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Nemani L, Palmer LJ, Nabzdyk CGS. Echocardiography in Sepsis: Can One Snapshot Tell the Whole Story? J Cardiothorac Vasc Anesth 2024; 38:1620-1622. [PMID: 38839490 DOI: 10.1053/j.jvca.2024.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Accepted: 04/14/2024] [Indexed: 06/07/2024]
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2
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Martinet C, Cungi PJ, Morin J. Usefulness of an Ultrasound-guided Prehospital Care for SCUBA Diving Accidents. Mil Med 2024:usae206. [PMID: 38771008 DOI: 10.1093/milmed/usae206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 02/22/2024] [Accepted: 04/30/2024] [Indexed: 05/22/2024] Open
Abstract
The incidence of diving accidents is increasing. Point-of-care ultrasound is the only imaging tool available in the field for the military physician who practices in isolated conditions. While ultrasound is integrated in the pre-hospital evaluation protocols of severe trauma patients, few applications are described for diving accident victims. Through a clinical case, we propose an algorithm of ultrasound triage for diving accidents with pulmonary symptoms. Point-of-care ultrasound makes it possible to avoid a risky transfer, by supporting a diagnosis and the treatment on the spot, to rule out contraindications to recompression, and to detect and monitor the treatment of high-risk complications such as the capillary leak syndrome.
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Affiliation(s)
- Camille Martinet
- Emergency Ward, Hôpital d'Instruction des Armées Laveran, Marseille 13013, France
| | - Pierre-Julien Cungi
- Resuscitation ward, Hôpital d'Instruction des Armées Sainte-Anne, Toulon 83000, France
| | - Jean Morin
- Diving and hyperbaric medicine ward, Hôpital d'Instruction des Armées Sainte-Anne, Toulon 83000, France
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3
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Ablordeppey EA, Zhao A, Ruggeri J, Hassan A, Wallace L, Agarwal M, Stickles SP, Holthaus C, Theodoro D. Does Point-of-Care Ultrasound Affect Fluid Resuscitation Volume in Patients with Septic Shock: A Retrospective Review. Emerg Med Int 2024; 2024:5675066. [PMID: 38742136 PMCID: PMC11090677 DOI: 10.1155/2024/5675066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 03/27/2024] [Accepted: 04/13/2024] [Indexed: 05/16/2024] Open
Abstract
Background Fixed, large volume resuscitation with intravenous fluids (IVFs) in septic shock can cause inadvertent hypervolemia, increased medical interventions, and death when unguided by point-of-care ultrasound (POCUS). The primary study objective was to evaluate whether total IVF volume differs for emergency department (ED) septic shock patients receiving POCUS versus no POCUS. Methods We conducted a retrospective observational cohort study from 7/1/2018 to 8/31/2021 of atraumatic adult ED patients with septic shock. We agreed upon a priori variables and defined septic shock as lactate ≥4 and hypotension (SBP <90 or MAP <65). A sample size of 300 patients would provide 85% power to detect an IVF difference of 500 milliliters between POCUS and non-POCUS cohorts. Data are reported as frequencies, median (IQR), and associations from bivariate logistic models. Results 304 patients met criteria and 26% (78/304) underwent POCUS. Cardiac POCUS demonstrated reduced ejection fraction in 15.4% of patients. Lung ultrasound showed normal findings in 53% of patients. The POCUS vs. non-POCUS cohorts had statistically significant differences for the following variables: higher median lactate (6.7 [IQR 5.2-8.7] vs. 5.6], p = 0.003), lower systolic blood pressure (77.5 [IQR 61-86] vs. 85.0, p < 0.001), more vasopressor use (51% vs. 34%, p = 0.006), and more positive pressure ventilation (38% vs. 24%, p = 0.017). However, there were no statistically significant differences between POCUS and non-POCUS cohorts in total IVF volume ml/kg (33.02 vs. 32.1, p = 0.47), new oxygen requirement (68% vs. 59%, p = 0.16), ED death (3% vs. 4%, p = 0.15), or hospital death (31% vs. 27%, p = 0.48). There were similar distributions of lactate, total fluids, and vasopressors in patients with CHF and severe renal failure. Conclusions Among ED patients with septic shock, POCUS was more likely to be used in sicker patients. Patients who had POCUS were given similar volume of crystalloids although these patients were more critically ill. There were no differences in new oxygen requirement or mortality in the POCUS group compared to the non-POCUS group.
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Affiliation(s)
- Enyo A. Ablordeppey
- Department of Anaesthesiology, Washington University School of Medicine, St. Louis, MO, USA
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Amy Zhao
- Washington University School of Medicine, St. Louis, MO, USA
| | - Jeffery Ruggeri
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Ahmad Hassan
- Washington University School of Medicine, St. Louis, MO, USA
| | - Laura Wallace
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Mansi Agarwal
- Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, USA
| | - Sean P. Stickles
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Christopher Holthaus
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel Theodoro
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
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4
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Ovesen SH, Clausen AH, Kirkegaard H, Løfgren B, Aagaard R, Skaarup SH, Arvig MD, Lorentzen MH, Kristensen AH, Cartuliares MB, Falster C, Tong L, Rabajoli A, Leth R, Desy J, Ma IWY, Weile J. Point-of-Care Lung Ultrasound in Emergency Medicine: A Scoping Review With an Interactive Database. Chest 2024:S0012-3692(24)00290-3. [PMID: 38458431 DOI: 10.1016/j.chest.2024.02.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/29/2024] [Accepted: 02/29/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND This scoping review was conducted to provide an overview of the evidence of point-of-care lung ultrasound (LUS) in emergency medicine. By emphasizing clinical topics, time trends, study designs, and the scope of the primary outcomes, a map is provided for physicians and researchers to guide their future initiatives. RESEARCH QUESTION Which study designs and primary outcomes are reported in published studies of LUS in emergency medicine? STUDY DESIGN AND METHODS We performed a systematic search in the PubMed/MEDLINE, Embase, Web of Science, Scopus, and Cochrane Library databases for LUS studies published prior to May 13, 2023. Study characteristics were synthesized quantitatively. The primary outcomes in all papers were categorized into the hierarchical Fryback and Thornbury levels. RESULTS A total of 4,076 papers were screened and, following selection and handsearching, 406 papers were included. The number of publications doubled from January 2020 to May 2023 (204 to 406 papers). The study designs were primarily observational (n = 375 [92%]), followed by randomized (n = 18 [4%]) and case series (n = 13 [3%]). The primary outcome measure concerned diagnostic accuracy in 319 papers (79%), diagnostic thinking in 32 (8%), therapeutic changes in 4 (1%), and patient outcomes in 14 (3%). No increase in the proportions of randomized controlled trials or the scope of primary outcome measures was observed with time. A freely available interactive database was created to enable readers to search for any given interest (https://public.tableau.com/app/profile/blinded/viz/LUSinEM_240216/INFO). INTERPRETATION Observational diagnostic studies have been produced in abundance, leaving a paucity of research exploring clinical utility. Notably, research exploring whether LUS causes changes to clinical decisions is imperative prior to any further research being made into patient benefits.
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Affiliation(s)
- Stig Holm Ovesen
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Emergency Department, Horsens Regional Hospital, Horsens, Denmark.
| | | | - Hans Kirkegaard
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Bo Løfgren
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Internal Medicine, Randers Regional Hospital, Randers, Denmark
| | - Rasmus Aagaard
- Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark
| | - Søren Helbo Skaarup
- Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | - Michael Dan Arvig
- Department of Emergency Medicine, Slagelse Hospital, Slagelse, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Morten Hjarnø Lorentzen
- Department of Emergency Medicine, Hospital Sønderjylland, Aabenraa, Denmark; Department of Regional Health Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
| | - Anne Heltborg Kristensen
- Department of Emergency Medicine, Hospital Sønderjylland, Aabenraa, Denmark; Department of Regional Health Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
| | - Mariana Bichuette Cartuliares
- Department of Emergency Medicine, Hospital Sønderjylland, Aabenraa, Denmark; Department of Regional Health Research, University of Southern Denmark Faculty of Health Sciences, Odense, Denmark
| | - Casper Falster
- Department of Respiratory Medicine, Odense University Hospital, Odense, Denmark; Odense Respiratory Research Unit (ODIN), Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Liting Tong
- Emergency Department, Nykøbing F. Hospital, Zealand Denmark Region, Denmark
| | - Alessandra Rabajoli
- Division of Emergency Medicine and High Dependency Unit, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Ronja Leth
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Emergency Department, Horsens Regional Hospital, Horsens, Denmark
| | - Janeve Desy
- Division of General Internal Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Office of Undergraduate Medical Education, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Irene W Y Ma
- Division of General Internal Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jesper Weile
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Emergency Department, Horsens Regional Hospital, Horsens, Denmark
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5
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Blank SP, Blank RM. Echocardiography Does not Reduce Mortality in Sepsis: A Re-Evaluation Using the Medical Information Mart for Intensive Care IV Dataset. Crit Care Med 2024; 52:248-257. [PMID: 38240507 DOI: 10.1097/ccm.0000000000006069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
OBJECTIVES Echocardiography is commonly used for hemodynamic assessment in sepsis, but data regarding its association with outcome are conflicting. The aim of this study was to evaluate the association between echocardiography and outcomes in patients with septic shock using the Medical Information Mart for Intensive Care IV database. DESIGN Retrospective cohort study comparing patients who did or did not undergo transthoracic echocardiography within the first 5 days of admission for the primary outcome of 28-day mortality. SETTING Admissions to the Beth Israel Deaconess Medical Center intensive care from 2008 to 2019. PATIENTS Adults 16 years old or older with septic shock requiring vasopressor support within 48 hours of admission. Readmissions and patients admitted to the coronary care unit or cardiovascular intensive care were excluded, as well as patients with ST-elevation myocardial infarction or cardiac arrest. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Echocardiography was performed in 1,515 (27%) of 5,697 eligible admissions. The primary outcome was analyzed using a marginal structural model and rolling entry matching to adjust for baseline and time-varying confounders. Patients who underwent echocardiography showed no significant difference in 28-day mortality (adjusted hazard ratio 1.09; 95% CI, 0.95-1.25; p = 0.24). This was consistent across multiple sensitivity analyses. Secondary outcomes were changes in management instituted within 4 hours of imaging. Treatment changes occurred in 493 patients (33%) compared with 431 matched controls (29%), with the most common intervention being the administration of a fluid bolus. CONCLUSIONS Echocardiography in sepsis was not associated with a reduction in 28-day mortality based on observational data. These findings do not negate the utility of echo in cases of diagnostic uncertainty or inadequate response to initial treatment.
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Affiliation(s)
| | - Ruth M Blank
- Department of Anesthesia, Royal Darwin Hospital, Darwin, NT, Australia
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Kameda T, Ishii H, Oya S, Katabami K, Kodama T, Sera M, Takei H, Taniguchi H, Nakao S, Funakoshi H, Yamaga S, Senoo S, Kimura A. Guidance for clinical practice using emergency and point-of-care ultrasonography. Acute Med Surg 2024; 11:e974. [PMID: 38933992 PMCID: PMC11201855 DOI: 10.1002/ams2.974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/11/2024] [Accepted: 06/03/2024] [Indexed: 06/28/2024] Open
Abstract
Owing to the miniaturization of diagnostic ultrasound scanners and their spread of their bedside use, ultrasonography has been actively utilized in emergency situations. Ultrasonography performed by medical personnel with focused approaches at the bedside for clinical decision-making and improving the quality of invasive procedures is now called point-of-care ultrasonography (POCUS). The concept of POCUS has spread worldwide; however, in Japan, formal clinical guidance concerning POCUS is lacking, except for the application of focused assessment with sonography for trauma (FAST) and ultrasound-guided central venous cannulation. The Committee for the Promotion of POCUS in the Japanese Association for Acute Medicine (JAAM) has often discussed improving the quality of acute care using POCUS, and the "Clinical Guidance for Emergency and Point-of-Care Ultrasonography" was finally established with the endorsement of JAAM. The background, targets for acute care physicians, rationale based on published articles, and integrated application were mentioned in this guidance. The core points include the fundamental principles of ultrasound, airway, chest, cardiac, abdominal, and deep venous ultrasound, ultrasound-guided procedures, and the usage of ultrasound based on symptoms. Additional points, which are currently being considered as potential core points in the future, have also been widely mentioned. This guidance describes the overview and future direction of ultrasonography for acute care physicians and can be utilized for emergency ultrasound education. We hope this guidance will contribute to the effective use of ultrasonography in acute care settings in Japan.
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Affiliation(s)
- Toru Kameda
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Clinical Laboratory MedicineJichi Medical UniversityShimotsukeJapan
| | - Hiromoto Ishii
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency and Critical Care MedicineNippon Medical SchoolTokyoJapan
| | - Seiro Oya
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency MedicineShizuoka Medical CenterShizuokaJapan
| | - Kenichi Katabami
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency and Critical Care CenterHokkaido University HospitalSapporoJapan
| | - Takamitsu Kodama
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency and General Internal MedicineTajimi City HospitalTajimiJapan
| | - Makoto Sera
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency MedicineFukui Prefectural HospitalFukuiJapan
| | - Hirokazu Takei
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency MedicineHyogo Prefectural Kobe Children's HospitalKobeJapan
| | - Hayato Taniguchi
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Advanced Critical Care and Emergency CenterYokohama City University Medical CenterYokohamaJapan
| | - Shunichiro Nakao
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Traumatology and Acute Critical MedicineOsaka University Graduate School of MedicineOsakaJapan
| | - Hiraku Funakoshi
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency and Critical Care MedicineTokyo Bay Urayasu Ichikawa Medical CenterUrayasuJapan
| | - Satoshi Yamaga
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Radiation Disaster Medicine, Research Institute for Radiation Biology and MedicineHiroshima UniversityHiroshimaJapan
| | - Satomi Senoo
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency and Critical Care MedicineSaiseikai Yokohamashi Tobu HospitalYokohamaJapan
| | - Akio Kimura
- Committee for the Promotion of Point‐of‐Care UltrasonographyJapanese Association for Acute MedicineJapan
- Department of Emergency and Critical CareCenter Hospital of the National Center for Global Health and MedicineTokyoJapan
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7
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Kim DJ, Atkinson P, Sheppard G, Chenkin J, Thavanathan R, Lewis D, Bell CR, Jelic T, Lalande E, Buchanan IM, Heslop CL, Burwash-Brennan T, Myslik F, Olszynski P. POCUS literature primer: key papers on POCUS in cardiac arrest and shock. CAN J EMERG MED 2024; 26:15-22. [PMID: 37996693 DOI: 10.1007/s43678-023-00611-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/25/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVE The objective of this study is to identify the top five most influential papers published on the use of point-of-care ultrasound (POCUS) in cardiac arrest and the top five most influential papers on the use of POCUS in shock in adult patients. METHODS An expert panel of 14 members was recruited from the Canadian Association of Emergency Physicians (CAEP) Emergency Ultrasound Committee and the Canadian Ultrasound Fellowship Collaborative. The members of the panel are ultrasound fellowship trained or equivalent, are engaged in POCUS research, and are leaders in POCUS locally and nationally in Canada. A modified Delphi process was used, consisting of three rounds of sequential surveys and discussion to achieve consensus on the top five most influential papers for the use of POCUS in cardiac arrest and shock. RESULTS The panel identified 39 relevant papers on POCUS in cardiac arrest and 42 relevant papers on POCUS in shock. All panel members participated in all three rounds of the modified Delphi process, and we ultimately identified the top five most influential papers on POCUS in cardiac arrest and also on POCUS in shock. Studies include descriptions and analysis of safe POCUS protocols that add value from a diagnostic and prognostic perspective in both populations during resuscitation. CONCLUSION We have developed a reading list of the top five influential papers on the use of POCUS in cardiac arrest and shock to better inform residents, fellows, clinicians, and researchers on integrating and studying POCUS in a more evidence-based manner.
