency and critical care healthcare providers is presented. The daily hemodynamic management of critically ill patients involves the implementation of new protocols, such as VexUS or the evaluation of the renal resistance index. The role of ultrasound in managing acute nephropathy and genitourinary issues is increasingly crucial given its bedside availability, thus this imaging modality not only facilitates the initiation of therapeutic interventions but also provides swift prognostic insights that are vital to provide tailored patient care. As further advances in ultrasound will arise, it is important for healthcare providers to foster the use of these technologies capable of improving patient outcomes.

Update in Pediatric Neurocritical Care: What a Neurologist Caring for Critically Ill Children Needs to Know

Currently nearly one-quarter of admissions to pediatric intensive care units (PICUs) worldwide are for neurocritical care diagnoses that are associated with significant morbidity and mortality. Pediatric neurocritical care is a rapidly evolving field with unique challenges due to not only age-related responses to primary neurologic insults and their treatments but also the rarity of pediatric neurocritical care conditions at any given institution. The structure of pediatric neurocritical care services therefore is most commonly a collaborative model where critical care medicine physicians coordinate care and are supported by a multidisciplinary team of pediatric subspecialists, including neurologists. While pediatric neurocritical care lies at the intersection between critical care and the neurosciences, this narrative review focuses on the most common clinical scenarios encountered by pediatric neurologists as consultants in the PICU and synthesizes the recent evidence, best practices, and ongoing research in these cases. We provide an in-depth review of (1) the evaluation and management of abnormal movements (seizures/status epilepticus and status dystonicus); (2) acute weakness and paralysis (focusing on pediatric stroke and select pediatric neuroimmune conditions); (3) neuromonitoring modalities using a pathophysiology-driven approach; (4) neuroprotective strategies for which there is evidence (e.g., pediatric severe traumatic brain injury, post-cardiac arrest care, and ischemic stroke and hemorrhagic stroke); and (5) best practices for neuroprognostication in pediatric traumatic brain injury, cardiac arrest, and disorders of consciousness, with highlights of the 2023 updates on Brain Death/Death by Neurological Criteria. Our review of the current state of pediatric neurocritical care from the viewpoint of what a pediatric neurologist in the PICU needs to know is intended to improve knowledge for providers at the bedside with the goal of better patient care and outcomes.

Lung ultrasound teaching in medical education: a pilot study at a Brazilian medical school

OBJECTIVE

To evaluate cognitive learning, ability to perform and interpret lung ultrasound exams, and self-perception of learning among medical students after a short pedagogical intervention at a medical school in Brazil.

METHODS

An experimental pilot study was conducted with medical students at different stages of their education (basic cycle, clinical cycle, and medical internship). The participants underwent a cognitive test before and after the intervention, a practical test, a test to recognize lung ultrasound pathologies, and a qualitative evaluation test at the end of the intervention. Statistical analysis was performed using a significance level of p < 0.05.

RESULTS

A total of 42 students were included in the study, with a median age of 23 years and a predominance of males. The mean score of the pre-intervention cognitive test was 2.97 ± 0.87, and that of the post-intervention test was 6.57 ± 1.41, showing significant improvement (p < 0.001). The score of the practical test and that of the recognition of pathologies test also showed significant improvement after the intervention. There was no significant difference in execution time between the groups. Students in the clinical cycle had a better self-perception of learning.

CONCLUSIONS

Theoretical teaching and practical training of lung ultrasound in a short pedagogical intervention can improve cognitive performance, practical skills, and interpretation of the exam. The level of learning achievement was higher among more advanced students in medical education. Additionally, the students in the clinical cycle had a better perception of their learning.

Transcranial Doppler and Color-Coded Doppler Use for Brain Death Determination in Adult Patients: A Pictorial Essay

Transcranial Doppler (TCD) is a repeatable, at-the-bedside, helpful tool for confirming cerebral circulatory arrest (CCA). Despite its variable accuracy, TCD is increasingly used during brain death determination, and it is considered among the optional ancillary tests in several countries. Among its limitations, the need for skilled operators with appropriate knowledge of typical CCA patterns and the lack of adequate acoustic bone windows for intracranial arteries assessment are critical. The purpose of this review is to describe how to evaluate cerebral circulatory arrest in the intensive care unit with TCD and transcranial duplex color-coded doppler (TCCD).

Best Practices for Point of Care Ultrasound: An Interdisciplinary Expert Consensus

Despite the growing use of point of care ultrasound (POCUS) in contemporary medical practice and the existence of clinical guidelines addressing its specific applications, there remains a lack of standardization and agreement on optimal practices for several areas of POCUS use. The Society of Point of Care Ultrasound (SPOCUS) formed a working group in 2022 to establish a set of recommended best practices for POCUS, applicable to clinicians regardless of their training, specialty, resource setting, or scope of practice. Using a three-round modified Delphi process, a multi-disciplinary panel of 22 POCUS experts based in the United States reached consensus on 57 statements in domains including: (1) The definition and clinical role of POCUS; (2) Training pathways; (3) Credentialing; (4) Cleaning and maintenance of POCUS devices; (5) Consent and education; (6) Security, storage, and sharing of POCUS studies; (7) Uploading, archiving, and reviewing POCUS studies; and (8) Documenting POCUS studies. The consensus statements are provided here. While not intended to establish a standard of care or supersede more targeted guidelines, this document may serve as a useful baseline to guide clinicians, leaders, and systems considering initiation or enhancement of POCUS programs.

Consistency of data reporting in fluid responsiveness studies in the critically ill setting: the CODEFIRE consensus from the Cardiovascular Dynamic section of the European Society of Intensive Care Medicine

PURPOSE

To provide consensus recommendations regarding hemodynamic data reporting in studies investigating fluid responsiveness and fluid challenge (FC) use in the intensive care unit (ICU).

METHODS

The Executive Committee of the European Society of Intensive Care Medicine (ESICM) commissioned and supervised the project. A panel of 18 international experts and a methodologist identified main domains and items from a systematic literature, plus 2 ancillary domains. A three-step Delphi process based on an iterative approach was used to obtain the final consensus. In the Delphi 1 and 2, the items were selected with strong (≥ 80% of votes) or week agreement (70-80% of votes), while the Delphi 3 generated recommended (≥ 90% of votes) or suggested (80-90% of votes) items (RI and SI, respectively).

RESULTS

We identified 5 main domains initially including 117 items and the consensus finally resulted in 52 recommendations or suggestions: 18 RIs and 2 SIs statements were obtained for the domain "ICU admission", 11 RIs and 1 SI for the domain "mechanical ventilation", 5 RIs for the domain "reason for giving a FC", 8 RIs for the domain pre- and post-FC "hemodynamic data", and 7 RIs for the domain "pre-FC infused drugs". We had no consensus on the use of echocardiography, strong agreement regarding the volume (4 ml/kg) and the reference variable (cardiac output), while weak on administration rate (within 10 min) of FC in this setting.

CONCLUSION

This consensus found 5 main domains and provided 52 recommendations for data reporting in studies investigating fluid responsiveness in ICU patients.

How to perform and interpret a middle cerebral artery transcranial Doppler examination in children at risk of brain injury

Transcranial Doppler (TCD) ultrasound is a non-invasive neuromonitoring technique that falls under the umbrella of point-of-care ultrasound. In this article, we provide a primer to encourage clinicians to perform TCD examinations and to aid them with accurately interpreting the scans. We focus on the middle cerebral artery waveforms and use traumatic brain injury as a model for brain insult.

Formal ultrasound curriculum for surgical critical care fellows leads to improvement in comfort and skills in the intensive care unit

BACKGROUND

Despite its importance, there are no official guidelines for point of care ultrasound training during surgical critical care fellowship. The primary objective of this study was to evaluate the comfort and competency of fellows after implementation of a point of care ultrasound program.

