Focused Cardiac Ultrasound: Recommendations from the American Society of Echocardiography

Blood or Fat? Differentiating Hemopericardium versus Epicardial Fat Using Focused Cardiac Ultrasound

Basic point-of-care ultrasound of the heart-also known as Focused Cardiac Ultrasound (FoCUS)-has emerged as a powerful bedside tool to narrow the differential diagnosis of causes of hypotension. The list of causes of hypotension that a FoCUS provider is expected to be able to recognize includes a compressive pericardial effusion due to hemopericardium (blood in the pericardial sac). But hemopericardium can be difficult to distinguish from a more common condition that is not immediately life-threatening: epicardial fat. This paper reviews illustrative images of both epicardial fat and hemopericardium to provide practice guidance to the FoCUS user on how to differentiate these two phenomena.

Implementing focused echocardiography and AI-supported analysis in a population-based survey in Lesotho: implications for community-based cardiovascular disease care models

In settings where access to expert echocardiography is limited, focused echocardiography, combined with artificial intelligence (AI)-supported analysis, may improve diagnosis and monitoring of left ventricular hypertrophy (LVH). Sixteen nurses/nurse-assistants without prior experience in echocardiography underwent a 2-day hands-on intensive training to learn how to assess parasternal long axis views (PLAX) using an inexpensive hand-held ultrasound device in Lesotho, Southern Africa. Loops were stored on a cloud-drive, analyzed using deep learning algorithms at the University Hospital Basel, and afterwards confirmed by a board-certified cardiologist. The nurses/nurse-assistants obtained 756 echocardiograms. Of the 754 uploaded image files, 628 (83.3%) were evaluable by deep learning algorithms. Of those, results of 514/628 (81.9%) were confirmed by a cardiologist. Of the 126 not evaluable by the AI algorithm, 46 (36.5%) were manually evaluable. Overall, 660 (87.5%) uploaded files were evaluable and confirmed. Following short-term training of nursing cadres, a high proportion of obtained PLAX was evaluable using AI-supported analysis. This could be a basis for AI- and telemedical support in hard-to-reach areas with minimal resources.

Enhancing ST-Elevation Myocardial Infarction Diagnosis and Management: The Integral Role of Echocardiography in Patients Rushed to the Cardiac Catheterization Laboratory

Coronary artery disease (CAD) remains a significant global health concern, necessitating timely and precise diagnosis, especially for acute coronary syndromes (ACSs). Traditional diagnostic methods like electrocardiograms (ECGs) are critical, yet the advent of echocardiography has revolutionized cardiac care by providing comprehensive insights into heart function. This article examines the integration of echocardiography in the cardiac catheterization laboratory, emphasizing its role in augmenting traditional diagnostics, enhancing patient outcomes, and preparing for targeted interventions. Specifically, we argue for the routine use of focused echocardiographic evaluations in patients presenting with ST-Elevation Myocardial Infarction (STEMI) to the cath lab, illustrating how this practice can significantly refine diagnostic accuracy, identify concurrent life-threatening conditions, and inform the management of STEMI and its complications.

Automated Atrial Fibrillation Diagnosis by Echocardiography without ECG: Accuracy and Applications of a New Deep Learning Approach

BACKGROUND

Automated rhythm detection on echocardiography through artificial intelligence (AI) has yet to be fully realized. We propose an AI model trained to identify atrial fibrillation (AF) using apical 4-chamber (AP4) cines without requiring electrocardiogram (ECG) data.

METHODS

Transthoracic echocardiography studies of consecutive patients ≥ 18 years old at our tertiary care centre were retrospectively reviewed for AF and sinus rhythm. The study was first interpreted by level III-trained echocardiography cardiologists as the gold standard for rhythm diagnosis based on ECG rhythm strip and imaging assessment, which was also verified with a 12-lead ECG around the time of the study. AP4 cines with three cardiac cycles were then extracted from these studies with the rhythm strip and Doppler information removed and introduced to the deep learning model ResNet(2+1)D with an 80:10:10 training-validation-test split ratio.