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Affiliation(s)
- Daniel J Kim
- Department of Emergency Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada.
| | - Paul Atkinson
- Department of Emergency Medicine, Dalhousie Medicine New Brunswick, Saint John, NB, Canada
| | - Gillian Sheppard
- Discipline of Emergency Medicine, Memorial University of Newfoundland, St. John's, NF, Canada
| | - Jordan Chenkin
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Rajiv Thavanathan
- Department of Emergency Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - David Lewis
- Department of Emergency Medicine, Dalhousie Medicine New Brunswick, Saint John, NB, Canada
| | - Colin R Bell
- Department of Emergency Medicine, University of Calgary, Calgary, AB, Canada
| | - Tomislav Jelic
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Elizabeth Lalande
- Department of Emergency Medicine, Université Laval, Quebec City, QC, Canada
| | - Ian M Buchanan
- Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Claire L Heslop
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Talia Burwash-Brennan
- Department of Family and Emergency Medicine, Université de Montréal, Montreal, QC, Canada
| | - Frank Myslik
- Division of Emergency Medicine, Department of Medicine, Western University, London, ON, Canada
| | - Paul Olszynski
- Department of Emergency Medicine, University of Saskatchewan, Saskatoon, SK, Canada
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Calderon Martinez E, Diarte E, Othon Martinez D, Rodriguez Reyes L, Aguirre Cano DA, Cantu Navarro C, Ycaza Zurita MG, Arriaga Escamilla D, Choudhari J, Michel G. Point-of-Care Ultrasound for the Diagnosis of Frequent Cardiovascular Diseases: A Review. Cureus 2023; 15:e51032. [PMID: 38264374 PMCID: PMC10805123 DOI: 10.7759/cureus.51032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2023] [Indexed: 01/25/2024] Open
Abstract
Point-of-care ultrasound (POCUS) has emerged as an indispensable diagnostic tool in cardiology, particularly within the emergency department. This narrative synthesis provides a comprehensive exploration of POCUS applications in cardiovascular diseases, elucidating its multifaceted roles and addressing challenges. The review delves into the technical attributes of POCUS, emphasizing its non-invasive nature, radiation-free qualities, and suitability for non-radiologists. It navigates through educational strategies, stressing the importance of structured programs for the seamless integration of POCUS into clinical practice. Highlighting its efficacy, the synthesis discusses POCUS applications in various scenarios such as dyspnea, chest pain, cardiac arrest, aortic dissection, pericardial effusion, and pulmonary embolism. Beyond acute care, the review explores the role of POCUS in outpatient and inpatient settings, focusing on chronic and acute heart failure, valvular heart diseases, and more. Acknowledging operator-dependent challenges and the need for continuous education, the review underscores the transformative potential of POCUS across diverse healthcare settings. This narrative synthesis accentuates POCUS as a valuable and versatile diagnostic tool in cardiology, offering efficiency, safety, and cost-effectiveness. Despite challenges, POCUS stands out as a transformative addition to clinical practices, poised to enhance patient outcomes and reshape the landscape of cardiovascular diagnostics.
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Affiliation(s)
| | - Edna Diarte
- Medicine, Universidad Autónoma de Sinaloa, Culiacán, MEX
| | | | | | | | | | | | | | - Jinal Choudhari
- Research & Academic Affairs, Larkin Community Hospital, South Miami, USA
| | - George Michel
- Internal Medicine, Larkin Community Hospital, South Miami, USA
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Mans PA, Yogeswaran P, Adeniyi OV. Building Consensus on the Point-of-Care Ultrasound Skills Required for Effective Healthcare Service Delivery at District Hospitals in South Africa: A Delphi Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:7126. [PMID: 38063556 PMCID: PMC10705875 DOI: 10.3390/ijerph20237126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/22/2023] [Accepted: 11/23/2023] [Indexed: 12/18/2023]
Abstract
BACKGROUND Despite the widespread availability of ultrasound machines in South African district hospitals, there are no guidelines on the competency in point-of-care ultrasound (POCUS) use required by generalist doctors in this setting. This study aimed to define the required POCUS competencies by means of consensus via the Delphi method. METHODS An online Delphi process was initiated in June 2022, using the existing American Academy of Family Physicians' ultrasound curriculum (84 skillsets) as the starting questionnaire. Panelists were selected across the country, including two from district hospitals in each province and two from each academic family medicine department in South Africa (N = 36). In each iterative round, the participants were asked to identify which POCUS skillsets were essential, optional (region-specific), or non-essential for South African district hospitals. This process continued until consensus (>70% agreement) was achieved on all of the skillsets. RESULTS Consensus was achieved on 81 of the 84 skillsets after 5 iterative rounds (96.4%), with 3 skillsets that could not achieve consensus (defined as <5% change over more than 2 consecutive rounds). The final consensus identified 38 essential, 28 optional, and 15 non-essential POCUS skillsets for the South African district hospital context. CONCLUSIONS The list of essential POCUS skillsets provided by this study highlights the predominance of obstetric- and trauma-based skillsets required for generalist healthcare workers in South African district hospitals. The findings will require priority setting and revalidation prior to their implementation across the country.
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Affiliation(s)
- Pierre-Andre Mans
- Department of Family Medicine, Cecilia Makiwane Hospital, Mdantsane, East London 5201, South Africa;
- Department of Family Medicine and Rural Health, Faculty of Health Sciences, Walter Sisulu University, Mthatha 5117, South Africa;
| | - Parimalaranie Yogeswaran
- Department of Family Medicine and Rural Health, Faculty of Health Sciences, Walter Sisulu University, Mthatha 5117, South Africa;
- Department of Family Medicine, Mthatha Regional Hospital, Mthatha 5100, South Africa
| | - Oladele Vincent Adeniyi
- Department of Family Medicine, Cecilia Makiwane Hospital, Mdantsane, East London 5201, South Africa;
- Department of Family Medicine and Rural Health, Faculty of Health Sciences, Walter Sisulu University, Mthatha 5117, South Africa;
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10
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Ramadan A, Abdallah T, Abdelsalam H, Mokhtar A, Razek AA. Evaluation of parameters used in echocardiography and ultrasound protocol for the diagnosis of shock etiology in emergency setting. BMC Emerg Med 2023; 23:132. [PMID: 37946147 PMCID: PMC10636955 DOI: 10.1186/s12873-023-00902-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/30/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND Early recognition and appropriate treatment has shown to decrease morbidity and mortality in patients with undifferentiated shock. There are many ultrasound protocols in shock; each protocol combines core ultrasound elements such as IVC and cardiac assessment which includes detection of cardiac tamponade, left ventricular function and right ventricular strain.Valvular assessment is absent in majority of ultasound protocols, while lung ultrasound is included in some of them. OBJECTIVE In this study we investigated which parameters used in Echo - US protocol help differentiate shock types. METHODS This cross sectional study was conducted on 150 patients with shock (140 patients were included while, 10 patients were excluded).Sensitivity and specificity of different parameters used in the Echo-US protocol were analyzed to detect which parameters can diffentiate shock types. RESULTS Velocity time integral of Aorta and IVC maximum diameter were good discriminators for distributive shock, with area under the ROC curve (AUC) = 0.8885 (95% CI 0.8144 to 0.9406) and 0.7728 (95% CI 0.6832 to 0.8473) (Z = 10.256 p < 0.0001) and (Z = 5.079 p < 0.0001) respectively. Left ventricular systolic function, presence of pneumonia, pneumothorax or valve vegetations were of great value in differentiating shock types, while CUST, FAST, TAPSE and RV diameter were not useful in differentiating shock types. CONCLUSION Ultrasound and echocardiography are powerful tools that can be used to identify shock etiology when the clinical picture overlaps.
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Affiliation(s)
- Asmaa Ramadan
- Department of Emergency Medicine, Alexandria University, Alexandria, Egypt.
| | - Tamer Abdallah
- Department of Critical Care Medicine, Alexandria University, Alexandria, Egypt
| | | | - Ahmed Mokhtar
- Department of Cardiology and Angiology, Alexandria University, Alexandria, Egypt
| | - Assem Abdel Razek
- Department of Anesthesia and Surgical Intensive Care Unit, Alexandria University, Alexandria, Egypt
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11
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Gupta PB, Lighthall G, Htet N. Use of Point-of-Care Ultrasound by Intensive Care Unit Triage Teams in Evaluating Unstable Patients Outside Intensive Care Units. Cureus 2023; 15:e49114. [PMID: 38125228 PMCID: PMC10732337 DOI: 10.7759/cureus.49114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2023] [Indexed: 12/23/2023] Open
Abstract
Introduction Point-of-care ultrasound (POCUS) has become an integral asset in intensive care units (ICUs). However, there is limited literature on the value of POCUS in evaluating deteriorating patients outside the ICU. In this study, we sought to investigate the use and impact of POCUS by ICU triage teams in hospitals outside of the ICU setting. Methods ICU triage fellows were provided a portable ultrasound to use as part of their evaluations during consultations and hospital code activations. Fellows were asked to fill out a survey on how ultrasound was used and its impact on patient management. Free-text data such as reason for ultrasound use, views obtained, clinical impressions before and after ultrasound, and clinical actions were recorded. These data were transcribed and categorized electronically. Results A total of 51 total resuscitations were documented. The most common reason for ICU triage team evaluation was hypotension (53%, N=27). The most common clinical focus for ultrasound use was cardiac assessment (53%, N=27), followed by volume status assessment (35%, N=18). The most common ultrasound views per encounter obtained were parasternal long (82%, N=42), followed by apical four-chamber view (76%, N=39) and subcostal view (75%, N=38). Out of 38 encounters with clinical impressions documented, 79% (N=30) of pre-ultrasound clinical impressions were confirmed by ultrasound use. Of total encounters, 35% (N=18) had a significant clinical action taken based on ultrasound findings (fluid resuscitation, vasopressor initiation, etc.). Conclusions Ultrasound is a valuable tool for patient evaluation in non-ICU wards, especially in confirming clinical impressions and guiding therapeutic actions. Some limitations of this study include reporting bias and incomplete capture of ultrasound use in non-ICU wards.
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Affiliation(s)
- Pranjal B Gupta
- Department of Emergency Medicine, Stanford University, Palo Alto, USA
| | - Geoffrey Lighthall
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, USA
- Department of Anesthesia, Veterans Affairs Medical Center, Palo Alto, USA
| | - Natalie Htet
- Department of Emergency Medicine, Stanford University, Palo Alto, USA
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Dunfield R, Ross P, Dutton D, Chandra K, Lewis D, Scheuermeyer F, Fraser J, Boreskie P, Pham C, Ali S, Lamprecht H, Stander M, Keyes C, Henneberry R, Atkinson P. SHoC-IVC: Does assessment of the inferior vena cava by point-of-care ultrasound independently predict fluid status in spontaneously breathing patients with undifferentiated hypotension? CAN J EMERG MED 2023; 25:902-908. [PMID: 37755657 DOI: 10.1007/s43678-023-00584-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 08/17/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND Accurately determining the fluid status of a patient during resuscitation in the emergency department (ED) helps guide appropriate fluid administration in the setting of undifferentiated hypotension. Our goal was to determine the diagnostic utility of point-of-care ultrasound (PoCUS) for inferior vena cava (IVC) size and collapsibility in predicting a volume overload fluid status in spontaneously breathing hypotensive ED patients. METHODS This was a post hoc secondary analysis of the SHOC-ED data, a prospective randomized controlled trial investigating PoCUS in patients with undifferentiated hypotension. We prospectively collected data on IVC size and collapsibility for 138 patients in the PoCUS group using a standard data collection form, and independently assigned a fluid status (volume overloaded, normal, volume deplete) from a composite clinical chart review blinded to PoCUS findings. The primary outcome was the diagnostic performance of IVC characteristics on PoCUS in the detection of a volume overloaded fluid status. RESULTS One hundred twenty-nine patients had completed determinant IVC assessment by PoCUS, with one hundred twenty-five receiving successful final fluid status determination, of which one hundred and seven were classified as volume deplete, thirteen normal, and seven volume overloaded. A receiver operating characteristic (ROC) curve was plotted using several IVC size and collapsibility categories. The best overall performance utilized the combined parameters of a dilated IVC (> 2.5 cm) with minimal collapsibility (less than 50%) which had a sensitivity of 85.7% and specificity of 86.4% with an area under the curve (AOC) of 0.92 for predicting an volume overloaded fluid status. CONCLUSION IVC PoCUS is feasible in spontaneously breathing hypotensive adult ED patients, and demonstrates potential value as a predictor of a volume overloaded fluid status in patients with undifferentiated hypotension. IVC size may be the preferred measure.