METHODS

Surgical critical care fellows (n = 7) participated in an ultrasound rotation (2021-2022), including dedicated lectures and training with interventional and echocardiography technicians. Pre and post self-assessments were administered evaluating comfort in point of care ultrasound for focused assessment with sonography for trauma, vascular access, drainage procedures, volume status, cardiac activity during arrest, and global cardiac function. Technicians assessed fellow skill in probe orientation, location, image manipulation, machine adjustment, and image quality. All questions were answered on a 7-point Likert scale (1, not-at-all; 7, yes/very much). Pre and post cohorts were compared using Wilcoxon signed-rank tests.

RESULTS

After the rotation, fellows reported improvement in comfort level for ultrasound-guided technique for focused assessment with sonography for trauma, drainage procedures, volume status, and cardiac assessment. Technician evaluations demonstrated improvement in probe orientation (5 [4-6] vs 7 [7-7], P = .02) and location (5 [3-6] vs 7 [7-7], P = .02), image manipulation (5 [4-5] vs 7 [7-7], P = .02), machine adjustment (5 [4-5] vs 7 [7-7], P = .02), and overall image quality (4 [4-6] vs 7 [7-7], P = .02) after the rotation. All fellows reported the course significantly improved their skill, comfort level, and was worthwhile.

CONCLUSION

All fellows exhibited significant improvement in skill and comfort with point of care ultrasound after this rotation. This is the first study to describe a dedicated ultrasound curriculum for surgical critical care with significant skill acquisition.

Transcranial sonography in the critical patient

Transcranial ultrasonography is a non-invasive, bedside technique that has become a widely implemented tool in the evaluation and management of neurocritically ill patients. It constitutes a technique in continuous growth whose fundamentals (and limitations) must be known by the intensivist. This review provides a practical approach for the intensivist, including the different sonographic windows and planes of insonation and its role in different conditions of the neurocritical patients and in critical care patients of other etiologies.

Lung ultrasound training: how short is too short? observational study on the effects of a focused theoretical training for novice learners

BACKGROUND

Lung ultrasound has been increasingly used in the last years for the assessment of patients with respiratory diseases; it is considered a simple technique, now spreading from physicians to other healthcare professionals as nurses and physiotherapists, as well as to medical students. These providers may require a different training to acquire lung ultrasound skills, since they are expected to have no previous experience with ultrasound. The aim of the study was to assess the impact of a short theoretical training focused on lung ultrasound pattern recognition in a population of novice nurse learners with no previous experience with ultrasound.

METHODS

We included the nurses attending a critical care advanced course for nurses performed at the University of Pavia. Images' interpretation skills were tested on two slide sets (a 25-clip set focused on B-pattern recognition and a 25-clip set focused on identification of pleural movement as lung sliding, lung pulse, lung point, no movement) before and after three 30-minute teaching modules dedicated to general ultrasound principles, B-lines assessment and lung sliding assessment. A cut off of 80% was considered acceptable for correctly interpreted images after this basic course.

RESULTS

22 nurses were enrolled (age 26.0 [24.0-28.0] years; men 4 (18%)); one nurse had previous experience with other ultrasound techniques, none of them had previous experience with lung ultrasound. After the training, the number of correctly interpreted clips improved from 3.5 [0.0-13.0] to 22.0 [19.0-23.0] (p < 0.0001) for B-pattern and from 0.5 [0.0-2.0] to 8.5 [6.0-12.0] (p < 0.0001) for lung sliding assessment. The number of correct answers for B-pattern recognition was significantly higher than for lung sliding assessment, both before (3.5 [0.0-13.0] vs. 0.5 [0.0-2.0]; p = 0.0036) and after (22.0 [19.0-23.0] vs. 8.5 [6.0-12.0]; p < 0.0001) the training. After the training, nurses were able to correctly recognize the presence or the absence of a B-pattern in 84.2 ± 10.3% of cases; lung sliding was correctly assessed in 37.1 ± 15.3% of cases.

CONCLUSIONS

Lung ultrasound is considered a simple technique; while a short, focused training significantly improves B-pattern recognition, lung sliding assessment may require a longer training for novice learners.

TRIAL REGISTRATION

Not applicable.

Coexistence of a fluid responsive state and venous congestion signals in critically ill patients: a multicenter observational proof-of-concept study

BACKGROUND

Current recommendations support guiding fluid resuscitation through the assessment of fluid responsiveness. Recently, the concept of fluid tolerance and the prevention of venous congestion (VC) have emerged as relevant aspects to be considered to avoid potentially deleterious side effects of fluid resuscitation. However, there is paucity of data on the relationship of fluid responsiveness and VC. This study aims to compare the prevalence of venous congestion in fluid responsive and fluid unresponsive critically ill patients after intensive care (ICU) admission.

METHODS

Multicenter, prospective cross-sectional observational study conducted in three medical-surgical ICUs in Chile. Consecutive mechanically ventilated patients that required vasopressors and admitted < 24 h to ICU were included between November 2022 and June 2023. Patients were assessed simultaneously for fluid responsiveness and VC at a single timepoint. Fluid responsiveness status, VC signals such as central venous pressure, estimation of left ventricular filling pressures, lung, and abdominal ultrasound congestion indexes and relevant clinical data were collected.

RESULTS

Ninety patients were included. Median age was 63 [45-71] years old, and median SOFA score was 9 [7-11]. Thirty-eight percent of the patients were fluid responsive (FR+), while 62% were fluid unresponsive (FR-). The most prevalent diagnosis was sepsis (41%) followed by respiratory failure (22%). The prevalence of at least one VC signal was not significantly different between FR+ and FR- groups (53% vs. 57%, p = 0.69), as well as the proportion of patients with 2 or 3 VC signals (15% vs. 21%, p = 0.4). We found no association between fluid balance, CRT status, or diagnostic group and the presence of VC signals.

CONCLUSIONS

Venous congestion signals were prevalent in both fluid responsive and unresponsive critically ill patients. The presence of venous congestion was not associated with fluid balance or diagnostic group. Further studies should assess the clinical relevance of these results and their potential impact on resuscitation and monitoring practices.

The Role of Ultrasonography in the Process of Weaning from Mechanical Ventilation in Critically Ill Patients

Weaning patients from mechanical ventilation (MV) is a complex process that may result in either success or failure. The use of ultrasound at the bedside to assess organs may help to identify the underlying mechanisms that could lead to weaning failure and enable proactive measures to minimize extubation failure. Moreover, ultrasound could be used to accurately identify pulmonary diseases, which may be responsive to respiratory physiotherapy, as well as monitor the effectiveness of physiotherapists' interventions. This article provides a comprehensive review of the role of ultrasonography during the weaning process in critically ill patients.

Challenges in Septic Shock: From New Hemodynamics to Blood Purification Therapies

Sepsis and septic shock are associated with high mortality, with diagnosis and treatment remaining a challenge for clinicians. Their management classically encompasses hemodynamic resuscitation, antibiotic treatment, life support, and focus control; however, there are aspects that have changed. This narrative review highlights current and avant-garde methods of handling patients experiencing septic shock based on the experience of its authors and the best available evidence in a context of uncertainty. Following the first recommendation of the Surviving Sepsis Campaign guidelines, it is recommended that specific sepsis care performance improvement programs are implemented in hospitals, i.e., "Sepsis Code" programs, designed ad hoc, to achieve this goal. Regarding hemodynamics, the importance of perfusion and hemodynamic coherence stand out, which allow for the recognition of different phenotypes, determination of the ideal time for commencing vasopressor treatment, and the appropriate fluid therapy dosage. At present, this is not only important for the initial timing, but also for de-resuscitation, which involves the early weaning of support therapies, directed elimination of fluids, and fluid tolerance concept. Finally, regarding blood purification therapies, those aimed at eliminating endotoxins and cytokines are attractive in the early management of patients in septic shock.

