Ultrasound: The New Stethoscope (Point-of-Care Ultrasound)

Next-generation monitoring in obstetrics: Assessing the accuracy of non-piezo portable ultrasound technology

INTRODUCTION

The emergence of handheld ultrasound devices capable of connecting to cell phones or tablets heralds a significant advancement in medical technology, particularly within the field of obstetrics. These devices offer the promise of immediate bedside ultrasound examinations, potentially revolutionizing patient care by enabling fetal assessments in diverse settings.

MATERIAL AND METHODS

This prospective study aimed to validate the reliability of non-piezo, chip-based handheld ultrasound devices in clinical obstetric practice. Conducted in a university hospital obstetric ward, the study included 100 pregnant women between 17 and 41 weeks of gestation. Participants underwent ultrasound examinations using both conventional and portable point-of-care ultrasound (POCUS) devices to compare the accuracy in estimating fetal weight and other parameters, such as cardiac activity, fetal presentation, placental location, and amniotic fluid volume. The reliability and agreement between the devices were assessed using intraclass correlation coefficients, Bland-Altman plots, and Pearson correlation coefficients.

RESULTS

The results show a near-perfect agreement (0.98) and correlation (r = 0.98, p < 0.001) for estimated fetal weight and most biometry measurements between the two types of ultrasound devices, with slight deviations in head circumference and amniotic fluid index measurements. Subgroup analysis revealed variations in agreement and correlation rates with higher BMI and advanced gestational age, indicating areas for further refinement.

CONCLUSIONS

These findings affirm the high reliability of handheld ultrasound devices for basic obstetric ultrasound evaluations, supporting their integration into daily clinical practice. This technology improves the flexibility and immediacy of prenatal care, although further research is needed to optimize its application across patient populations and treatment settings.

South African medical interns' perspectives on the use of point of care ultrasound

BACKGROUND

 Point of care ultrasound (POCUS) has become such a part of patient care that it is included in undergraduate medical training in many high-income countries. In South Africa, despite the availability of ultrasound units, there is no information on the exposure or training required for medical interns to perform POCUS in their community service year. This study examines interns' self-reported POCUS training and competency, as well as their perceived readiness for their community service year.

METHODS

 In this cross-sectional web-based survey, 43 interns were invited to complete a self-administered questionnaire after completing their 6-month decentralised family medicine rotation in 2022.

RESULTS

 Thirty complete responses (69% response rate) were included for analysis. Eleven graduates from three medical schools reported undergraduate exposure to POCUS. Ten participants completed formal postgraduate ultrasound training. Eight participants felt confident to independently perform POCUS. Thirteen participants felt adequately prepared for their community service year, 10 of whom had received POCUS training. Nearly all the participants (29 of 30) felt that ultrasound training should be incorporated into both undergraduate and internship training.

CONCLUSION

 Medical interns expressed a need for more POCUS training. Most of the studied sample did not feel adequately prepared to perform POCUS independently. The high uptake of additional ultrasound courses highlights the need to include POCUS training. More research is needed to determine the extent and level at which POCUS training should be offered to medical interns in the South African setting.Contribution: This study looks at the perceived need of South African medical interns for formal POCUS training. It highlights a potential gap in training based on the expected clinical requirements of the community service year.

Role of Point-of-Care Diagnostics in Lower- and Middle-Income Countries and Austere Environments

INTRODUCTION

Austere environments include the wilderness and many lower- and middle-income countries, with many of these countries facing unrest and war. The access to advanced diagnostic equipment is often unaffordable, even if available, and the equipment is often liable to break down.

METHODS

A short review paper examining the options available to medical professionals to undertake clinical and point-of-care diagnostic testing in resource-constrained environments that also illustrates the development of mobile advanced diagnostic equipment. The aim is to provide an overview of the spectrum and functionality of these devices beyond clinical acumen.

RESULTS

Details and examples of products covering all aspects of diagnostic testing are provided. Where relevant, reliability and cost implications are discussed.

CONCLUSIONS

The review highlights the need for more cost-effective accessible and utilitarian products and devices that will bring cost-effective health care to many in lower- and middle-income or austere environments.

Point-of-Care Thoracic Ultrasound in Children: New Advances in Pediatric Emergency Setting

Point-of-care thoracic ultrasound at the patient's bedside has increased significantly recently, especially in pediatric settings. Its low cost, rapidity, simplicity, and repeatability make it a practical examination to guide diagnosis and treatment choices, especially in pediatric emergency departments. The fields of application of this innovative imaging method are many and include primarily the study of lungs but also that of the heart, diaphragm, and vessels. This manuscript aims to describe the most important evidence for using thoracic ultrasound in the pediatric emergency setting.

Bow-and-arrow sign on point-of-care ultrasound for diagnosis of pacemaker lead-induced heart perforation: A case report and literature review

BACKGROUND

Pacemaker lead-induced heart perforation is a rare but life-threatening complication of pacemaker implantation, and timely diagnosis remains a challenge for clinicians. Here, we report a case of pacemaker lead-induced cardiac perforation rapidly diagnosed by a “bow-and-arrow” sign on point-of-care ultrasound (POCUS).