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Affiliation(s)
- Robert Dunfield
- Department of Emergency Medicine, Dalhousie Medicine New Brunswick, Horizon Health Network, Saint John, NB, Canada
| | - Peter Ross
- Department of Emergency Medicine, Dalhousie Medicine New Brunswick, Horizon Health Network, Saint John, NB, Canada
| | - Daniel Dutton
- Department of Emergency Medicine, Dalhousie Medicine New Brunswick, Horizon Health Network, Saint John, NB, Canada
| | - Kavish Chandra
- Department of Emergency Medicine, Dalhousie Medicine New Brunswick, Horizon Health Network, Saint John, NB, Canada
| | - David Lewis
- Department of Emergency Medicine, Dalhousie Medicine New Brunswick, Horizon Health Network, Saint John, NB, Canada
| | - Frank Scheuermeyer
- Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jacqueline Fraser
- Department of Emergency Medicine, Horizon Health Network, Saint John, NB, Canada
| | - Patrick Boreskie
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Chau Pham
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Sultan Ali
- Department of Emergency Medicine, Dalhousie Medicine New Brunswick, Horizon Health Network, Saint John, NB, Canada
| | - Hein Lamprecht
- Division of Emergency Medicine, University of Stellenbosch, Cape Town, South Africa
| | - Melanie Stander
- Division of Emergency Medicine, University of Stellenbosch, Cape Town, South Africa
| | - Cameron Keyes
- St. Francis Xavier University, Antigonish, NS, Canada
| | - Ryan Henneberry
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
| | - Paul Atkinson
- Department of Emergency Medicine, Dalhousie Medicine New Brunswick, Horizon Health Network, Saint John, NB, Canada.
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Ekambaram K, Hassan K. Establishing a Novel Diagnostic Framework Using Handheld Point-of-Care Focused-Echocardiography (HoPE) for Acute Left-Sided Cardiac Valve Emergencies: A Bayesian Approach for Emergency Physicians in Resource-Limited Settings. Diagnostics (Basel) 2023; 13:2581. [PMID: 37568944 PMCID: PMC10416975 DOI: 10.3390/diagnostics13152581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/23/2023] [Accepted: 08/02/2023] [Indexed: 08/13/2023] Open
Abstract
Acute severe cardiac valve emergencies, such as acute severe mitral regurgitation (AMR) and acute severe aortic regurgitation (AAR), present significant challenges in terms of diagnosis and management. Handheld point-of-care ultrasound devices have emerged as potentially pivotal tools in ensuring the prompt and accurate diagnosis of these left-sided valve emergencies by emergency physicians, particularly in resource-limited settings. Despite the increased utilisation of point-of-care ultrasound by emergency physicians for the management of patients in states of acute cardiorespiratory failure, current diagnostic protocols cannot perform sufficient quantitative assessments of the left-sided cardiac valves. This review elucidates and evaluates the diagnostic utility of handheld point-of-care focused-echocardiography (HoPE) in native AMR and AAR by reviewing the relevant literature and the use of clinical case examples from the Emergency Department at Port Shepstone Regional Hospital (PSRH-ED)-a rural, resource-limited hospital located in KwaZulu-Natal, South Africa. Combining the findings of the review and clinical case illustrations, this review proceeds to synthesise a novel, Bayesian-inspired, iterative diagnostic framework that integrates HoPE into the evaluation of patients with acute cardiorespiratory failure and suspected severe left-sided valve lesions.
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Affiliation(s)
- Kamlin Ekambaram
- Port Shepstone Regional Hospital, University of KwaZulu-Natal, Durban 4041, South Africa
| | - Karim Hassan
- Life Bay View Private Hospital, Mossel Bay 6506, South Africa;
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14
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Huang CT, Chang CH, Chen JY, Ling DA, Lee AF, Wang PH, Wu CK, Ko YC, Hsiao YT, Lien WC, Chang WT, Huang CH. The effect of point-of-care ultrasound on length of stay and mortality in patients with chest pain/dyspnea. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2023; 44:389-394. [PMID: 37072032 DOI: 10.1055/a-2048-6274] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
PURPOSE This study aims to investigate the effects of point-of-care ultrasound (PoCUS) on length of stay (LOS) and mortality in hemodynamically stable patients with chest pain/dyspnea. MATERIALS AND METHODS The prospective study was conducted from June 2020 to May 2021. A convenience sample of adult non-traumatic patients with chest pain/dyspnea was included and evaluated by PoCUS. The primary outcome was the relationship between the door-to-PoCUS time and LOS/mortality categorized by the ST-segment elevation (STE) and non-STE on the initial electrocardiogram. The diagnostic accuracy of PoCUS was computed, compared to the final diagnosis. RESULTS A total of 465 patients were included. 3 of 18 patients with STE had unexpected cardiac tamponade and 1 had myocarditis with pulmonary edema. PoCUS had a minimal effect on LOS and mortality in patients with STE. In the non-STE group, the shorter door-to-PoCUS time was associated with a shorter LOS (coefficient, 1.26±0.47, p=0.008). After categorizing the timing of PoCUS as 30, 60, 90, and 120 minutes, PoCUS had a positive effect, especially when performed within 90 minutes of arrival, on LOS of less than 360 minutes (OR, 2.42, 95% CI, 1.61-3.64) and patient survival (OR, 3.32, 95% CI, 1.14-9.71). The overall diagnostic performance of PoCUS was 96.6% (95% CI, 94.9-98.2%), but lower efficacy occurred in pulmonary embolism and myocardial infarction. CONCLUSION The use of PoCUS was associated with a shorter LOS and less mortality in patients with non-STE, especially when performed within 90 minutes of arrival. Although the effect on patients with STE was minimal, PoCUS played a role in discovering unexpected diagnoses.
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Affiliation(s)
- Chien-Tai Huang
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Heng Chang
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Jia-Yu Chen
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Dean-An Ling
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
| | - An-Fu Lee
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Pei-Hsiu Wang
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Chien-Kai Wu
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Ying-Chih Ko
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Tse Hsiao
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Wan-Ching Lien
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Wei-Tien Chang
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
| | - Chien-Hua Huang
- Emergency Department, National Taiwan University Hospital, Taipei, Taiwan
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15
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Elhassan MG, Grewal S, Nezarat N. Point-of-Care Ultrasonography in Internal Medicine: Limitations and Pitfalls for Novice Users. Cureus 2023; 15:e43655. [PMID: 37600433 PMCID: PMC10436027 DOI: 10.7759/cureus.43655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 08/22/2023] Open
Abstract
Point-of-care ultrasound (POCUS) is increasingly being adopted in the field of internal medicine, leading to the development of POCUS curricula in undergraduate and postgraduate medical education programs. Prominent internal medicine societies and organizations worldwide recognize the expanding utilization of POCUS by internal medicine physicians, emphasizing the need for practitioners to be aware of both its benefits and limitations. Despite the growing enthusiasm for POCUS, clinicians, particularly those with limited clinical experience, must be cautious regarding its inherent limitations and the potential impact on their clinical practice. This review aims to outline the limitations and potential drawbacks of POCUS for medical students, residents, and internists who wish to stay abreast of the escalating use of POCUS in internal medicine and have a desire, or have already commenced, to incorporate POCUS into their practice. Additionally, it provides recommendations for enhancing POCUS proficiency to mitigate these limitations.
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Affiliation(s)
| | - Sarbjot Grewal
- Internal Medicine, Saint Agnes Medical Center, Fresno, USA
| | - Negin Nezarat
- Internal Medicine, Saint Agnes Medical Center, Fresno , USA
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16
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Muzaffar SN, Pradhan A, Siddiqui SS, Roy S, Suresh T. Monitoring Macro- and Microcirculation in the Critically Ill: A Narrative Review. Avicenna J Med 2023; 13:138-150. [PMID: 37799180 PMCID: PMC10550369 DOI: 10.1055/s-0043-1772175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023] Open
Abstract
Circulatory shock is a common and important diagnosis in the critical care environment. Hemodynamic monitoring is quintessential in the management of shock. The currently used hemodynamic monitoring devices not only measure cardiac output but also provide data related to the prediction of fluid responsiveness, extravascular lung water, and also pulmonary vascular permeability. Additionally, these devices are minimally invasive and associated with fewer complications. The area of hemodynamic monitoring is progressively evolving with a trend toward the use of minimally invasive devices in this area. The critical care physician should be well-versed with current hemodynamic monitoring limitations and stay updated with the upcoming advances in this field so that optimal therapy can be delivered to patients in circulatory shock.
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Affiliation(s)
- Syed Nabeel Muzaffar
- Department of Critical Care Medicine, King George's Medical University (KGMU), Lucknow, Uttar Pradesh, India
| | - Akshyaya Pradhan
- Department of Cardiology, King George's Medical University (KGMU), Lucknow, Uttar Pradesh, India
| | - Suhail Sarwar Siddiqui
- Department of Critical Care Medicine, King George's Medical University (KGMU), Lucknow, Uttar Pradesh, India
| | - Shubhajeet Roy
- Faculty of Medical Sciences, King George's Medical University (KGMU), Lucknow, Uttar Pradesh, India
| | - Timil Suresh
- Faculty of Medical Sciences, King George's Medical University (KGMU), Lucknow, Uttar Pradesh, India
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Polyzogopoulou E, Velliou M, Verras C, Ventoulis I, Parissis J, Osterwalder J, Hoffmann B. Point-of-Care Ultrasound: A Multimodal Tool for the Management of Sepsis in the Emergency Department. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1180. [PMID: 37374384 DOI: 10.3390/medicina59061180] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/15/2023] [Accepted: 06/17/2023] [Indexed: 06/29/2023]
Abstract
Sepsis and septic shock are life-threatening emergencies associated with increased morbidity and mortality. Hence, early diagnosis and management of both conditions is of paramount importance. Point-of-care ultrasound (POCUS) is a cost-effective and safe imaging modality performed at the bedside, which has rapidly emerged as an excellent multimodal tool and has been gradually incorporated as an adjunct to physical examination in order to facilitate evaluation, diagnosis and management. In sepsis, POCUS can assist in the evaluation of undifferentiated sepsis, while, in cases of shock, it can contribute to the differential diagnosis of other types of shock, thus facilitating the decision-making process. Other potential benefits of POCUS include prompt identification and control of the source of infection, as well as close haemodynamic and treatment monitoring. The aim of this review is to determine and highlight the role of POCUS in the evaluation, diagnosis, treatment and monitoring of the septic patient. Future research should focus on developing and implementing a well-defined algorithmic approach for the POCUS-guided management of sepsis in the emergency department setting given its unequivocal utility as a multimodal tool for the overall evaluation and management of the septic patient.
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Affiliation(s)
- Effie Polyzogopoulou
- Emergency Medicine Department, Attikon University Hospital, 12462 Athens, Greece
| | - Maria Velliou
- Emergency Medicine Department, Attikon University Hospital, 12462 Athens, Greece
| | - Christos Verras
- Emergency Medicine Department, Attikon University Hospital, 12462 Athens, Greece
- National Centre of Emergency Care (EKAB), 11527 Athens, Greece
| | - Ioannis Ventoulis
- Department of Occupational Therapy, University of Western Macedonia, 50200 Ptolemaida, Greece
| | - John Parissis
- Emergency Medicine Department, Attikon University Hospital, 12462 Athens, Greece
| | | | - Beatrice Hoffmann
- Department of Emergency Medicine BIDMC, One Deaconess Rd, WCC2, Boston, MA 02215, USA
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Kula R, Popela S, Klučka J, Charwátová D, Djakow J, Štourač P. Modern Paediatric Emergency Department: Potential Improvements in Light of New Evidence. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10040741. [PMID: 37189990 DOI: 10.3390/children10040741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 05/17/2023]
Abstract
The increasing attendance of paediatric emergency departments has become a serious health issue. To reduce an elevated burden of medical errors, inevitably caused by a high level of stress exerted on emergency physicians, we propose potential areas for improvement in regular paediatric emergency departments. In an effort to guarantee the demanded quality of care to all incoming patients, the workflow in paediatric emergency departments should be sufficiently optimised. The key component remains to implement one of the validated paediatric triage systems upon the patient's arrival at the emergency department and fast-tracking patients with a low level of risk according to the triage system. To ensure the patient's safety, emergency physicians should follow issued guidelines. Cognitive aids, such as well-designed checklists, posters or flow charts, generally improve physicians' adherence to guidelines and should be available in every paediatric emergency department. To sharpen diagnostic accuracy, the use of ultrasound in a paediatric emergency department, according to ultrasound protocols, should be targeted to answer specific clinical questions. Combining all mentioned improvements might reduce the number of errors linked to overcrowding. The review serves not only as a blueprint for modernising paediatric emergency departments but also as a bin of useful literature which can be suitable in the paediatric emergency field.
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Affiliation(s)
- Roman Kula
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Physiology, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
| | - Stanislav Popela
- Emergency Department, University Hospital Olomouc and Faculty of Medicine, Palacký University, I.P. Pavlova 185/6, 779 00 Olomouc, Czech Republic
- Emergency Medical Service of the South Moravian Region, Kamenice 798, 625 00 Brno, Czech Republic
| | - Jozef Klučka
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
| | - Daniela Charwátová
- Department of Surgery, Vyškov Hospital, Purkyňova 235/36, 682 01 Vyškov, Czech Republic
| | - Jana Djakow
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Paediatric Intensive Care Unit, NH Hospital Inc., 268 01 Hořovice, Czech Republic
| | - Petr Štourač
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
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Turk M, Robertson T, Koratala A. Point-of-care ultrasound in diagnosis and management of congestive nephropathy. World J Crit Care Med 2023; 12:53-62. [PMID: 37034023 PMCID: PMC10075049 DOI: 10.5492/wjccm.v12.i2.53] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/08/2023] [Accepted: 02/17/2023] [Indexed: 03/07/2023] Open
Abstract
Congestive nephropathy is kidney dysfunction caused by the impact of elevated venous pressures on renal hemodynamics. As a part of cardiorenal syndrome, the diagnosis is usually made based on history and physical examination, with findings such as jugular venous distension, a third heart sound, and vital signs as supporting findings. More recently, however, these once though objective measures have come under scrutiny for their accuracy. At the same time, bedside ultrasound has increased in popularity and is routinely being used by clinicians to take some of the guess work out of making the diagnosis of volume overload and venous congestion. In this mini-review, we will discuss some of the traditional methods used to measure venous congestion, describe the role of point-of-care ultrasound and how it can ameliorate a clinician’s evaluation, and offer a description of venous excess ultrasound score, a relatively novel scoring technique used to objectively quantify congestion. While there is a paucity of published large scale clinical trials evaluating the potential benefit of ultrasonography in venous congestion compared to gold standard invasive measurements, more study is underway to solidify the role of this objective measure in daily clinical practice.