Setting positive end-expiratory pressure: lung and diaphragm ultrasound

PURPOSE OF REVIEW

The purpose of this review is to summarize the role of lung ultrasound and diaphragm ultrasound in guiding ventilator settings with an emphasis on positive end-expiratory pressure (PEEP). Recent advances for using ultrasound to assess the effects of PEEP on the lungs and diaphragm are discussed.

RECENT FINDINGS

Lung ultrasound can accurately diagnose the cause of acute respiratory failure, including acute respiratory distress syndrome and can identify focal and nonfocal lung morphology in these patients. This is essential in determining optimal ventilator strategy and PEEP level. Assessment of the effect of PEEP on lung recruitment using lung ultrasound is promising, especially in the perioperative setting. Diaphragm ultrasound can monitor the effects of PEEP on the diaphragm, but this needs further validation. In patients with an acute exacerbation of chronic obstructive pulmonary disease, diaphragm ultrasound can be used to predict noninvasive ventilation failure. Lung and diaphragm ultrasound can be used to predict weaning outcome and accurately diagnose the cause of weaning failure.

SUMMARY

Lung and diaphragm ultrasound are useful for diagnosing the cause of respiratory failure and subsequently setting the ventilator including PEEP. Effects of PEEP on lung and diaphragm can be monitored using ultrasound.

Efficiency of Simulation-Based Learning Using an ABC POCUS Protocol on a High-Fidelity Simulator

Critically ill patients with rapidly deteriorating clinical status secondary to respiratory and cardio-vascular compromise are at risk for immediate collapse if the underlying pathology is not recognized and treated. Rapid diagnosis is of utmost importance regardless of the setting. Although there are data to support the use of point-of-care ultrasound in critical patients, there is no consensus about the best educational strategy to implement. We designed a curriculum based on the ABC (Airway, Breathing, Circulation) protocol that covers essential airway, lung, and cardiac ultrasound skills needed for fast diagnosis in critical patients and applied it in high-fidelity simulation-based medical education sessions for anesthesia and intensive care residents year one and two. After theoretical and practical assessments, our results show statistical differences in the theoretical knowledge and above-average results in practical assessment. Our proposed curriculum based on a simple ABC POCUS protocol, with an Airway, Breathing, and Circulation approach, is useful in teaching ultrasound basics regarding airway, lung, and cardiac examination using high-fidelity simulation training to anesthesia and intensive care residents, but further research is needed to establish the utility of Simulation-Based Medical Education in Point of Care Ultrasound in the critical patient.

Mastering the brain in critical conditions: an update

Acute brain injuries, such as traumatic brain injury and ischemic and hemorragic stroke, are a leading cause of death and disability worldwide. While characterized by clearly distict primary events-vascular damage in strokes and biomechanical damage in traumatic brain injuries-they share common secondary injury mechanisms influencing long-term outcomes. Growing evidence suggests that a more personalized approach to optimize energy substrate delivery to the injured brain and prognosticate towards families could be beneficial. In this context, continuous invasive and/or non-invasive neuromonitoring, together with clinical evaluation and neuroimaging to support strategies that optimize cerebral blood flow and metabolic delivery, as well as approaches to neuroprognostication are gaining interest. Recently, the European Society of Intensive Care Medicine organized a 2-day course focused on a practical case-based clinical approach of acute brain-injured patients in different scenarios and on future perspectives to advance the management of this population. The aim of this manuscript is to update clinicians dealing with acute brain injured patients in the intensive care unit, describing current knowledge and clinical practice based on the insights presented during this course.

Role of ultrasound in the critical ill patient with ECMO

Ultrasound is an essential diagnostic tool in critically ill patients with extracorporeal membrane oxygenation (ECMO). With it, we can make an anatomical and functional (cardiac, pulmonary and vascular) evaluation which allows us to execute an adequate configuration, guides implantation, helps clinical monitorization and detects complications, facilitates withdrawal and complete post-implant evaluation. In patients with ECMO as respiratory support (veno-venous), thoracic ultrasound allows monitoring pulmonary illness evolution and echocardiography the evaluation of biventricular function, especially right ventricle function, and cardiac output to optimize oxygen transport. In ECMO as circulatory support (veno-arterial), echocardiography is the guide of hemodynamic monitoring, allows detecting the most frequent complications and helps the weaning. In ECMO teams, for a proper management of these patients, there must be trained intensivists with advanced knowledge on this technique.

Pressure-support compared with pressure-controlled ventilation mitigates lung and brain injury in experimental acute ischemic stroke in rats

BACKGROUND

We aimed to evaluate the pulmonary and cerebral effects of low-tidal volume ventilation in pressure-support (PSV) and pressure-controlled (PCV) modes at two PEEP levels in acute ischemic stroke (AIS).

METHODS

In this randomized experimental study, AIS was induced by thermocoagulation in 30 healthy male Wistar rats. After 24 h, AIS animals were randomly assigned to PSV or PCV with VT = 6 mL/kg and PEEP = 2 cmH2O (PSV-PEEP2 and PCV-PEEP2) or PEEP = 5 cmH2O (PSV-PEEP5 and PCV-PEEP5) for 2 h. Lung mechanics, arterial blood gases, and echocardiography were evaluated before and after the experiment. Lungs and brain tissue were removed for histologic and molecular biology analysis. The primary endpoint was diffuse alveolar damage (DAD) score; secondary endpoints included brain histology and brain and lung molecular biology markers.

RESULTS

In lungs, DAD was lower with PSV-PEEP5 than PCV-PEEP5 (p < 0.001); interleukin (IL)-1β was lower with PSV-PEEP2 than PCV-PEEP2 (p = 0.016) and PSV-PEEP5 than PCV-PEEP5 (p = 0.046); zonula occludens-1 (ZO-1) was lower in PCV-PEEP5 than PCV-PEEP2 (p = 0.042). In brain, necrosis, hemorrhage, neuropil edema, and CD45 + microglia were lower in PSV than PCV animals at PEEP = 2 cmH2O (p = 0.036, p = 0.025, p = 0.018, p = 0.011, respectively) and PEEP = 5 cmH2O (p = 0.003, p = 0.003, p = 0.007, p = 0.003, respectively); IL-1β was lower while ZO-1 was higher in PSV-PEEP2 than PCV-PEEP2 (p = 0.009, p = 0.007, respectively), suggesting blood-brain barrier integrity. Claudin-5 was higher in PSV-PEEP2 than PSV-PEEP5 (p = 0.036).

CONCLUSION

In experimental AIS, PSV compared with PCV reduced lung and brain injury. Lung ZO-1 reduced in PCV with PEEP = 2 versus PEEP = 5 cmH2O, while brain claudin-5 increased in PSV with PEEP = 2 versus PEEP = 5 cmH2O.

Ultrasonography and procedures in intensive care medicine

The use of point-of-care ultrasonography (POCUS) is not limited to the diagnosis and/or monitoring of critically ill patients. Further, ultrasound guidance is of paramount relevance to aid in successfully and safely performing several procedures in the intensive care unit (ICU). In this article, we review the role of POCUS as a procedural guidance in the ICU. Core procedures include, but are not limited to, vascular cannulation, pericardiocentesis, thoracentesis, paracentesis, aspiration of soft-tissue collections/arthrocentesis and lumbar puncture. With time, the procedures performed by intensivists may extend beyond the core competencies depicted in this review. Ultrasound guidance should be part of the intensivist's competencies, for which appropriate training should be achieved.