CASE SUMMARY

A 74-year-old Chinese woman who had undergone permanent pacemaker implantation 26 d before suddenly developed severe dyspnea, chest pain, and hypotension. The patient had received emergency laparotomy for an incarcerated groin hernia and was transferred to the intensive care unit 6 d before. Computed tomography was not available due to unstable hemodynamic status, so POCUS was performed at the bedside and revealed severe pericardial effusion and cardiac tamponade. Subsequent pericardiocentesis yielded a large volume of bloody pericardial fluid. Further POCUS by an ultrasonographist revealed a unique “bow-and-arrow” sign indicating right ventricular (RV) apex perforation by the pacemaker lead, which facilitated the rapid diagnosis of lead perforation. Given the persistent drainage of pericardial bleeding, urgent off-pump open chest surgery was performed to repair the perforation. However, the patient died of shock and multiple organ dysfunction syndrome within 24 h post-surgery. In addition, we also performed a literature review on the sonographic features of RV apex perforation by lead.

CONCLUSION

POCUS enables the early diagnosis of pacemaker lead perforation at the bedside. A step-wise ultrasonographic approach and the “bow-and-arrow” sign on POCUS are helpful for rapid diagnosis of lead perforation.

Point-of-care ultrasound use in emergencies: what every anaesthetist should know

Point-of-care ultrasound has been embraced by anaesthetists as an invaluable tool for rapid diagnosis of haemodynamic instability, to ensure procedural safety and monitor response to treatments. Increasingly available, affordable and portable, with emerging evidence of improved patient outcomes, point-of-care ultrasound has become a valuable tool in the emergency setting. This state-of-the-art review describes the feasibility of point-of-care ultrasound practice, training and maintenance of competence. It also describes the many uses of point-of-care ultrasound for the anaesthetist and describes the most salient point-of-care ultrasound views for anaesthetic emergencies including: undifferentiated shock; hypoxemia; and trauma. Procedural safety is also discussed in addition to relevant important governance aspects. Cardiac function should be assessed using the parasternal long axis, parasternal short basal/mid-papillary/apical, apical four chamber and subcostal four chamber views, and should include a visual estimation of global left ventricular ejection fraction. Other cardiovascular conditions that can be identified using point-of-care ultrasound include: pericardial effusion; cardiac tamponade; and pulmonary embolism. Pulmonary emergency conditions that can be diagnosed using point-of-care ultrasound include pneumothorax; pleural effusion; and interstitial syndrome. The extended focused assessment with sonography for trauma examination may of value in patients who are hypotensive in order to identify intra-abdominal haemorrhage, pneumothoraces and haemothoraces.

Feasibility of handheld ultrasound to assess heart rate in newborn nursery

BACKGROUND AND OBJECTIVES

Heart rate (HR) assessment is important during neonatal resuscitation. The most reliable ways of assessing HR at birth are pulse oximetry (PO) and/or electrocardiograph (ECG). However, delayed recording time due to poor perfusion or probe and electrode placement has been a concern. Point-of-care ultrasound (POCUS) provides a real-time instant view of the heart. The aim of this study was to look at the feasibility of POCUS in assessing the heart rate of stable, healthy, term neonates.

METHODS

The study was approved by the institutional review board, and informed consent was obtained from the subject's mother. A real-time video image was obtained from the POCUS probe using the app on the smartphone. The principal investigator (PI) counted the heart beats for six seconds using a stopwatch, which was then multiplied by 10 to give the HR per minute. The assistant recorded the simultaneous HR using the PO. The HRs obtained from both methods were recorded and then compared using the Pearson correlation and Bland-Altman plot.

RESULTS

A total of 30 HR observations were made using the POCUS and PO simultaneously. The correlation coefficient (r) was noted to be 0.75 with a p-value of <0.0001 for pairwise correlation. A strong agreement was noted between the two methods using Bland-Altman Plot.

CONCLUSION

We were able to demonstrate the feasibility of using handheld POCUS in assessing the HR of stable NB infants in the newborn nursery. A follow-up study is planned to evaluate its feasibility in the delivery room.

Ultrasonographic Confirmation of Nasogastric Tube Placement in the COVID-19 Era

Background: Nasogastric tube (NGT) placement is a daily routine in the Intensive Care Unit (ICU), and misplacement of the NGT can cause serious complications. In COVID-19 ARDS patients, proning has emerged the need for frequent NGT re-evaluations. The gold standard technique, chest X-ray, is not always feasible. In the present study we report our experience with the use of ultrasonographic confirmation of NGT position. Methods: A prospective study in 276 COVID-19 ARDS patients admitted after intubation in the ICU. Ultrasonographic evaluation was performed using longitudinal or sagittal epigastric views. Examinations were performed during the initial NGT placement and every time the patients returned to the supine position after they had been proned or whenever critical care physicians or nurses considered that reconfirmation was necessary. Results: Ultrasonographic confirmation of correct NGT placement was feasible in 246/276 (89.13%) patients upon ICU admission. In 189/246 (76.8%) the tube could be visualized in the stomach (two parallel lines), in 172/246 (69.9%) the ultrasonographic whoosh test (“flash” due to air instillation through the tube, seen with ultrasonography) was evident, while in 164/246 (66.7%) both tests confirmed correct NGT placement. During ICU stay 590 ultrasonographic NGT evaluations were performed, and in 462 (78.14%) cases correct NGT placement were confirmed. In 392 cases, a chest X-ray was also ordered. The sensitivity of ultrasonographic NGT confirmation in these cases was 98.9%, specificity 57.9%, PPV 96.2%, and NPV 3.8%. The time for the full evaluation was 3.8 ± 3.4 min. Conclusion: Ultrasonographic confirmation of correct NGT placement is feasible in the initial placement, but also whenever needed thereafter, especially in the COVID-19 era, when changes in posture have become a daily practice in ARDS patients.