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Affiliation(s)
- Michael Turk
- Department of Medicine, Allegheny Health Network, Pittsburgh, PA 15222, United States
| | - Thomas Robertson
- Department of Medicine, Allegheny Health Network, Pittsburgh, PA 15222, United States
| | - Abhilash Koratala
- Division of Nephrology, Medical College of Wisconsin, Milwaukee, WI 53226, United States
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Prager R, Bowdridge J, Pratte M, Cheng J, McInnes MDF, Arntfield R. Indications, Clinical Impact, and Complications of Critical Care Transesophageal Echocardiography: A Scoping Review. J Intensive Care Med 2023; 38:245-272. [PMID: 35854414 PMCID: PMC9806486 DOI: 10.1177/08850666221115348] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Critical care transesophageal echocardiography (ccTEE) is an increasingly popular tool used by intensivists to characterize and manage hemodynamics at the bedside. Its usage appears to be driven by expanded diagnostic scope as well as the limitations of transthoracic echocardiography (TTE) - lack of acoustic windows, patient positioning, and competing clinical interests (eg, the need to perform chest compressions). The objectives of this scoping review were to determine the indications, clinical impact, and complications of ccTEE. METHODS MEDLINE, EMBASE, Cochrane, and six major conferences were searched without a time or language restriction on March 31st, 2021. Studies were included if they assessed TEE performed for adult critically ill patients by intensivists, emergency physicians, or anesthesiologists. Intraoperative or post-cardiac surgical TEE studies were excluded. Study demographics, indication for TEE, main results, and complications were extracted in duplicate. RESULTS Of the 4403 abstracts screened, 289 studies underwent full-text review, with 108 studies (6739 patients) included. Most studies were retrospective (66%), performed in academic centers (84%), in the intensive care unit (73%), and were observational (55%). The most common indications for ccTEE were hemodynamic instability, trauma, cardiac arrest, respiratory failure, and procedural guidance. Across multiple indications, ccTEE was reported to change the diagnosis in 52% to 78% of patients and change management in 32% to79% patients. During cardiac arrest, ccTEE identified the cause of arrest in 25% to 35% of cases. Complications of ccTEE included two cases of significant gastrointestinal bleeding requiring intervention, but no other major complications (death or esophageal perforation) reported. CONCLUSIONS The use of ccTEE has been described for the diagnosis and management of a broad range of clinical problems. Overall, ccTEE was commonly reported to offer additional diagnostic yield beyond TTE with a low observed complication rate. Additional high quality ccTEE studies will permit stronger conclusions and a more precise understanding of the trends observed in this scoping review.
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Affiliation(s)
- Ross Prager
- Division of Critical Care, Western University, Stn B. London, ON, Canada,Ross Prager, Critical Care Trauma Centre,
Victoria Hospital. Rm # D2-528 London Health Sciences Centre, 800 Commissioners
Rd. E, London, ON N6A 5W9, Canada.
| | - Joshua Bowdridge
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Michael Pratte
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jason Cheng
- Division of Critical Care, Western University, Stn B. London, ON, Canada
| | - Matthew DF McInnes
- Department of Radiology, University of Ottawa, Ottawa, ON, Canada, Clinical Epidemiology Program, The Ottawa Hospital Research
Institute, Ottawa, ON, Canada
| | - Robert Arntfield
- Division of Critical Care, Western University, Stn B. London, ON, Canada
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Kaiser RS, Sarkar M, Raut SK, Mahapatra MK, Zaman MAU, Roy O, Chowdhoury SR, Nandi M. A Study to Compare Ultrasound-guided and Clinically Guided Fluid Management in Children with Septic Shock. Indian J Crit Care Med 2023; 27:139-146. [PMID: 36865513 PMCID: PMC9973056 DOI: 10.5005/jp-journals-10071-24410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 01/24/2023] [Indexed: 02/04/2023] Open
Abstract
Background To evaluate the role of ultrasound during initial fluid resuscitation along with clinical guidance in reducing the incidence of fluid overload on day 3 in children with septic shock. Materials and methods It was a prospective, parallel limb open-labeled randomized controlled superiority trial done in the PICU of a government-aided tertiary care hospital in Eastern India. Patient enrolment took place between June 2021 and March 2022. Fifty-six children aged between 1 month and 12 years, with proven or suspected septic shock, were randomized to receive either ultrasound-guided or clinically guided fluid boluses (1:1 ratio) and subsequently followed up for various outcomes. The primary outcome was frequency of fluid overload on day 3 of admission. The treatment group received ultrasound-guided fluid boluses along with the clinical guidance and the control group received the same but without ultrasound guidance upto 60 mL/kg of fluid boluses. Results The frequency of fluid overload on day 3 of admission was significantly lower in the ultrasound group (25% vs 62%, p = 0.012) as was the median (IQR) cumulative fluid balance percentage on day 3 [6.5 (3.3-10.3) vs 11.3 (5.4-17.5), p = 0.02]. The amount of fluid bolus administered was also significantly lower by ultrasound [median 40 (30-50) vs 50 (40-80) mL/kg, p = 0.003]. Resuscitation time was shorter in the ultrasound group (13.4 ± 5.6 vs 20.5 ± 8 h, p = 0.002). Conclusion Ultrasound-guided fluid boluses were found to be significantly better than clinically guided therapy, in preventing fluid overload and its associated complications in children with septic shock. These factors make ultrasound a potentially useful tool for resuscitation of children with septic shock in the PICU. How to cite this article Kaiser RS, Sarkar M, Raut SK, Mahapatra MK, Uz Zaman MA, Roy O, et al. A Study to Compare Ultrasound-guided and Clinically Guided Fluid Management in Children with Septic Shock. Indian J Crit Care Med 2023;27(2):139-146.
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Affiliation(s)
- Ryan Sohail Kaiser
- Department of Pediatrics, Kolkata Medical College, Kolkata, West Bengal, India
| | - Mihir Sarkar
- Department of Pediatrics, Kolkata Medical College, Kolkata, West Bengal, India
| | - Sumantra Kumar Raut
- Department of Nephrology, North Bengal Medical College, Kolkata, West Bengal India
| | | | | | - Oishik Roy
- Department of Pediatrics, Kolkata Medical College, Kolkata, West Bengal, India
| | - Satyabrata Roy Chowdhoury
- Department of Pediatrics, North Bengal Medical College, Kolkata, West Bengal India,Satyabrata Roy Chowdhoury, Department of Pediatrics, North Bengal Medical College, Kolkata, West Bengal, India, Phone: +91 9433765529, e-mail:
| | - Mousumi Nandi
- Department of Pediatrics, Kolkata Medical College, Kolkata, West Bengal, India
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Jarman RD, McDermott C, Colclough A, Bøtker M, Knudsen L, Harris T, Albaroudi B, Albaroudi O, Haddad M, Darke R, Berry E, Breslin T, Fitzpatrick G, Flanagan L, Olusanya O, Craver D, Omar A, Simpson T, Cherian N, Dore M, Prosen G, Kay S, Villén-Villegas T, Gargani L, Carley S, Woo M, Dupriez F, Hussain A, Via G, Connolly JA, Peck M, Melniker L, Walden A, Attard Biancardi MA, Żmijewska-Kaczor O, Lalande E, Geukens P, McLaughlin R, Olszynski P, Hoffmann B, Chin E, Muhr C, Kim DJ, Mercieca A, Shukla D, Hayward S, Smith M, Gaspari R, Smallwood N, Pes P, Tavazzi G, Corradi F, Lambert M, Morris C, Trauer M, Baker K, Bystrzycki A, Goudie A, Liu R, Rudd L, Dietrich CF, Jenssen C, Sidhu PS. EFSUMB Clinical Practice Guidelines for Point-of-Care Ultrasound: Part One (Common Heart and Pulmonary Applications) LONG VERSION. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2023; 44:e1-e24. [PMID: 36228631 DOI: 10.1055/a-1882-5615] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
AIMS To evaluate the evidence and produce a summary and recommendations for the most common heart and lung applications of point-of-care ultrasound (PoCUS). METHODS We reviewed 10 clinical domains/questions related to common heart and lung applications of PoCUS. Following review of the evidence, a summary and recommendation were produced, including assignment of levels of evidence (LoE) and grading of the recommendation, assessment, development, and evaluation (GRADE). 38 international experts, the expert review group (ERG), were invited to review the evidence presented for each question. A level of agreement of over 75 % was required to progress to the next section. The ERG then reviewed and indicated their level of agreement regarding the summary and recommendation for each question (using a 5-point Likert scale), which was approved if a level of agreement of greater than 75 % was reached. A level of agreement was defined as a summary of "strongly agree" and "agree" on the Likert scale responses. FINDINGS AND RECOMMENDATIONS One question achieved a strong consensus for an assigned LoE of 3 and a weak GRADE recommendation (question 1). The remaining 9 questions achieved broad agreement with one assigned an LoE of 4 and weak GRADE recommendation (question 2), three achieving an LoE of 3 with a weak GRADE recommendation (questions 3-5), three achieved an LoE of 3 with a strong GRADE recommendation (questions 6-8), and the remaining two were assigned an LoE of 2 with a strong GRADE recommendation (questions 9 and 10). CONCLUSION These consensus-derived recommendations should aid clinical practice and highlight areas of further research for PoCUS in acute settings.
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Affiliation(s)
- Robert David Jarman
- Emergency Department, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom of Great Britain and Northern Ireland
- School of Health and Life Sciences, Teesside University, Middlesbrough, United Kingdom of Great Britain and Northern Ireland
| | - Cian McDermott
- Emergency Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Anna Colclough
- Emergency Medicine, University Hospital Lewisham, London, United Kingdom of Great Britain and Northern Ireland
| | - Morten Bøtker
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Prehospital Emergency Medical Services, Central Denmark Region, Viborg, Denmark
| | - Lars Knudsen
- Department of Anaesthesia, Aarhus University Hospital, Aarhus, Denmark
| | - Tim Harris
- Emergency Medicine, Queen Mary University of London, United Kingdom of Great Britain and Northern Ireland
- Emergency Medicine, Hamad Medical Corporation, Doha, Qatar
| | | | - Omar Albaroudi
- Emergency Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Mahmoud Haddad
- Emergency Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Robert Darke
- Emergency Medicine and Intensive Care Medicine, Health Education England North East, Newcastle upon Tyne, United Kingdom of Great Britain and Northern Ireland
| | - Edward Berry
- Emergency Medicine, Torbay Hospital, Torquay, United Kingdom of Great Britain and Northern Ireland
| | - Tomas Breslin
- Emergency Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Ireland
| | | | - Leah Flanagan
- Emergency Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Olusegun Olusanya
- Intensive Care Medicine, University College Hospital, London, United Kingdom of Great Britain and Northern Ireland
| | - Dominic Craver
- Emergency Medicine, The Royal London Hospital, London, United Kingdom of Great Britain and Northern Ireland
| | - Adhnan Omar
- Respiratory Medicine, University Hospital Lewisham, London, United Kingdom of Great Britain and Northern Ireland
| | - Thomas Simpson
- Respiratory Medicine, Lewisham and Greenwich NHS Trust, London, United Kingdom of Great Britain and Northern Ireland
| | - Nishant Cherian
- Emergency Medicine, The Alfred Emergency & Trauma Centre, Melbourne, Australia
- School of Health and Life Sciences, Teesside University, Middlesbrough, United Kingdom of Great Britain and Northern Ireland
| | - Martin Dore
- Emergency Medicine, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom of Great Britain and Northern Ireland
| | - Gregor Prosen
- Center for Emergency Medicine, University Medical Centre Maribor, Slovenia
| | - Sharon Kay
- Cardiac Physiology and Echocardiography, The University of Sydney, Australia
| | | | - Luna Gargani
- Cardiology, Institute of Clinical Physiology National Research Council, Pisa, Italy
| | - Simon Carley
- Emergency Medicine, Manchester University NHS Foundation Trust, Manchester, United Kingdom of Great Britain and Northern Ireland
- Emergency Medicine, Manchester Metropolitan University, Manchester, United Kingdom of Great Britain and Northern Ireland
| | - Michael Woo
- Emergency Medicine, University of Ottawa, Canada
- Emergency Medicine, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Florence Dupriez
- Emergency Medicine, Cliniques universitaires Saint-Luc, Bruxelles, Belgium
| | - Arif Hussain
- Cardiac Critical Care, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Gabriele Via
- Anesthesiology, Intensive Care and Pain Medicine, Istituto Cardiocentro Ticino Ente Ospedaliero Cantonale, Lugano, Switzerland, Pavia, Italy
| | - James Anthony Connolly
- Emergency Medicine, Royal Victoria Infirmary, Newcastle-upon-Tyne, United Kingdom of Great Britain and Northern Ireland
| | - Marcus Peck
- Anaesthesia and Intensive Care, Frimley Park Hospital NHS Trust, Frimley, United Kingdom of Great Britain and Northern Ireland
| | - Larry Melniker
- Emergency Medicine, New York-Presbyterian Brooklyn Methodist Hospital, Brooklyn, United States
| | - Andrew Walden