The "CHEOPS" bundle for the management of Left Ventricular Diastolic Dysfunction in critically ill patients: an experts' opinion

The impact of left ventricular (LV) diastolic dysfunction (DD) on the outcome of patients with heart failure was established over three decades ago. Nevertheless, the relevance of LVDD for critically ill patients admitted to the intensive care unit has seen growing interest recently, and LVDD is associated with poor prognosis. Whilst an assessment of LV diastolic function is desirable in critically ill patients, treatment options for LVDD are very limited, and pharmacological possibilities to rapidly optimize diastolic function have not been found yet. Hence, a proactive approach might have a substantial role in improving the outcomes of these patients. Recalling historical Egyptian parallelism suggesting that Doppler echocardiography has been the "Rosetta stone" to decipher the study of LV diastolic function, we developed a potentially useful acronym for physicians at the bedside to optimize the management of critically ill patients with LVDD with the application of the bundle. We summarized the bundle under the acronym of the famous ancient Egyptian pharaoh CHEOPS: Chest Ultrasound, combining information from echocardiography and lung ultrasound; HEmodynamics assessment, with careful evaluation of heart rate and rhythm, as well as afterload and vasoactive drugs; OPtimization of mechanical ventilation and pulmonary circulation, considering the effects of positive end-expiratory pressure on both right and left heart function; Stabilization, with cautious fluid administration and prompt fluid removal whenever judged safe and valuable. Notably, the CHEOPS bundle represents experts' opinion and are not targeted at the initial resuscitation phase but rather for the optimization and subsequent period of critical illness.

Venous Excess Ultrasound (VExUS Grading to Assess Perioperative Fluid Status for Noncardiac Surgeries: a Prospective Observational Pilot Study

Objectives: Perioperative fluid administration impacts the rate of complications following surgery. VExUS grading system is a standardized point of care ultrasound (POCUS)-based, comprehensive method to assess volume status. VExUS could serve as a tool to guide fluid management, if validated perioperatively. The primary aim was to assess the success rate of obtaining required windows for VExUS grading , as well as the feasibility within a perioperative setting among noncardiac surgery. Further, this study describes the incidence of perioperative venous congestion and associations with 30-day postoperative complications. Methods: This observational study was conducted in non-critically ill adults undergoing noncardiac surgery. Patients were scanned preoperatively, in the post anesthesia care unit (PACU), and 24 hours postoperatively for venous congestion. Researchers retrospectively captured 30-day complications for multivariate analyses. Results: The cohort included 69 participants. Ninety-one percent of scans over all timepoints were successfully completed. Pre-operatively, 57 (83%) scans were Grade 0, and 11 (16%) were Grade 1. Venous congestion was observed in 29 (44%) patients in the PACU (n=66). 22 (33%) patients were Grade 1, while 7 (11%) were Grade 2. At 24 hours (n=63), 31 patients (49%) had venous congestion: 20 (32%) Grade 1 and 11 (17%) Grade 2. Of the pre-operative Grade 0, 28 (50%) had at least one postoperative scan with venous congestion. No patients were Grade 3 at any timepoint. The 30-day complication rate was 32% (n=22). Eleven (16%) patients developed acute kidney injury (AKI). There was no statistically significant association between VExUS grading and all-cause complications or AKI. Conclusion: This study demonstrates that perioperative VExUS scoring is a feasible tool among a variety of noncardiac surgeries. We highlight that venous congestion is common and increases postoperatively within non-ICU populations. Larger studies are needed to assess the relationship between VExUS grading and postoperative complications.

Abdominal ultrasound and VExUS score in critical care

The use of ultrasound while caring for critically ill patients has been increasing exponentially in the last two decades and now is an essential component of intensive care practice. Abdominal ultrasound is an established technique in other specialties, but its use in intensive care has lagged behind other ultrasound modalities. However, its potential role in the diagnosis and management of patients will make it an invaluable tool for intensivists. The main use of abdominal ultrasound at the bedside is for free fluid detection in trauma patients. But abdominal ultrasound can also help us diagnose patients with abdominal pain, hypovolemia or anuria, and it can guide us during procedures such as paracentesis or bladder catheter and gastric tube placement.

The Role of Focused 2-Dimensional Echocardiography in Managing Left Ventricular Outflow Tract Obstruction Mimicking Cardiogenic Shock

Left ventricular outflow tract obstruction (LVOTO) is a common cardiogenic shock (CS) mimic. We present 3 cases of patients presenting with CS following myocardial infarction, exhibiting a poor response to conventional treatment with inotropy and mechanical circulatory support. This triggered echocardiographic assessment by critical care physicians using focused 2-dimensional (2D) echocardiography. This timely assessment identified anterior mitral valve leaflet entrainment into the left ventricular outflow tract (LVOT), causing LVOTO as the underlying shock mechanism. Echocardiographic findings have led to significant changes in management. The patients underwent fluid administration, weaning from inotropy, and mechanical circulatory support explantation, leading to relief of LVOTO and improved hemodynamics. Critical care basic 2D echocardiography accreditations focus on myocardial function and pericardial effusions. Relevant societies administering these accreditations should consider adding LVOT assessment to enable timely diagnosis of this life-threatening CS mimic.

Echocardiographic hemodynamic assessment in decompensated cirrhosis: comparison between Intensivists and Gastroenterologists

BACKGROUND & AIMS

Ascites is a frequent complication of cirrhosis. In intensive care units, initial hemodynamic assessment is frequently performed by echocardiography. This study evaluated the feasibility and usefulness of early hemodynamic assessment in the gastroenterology ward.

METHODS

This observational cohort study prospectively included all patients admitted to a teaching hospital's gastroenterology unit for decompensated cirrhosis. A gastroenterologist with minimal training and an intensivist both performed an echocardiography exam. The primary outcome was inter-rater agreement and reliability for three echocardiography parameters: visual LVEF (Left Ventricular Ejection Fraction), subaortic VTI (velocity time integral) and E wave velocity. Secondary outcomes were agreement for presence of pleural effusion, description of 3 hemodynamics profiles (hypovolemic, hyperkinetic and intermediate), and 28-day mortality.

RESULTS

From March 2018 to March 2020, 53 patients were included. The median age was 62 years and 81% were men. Patients presented mostly advanced liver disease, with 43% Child-Pugh C and median MELD score of 15.2. The limits of agreement between intensivists and gastroenterologists for subaortic VTI were - 6.6 to 7.2 cm, and ranged from - 0.6 to 0.37 m.s-1 for E wave velocity. Clinically significant differences between intensivists and gastroenterologists were found in 22% for subaortic VTI and 24.5% for E wave velocity. Reliability was good for subaortic VTI (ICC: 0.79, 95% CI [0.58; 0.9;]) and moderate for E wave velocity (0.53, 95% CI [0.19; 0.74]). The three hemodynamics profiles had different prognosis, with a 28-day mortality for Hypovolemic, Intermediate and Hyperkinetic group of 31, 18, and 4%, respectively.

CONCLUSION

Reliability of hemodynamic assessment by gastroenterologists was good, while agreement was unsatisfactory, advocating for further training. Transthoracic echocardiography can differentiate hypovolemia from hyperkinetic states. The role of transthoracic echocardiography in managing decompensated cirrhosis requires further study.

CLINICAL TRIAL NUMBER

NCT03650660.

Role of ultrasound in acute respiratory failure and in the weaning of mechanical ventilation

Comprehensive ultrasound assessment has become an essential tool to facilitate the diagnosis and therapeutic management of critically ill patients with acute respiratory failure (ARF). There is evidence supporting the use of ultrasound for the diagnosis of pneumothorax, acute respiratory distress syndrome, cardiogenic pulmonary edema, pneumonia and acute pulmonary thromboembolism, and in patients with COVID-19. In addition, in recent years, the use of ultrasound to evaluate responses to treatment in critically ill patients with ARF has been developed, providing a noninvasive tool for titrating positive end-expiratory pressure, monitoring recruitment maneuvers and response to prone position, as well as for facilitating weaning from mechanical ventilation. The objective of this review is to summarize the basic concepts on the utility of ultrasound in the diagnosis and monitoring of critically ill patients with ARF.