RESULTS

634 patient studies (1205 cines) were included. After training, the AI model achieved high accuracy on validation for detection of both AF and sinus rhythm (mean F1-score = 0.92; AUROC = 0.95). Performance was consistent on the test dataset (mean F1-score = 0.94, AUROC = 0.98) when using the cardiologist's assessment of the ECG rhythm strip as the gold standard, who had access to the full study and external ECG data, while the AI model did not.

CONCLUSIONS

AF detection by AI on echocardiography without ECG appears accurate when compared to an echocardiography cardiologist's assessment of the ECG rhythm strip as the gold standard. This has potential clinical implications in point-of-care ultrasound and stroke risk stratification.

Diagnostic accuracy of left ventricular outflow tract velocity time integral versus inferior vena cava collapsibility index in predicting post-induction hypotension during general anesthesia: an observational study

BACKGROUND

Point of care ultrasound (POCUS) is being explored for dynamic measurements like inferior vena cava collapsibility index (IVC-CI) and left ventricular outflow tract velocity time integral (LVOT-VTI) to guide anesthesiologists in predicting fluid responsiveness in the preoperative period and in treating post-induction hypotension (PIH) with varying accuracy.

METHODS

In this prospective, observational study on included 100 adult patients undergoing elective surgery under general anesthesia, the LVOT-VTI and IVC-CI measurements were performed in the preoperative room 15 minutes prior to surgery, and PIH was measured for 20 minutes in the post-induction period.

RESULTS

The incidence of PIH was 24%. The area under the curve, sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of the two techniques at 95% confidence interval was 0.613, 30.4%, 93.3%, 58.3%, 81.4%, 73.6% for IVC-CI and 0.853, 83.3%, 80.3%, 57.1%, 93.8%, 77.4% for LVOT-VTI, respectively. In multivariate analysis, the cutoff value for IVC-CI was >51.5 and for LVOT-VTI it was ≤17.45 for predicting PIH with odd ratio [OR] of 8.491 (P=0.025) for IVCCI and OR of 17.427 (P<0.001) for LVOT. LVOT-VTI assessment was possible in all the patients, while 10% of patients were having poor window for IVC measurements.

CONCLUSIONS

We recommend the use of POCUS using LVOT-VTI or IVC-CI to predict PIH, to decrease the morbidity of patients undergoing surgery. Out of these, we recommend LVOT-VTI measurements as it has showed a better diagnostic accuracy (77.4%) with no failure rate.

Evolving the Scope of Cardiac Point-of-Care Ultrasound in the Current Era

Point-of-care ultrasound (POCUS) has become a flexible and multifaceted diagnostic instrument in the realm of cardiac care, transforming the landscape of cardiovascular assessment. This review aims to explore the extensive scope of POCUS applications in cardiac care, highlighting its diverse utility across various medical specialties. POCUS, conducted at the patient's bedside, offers real-time insights into cardiac anatomy and function, providing a valuable adjunct to traditional diagnostic methods. In critically ill patients, POCUS has demonstrated its effectiveness in the rapid evaluation of the left and right ventricular function, identification of pericardial effusion and tamponade, assessment of volume status, and detection of valvular lesions. Its role as an adjunct to the physical examination has been particularly impactful, leading to early diagnoses and significantly influencing medical management decisions. The review also discusses the current limitations of POCUS technology. As the utilization of POCUS continues to expand across diverse medical disciplines, its ability to offer timely and accurate diagnostic information is poised to reshape the standard of care in cardiac medicine. This comprehensive review provides insights into the evolving role of POCUS in cardiac care and underscores its potential to enhance patient outcomes through rapid and informed decision-making at the point of care.

Hand-Held Echocardiography by Advanced Practice Providers in Patients with Congestive Heart Failure

OBJECTIVES

The performed hand-held echocardiography (HHE) was evaluated and interpreted by trained advanced practice providers (APPs) on hospitalized CHF patients for image quality and interpretation by comparing with expert echocardiographer and SE findings.