- Acute and Intensive Care Medicine, Royal Berkshire Hospital, Reading, United Kingdom of Great Britain and Northern Ireland
- Acute Medicine and Intensive Care Medicine, University of Oxford, United Kingdom of Great Britain and Northern Ireland
| | | | - Olga Żmijewska-Kaczor
- Emergency Medicine, Royal Cornwall Hospital, Truro, United Kingdom of Great Britain and Northern Ireland
| | - Elizabeth Lalande
- Emergency Medicine, Centre Hospitalier de l'Université Laval, Sainte-Foy, Canada
| | - Paul Geukens
- Intensive Care Medicine, Hopital de Jolimont, Haine-Saint-Paul, Belgium
| | - Russell McLaughlin
- Emergency Medicine, Royal Victoria Hospital, Belfast, United Kingdom of Great Britain and Northern Ireland
- Medical Director, Northern Ireland Ambulance Service, Belfast, United Kingdom of Great Britain and Northern Ireland
| | - Paul Olszynski
- Emergency Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Beatrice Hoffmann
- Emergency Department, Harvard Medical School Department of Emergency Medicine Beth Israel Deaconess Medical Center, Boston, United States
| | - Eric Chin
- Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, United States
| | - Christopher Muhr
- Emergency Medicine and Internal Medicine, Capio Sankt Gorans Sjukhus, Stockholm, Sweden
| | - Daniel J Kim
- Emergency Medicine, The University of British Columbia, Vancouver, Canada
- Emergency Medicine, Vancouver General Hospital, Vancouver, Canada
| | | | | | - Simon Hayward
- Physiotherapy, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, United Kingdom of Great Britain and Northern Ireland
| | - Michael Smith
- School of Healthcare Sciences, Cardiff University College of Biomedical and Life Sciences, Cardiff, United Kingdom of Great Britain and Northern Ireland
| | - Romolo Gaspari
- Emergency Medicine, UMass Memorial Medical Center, Worcester, United States
- Emergency Medicine, UMass Medical School, Worcester, United States
| | - Nick Smallwood
- Acute Medicine, East Surrey Hospital, Redhill, United Kingdom of Great Britain and Northern Ireland
| | - Philippe Pes
- Emergency Medicine, University Hospital Centre Nantes, France
| | - Guido Tavazzi
- Anesthesia and Intensive Care Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Dipartimento di Scienze Clinico-Chirurgiche, Diagnostiche e Pediatriche, Università degli Studi di Pavia Facoltà di Medicina e Chirurgia, Pavia, Italy
| | - Francesco Corradi
- Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Italy
| | - Michael Lambert
- Emergency Medicine, Advocate Christ Medical Center, Oak Lawn, United States
| | - Craig Morris
- Intensive Care, Royal Derby Hospital, Derby, United Kingdom of Great Britain and Northern Ireland
| | - Michael Trauer
- Emergency Medicine, St Thomas' Hospital, London, United Kingdom of Great Britain and Northern Ireland
| | - Kylie Baker
- Emergency Medicine, Ipswich Hospital, Ipswich, Australia
- Faculty of Medicine, The University of Queensland, Saint Lucia, Australia
| | - Adam Bystrzycki
- Emergency Medicine, The Alfred Emergency & Trauma Centre, Melbourne, Australia
- Department of Epidemiology & Preventive Medicine, Monash University, Clayton, Australia
| | - Adrian Goudie
- Emergency Medicine, Fiona Stanley Hospital, Murdoch, Australia
| | - Rachel Liu
- Emergency Medicine, Yale School of Medicine, New Haven, United States
| | - Lynne Rudd
- General Secretary, European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB), London, United Kingdom of Great Britain and Northern Ireland
| | - Christoph F Dietrich
- Department Allgemeine Innere Medizin, Kliniken Hirslanden Beau Site, Salem und Permanence, Bern, Switzerland
| | - Christian Jenssen
- Klinik für Innere Medizin, Krankenhaus Märkisch Oderland Strausberg/ Wriezen, Germany
| | - Paul S Sidhu
- Radiology, King's College London, United Kingdom of Great Britain and Northern Ireland
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Verras C, Ventoulis I, Bezati S, Matsiras D, Parissis J, Polyzogopoulou E. Point of Care Ultrasonography for the Septic Patient in the Emergency Department: A Literature Review. J Clin Med 2023; 12:jcm12031105. [PMID: 36769753 PMCID: PMC9917776 DOI: 10.3390/jcm12031105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/17/2023] [Accepted: 01/28/2023] [Indexed: 02/04/2023] Open
Abstract
The point-of-care ultrasound (POCUS) has been effectively used in intensive care units for the management of septic patients. Since it is a time- and cost-effective non-invasive imaging modality, its use in the emergency department (ED) has been advocated for by medical experts. This review summarizes the existing literature regarding the breadth of POCUS as a supplementary tool to the holistic approach of septic patients in the ED setting. A literature search was conducted via PubMed (MEDLINE), Cochrane Library, and Scopus databases, analyzing studies which examined the use of POCUS in the ED for non-traumatic, septic, and/or undifferentiated hypotensive patients, resulting in 26 studies. The first cluster of studies investigates the efficiency of POCUS protocols in the differential diagnosis and its reliability for distributive/septic shock and sepsis management. In the second cluster, POCUS use results in faster sepsis cause identification and improves therapeutic management. The third cluster confirms that POCUS aids in the accurate diagnosis and management, even in rare and complicated cases. The results of the present review support the well-documented utility of POCUS and highlight the importance of POCUS incorporation in the comprehensive management of the septic patient in the ED setting.
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Affiliation(s)
- Christos Verras
- Emergency Department, National and Kapodistrian University of Athens, Attikon University Hospital, 12462 Athens, Greece
- Correspondence: ; Tel.: +30-6936585677
| | - Ioannis Ventoulis
- Department of Occupational Therapy, University of Western Macedonia, 50100 Kozani, Greece
| | - Sofia Bezati
- Emergency Department, National and Kapodistrian University of Athens, Attikon University Hospital, 12462 Athens, Greece
| | - Dionysis Matsiras
- Emergency Department, National and Kapodistrian University of Athens, Attikon University Hospital, 12462 Athens, Greece
| | - John Parissis
- Emergency Department, National and Kapodistrian University of Athens, Attikon University Hospital, 12462 Athens, Greece
| | - Effie Polyzogopoulou
- Emergency Department, National and Kapodistrian University of Athens, Attikon University Hospital, 12462 Athens, Greece
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24
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Focus the POCUS on the patient. CAN J EMERG MED 2023; 25:9-10. [PMID: 36617616 DOI: 10.1007/s43678-022-00438-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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25
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Dalla Betta MB, Esener D, Swanson W, Kaddis A, Aguayo Romero F, Fields JM. The Frequency of POCUS in the Treatment of Sepsis in the Emergency Department: A Retrospective Cohort Study. POCUS JOURNAL 2023; 8:71-80. [PMID: 37152333 PMCID: PMC10155732 DOI: 10.24908/pocus.v8i1.15683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
Background: Point of care ultrasound (POCUS) is ubiquitous in the modern emergency department (ED). POCUS can be helpful in the management of patients with sepsis in many ways including determining the cause of sepsis, assessing fluid status, guiding resuscitation, and performing procedures. However, the frequency and manner in which POCUS is incorporated into the care of septic patients in community emergency medicine remains unclear. Objective: To evaluate POCUS frequency and exam types used in the care of patients with sepsis in two community EDs in Southern California. Methods: We performed a retrospective analysis of 5,264 ED visits with a diagnosis of sepsis at two community emergency departments between January 2014 and December 2018. Patients 18 years or older who were diagnosed with sepsis and had either lactate ≥ 4 mmol, a documented mean arterial pressure (MAP) < 65 mmHg, or a systolic blood pressure (SBP) < 90 mmHg were included. Charts were reviewed to determine if POCUS was used during the ED evaluation. Primary outcomes were frequency of POCUS use in the cohort, change in POCUS use over the study period, and the types of exams performed. Results: POCUS was used in 21% of encounters meeting inclusion criteria and was positively correlated with ED arrival year (OR = 1.09; CI 1.04, 1.15; p=0.001). The most common POCUS exam was ultrasound-guided central line placement, with the next most common exams being cardiac, followed by inferior vena cava (IVC). Only the frequency of cardiac, IVC, lung and Focused Assessment with Sonography in Trauma (FAST) exams were found to increase significantly over the study period. Conclusions: Total POCUS use increased significantly in this cohort of septic patients over the study period due to more cardiac, IVC, lung and FAST exams being performed.
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Affiliation(s)
- M Bryan Dalla Betta
- Department of Emergency Medicine, Kaiser Permanente San DiegoSan Diego, CAUSA
| | - Dasia Esener
- Department of Emergency Medicine, Kaiser Permanente San DiegoSan Diego, CAUSA
| | - William Swanson
- Department of Emergency Medicine, Kaiser Permanente San DiegoSan Diego, CAUSA
| | - Andrew Kaddis
- Department of Emergency Medicine, Scripps Mercy HospitalSan Diego, CAUSA
| | | | - J Matthew Fields
- Department of Emergency Medicine, Thomas Jefferson UniversityPhiladelphia, PAUSA
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26
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Pannu A. Circulatory shock in adults in emergency department. Turk J Emerg Med 2023. [PMID: 37529784 PMCID: PMC10389095 DOI: 10.4103/2452-2473.367400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Circulatory shock is a common condition that carries high morbidity and mortality. This review aims to update the critical steps in managing common types of shock in adult patients admitted to medical emergency and intensive care units. A literature review was performed by searching PubMed, EMBASE Ovid, and Cochrane Library, using the following search items: ("shock" OR "circulatory shock" OR "septic shock" OR "cardiogenic shock") AND ("management" OR "treatment" OR "resuscitation"). The review emphasizes prompt shock identification with tissue hypoperfusion, knowledge of the underlying pathophysiological mechanism, initial fluid resuscitation with balanced crystalloids, norepinephrine as the preferred vasopressor in septic and profound cardiogenic shock, and tailored intervention addressing specific etiologies. Point-of-care ultrasound may help evaluate an undifferentiated shock and determine fluid responsiveness. The approach to septic shock is improving; however, confirmatory studies are required for many existing (e.g., amount of initial fluids and steroids) and emerging (e.g., angiotensin II) therapies. Knowledge gaps and wide variations persist in managing cardiogenic shock that needs urgent addressing to improve outcomes.
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27
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Peach M, Milne J, Diegelmann L, Lamprecht H, Stander M, Lussier D, Pham C, Henneberry R, Fraser J, Chandra K, Howlett M, Mekwan J, Ramrattan B, Middleton J, van Hoving N, Taylor L, Dahn T, Hurley S, MacSween K, Richardson L, Stoica G, Hunter S, Olszynski P, Chandra K, Lewis D, Atkinson P. Does point-of-care ultrasonography improve diagnostic accuracy in emergency department patients with undifferentiated hypotension? An international randomized controlled trial from the SHOC-ED investigators. CAN J EMERG MED 2023; 25:48-56. [PMID: 36577931 DOI: 10.1007/s43678-022-00431-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 11/30/2022] [Indexed: 12/29/2022]
Abstract
PURPOSE Point-of-care ultrasonography (POCUS) is an established tool in the management of hypotensive patients in the emergency department (ED). We compared the diagnostic accuracy of a POCUS protocol versus standard assessment without POCUS in patients with undifferentiated hypotension. METHODS This was an international, multicenter randomized controlled trial included three EDs in North America and three in South Africa from September 2012 to December 2016. Hypotensive patients were randomized to early POCUS protocol plus standard care (POCUS group) or standard care without POCUS (control group). Initial and secondary diagnoses were recorded at 0 and 60 min. The main outcome was measures of diagnostic accuracy of a POCUS protocol in differentiating between cardiogenic and non-cardiogenic shock. Secondary outcomes were diagnostic performance for shock sub-types, as well as changes in perceived category of shock and overall diagnosis. RESULTS Follow-up was completed for 270 of 273 patients. For cardiogenic shock, the POCUS-based diagnostic approach (POCUS) performed similarly to the non-POCUS approach (control) for specificity [95.5% (89.9-98.5) vs.93.8% (87.7-97.5)]; positive likelihood ratio (17.92 vs 14.80); negative likelihood ratio (0.21 vs 0.09) and diagnostic odds ratio (85.6 vs 166.57), with a similar overall diagnostic accuracy between the two approaches [93.7% (88-97.2) vs 93.6% (87.8-97.2)]. Diagnostic performance measures were similar across sub-categories of shock. CONCLUSION This is the first randomized controlled trial to compare diagnostic performance of a POCUS protocol to standard care without POCUS in undifferentiated hypotensive ED patients. POCUS performed well diagnostically in undifferentiated hypotensive patients, especially as a rule-in test; however, performance did not differ meaningfully from standard assessment.