Ultrasound simulation training to meet the 2021 Royal College of Radiologists' curriculum for radiology trainees: South East London experience

AIM

To enhance ultrasound teaching delivery to radiology trainees using a simulation course matched to the 2021 Royal College of Radiologists (RCR) curriculum.

MATERIAL AND METHODS

An ultrasound simulation training course was designed for specialty trainees (ST) 1 in radiology, which was based on the 2021 RCR curriculum and covered the top ultrasound training priorities. The course was piloted initially on two occasions in a 1-day format to the August 2021 and the March 2022 ST1 intake trainees. Based on the feedback, a comprehensive 4-day course was developed and delivered between October and December 2022 for the August 2022 ST1 intake, funded by Health Education England. The outcomes measured were subjective trainee feedback using numerical scores and free text.

RESULTS

All King's College Hospital NHS Foundation Trust radiology ST1 trainees from the August 2021 to the August 2022 intake participated in ultrasound simulation training. The training matched the RCR curriculum and increased the trainees' confidence and competency in medical ultrasound.

CONCLUSIONS

Ultrasound simulation training can be successfully delivered to ST1 trainees to match the 2021 RCR curriculum and enhance training in medical ultrasound for radiologists.

A study protocol for investigating the sonographic characteristics of neonates with critical illness: an observational cohort study

BACKGROUND

Haemodynamic instability and hypoxaemia are common and serious threats to the survival of neonates. A growing body of literature indicates that critical care ultrasound has become the optimal evaluation tool for sick neonates. However, few studies have described sonographic characteristics of haemodynamics systematically in the neonates with critical illness. This protocol describes a prospective observational cohort study aimed at (1) characterising the sonographic characteristics of the neonates with critical diseases; and (2) assessing the mortality, significant morbidity, utility of vasoactive medications, fluid resuscitation, duration of ventilation, etc. METHODS AND ANALYSIS: This is a single-centre, prospective and observational study conducted in Chengdu Women's and Children's Central Hospital from 1 December 2022 to 31 December 2027. Neonates admitted to the neonatal intensive care unit will be recruited. After inclusion, the neonates will undergo the neonatal critical care ultrasound. The data collected via case report forms include clinical variables and sonographic measures. The primary outcome is to identify the sonographic characteristics of sick neonates with different diseases, and the secondary outcome is to describe the mortality, significant morbidity, utility of vasoactive medications, fluid resuscitation and duration of ventilation.

DISCUSSION

Our study provided an organised neonatal critical care ultrasound workflow, which can be applied in practice. Accordingly, this study will first set up large data on the sonographic description of the neonates with critical illness, which can help to understand the pathophysiology of the critical illness, potentially titrating the treatment.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry (ChiCTR2200065581; https://www.chictr.org.cn/com/25/showproj.aspx?proj=184095).

Diagnostic accuracy of point-of-care ultrasound for shock: a systematic review and meta-analysis

BACKGROUND

 Circulatory failure is classified into four types of shock (obstructive, cardiogenic, distributive, and hypovolemic) that must be distinguished as each requires a different treatment. Point-of-care ultrasound (POCUS) is widely used in clinical practice for acute conditions, and several diagnostic protocols using POCUS for shock have been developed. This study aimed to evaluate the diagnostic accuracy of POCUS in identifying the etiology of shock.

METHODS

We conducted a systematic literature search of MEDLINE, Cochrane Central Register of Controlled Trials, Embase, Web of Science, Clinicaltrial.gov, European Union Clinical Trials Register, WHO International Clinical Trials Registry Platform, and University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR) until June 15, 2022. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and assessed study quality using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Meta-analysis was conducted to pool the diagnostic accuracy of POCUS for each type of shock. The study protocol was prospectively registered in UMIN-CTR (UMIN 000048025).

RESULTS

Of the 1553 studies identified, 36 studies were full-text reviewed, and 12 studies with 1132 patients were included in the meta-analysis. Pooled sensitivity and specificity were 0.82 [95% confidence interval (CI) 0.68-0.91] and 0.98 [95% CI 0.92-0.99] for obstructive shock, 0.78 [95% CI 0.56-0.91] and 0.96 [95% CI 0.92-0.98] for cardiogenic shock, 0.90 [95% CI 0.84-0.94] and 0.92 [95% CI 0.88-0.95] for hypovolemic shock, and 0.79 [95% CI 0.71-0.85] and 0.96 [95% CI 0.91-0.98] for distributive shock, respectively. The area under the receiver operating characteristic curve for each type of shock was approximately 0.95. The positive likelihood ratios for each type of shock were all greater than 10, especially 40 [95% CI 11-105] for obstructive shock. The negative likelihood ratio for each type of shock was approximately 0.2.

CONCLUSIONS

 The identification of the etiology for each type of shock using POCUS was characterized by high sensitivity and positive likelihood ratios, especially for obstructive shock.

Lung Ultrasound in Critical Care and Emergency Medicine: Clinical Review

Lung ultrasound has become a part of the daily examination of physicians working in intensive, sub-intensive, and general medical wards. The easy access to hand-held ultrasound machines in wards where they were not available in the past facilitated the widespread use of ultrasound, both for clinical examination and as a guide to procedures; among point-of-care ultrasound techniques, the lung ultrasound saw the greatest spread in the last decade. The COVID-19 pandemic has given a boost to the use of ultrasound since it allows to obtain a wide range of clinical information with a bedside, not harmful, repeatable examination that is reliable. This led to the remarkable growth of publications on lung ultrasounds. The first part of this narrative review aims to discuss basic aspects of lung ultrasounds, from the machine setting, probe choice, and standard examination to signs and semiotics for qualitative and quantitative lung ultrasound interpretation. The second part focuses on how to use lung ultrasound to answer specific clinical questions in critical care units and in emergency departments.

Establishing proof of concept for sonolucent cranioplasty and point of care ultrasound imaging after posterior fossa decompression for Chiari malformation

BACKGROUND

Evaluation after posterior fossa decompression for Chiari malformation can require repeated imaging, particularly with persistent symptoms. Typically, CT or MRI is used. However, CT carries radiation risk and MRI is costly. Ultrasound is an inexpensive, radiation-free, point-of-care modality that has, thus far, been limited by intact skull and traditional cranioplasty materials. Ultrasound also allows for imaging in different head positions and body postures, which may lend insight into cause for persistent symptoms despite adequate decompression on traditional neutral static CT or MRI. We evaluate safety and feasibility of ultrasound as a post-operative imaging modality in patients reconstructed with sonolucent cranioplasty during posterior fossa decompression for Chiari malformation.

METHODS

Outcomes were analyzed for 26 consecutive patients treated with a Chiari-specific sonolucent cranioplasty. This included infection, need for revision, CSF leak, and pseudomeningocele. Ultrasound was performed point-of-care in the outpatient clinic by the neurosurgery team to assess feasibility.

RESULTS

In eight months mean follow up, there were no surgical site infections or revisions with this novel sonolucent cranioplasty. Posterior fossa anatomy was discernable via transcutaneous ultrasound obtained point-of-care in the clinic setting at follow up visits.

CONCLUSION

We demonstrate proof of concept for ultrasound as a post-operative imaging modality after posterior fossa decompression for Chiari malformation. With further investigation, ultrasound may prove to serve as an alternative to CT and MRI in this patient population, or as an adjunct to provide positional and dynamic information. Use of sonolucent cranioplasty is safe. This technique deserves further study.