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Affiliation(s)
- M Peach
- Department of Emergency Medicine, Dalhousie University, Horizon Health Network, Saint John Regional Hospital, 400 University Ave, Saint John, NB, NB E2L 4L2, Canada
- Dalhousie Medicine New Brunswick, Saint John, NB, Canada
| | - J Milne
- Dalhousie Medicine New Brunswick, Saint John, NB, Canada
- Fraser Health Authority, Vancouver, BC, Canada
| | - L Diegelmann
- Division of Emergency Medicine, University of Stellenbosch, Cape Town, South Africa
- Department of Emergency Medicine, University of Maryland Medical Center, Baltimore, USA
| | - H Lamprecht
- Division of Emergency Medicine, University of Stellenbosch, Cape Town, South Africa
| | - M Stander
- Division of Emergency Medicine, University of Stellenbosch, Cape Town, South Africa
| | - D Lussier
- Department of Emergency Medicine, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
| | - C Pham
- Department of Emergency Medicine, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
| | - R Henneberry
- Department of Emergency Medicine, Dalhousie University, QEII, Halifax, NS, Canada
| | - J Fraser
- Department of Emergency Medicine, Dalhousie University, Horizon Health Network, Saint John Regional Hospital, 400 University Ave, Saint John, NB, NB E2L 4L2, Canada
| | - K Chandra
- Department of Emergency Medicine, Dalhousie University, Horizon Health Network, Saint John Regional Hospital, 400 University Ave, Saint John, NB, NB E2L 4L2, Canada
- Dalhousie Medicine New Brunswick, Saint John, NB, Canada
- Discipline of Emergency Medicine, Memorial University, Saint John, NL, Canada
| | - M Howlett
- Department of Emergency Medicine, Dalhousie University, Horizon Health Network, Saint John Regional Hospital, 400 University Ave, Saint John, NB, NB E2L 4L2, Canada
- Dalhousie Medicine New Brunswick, Saint John, NB, Canada
- Discipline of Emergency Medicine, Memorial University, Saint John, NL, Canada
| | - J Mekwan
- Department of Emergency Medicine, Dalhousie University, Horizon Health Network, Saint John Regional Hospital, 400 University Ave, Saint John, NB, NB E2L 4L2, Canada
- Dalhousie Medicine New Brunswick, Saint John, NB, Canada
- Discipline of Emergency Medicine, Memorial University, Saint John, NL, Canada
| | - B Ramrattan
- Department of Emergency Medicine, Dalhousie University, Horizon Health Network, Saint John Regional Hospital, 400 University Ave, Saint John, NB, NB E2L 4L2, Canada
- Dalhousie Medicine New Brunswick, Saint John, NB, Canada
- Discipline of Emergency Medicine, Memorial University, Saint John, NL, Canada
| | - J Middleton
- Department of Emergency Medicine, Dalhousie University, Horizon Health Network, Saint John Regional Hospital, 400 University Ave, Saint John, NB, NB E2L 4L2, Canada
- Dalhousie Medicine New Brunswick, Saint John, NB, Canada
- Discipline of Emergency Medicine, Memorial University, Saint John, NL, Canada
| | - N van Hoving
- Division of Emergency Medicine, University of Stellenbosch, Cape Town, South Africa
| | - L Taylor
- Department of Emergency Medicine, Dalhousie University, Horizon Health Network, Saint John Regional Hospital, 400 University Ave, Saint John, NB, NB E2L 4L2, Canada
| | - T Dahn
- Department of Emergency Medicine, Dalhousie University, QEII, Halifax, NS, Canada
| | - S Hurley
- Department of Emergency Medicine, Dalhousie University, QEII, Halifax, NS, Canada
| | - K MacSween
- Department of Emergency Medicine, Dalhousie University, QEII, Halifax, NS, Canada
| | - L Richardson
- Department of Emergency Medicine, Dalhousie University, QEII, Halifax, NS, Canada
| | - G Stoica
- Research Services, Horizon Health Network, Saint John, NB, Canada
| | - Samuel Hunter
- Faculty of Science, University of Ottawa, Ottawa, ON, Canada
| | - P Olszynski
- Department of Emergency Medicine, University of Saskatchewan, Royal University Hospital, Saskatoon, SK, Canada
| | - K Chandra
- Department of Emergency Medicine, Dalhousie University, Horizon Health Network, Saint John Regional Hospital, 400 University Ave, Saint John, NB, NB E2L 4L2, Canada
- Dalhousie Medicine New Brunswick, Saint John, NB, Canada
- Discipline of Emergency Medicine, Memorial University, Saint John, NL, Canada
| | - D Lewis
- Department of Emergency Medicine, Dalhousie University, Horizon Health Network, Saint John Regional Hospital, 400 University Ave, Saint John, NB, NB E2L 4L2, Canada
- Dalhousie Medicine New Brunswick, Saint John, NB, Canada
- Discipline of Emergency Medicine, Memorial University, Saint John, NL, Canada
| | - P Atkinson
- Department of Emergency Medicine, Dalhousie University, Horizon Health Network, Saint John Regional Hospital, 400 University Ave, Saint John, NB, NB E2L 4L2, Canada.
- Dalhousie Medicine New Brunswick, Saint John, NB, Canada.
- Discipline of Emergency Medicine, Memorial University, Saint John, NL, Canada.
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28
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Kok B, Wolthuis D, Bosch F, van der Hoeven H, Blans M. POCUS in dyspnea, nontraumatic hypotension, and shock; a systematic review of existing evidence. Eur J Intern Med 2022; 106:9-38. [PMID: 35927185 DOI: 10.1016/j.ejim.2022.07.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/20/2022] [Accepted: 07/26/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Point-of-care ultrasound (POCUS) has been adopted as a powerful tool in acute medicine. This systematic review aims to critically appraise the existing literature on point-of-care ultrasound in respiratory or circulatory deterioration. METHODS Original studies on POCUS and dyspnea, nontraumatic hypotension, and shock from March 2002 until March 2022 were assessed in the PubMed and Embase Databases. Two reviewers independently screened articles for inclusion, extracted data, and assessed the quality of included studies using an established checklist. RESULTS We included 89 articles in this review. Point-of-care ultrasound in the initial workup increases the diagnostic accuracy in patients with dyspnea, nontraumatic hypotension and shock in the ED, ICU and medical ward setting. No improvement is found in patients with severe sepsis in the ICU setting. POCUS is capable of narrowing the differential diagnoses and is faster, and more feasible in the acute setting than other diagnostics available. Results on outcome measures are heterogenous. The quality of the included studies is considered low most of the times, mainly because of performance and selection bias and absence of a gold standard as the reference test. CONCLUSION We conclude that POCUS contributes to a higher diagnostic accuracy in dyspnea, nontraumatic hypotension, and shock. It aides in narrowing the differential diagnoses and shortening the time to correct diagnosis and effective treatment. TRIAL REGISTRY INPLASY; Registration number: INPLASY202220020; URL: https://inplasy.com/.
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Affiliation(s)
- Bram Kok
- Department of Internal Medicine, Radboudumc, Geert Grooteplein Zuid 10, Nijmegen, GA 6525, the Netherlands.
| | - David Wolthuis
- Department of Internal Medicine, Radboudumc, Geert Grooteplein Zuid 10, Nijmegen, GA 6525, the Netherlands
| | - Frank Bosch
- Department of Internal Medicine, Radboudumc, Geert Grooteplein Zuid 10, Nijmegen, GA 6525, the Netherlands; Department of Internal Medicine, Rijnstate, Arnhem, the Netherlands
| | | | - Michiel Blans
- Department of Internal Medicine, Rijnstate, Arnhem, the Netherlands; Intensive Care Unit, Rijnstate, Arnhem, the Netherlands
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29
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van Hoving DJ, Alenyo AN, Komagum F, Lamprecht H. Current use and perceived barriers of emergency point-of-care ultrasound by African health care practitioners. Afr J Emerg Med 2022; 12:333-338. [PMID: 35967088 PMCID: PMC9363966 DOI: 10.1016/j.afjem.2022.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 07/06/2022] [Accepted: 07/24/2022] [Indexed: 12/04/2022] Open
Abstract
Point-of-care ultrasound is a key skill for emergency care practitioners in Africa. Access barriers to point-of-care ultrasound training and equipment are still relevant in Africa. Many users of point-of-care ultrasound in Africa have not been formally credentialed. A potential discordance exists between local burden of disease and point-of-care ultrasound training.
Introduction The African Federation of Emergency Medicine (AFEM) recommends the use of emergency point-of-care ultrasound (ePOCUS) as a core skill for health care practitioners in Africa. The study explored the use of ePOCUS by health care practitioners among AFEM members who work across Africa. Methods An anonymous online survey was distributed to individual members of AFEM and affiliated organisations. The questionnaire was tested by the AFEM Scientific Committee for potential content modifications prior to distribution. Summary statistics are presented. Results Of the 220 participants that were analysed, 148 (67.3%) were using ePOCUS. The mean age was 36 years; 146 (66%) were male; and 198 (90%) obtained their primary medical qualification in Africa. In total, 168 (76%) were doctors, and most participants (n = 204, 93%) have worked in Africa during the last 5 years. Reasons for not using ePOCUS mainly related to lack of training and problems with ultrasound machines or consumables. Most ePOCUS users (116/148, 78%) attended courses with hands-on training, but only 65 (44%) participants were credentialed (by 18 different organizations). The median score for self-perceived level of ePOCUS skills was 75 in credentialed users versus 50 in those that were not credentialed. Ultrasound in trauma was the most frequently used module (n = 141, 99%), followed by focused cardiac assessment (n = 128, 90%) and thoracic (including lung) assessment (n = 128, 90.1%). The FASH-module (Focused Assessment with Sonography for HIV/TB) was the least used (n = 69, 49%). Conclusion Access barriers to ePOCUS training, mentorship, equipment and consumables are still relevant in Africa. The low credentialing rate and the potential discordance between local burden of disease and ePOCUS training requires further investigation.
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Affiliation(s)
| | | | - Faith Komagum
- Department of Emergency Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Hein Lamprecht
- Division of Emergency Medicine, Stellenbosch University, Cape Town, South Africa
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Morales G, Adedipe A, Morse S, McCabe J, Mahr C, Nichol G. Feasibility of Very Early Identification of Cardiogenic Shock by Semi-automated Ultrasound Exam in the Emergency Department. Cureus 2022; 14:e30927. [DOI: 10.7759/cureus.30927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2022] [Indexed: 11/06/2022] Open
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Focused Cardiac Ultrasound Training for Non-cardiologists: An Overview and Recommendations for a Lower Middle-Income Country. Crit Care Clin 2022; 38:827-837. [PMID: 36162913 DOI: 10.1016/j.ccc.2022.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Poor outcomes among the critically ill in low- and middle-income countries (LMICs) have been attributed in part to the challenge of diagnostic delays caused by lack of skilled personnel. Focused cardiac ultrasound (FoCUS) by non-cardiologists may mitigate the shortage of echocardiography experts to perform emergency echocardiography at the point of care in these settings. It is however crucial that FoCUS training for non-cardiologists in LMICs be based on robust evidence to support training delivery if diagnostic accuracy is to be assured.
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Southerland LT, Benson KK, Schoeffler AJ, Lashutka MA, Borson S, Bischof JJ. Inclusion of older adults and reporting of consent processes in randomized controlled trials in the emergency department: A scoping review. J Am Coll Emerg Physicians Open 2022; 3:e12774. [PMID: 35919513 PMCID: PMC9337842 DOI: 10.1002/emp2.12774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 06/06/2022] [Accepted: 06/07/2022] [Indexed: 01/07/2023] Open
Abstract
Objective Conducting research in the emergency department (ED) is often complicated by patients' acute and chronic illnesses, which can adversely affect cognition and subsequently capacity to consent for research, especially in older adults. Validated screening tools to assess capacity to consent for research exist, but neither the frequency of use nor which ones are used for ED research are known. Methods We conducted a scoping review using standard review techniques. Inclusion criteria included (1) randomized controlled trials (RCTs) from publication years 2014-2019 that (2) enrolled participants only in the ED, (3) included patients aged 65+ years, and (4) were fully published in English. Articles were sourced from Embase and screened using Covidence. Results From 3130 search results, 269 studies passed title/abstract and full text screening. Average of the mean or median ages was 55.7 years (SD 14.2). The mean number of study participants was 311.9 [range 8-10,807 participants]. A few (n = 13, 4.8%) waived or had exception from informed consent. Of the 256 studies requiring consent, a fourth (26.5%, n = 68) specifically excluded patients due to impaired capacity to consent. Only 11 (4.3%) documented a formal capacity screening tool and only 13 (5.1%) reported consent by legally authorized representative (LAR). Conclusions Most RCTs enrolling older adults in EDs did not report assessment of capacity to consent or use of LARs. This snapshot of informed consent procedures is potentially concerning and suggests that either research consent processes for older patients and/or reporting of consent processes require improvement.
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Affiliation(s)
- Lauren T Southerland
- Department of Emergency MedicineThe Ohio State University Wexner Medical CenterColumbusOhioUSA
| | | | | | - Margaret A. Lashutka
- Department of Emergency MedicineThe Ohio State University Wexner Medical CenterColumbusOhioUSA
| | - Soo Borson
- Department of Family MedicineKeck School of Medicine University of Southern CaliforniaLos AngelesCaliforniaUSA
| | - Jason J. Bischof
- Department of Emergency MedicineThe Ohio State University Wexner Medical CenterColumbusOhioUSA
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Ramadan A, Abdallah T, Abdelsalam H, Mokhtar A, Razek AA. Accuracy of echocardiography and ultrasound protocol to identify shock etiology in emergency department. BMC Emerg Med 2022; 22:117. [PMID: 35768775 PMCID: PMC9245270 DOI: 10.1186/s12873-022-00678-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 06/17/2022] [Indexed: 11/27/2022] Open
Abstract
Background Early diagnosis and appropriate management of shock aimed at prevention of prolonged hypoperfusion has shown to decrease morbidity and mortality in patients with undifferentiated shock. However, there is often a challenge in emergency department (ED) – where diagnosis is mainly based on clinical signs and standard monitoring parameters. Early use of point of care ultrasound could reduce the diagnostic time and improve diagnostic accuracy. Purpose The aim of this study is to investigate the accuracy of echocardiography - ultrasound protocol to identify the cause of shock in ED. Method The study was conducted on 150 shocked patients admitted to emergency department of Alexandria Main University Hospital from December 2018 to December 2020. The study was conducted to reach initial impression about shock etiology which was then compared to final diagnosis to determine accuracy, agreement, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). Results One hundred forty patients were included in the study (10 patients were excluded). The protocol was 100% accurate for diagnosing cases with obstructive and mixed obstructive distributive shock. It showed excellent rule- out characteristics for cardiogenic shock (sensitivity and NPV = 100%). There was almost perfect agreement between provisional and final shock type for mixed distributive cardiogenic shock (kappa 0.915). Echo- US protocol had lowest agreement and PPV for patients with hypovolemic shock Kappa 0.48 and 35% respectively. Conclusion The Echo- US protocol showed a high accuracy in identifying shock etiology in ED and is likely a promising diagnostic tool in emergency care.