Neuromuscular Ultrasound in Intensive Care Unit-Acquired Weakness: Current State and Future Directions

Intensive care unit-acquired weakness (ICUAW) is one of the most common causes of muscle atrophy and functional disability in critically ill intensive care patients. Clinical examination, manual muscle strength testing and monitoring are frequently hampered by sedation, delirium and cognitive impairment. Many different attempts have been made to evaluate alternative compliance-independent methods, such as muscle biopsies, nerve conduction studies, electromyography and serum biomarkers. However, they are invasive, time-consuming and often require special expertise to perform, making them vastly impractical for daily intensive care medicine. Ultrasound is a broadly accepted, non-invasive, bedside-accessible diagnostic tool and well established in various clinical applications. Hereby, neuromuscular ultrasound (NMUS), in particular, has been proven to be of significant diagnostic value in many different neuromuscular diseases. In ICUAW, NMUS has been shown to detect and monitor alterations of muscles and nerves, and might help to predict patient outcome. This narrative review is focused on the recent scientific literature investigating NMUS in ICUAW and highlights the current state and future opportunities of this promising diagnostic tool.

Thoracic UltrasONOgraphy Reporting: The TUONO Consensus

The widespread use of the lung ultrasound (LUS) has not been followed by the development of a comprehensive standardized tool for its reporting in the intensive care unit (ICU) which could be useful to promote consistency and reproducibility during clinical examination. This work aims to define the essential features to be included in a standardized reporting tool and provides a structured model form to fully express the diagnostic potential of LUS and facilitate intensivists in the use of a LUS in everyday clinical ICU examination. We conducted a modified Delphi process to build consensus on the items to be integrated in a standardized report form and on its structure. A committee of 19 critical care physicians from 19 participating ICUs in Italy was formed, including intensivists experienced in ultrasound from both teaching hospitals and referral hospitals, and internationally renowned experts on the LUS. The consensus for 31 statements out of 33 was reached at the third Delphi round. A structured model form was developed based on the approved statements. The development of a standardized model as a backbone to report a LUS may facilitate the guidelines' application in clinical practice and increase inter-operator agreement. Further studies are needed to evaluate the effects of standardized reports in critically ill patients.

Transpulmonary thermodilution

PURPOSE OF REVIEW

The purpose of this article is to systematically review and critically assess the existing data regarding the use of transpulmonary thermodilution (TPTD), by providing a detailed description of technical aspects of TPTD techniques, appraising the use of TPTD-derived parameters in specific clinical settings, and exploring the limits of this technique.

RECENT FINDINGS

The aim of hemodynamic monitoring is to optimize cardiac output (CO) and therefore improve oxygen delivery to the tissues. Hemodynamic monitoring plays a fundamental role in the management of acutely ill patients. TPTD is a reliable, multiparametric, advanced cardiopulmonary monitoring technique providing not only hemodynamic parameters related to cardiac function, but also to the redistribution of the extravascular water in the thorax. The hemodynamic monitors available in the market usually couple the intermittent measurement of the CO by TPTD with the arterial pulse contour analysis, offering automatic calibration of continuous CO and an accurate assessment of cardiac preload and fluid responsiveness.

SUMMARY

The TPTD is an invasive but well tolerated, multiparametric, advanced cardiopulmonary monitoring technique, allowing a comprehensive assessment of cardiopulmonary condition. Beyond the CO estimation, TPTD provides several indices that help answering questions that clinicians ask themselves during hemodynamic management. TPTD-guided algorithm obtained by pulse contour analysis may be useful to optimize fluid resuscitation by titrating fluid therapy according to functional hemodynamic monitoring and to define safety criteria to avoid fluid overload by following the changes in the extravascular lung water (EVLW) and pulmonary vascular permeability index (PVPI).

Neuromonitoring in Critically Ill Patients

OBJECTIVES

Critically ill patients are at high risk of acute brain injury. Bedside multimodality neuromonitoring techniques can provide a direct assessment of physiologic interactions between systemic derangements and intracranial processes and offer the potential for early detection of neurologic deterioration before clinically manifest signs occur. Neuromonitoring provides measurable parameters of new or evolving brain injury that can be used as a target for investigating various therapeutic interventions, monitoring treatment responses, and testing clinical paradigms that could reduce secondary brain injury and improve clinical outcomes. Further investigations may also reveal neuromonitoring markers that can assist in neuroprognostication. We provide an up-to-date summary of clinical applications, risks, benefits, and challenges of various invasive and noninvasive neuromonitoring modalities.

DATA SOURCES

English articles were retrieved using pertinent search terms related to invasive and noninvasive neuromonitoring techniques in PubMed and CINAHL.

STUDY SELECTION

Original research, review articles, commentaries, and guidelines.

DATA EXTRACTION

Syntheses of data retrieved from relevant publications are summarized into a narrative review.

DATA SYNTHESIS

A cascade of cerebral and systemic pathophysiological processes can compound neuronal damage in critically ill patients. Numerous neuromonitoring modalities and their clinical applications have been investigated in critically ill patients that monitor a range of neurologic physiologic processes, including clinical neurologic assessments, electrophysiology tests, cerebral blood flow, substrate delivery, substrate utilization, and cellular metabolism. Most studies in neuromonitoring have focused on traumatic brain injury, with a paucity of data on other clinical types of acute brain injury. We provide a concise summary of the most commonly used invasive and noninvasive neuromonitoring techniques, their associated risks, their bedside clinical application, and the implications of common findings to guide evaluation and management of critically ill patients.

CONCLUSIONS

Neuromonitoring techniques provide an essential tool to facilitate early detection and treatment of acute brain injury in critical care. Awareness of the nuances of their use and clinical applications can empower the intensive care team with tools to potentially reduce the burden of neurologic morbidity in critically ill patients.

Current status of point of care ultrasonography for the perioperative care of trauma patients

PURPOSE OF REVIEW

The incorporation of point of care ultrasound into the field of anesthesiology and perioperative medicine is growing at rapid pace. The benefits of this modality align with the acuity of patient care and decision-making in anesthetic care of a trauma patient.

RECENT FINDINGS

Cardiac ultrasound can be used to diagnose cardiac tamponade or investigate the inferior vena cava to assess volume status in patients who may suffer from hemorrhagic shock. Thoracic ultrasound may be used to rapidly identify pneumothorax or hemothorax in a patient suffering chest wall trauma. In addition, investigators are exploring the utility of ultrasonography in traumatic airway management and elevated intracranial pressure. In addition, the utility of gastric ultrasound on trauma patients is briefly discussed.

SUMMARY

Incorporation of point of care ultrasound techniques into the practice of trauma anesthesiology is important for noninvasive, mobile and expeditious assessment of trauma patients. In addition, further large-scale studies are needed to investigate how point of care ultrasound impacts outcomes in trauma patients.

Ten Influential Point-of-Care Ultrasound Papers: 2022 in Review

Keeping up with the latest developments in the point-of-care ultrasound (POCUS) literature is challenging, as with any area of medicine. Our group of POCUS experts has selected 10 influential papers from the past 12 months and provided a short summary of each. We hope to provide emergency physicians, intensivists, and other acute care providers with a succinct update concerning some key areas of ultrasound interest.

The Impact of Thoracic Ultrasound on Clinical Management of Critically Ill Patients (UltraMan): An International Prospective Observational Study

OBJECTIVES

To investigate the impact of thoracic ultrasound (TUS) examinations on clinical management in adult ICU patients.

DESIGN

A prospective international observational study.

SETTING

Four centers in The Netherlands and Italy.

PATIENTS

Adult ICU patients (> 18 yr) that received a clinically indicated lung ultrasound examination.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Clinicians performing TUS completed a pre- and post-examination case report form. Patient characteristics, TUS, and resulting clinical effects were recorded. First, change of management, defined as a TUS-induced change in clinical impression leading to a change in treatment plan, was reported. Second, execution of intended management changes within 8 hours was verified. Third, change in fluid balance after 8 hours was calculated. A total of 725 TUS performed by 111 operators across 534 patients (mean age 63 ± 15.0, 70% male) were included. Almost half of TUS caused a change in clinical impression, which resulted in change of management in 39% of cases. The remainder of TUS confirmed the clinical impression, while a minority (4%) did not contribute. Eighty-nine percent of management changes indicated by TUS were executed within 8 hours. TUS examinations that led to a change in fluid management also led to distinct and appropriate changes in patient's fluid balance.

CONCLUSIONS

In this international observational study in adult ICU patients, use of TUS had a major impact on clinical management. These results provide grounds for future randomized controlled trials to determine if TUS-induced changes in decision-making also lead to improved health outcomes.

First Experience With Postoperative Transcranial Ultrasound Through Sonolucent Burr Hole Covers in Adult Hydrocephalus Patients

BACKGROUND

Managing patients with hydrocephalus and cerebrospinal fluid (CSF) disorders requires repeated head imaging. In adults, it is typically computed tomography (CT) or less commonly magnetic resonance imaging (MRI). However, CT poses cumulative radiation risks and MRI is costly. Ultrasound is a radiation-free, relatively inexpensive, and optionally point-of-care alternative, but is prohibited by very limited windows through an intact skull.

OBJECTIVE

To describe our initial experience with transcutaneous transcranial ultrasound through sonolucent burr hole covers in postoperative hydrocephalus and CSF disorder patients.

METHODS

Using cohort study design, infection and revision rates were compared between patients who underwent sonolucent burr hole cover placement during new ventriculoperitoneal shunt placement and endoscopic third ventriculostomy over the 1-year study time period and controls from the period 1 year before. Postoperatively, trans-burr hole ultrasound was performed in the clinic, at bedside inpatient, and in the radiology suite to assess ventricular anatomy.

RESULTS

Thirty-seven patients with sonolucent burr hole cover were compared with 57 historical control patients. There was no statistically significant difference in infection rates between the sonolucent burr hole cover group (1/37, 2.7%) and the control group (0/57, P = .394). Revision rates were 13.5% vs 15.8% (P = 1.000), but no revisions were related to the burr hole or cranial hardware.

CONCLUSION

Trans-burr hole ultrasound is feasible for gross evaluation of ventricular caliber postoperatively in patients with sonolucent burr hole covers. There was no increase in infection rate or revision rate. This imaging technique may serve as an alternative to CT and MRI in the management of select patients with hydrocephalus and CSF disorders.

Time to FOCUS - 'Palliative Medicine Point-of-Care Ultrasound'

Point-of-care diagnosis has become the need of the hour and along with its guided interventions, ultrasound could be utilised bedside in a palliative care patient. Point-of-care ultrasound (POCUS) in palliative care medicine is fast emerging and has varied applications ranging from performing bedside diagnostic evaluation to the performance of interventional paracentesis, thoracocentesis and chronic pain interventions. Handheld ultrasound devices have transformed the application of POCUS and should revolutionise the future of home-based palliative care. Palliative care physicians should be enabled to carry out bedside ultrasounds at home care and hospice setting for achieving rapid symptom relief. The aim of POCUS in palliative care medicine should be adequate training of palliative care physicians, transforming the applicability of this technology to OPD as well as community driven to achieve home outreach. The goal is towards empowering technology by reaching out to the community rather than the terminally ill patient transported for the hospital admission. Palliative care physicians should receive mandatory training in POCUS to enable diagnostic proficiency and early triaging. The inclusion of ultrasound machine in an outpatient palliative care clinic brings about value addition in rapid diagnosis. Limiting POCUS application to certain selected sub-specialities such as emergency medicine, internal medicine and critical care medicine should be overcome. This would need acquiring higher training as well as improvised skill sets to perform bedside interventions. Ultrasonography competency among palliative care providers proposed as palliative medicine point-of-care ultrasound (PM-POCUS) could be achieved by imparting dedicated POCUS training within the core curriculum.

Critical care echocardiography: barriers, competencies and solutions. A survey of over 600 participants

INTRODUCTION

Critical care echocardiography (CCE) is at the core of point-of-care ultrasound (POCUS), and although a list of the necessary competencies has been created, most European countries do not have established training programmes to allow intensivists to gain such competencies. To address barriers to the implementation of CCE, we conducted an online European survey, and analysed the current barriers to this with the aim of providing novel, modern solutions to them including environmental considerations.

MATERIAL AND METHODS

A 23-item survey was distributed via email with support from the European Society of Intensive Care Medicine, national societies, and social media. Questions focused on bedside CCE prevalence, competencies, and barriers to its implementation. An additional questionnaire was sent to recognised experts in the field of CCE.

RESULTS

A total of 644 responses were recorded. Most respondents were anaesthesia and intensive care physicians [79% ( n = 468)], and younger, with 56% in their first five years after specialization ( n = 358). Most respondents [92% ( n = 594)] had access to an ultrasound machine with a cardiac probe, and 97% ( n = 623) reported being able to acquire basic CCE windows. The most common barriers identified by respondents to the implementation of CCE in practice were a lack of sufficient experience/skill [64% ( n = 343)], absence of formal qualifications [46% ( n = 246)] and lack of a mentor [45% ( n = 243)]. Twenty-eight experts responded and identified a lack of allocated time for teaching as a main barrier [60% ( n = 17)].

CONCLUSIONS

We found that bedside CCE is perceived as a crucial skill for intensive care medicine, especially by younger physicians; however, there remain several obstacles to training and implementation. The most important impediments reported by respondents were inadequate training, absence of formal qualifications and difficulties in finding a suitable mentor.

Echocardiography and Ultrasound Committee statement for the accreditation programme in point-of-care ultrasonography in Poland

Ultrasonography is becoming an essential part of the management of critically ill patients. There has been a sufficient body of evidence to support the incorporation of point-of-care ultrasound (POCUS) in anaesthesia and intensive care medicine training programme. Recently the European Society of Intensive Care Medicine reco-gnized POCUS as an essential skill for European Intensive Care Medicine specialists and updated Competency Based Training in Intensive Care (CoBaTrICe). Following European training standards, the Ultrasound and Echocardiography Committee of the Polish Society of Anaesthesiology and Intensive Therapy issued this Position Statement for recommendations for the accreditation process in POCUS in Poland.

Point‑of‑Care Ultrasound - accuracy, education

A review article discussing the reliability of Point-of-Care ultrasound and education in this method in various fields of medicine.

POCUS, how can we include the brain? An overview

Point-of-care ultrasound (POCUS) is an essential tool to assess and manage different pathologies in the intensive care unit, and many protocols have been proposed for its application in critical care literature. However, the brain has been overlooked in these protocols.

Brain ultrasonography (BU) is easily available, and it allows a goal-directed approach thanks to its repeatability and immediate interpretation and provides a quick management and real time assessment of patients’ conditions. Based on recent studies, the increasing interest from intensivists, and the undeniable benefits of ultrasound, the main goal of this overview is to describe the main evidence and progresses in the incorporation of BU into the POCUS approach in the daily practice, and thus becoming POCUS-BU. This integration would allow a noninvasive global assessment to entail an integrated analysis of the critical care patients.

Ultrasonography Comparison of Diaphragm Morphological Structure and Function in Young and Middle-Aged Subjects with and without Non-Specific Chronic Low Back Pain: A Case-Control Study

Background

It is reported that impaired postural control in patients with non-specific chronic low back pain (NCLBP) was associated with "core" trunk muscle incoordination. However, as the diaphragm is an important component of the "core" deep trunk muscle group, we still know little about the potential relationship between diaphragm dysfunction and NCLBP.