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Affiliation(s)
- Asmaa Ramadan
- Department of Emergency Medicine, Alexandria University, Alexandria, Egypt.
| | - Tamer Abdallah
- Department of Critical Care Medicine, Alexandria University, Alexandria, Egypt
| | | | - Ahmed Mokhtar
- Department of Cardiology and angiology, Alexandria University, Alexandria, Egypt
| | - Assem Abdel Razek
- Department of Anesthesia and Surgical Intensive Care Unit, Alexandria University, Alexandria, Egypt
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The use of contrast enhanced thoraco-abdominal CT in patients with non-traumatic undifferentiated hemodynamic shock. Eur J Radiol 2022; 151:110290. [DOI: 10.1016/j.ejrad.2022.110290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 03/22/2022] [Accepted: 03/31/2022] [Indexed: 11/21/2022]
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Chauvin A, Bossuyt P, Le Conte P. Clinical ultrasound not centered on patients has questionable value. Eur J Emerg Med 2022; 29:103-104. [PMID: 34483250 DOI: 10.1097/mej.0000000000000876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Anthony Chauvin
- Emergency Department and PreHospital EMS, Lariboisière's hospital, Assistance Publique Hôpitaux de Paris, Paris University
- Inserm U942 MASCOT, Université de Paris, Paris, France
| | - Patrick Bossuyt
- Department of Epidemiology and Data Science, Amsterdam Public Health, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Philippe Le Conte
- Emergency Department, University Hospital
- Medicine Faculty, University of Nantes, Nantes, France
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Berg I, Walpot K, Lamprecht H, Valois M, Lanctôt JF, Srour N, van den Brand C. A Systemic Review on the Diagnostic Accuracy of Point-of-Care Ultrasound in Patients With Undifferentiated Shock in the Emergency Department. Cureus 2022; 14:e23188. [PMID: 35444920 PMCID: PMC9009815 DOI: 10.7759/cureus.23188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 11/05/2022] Open
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Assessing Fluid Intolerance with Doppler Ultrasonography: A Physiological Framework. Med Sci (Basel) 2022; 10:medsci10010012. [PMID: 35225945 PMCID: PMC8883898 DOI: 10.3390/medsci10010012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/04/2022] [Accepted: 02/07/2022] [Indexed: 12/11/2022] Open
Abstract
Ultrasonography is becoming the favored hemodynamic monitoring utensil of emergentologists, anesthesiologists and intensivists. While the roles of ultrasound grow and evolve, many clinical applications of ultrasound stem from qualitative, image-based protocols, especially for diagnosing and managing circulatory failure. Often, these algorithms imply or suggest treatment. For example, intravenous fluids are opted for or against based upon ultrasonographic signs of preload and estimation of the left ventricular ejection fraction. Though appealing, image-based algorithms skirt some foundational tenets of cardiac physiology; namely, (1) the relationship between cardiac filling and stroke volume varies considerably in the critically ill, (2) the correlation between cardiac filling and total vascular volume is poor and (3) the ejection fraction is not purely an appraisal of cardiac function but rather a measure of coupling between the ventricle and the arterial load. Therefore, management decisions could be enhanced by quantitative approaches, enabled by Doppler ultrasonography. Both fluid ‘responsiveness’ and ‘tolerance’ are evaluated by Doppler ultrasound, but the physiological relationship between these constructs is nebulous. Accordingly, it is argued that the link between them is founded upon the Frank–Starling–Sarnoff relationship and that this framework helps direct future ultrasound protocols, explains seemingly discordant findings and steers new routes of enquiry.
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Albaroudi B, Haddad M, Albaroudi O, Abdel-Rahman ME, Jarman R, Harris T. Assessing left ventricular systolic function by emergency physician using point of care echocardiography compared to expert: systematic review and meta-analysis. Eur J Emerg Med 2022; 29:18-32. [PMID: 34406134 PMCID: PMC8691376 DOI: 10.1097/mej.0000000000000866] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 07/28/2021] [Indexed: 01/23/2023]
Abstract
Assessing left ventricular systolic function (LVSF) by echocardiography assists in the diagnosis and management of a diverse range of patients presenting to the emergency department (ED). We evaluated the agreement between ED-based clinician sonographers and apriori-defined expert sonographers. We conducted a systematic review and meta-analysis based on Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines. We searched Medline, EMBASE, Cochrane, ClinicalTrials.gov, TRIP and Google Scholar for eligible studies from inception to February 2021. Risk of bias was evaluated using Quality Assessment Tool for Diagnostic Accuracy Studies-2 tool. The level of agreement between clinician and expert sonographers was measured using kappa, sensitivity, specificity, positive and negative likelihood ratio statistics using random-effects models. Twelve studies were included (1131 patients, 1229 scans and 159 clinician sonographers). Significant heterogeneity was identified in patient selection, methods of assessment of LVSF, reference standards and statistical methods for assessing agreement. The overall quality of studies was low, with most being small, single centre convenience samples. A meta-analysis including seven studies (786 scans) where visual estimation method was used by clinician sonographers demonstrated simple Kappa of 0.68 [95% confidence interval (CI), 0.57-0.79], and sensitivity, specificity, positive and negative likelihood ratio of 89% (95% CI, 80-94%), 85% (95% CI, 80-89%), 5.98 (95% CI, 4.13-8.68) and 0.13 (95% CI, 0.06-0.24), respectively, between clinician sonographer and expert sonographer for normal/abnormal LVSF. The weighted kappa for five studies (429 scans) was 0.70 (95% CI, 0.61-0.80) for normal/reduced/severely reduced LVSF. There is substantial agreement between ED-based clinician sonographers and expert sonographers for assessing LVSF using visual estimation and ranking it as normal/reduced, or normal/reduced/severely reduced, in patients presenting to ED.
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Affiliation(s)
| | - Mahmoud Haddad
- Department of Emergency Medicine, Hamad Medical Corporation
| | - Omar Albaroudi
- Department of Emergency Medicine, Hamad Medical Corporation
| | | | - Robert Jarman
- Emergency Department, Royal Victoria Infirmary, Newcastle upon Tyne
- Teesside University, Middlesbrough
| | - Tim Harris
- Department of Emergency Medicine, Hamad Medical Corporation
- Barts Health NHS Trust and the Queen Mary University of London, London, UK
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Point of care ultrasonography: And now, where shall we go in perioperative medicine? Anaesth Crit Care Pain Med 2021; 41:101014. [PMID: 34954222 DOI: 10.1016/j.accpm.2021.101014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 12/20/2021] [Indexed: 11/20/2022]
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Cid-Serra X, Royse A, Canty D, Johnson DF, Maier AB, Fazio T, El-Ansary D, Royse CF. Effect of a Multiorgan Focused Clinical Ultrasonography on Length of Stay in Patients Admitted With a Cardiopulmonary Diagnosis: A Randomized Clinical Trial. JAMA Netw Open 2021; 4:e2138228. [PMID: 34932107 PMCID: PMC8693211 DOI: 10.1001/jamanetworkopen.2021.38228] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE There are accumulating data about the utility of diagnostic multiorgan focused clinical ultrasonography (FCU) in the assessment of patients admitted with cardiopulmonary symptoms. OBJECTIVE To determine whether adding multiorgan FCU to the initial clinical evaluation of patients admitted with cardiopulmonary symptoms reduces hospital length of stay, hospital readmissions, and in-hospital costs. DESIGN, SETTING, AND PARTICIPANTS This is a prospective, parallel-group, superiority, randomized clinical trial with a 1:1 allocation ratio. The study was conducted at The Royal Melbourne Hospital, a tertiary public hospital located in Melbourne, Victoria, Australia. Adults aged 18 years or older admitted to the internal medicine ward with a cardiopulmonary diagnosis were enrolled between September 2018 and December 2019 and were followed up until hospital discharge. Data analysis was performed from August 2020 to January 2021. INTERVENTIONS The intervention involved an internal medicine physician-performed heart, lung, and 2-point vein compression FCU in addition to standard clinical evaluation. MAIN OUTCOMES AND MEASURES The primary outcome was the difference in the mean length of hospital stay, defined as the number of hours from admission to the internal medicine ward to hospital discharge. A difference of 24 hours was defined as clinically important. Secondary outcomes included hospital readmissions at 30 days and hospital care costs. RESULTS A total of 250 participants were enrolled and 2 were excluded, leaving 248 participants (mean [SD] age, 80.1 [11.0] years; 121 women [48.7%]) in the final analysis. There were 124 patients in the intervention group and 124 patients in the control group. The most common initial diagnoses were acute decompensated heart failure (113 patients [45.5%]), pneumonia (45 patients [18.1%]), and exacerbated chronic pulmonary disease (32 patients [12.9%]). The length of hospital stay was 113.4 hours (95% CI, 91.7-135.1 hours) in the FCU group and 125.3 hours (95% CI, 101.7-148.8 hours) in the control group (P = .53). The 30-day readmission rate was not different between groups (FCU vs control, 20 of 124 patients [16.1%] vs 15 of 124 patients [12.0%]), nor were total in-hospital costs (FCU vs control, A$7831.1 [95% CI, A$5586.1-A$10 076.1] vs A$7895.7 [95% CI, A$6385.9-A$9.405.5]). CONCLUSIONS AND RELEVANCE In this randomized clinical trial, adult patients admitted to an internal medicine ward with a cardiopulmonary diagnosis, who underwent multiorgan FCU of the heart, lungs, and lower extremities veins during their initial clinical assessment, did not have a shorter hospital length of stay by more than 24 hours, compared with patients who received standard care. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry Identifier: ACTRN12618001442291.
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Affiliation(s)
- Ximena Cid-Serra
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Medicine and Community Care, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Alistair Royse
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Surgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - David Canty
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Anaesthesia and Pain Management, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Anesthesia and Perioperative Medicine, Monash Health, Melbourne, Victoria, Australia
| | - Douglas F. Johnson
- Department of Medicine and Community Care, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of General Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Andrea B. Maier
- Department of Medicine and Community Care, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Human Movement Sciences, @AgeAmsterdam, Amsterdam Movement Sciences, Vrije Universitet, Amsterdam, The Netherlands
- Department of Medicine and Aged Care, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Tim Fazio
- Department of Medicine and Community Care, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Health Intelligence Unit, Melbourne Health, Melbourne, Victoria, Australia
- Department of Medicine and Radiology, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia
| | - Doa El-Ansary
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Nursing and Allied Health, Swinburne University of Technology, Hawthorn, Melbourne, Victoria, Australia
- Department of Surgery, School of Medicine, University of Melbourne, Melbourne, Victoria, Australia
- Clinical Research Institute, Westmead Private Hospital, Westmead, Sydney, New South Wales, Australia
| | - Colin F. Royse
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
- Pain Management, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Outcomes Research Consortium, The Cleveland Clinic, Cleveland, Ohio
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Bernstein E, Wang TY. Point-of-Care Ultrasonography: Visually Satisfying Medicine or Evidence-Based Medicine? JAMA Intern Med 2021; 181:1558-1559. [PMID: 34633409 DOI: 10.1001/jamainternmed.2021.5831] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Eden Bernstein
- Cleveland Clinic Foundation, Cleveland Clinic Community Care, Cleveland, Ohio
| | - Tracy Y Wang
- Duke University, Duke Clinical Research Institute, Durham, North Carolina
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Affiliation(s)
- José L Díaz-Gómez
- From the Baylor College of Medicine, Houston (J.L.D.-G.); and the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead (P.H.M.), and the Albert Einstein College of Medicine, New York (S.J.K.) - both in New York
| | - Paul H Mayo
- From the Baylor College of Medicine, Houston (J.L.D.-G.); and the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead (P.H.M.), and the Albert Einstein College of Medicine, New York (S.J.K.) - both in New York
| | - Seth J Koenig
- From the Baylor College of Medicine, Houston (J.L.D.-G.); and the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead (P.H.M.), and the Albert Einstein College of Medicine, New York (S.J.K.) - both in New York
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Abstract
A 60-year-old female presents to the emergency department (ED) with a 3-day history of fatigue and mild breathlessness. She has a history of lung cancer. Her vitals indicate shock with a heart rate of 140 bpm, a systolic blood pressure (SBP) of 65 mmHg, a respiratory rate of 28, with an oxygen saturation of 90% on 100% a nonrebreather mask, and a normal temperature at 36°C. Her electrocardiograph (ECG) shows sinus tachycardia. She appears mottled and pale.
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Keefer S, Atkinson P, Chandra K, Henneberry RJ, Olszynski PA, Peach M, Diegelmann L, Lamprecht H, Stander M, Lussier D, Pham C, Milne J, Fraser J, Lewis D. Sonographic Findings of Left Ventricular Dysfunction to Predict Shock Type in Undifferentiated Hypotensive Patients: An Analysis From the Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED) Study. Cureus 2021; 13:e16360. [PMID: 34395137 PMCID: PMC8360322 DOI: 10.7759/cureus.16360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 07/07/2021] [Indexed: 11/05/2022] Open
Abstract
Introduction Patients that present to the emergency department (ED) with undifferentiated hypotension have a high mortality rate. Hypotension can be divided into four categories: obstructive, hypovolemic, distributive, and cardiogenic. While it is possible to have overlapping or concomitant shock states, being able to differentiate between cardiogenic shock and the other categories is important as it entails a different treatment regime and extra cautions. In this secondary analysis, we investigate if using focused cardiac ultrasonography (FOCUS) to determine left ventricular dysfunction (LVD) can serve as a reliable test for cardiogenic shock. Methods We prospectively collected FOCUS findings performed in 135 ED patients with undifferentiated hypotension as part of an international study. Patients with clearly identified etiologies for hypotension were excluded, along with other specific presumptive diagnoses. LVD was defined as the identification of a generally hypodynamic left ventricle in the setting of shock. FOCUS findings were collected using a standardized protocol and data collection form. All scans were performed by emergency physicians trained in ultrasound. Final shock type was defined as cardiogenic or noncardiogenic by independent specialist blinded chart review. Results In our findings, 135 patients had complete records for assessment of left ventricular function and additional follow-up data and so were included in this secondary analysis. The median age was 56 years and 53% of patients were male. Disease prevalence for cardiogenic shock was 12% and the mortality rate was 24%. The presence of LVD on FOCUS had a sensitivity of 62.50% (95% confidence interval 35.43% to 84.80%), specificity of 94.12% (88.26% to 97.60%), positive likelihood ratio (LR) 10.62 (4.71 to 23.95), negative LR 0.40 (0.21 to 0.75) and accuracy of 90.37% (84.10% to 94.77%) for detecting cardiogenic shock. Conclusion Detecting left ventricular dysfunction on FOCUS may be useful in the early identification of cardiogenic shock in otherwise undifferentiated hypotensive adult patients in the emergency department.