Objectives

This case-control study is intended to investigate the changes of diaphragm morphological structure and function in young and middle-aged subjects with and without NCLBP by ultrasound evaluation and its possible validity in predicating the occurrence of NCLBP.

Methods

31 subjects with NCLBP (NCLBP group) and 32 matched healthy controls (HC group) were enrolled in this study. The diaphragm thickness at the end of inspiration (T ^ins) or expiration (T ^exp) during deep breathing was measured through B-mode ultrasound, and the diaphragm excursion (T ^exc) was estimated at deep breathing through M-mode ultrasound. The diaphragm thickness change rate (T ^rate) was calculated by the formula: T ^rate=(T ^ins - T ^exp)/T ^exp × 100%.

Results

Compared with the HC group, the NCLBP group had a significant smaller degree of T^ins (t = -3.90, P < 0.001), T ^exp (Z = -2.79, P=0.005), and T ^rate (t = -2.03, P=0.047). However, there was no statistical difference in T ^exc between the two groups (t = -1.42, P=0.161). The binary logistic regression analysis indicated that T ^rate (OR = 16.038, P=0.014) and T ^exp (OR = 7.714, P=0.004) were potential risk factors for the occurrence of NCLBP.

Conclusions

The diaphragm morphological structure and function were changed in young and middle-aged subjects with NCLBP, while the diaphragm thickness change rate (T ^rate) and diaphragm thickness at the end of expiration (T ^exp) may be conductive to the occurrence of NCLBP. Furthermore, these findings may suggest that abnormal diaphragm reeducation is necessary for the rehabilitation of patients with NCLBP.

Lung ultrasound response to awake prone positioning predicts the need for intubation in patients with COVID-19 induced acute hypoxemic respiratory failure: an observational study

Background

Awake prone positioning (APP) reduces the intubation rate in COVID-19 patients treated by high-flow nasal cannula (HFNC). However, the lung aeration response to APP has not been addressed. We aimed to explore the lung aeration response to APP by lung ultrasound (LUS).

Methods

This two-center, prospective, observational study enrolled patients with COVID-19-induced acute hypoxemic respiratory failure treated by HFNC and APP. LUS score was recorded 5–10 min before, 1 h after APP, and 5–10 min after supine in the first APP session within the first three days. The primary outcome was LUS score changes in the first three days. Secondary outcomes included changes in SpO₂/FiO₂ ratio, respiratory rate and ROX index (SpO₂/FiO₂/respiratory rate) related to APP, and the rate of treatment success (patients who avoided intubation).

Results

Seventy-one patients were enrolled. LUS score decreased from 20 (interquartile range [IQR] 19–24) to 19 (18–21) (p < 0.001) after the first APP session, and to 19 (18–21) (p < 0.001) after three days. Compared to patients with treatment failure (n = 20, 28%), LUS score reduction after the first three days in patients with treatment success (n = 51) was greater (− 2.6 [95% confidence intervals − 3.1 to − 2.0] vs 0 [− 1.2 to 1.2], p = 0.001). A decrease in dorsal LUS score > 1 after the first APP session was associated with decreased risk for intubation (Relative risk 0.25 [0.09–0.69]). APP daily duration was correlated with LUS score reduction in patients with treatment success, especially in dorsal lung zones (r =  − 0.76; p < 0.001).

Conclusions

In patients with acute hypoxemic respiratory failure due to COVID-19 and treated by HFNC, APP reduced LUS score. The reduction in dorsal LUS scores after APP was associated with treatment success. The longer duration on APP was correlated with greater lung aeration.

Trial registration This study was prospectively registered on clinicaltrials.gov on April 22, 2021. Identification number NCT04855162.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04064-3.

A cross-sectional survey on the lung ultrasound training and practice of respiratory therapists in mainland China

Purpose

This national study aimed to investigate the lung ultrasound (LUS) training and practice of respiratory therapists (RTs) in mainland China.

Methods

A cross-sectional multicenter survey was conducted from May 22, 2021 to August 12, 2021, through online platforms. This survey included RTs in mainland China. The survey was divided into four sections: (1) demographic characteristics and basic information; (2) basic information about LUS training and practice; (3) LUS practice details; and (4) Other ultrasound training and practice.

Results

A total of 514 responses were received, and 494 valid responses were included in the analysis. 81.2% (401/494) participants’ highest degree of education was a bachelor’s degree, and 43.1% (213/494) participants were at level II in terms of job ranking. 99.2%(490/494) participants agreed that the RTs needed to learn lung ultrasound, but only 12.3% (61/494) participants had received a LUS training course. Further, 66.2% (327/494) experienced participants responded to Sect. 3. Most of RTs used LUS when the patient had hypoxia (265/327, 81%) or dyspnea (260/317, 79.5%); they also used it during spontaneous breathing trial(SBT) (191/327, 58.4%) or in prone position (177/327, 54.1%). The A-line (302/327, 92.4%), B-line (299/327, 91.4%), lung slide (263/327, 80.4%), and bat sign (259/327, 79.2%) were well known as LUS signs. Also, 30.6% (100/327) participants did not use the LUS protocol in their clinical practice, and only 25.4%(83/327) participants said they had used LUS scores. Moreover, 55.7% (182/327) participants frequently changed the respiratory therapy strategy according to LUS results.

Conclusions

We should improve the number and workplace of RTs in mainland China in the future. We should also standardize the application of LUS practice and training for RTs in mainland China and establish corresponding certification pathways.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-02213-6.

Pathophysiology of fluid administration in critically ill patients

Fluid administration is a cornerstone of treatment of critically ill patients. The aim of this review is to reappraise the pathophysiology of fluid therapy, considering the mechanisms related to the interplay of flow and pressure variables, the systemic response to the shock syndrome, the effects of different types of fluids administered and the concept of preload dependency responsiveness. In this context, the relationship between preload, stroke volume (SV) and fluid administration is that the volume infused has to be large enough to increase the driving pressure for venous return, and that the resulting increase in end-diastolic volume produces an increase in SV only if both ventricles are operating on the steep part of the curve. As a consequence, fluids should be given as drugs and, accordingly, the dose and the rate of administration impact on the final outcome. Titrating fluid therapy in terms of overall volume infused but also considering the type of fluid used is a key component of fluid resuscitation. A single, reliable, and feasible physiological or biochemical parameter to define the balance between the changes in SV and oxygen delivery (i.e., coupling “macro” and “micro” circulation) is still not available, making the diagnosis of acute circulatory dysfunction primarily clinical.

Fluids are drugs used in patients with shock to increase the cardiac output with the aim to improve oxygen delivery to the cells. The response to fluid administration is determined by the physiological interaction of cardiac function and venous return. In septic shock, the beneficial clinical response of fluid administration is rapidly reduced after few hours and fluid titration is crucial to avoid detrimental fluid overload. The fluid challenge is a fluid bolus given at a defined quantity and rate to assess fluid responsiveness.

The ideal fluid for critically ill patients does not exist; however, crystalloids should be used as first choice. Balanced crystalloid solutions may be associated with better outcomes but the evidence is still low. Albumin infusion may have a role in already fluid resuscitated patients at risk of fluid overload.

Fluid administration is integrated into the complex management of pressure and flow “macro” hemodynamic variables, coupled to the “micro” local tissue flow distribution and regional metabolism. Macro-variables are managed by measuring systemic blood pressure and evaluating the global cardiac function. The critical threshold of oxygen delivery to the cells is difficult to estimate, however, several indexes and clinical signs may be considered as surrogate of that, and integrated in a decision-making process at the bedside.