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Affiliation(s)
- Sam Keefer
- Faculty of Medicine, Dalhousie University, Halifax, CAN
| | - Paul Atkinson
- Emergency Medicine, Horizon Health Network, Saint John, CAN.,Emergency Medicine, Dalhousie Medicine New Brunswick, Saint John, CAN
| | - Kavish Chandra
- Emergency Medicine, Dalhousie Medicine New Brunswick, Saint John, CAN
| | | | | | - Mandy Peach
- Emergency Medicine, Dalhousie University, Saint John, CAN
| | | | - Hein Lamprecht
- Emergency Medicine, Stellenbosch University, Cape Town, ZAF
| | | | - David Lussier
- Emergency Medicine, University of Manitoba, Winnipeg, CAN
| | - Chau Pham
- Emergency Medicine, University of Manitoba, Winnipeg, CAN
| | - James Milne
- Family Medicine, Fraser Valley Health, Vancouver, CAN
| | - Jacqueline Fraser
- Emergency Medicine, Horizon Health Network, Saint John, CAN.,Emergency Medicine, Dalhousie University, Saint John, CAN
| | - David Lewis
- Emergency Medicine, Dalhousie University, Saint John, CAN.,Emergency Medicine, Saint John Regional Hospital, Saint John, CAN
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Prager R, Wu K, Bachar R, Unni RR, Bowdridge J, McGrath TA, Thavanathan R, Woo MY, McInnes MDF. Blinding practices during acute point-of-care ultrasound research: the BLIND-US meta-research study. BMJ Evid Based Med 2021; 26:110-111. [PMID: 33177166 DOI: 10.1136/bmjebm-2020-111577] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/26/2020] [Indexed: 01/28/2023]
Abstract
OBJECTIVES Point-of-care ultrasound (POCUS) diagnostic accuracy research has significant variation in blinding practices. This study characterises the blinding practices during acute POCUS research to determine whether research methodology adequately reflects POCUS use in routine clinical practice. DESIGN, SETTINGS AND PARTICIPANTS A search for POCUS diagnostic accuracy studies published in Emergency Medicine, Anaesthesia and Critical Care journals from January 2016 to January 2020 was performed. Studies were included if they were primary diagnostic accuracy studies. The study year, journal impact factor, population, hospital area, body region, study design, blinding of the POCUS interpreter to clinical information, whether the person performing the POCUS scan was the same person interpreting the scan, and whether the study reported incremental diagnostic yield were extracted in duplicate by two authors. Descriptive statistics were provided and prespecified subgroup analysis was performed. MAIN OUTCOME MEASURES The primary outcome was the number of studies that blinded the POCUS interpreter to at least some part of the clinical information. Secondary outcomes included whether the person performing the POCUS scan was the same person interpreting it and whether the study reported incremental diagnostic yield. RESULTS 520 abstracts were screened with 97 studies included. The POCUS interpreter was blinded to clinical information in 37 studies (38.1%), not blinded in 34 studies (35.1%) and not reported in 26 studies (26.8%). The POCUS interpreter was the same person obtaining the images in 72 studies (74.2%), different in 14 studies (14.4%) and not reported in 11 studies (11.3%). Only four studies (4.1%) reported incremental diagnostic yield for POCUS. Inter-rater reliability was moderate (k=0.64). Subgroup analysis based on impact factor, body region, hospital area, patient population and study design did not show significant differences after completing pairwise comparisons. CONCLUSIONS Although blinding the POCUS interpreter to clinical information may be done in a perceived attempt to limit bias, this may result in accuracy estimates that do not reflect routine clinical practice. Similarly, having a different clinician perform and interpret the POCUS scan significantly limits generalisability to practice as it does not truly reflect 'point-of-care' ultrasound at all. Reporting incremental diagnostic yield from implementing POCUS into a diagnostic pathway better reflects the value of POCUS; however, this methodology was infrequently used. TRIAL REGISTRATION NUMBER The study protocol was registered on Open Science Framework (https://osf.io/h5fe7/).
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Affiliation(s)
- Ross Prager
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Kay Wu
- Faculty of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Rudy R Unni
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Joshua Bowdridge
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Trevor A McGrath
- Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada
| | - Rajiv Thavanathan
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Michael Y Woo
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Matthew D F McInnes
- Department of Radiology, University of Ottawa, Ottawa, Ontario, Canada
- Department of Epidemiology, University of Ottawa, Ottawa, Ontario, Canada
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Kennedy TM, Dessie A, Kessler DO, Malia L, Rabiner JE, Firnberg MT, Ng L. Point-of-Care Ultrasound Findings in Multisystem Inflammatory Syndrome in Children: A Cross-Sectional Study. Pediatr Emerg Care 2021; 37:334-339. [PMID: 33871226 DOI: 10.1097/pec.0000000000002410] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Multisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease 2019 is a novel pediatric condition with significant morbidity and mortality. The primary objective of this investigation was to describe the point-of-care ultrasound (POCUS) findings in patients evaluated in the emergency department (ED) who were diagnosed with MIS-C. METHODS A retrospective cross-sectional study was conducted including patients <21-years-old who had POCUS performed for clinical care in a pediatric ED and were diagnosed with MIS-C. Point-of-care ultrasound studies were performed by pediatric emergency medicine attending physicians or fellows. Data abstracted by chart review included patient demographics, clinical history, physical examination findings, diagnostic test results, the time POCUS studies and echocardiograms were performed, therapies administered, and clinical course after admission. RESULTS For the 24 patients included, 17 focused cardiac ultrasound, 9 lung POCUS, 7 pediatric modified rapid ultrasound for shock and hypotension, 1 focused assessment with sonography for trauma, 1 POCUS for suspected appendicitis, and 1 ocular POCUS were performed by 13 physicians. Point-of-care ultrasound identified impaired cardiac contractility in 5 patients, large intraperitoneal free fluid with inflamed bowel in 1 patient, and increased optic nerve sheath diameters with elevation of the optic discs in 1 patient. Trace or small pericardial effusions, pleural effusions, and intraperitoneal free fluid were seen in 3 patients, 6 patients, and 4 patients, respectively. CONCLUSIONS This study demonstrates the spectrum of POCUS findings in MIS-C. Prospective studies are needed to help delineate the utility of incorporating POCUS into an ED management pathway for patients with suspected MIS-C.
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Affiliation(s)
- Thomas M Kennedy
- From the Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Columbia University Irving Medical Center | NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY
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Comparative Early Hemodynamic Profiles in Patients Presenting to the Emergency Department with Septic and Nonseptic Acute Circulatory Failure Using Focused Echocardiography. Shock 2021; 53:695-700. [PMID: 31568225 PMCID: PMC7237072 DOI: 10.1097/shk.0000000000001449] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Study Objective: We evaluated the early hemodynamic profile of patients presenting with acute circulatory failure to the Emergency Department (ED) using focused echocardiography performed by emergency physicians after a dedicated training program. Methods: Patients presenting to the ED with an acute circulatory failure of any origin were successively examined by a recently trained emergency physician and by an expert in critical care echocardiography. Operators independently performed and interpreted online echocardiographic examinations to determine the leading mechanism of acute circulatory failure. Results: Focused echocardiography could be performed in 100 of 114 screened patients (55 with sepsis/septic shock and 45 with shock of other origin) after a median fluid loading of 500 mL (interquartile range: 187–1,500 mL). A hypovolemic profile was predominantly observed whether the acute circulatory failure was of septic origin or not (33/55 [60%] vs. 23/45 [51%]: P = 0.37). Although a vasoplegic profile associated with a hyperkinetic left ventricle was most frequently identified in septic patients when compared with their counterparts (17/55 [31%] vs. 5/45 [11%]: P = 0.02), early left or right ventricular failure was observed in 31% of them. Hemodynamic profiles were adequately appraised by recently trained emergency physicians, as reflected by a good-to-excellent agreement with the expert's assessment (Κ: 0.61–0.85). Conclusions: Hypovolemia was predominantly identified in patients presenting to the ED with acute circulatory failure. Although vasoplegia was more frequently associated with sepsis, early ventricular dysfunction was also depicted in septic patients. Focused echocardiography seemed reliable when performed by recently trained emergency physicians without previous experience in ultrasound.
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Li X, Chen J, Gu C, Lu K, Wei L, Hu T, Song J, Zhang S, Chen Y, Li Q, Yu X, Du Y, Chen K, Mao Y, Li M, Wu H, Si Y, Li X, Li L, He X, Yu H, Boggett S, Royse C, Canty D, Liu J. The Impact on 30-Day Mortality From a Brief Focused Ultrasound-Guided Management Protocol Immediately Before Emergency Noncardiac Surgery in Critically Ill Patients: A Multicenter Randomized Controlled Trial. J Cardiothorac Vasc Anesth 2021; 36:1100-1110. [PMID: 34776351 DOI: 10.1053/j.jvca.2021.05.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/28/2021] [Accepted: 05/10/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To determine whether brief ultrasound-guided treatment of hemodynamic shock and respiratory failure immediately before emergency noncardiac surgery reduced 30-day mortality. DESIGN Parallel, nonblinded, randomized trial with 1:1 allocation to control and intervention groups. SETTING Twenty-eight major hospitals within China. PARTICIPANTS Six-hundred sixty patients ≥14 years of age, scheduled for emergency noncardiac surgery with evidence of shock (heart rate >120 beat/min, systolic blood pressure< 90 mmHg or requiring inotrope infusion), or respiratory failure (Pulse Oxygen Saturation <92%, respiratory rate >20 beat/min, or requiring mechanical ventilation). INTERVENTIONS A brief (<15 minutes) focused ultrasound of ventricular filling and function, lung, and peritoneal spaces, with predefined treatment recommendation based on the ultrasound was performed before surgery or standard care. MEASUREMENTS AND MAIN RESULTS The primary outcome was 30-day mortality. Secondary outcomes included changes in medical or surgical diagnosis and management due to ultrasound, intensive care unit, and hospital stay and cost, and Short Form-8 quality-of-life scores. Although there were frequent changes in diagnosis (82%) and management (49%) after the ultrasound, mortality at 30 days was not different between groups (50 [15.7%] v 53 [16.3%]; odds ratio 1.05, 0.69-1.6, p = 0.826). There were no differences in the secondary outcomes of the days spent in the hospital (mean 13.8 days, 95% confidence interval [CI] 12.1-15.6 v 14.4 d, 11.8-17.1, p = 0.718) or intensive care unit (mean 9.3 days, 95% CI 7.7-11.0 v 8.7 d, 7.2-10.2, p = 0.562), hospital cost (USD$14.5K, 12.2-16.7 v 13.7, 11.5-15.9, p = 0.611) or Short Form-8 scores at one year (mean 80.9, 95% CI 78.4-83.3 v 79.7, 76.9-82.5, p = 0.54) between participants allocated to the ultrasound and control groups. CONCLUSIONS In critically ill patients with hemodynamic shock or respiratory failure, a focused ultrasound-guided management did not reduce 30-day mortality but led to frequent changes in diagnosis and patient management.
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Affiliation(s)
- Xiaoqiang Li
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jiao Chen
- Department of Anesthesiology, The Second Nanning People's Hospital, Nanning, Guangxi, China
| | - ChunLin Gu
- Department of Anesthesiology, The Second Nanning People's Hospital, Nanning, Guangxi, China
| | - Kejian Lu
- Department of Anesthesiology, The Second Nanning People's Hospital, Nanning, Guangxi, China
| | - Lai Wei
- Department of Anesthesiology, Hunan Provincial People's Hospital, Changsha, Hunan, China
| | - Tao Hu
- Department of Anesthesiology, Hunan Provincial People's Hospital, Changsha, Hunan, China
| | - Jianqiang Song
- Department of Anesthesiology, Zhengzhou Central Hospital, Zhengzhou, Henan, China
| | - Shuanjun Zhang
- The 940th Hospital of Joint Logistics Support force of Chinese People's Liberation Army, Lanzhou, Gansu, China
| | - Ya Chen
- The 940th Hospital of Joint Logistics Support force of Chinese People's Liberation Army, Lanzhou, Gansu, China
| | - Qiang Li
- Department of Anesthesiology, Zigong Fourth People's Hospital, Zigong, Sichuan, China
| | - Xuan Yu
- Department of Anesthesiology, Zigong Fourth People's Hospital, Zigong, Sichuan, China
| | - Yiri Du
- The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia autonomous region, China
| | - Ke Chen
- Department of Anesthesiology, First Affiliated Hospital of Anhui Medical University, Shushan, Hefei, Anhui, China
| | - Yu Mao
- Department of Anesthesiology, First Affiliated Hospital of Anhui Medical University, Shushan, Hefei, Anhui, China
| | - Min Li
- Department of Anesthesiology and Perioperative Medicine, 900 Hospital of the Joint Logistics Team, Fuzhou, Fujian, China
| | - Huanghui Wu
- Department of Anesthesiology and Perioperative Medicine, 900 Hospital of the Joint Logistics Team, Fuzhou, Fujian, China
| | - Yan'na Si
- Consultant Anesthesiologist, Department of Anesthesiology Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xuze Li
- Department of Anesthesiology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Longyan Li
- Department of Anesthesiology, Xiangya Hospital, Central South University, Kaifu District, Changsha, China
| | - Xin He
- Department of Anesthesiology, Xiangya Hospital, Central South University, Kaifu District, Changsha, China
| | - Hui Yu
- Department of Anesthesiology, Beijing Hospital, National Center of Gerontology, Beijing, China
| | - Stuart Boggett
- Department of Surgery, The University of Melbourne, Melbourne, Australia
| | - Colin Royse
- Department of Surgery, The University of Melbourne, Melbourne, Australia
| | - David Canty
- Department of Surgery, The University of Melbourne, Melbourne, Australia
| | - Jin Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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Li L, Ai Y, Wang X, Zhang H, Ma X, Huang L, Ai M, Peng Q, Zhang L. Effect of focused cardiopulmonary ultrasonography on clinical outcome of septic shock: a randomized study. J Int Med Res 2021; 49:3000605211013176. [PMID: 33990145 PMCID: PMC8127760 DOI: 10.1177/03000605211013176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Objective To investigate the effect of focused ultrasonography on clinical outcomes of septic shock. Methods Patients with septic shock were randomized into an integrated cardiopulmonary ultrasonography (ICUS) group and conventional (CON) group. Within 1 hour of admission, the ICUS group underwent ICUS examination for hemodynamic decision-making, while the CON group received standard treatment. The primary endpoint was 28-day mortality after admission. The secondary endpoints were cumulative fluid administration in the first 6, 24, and 72 hours; use of vasoactive drugs; lactate clearance; duration of ventilation; and ICU stay. Results Ninety-four qualified patients were enrolled (ICUS group, 49; CON group, 45). ICUS showed no significant effect on 28-day mortality. Within the initial 6 hours, the ICUS group tended to have a higher fluid balance and fluid intake than the CON group. The duration of vasopressor support was shorter in the ICUS group. There were no differences in the cumulative fluid infusion within 24 or 72 hours, lactate clearance, ICU stay, or duration of ventilation. Conclusions The initially focused ICUS did not affect the clinical outcomes of septic shock, but it tended to be associated with a higher fluid balance within the initial 6 hours and shorter duration of vasopressor support.
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Affiliation(s)
- Li Li
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Yuhang Ai
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Xiaoting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Hongmin Zhang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Xinhua Ma
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Li Huang
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Meilin Ai
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Qianyi Peng
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China
| | - Lina Zhang
- Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, China
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