BACKGROUND

Congestive heart failure (CHF) is associated with increased hospital admissions and mortality. While a standard echocardiogram (SE) is the gold standard for cardiac assessment, it is not readily available. Hospitalized CHF patients require rapid assessment for expedited treatment.

METHODS

Over 6 months, five trained APPs performed HHE on hospitalized CHF patients and interpreted: (a) left ventricular (LV) size, (b) LV ejection fraction (LVEF), and (c) right atrial pressure (RAP). The study echocardiographer reviewed and blindly interpreted the HHE images and compared them with APPs and SE findings. Kappa statistics determined the degree of agreement between APPs and the study echocardiographer's interpretation of the HHE images and SE.

RESULTS

A total of 80 CHF patients (age 73 ± 14 years, 58% males; LVEF (by SE) 45 ± 19%; 36.3% body mass indexes ≥ 30 kg/m2) were enrolled. HHE interpretation by APPs had a good agreement for LVEF (kappa 0.79) with the study echocardiographer and SE (kappa 0.74) and a good agreement for RAP (kappa 0.67) with the study echocardiographer. The correlation between the absolute LVEF interpretation by the study echocardiographer on HHE and SE was r = 0.88 (p < 0.0001).

CONCLUSIONS

Trained APPs obtained diagnostic-quality HHE images and interpreted the LV function and RAP in CHF patients in good agreement with the study echocardiographer. LVEF by HHE correlated with LVEF by SE. Our study suggests trained APPs can use HHE to evaluate LVEF and RAP in CHF patients, leading to expedited and optimized treatment.

Guidance for clinical practice using emergency and point-of-care ultrasonography

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.

Feasibility of Focused Cardiac Ultrasound Performed by Trainees During Cesarean Delivery

BACKGROUND

Anesthesiology experts advocate for formal education in maternal critical care, including the use of focused cardiac ultrasound (FCU) in high-acuity obstetric units. While benefits and feasibility of FCU performed by experts have been well documented, little evidence exists on the feasibility of FCU acquired by examiners with limited experience. The primary aim of this study was to assess how often echocardiographic images of sufficient quality to guide clinical decision-making were attained by trainees with limited experience performing FCU in term parturients undergoing cesarean delivery (CD).

METHODS

In this prospective cohort study, healthy term parturients (American Society of Anesthesiologists [ASA] ≤ 3, ≥37 weeks of gestation) with singleton pregnancy, body mass index (BMI) <40 kg/m2, and no history of congenital and acquired cardiac disease undergoing scheduled, elective CD were recruited by a trainee. After undergoing standardized training, including an 8-hour online E-learning module, a 1-day hands-on FCU course, and 20 to 30 supervised scans until the trainee was assessed competent in image acquisition, 8 trainees with limited FCU experience performed apical 4-chamber (A4CH), parasternal long-axis (PLAX), and short-axis (PSAX) view preoperatively after spinal anesthesia (SPA) and intraoperatively after neonatal delivery (ND). Obtained FCU images were graded 1 to 5 by 2 blinded instructors (1 = no image to 5 = perfect image obtainable; ≥3 defined as image quality sufficient for clinical decision-making).

RESULTS

Following the screening of 95 women, 8 trainees with limited FCU experience each performed a median of 5 [3-8] FCUs in a total of 64 women. Images of sufficient quality were obtainable in 61 (95.3 %) and 57 (89.1 %) of women after SPA and ND, respectively. FCU images of perfect image quality were obtainable in 9 (14.1 %) and 7 (10.9 %) women preoperatively after SPA and intraoperatively after ND, respectively. A PLAX, PSAX, and A4CH view with grade ≥3 was obtained in 53 (82.8 %), 58 (90.6 %) and 40 (62.5 %) of women preoperatively after SPA and in 50 (78.1 %), 49 (76.6 %), and 29 (45.3 %) of women intraoperatively after ND. Left ventricular function could be assessed in 39 of 40 women (97.5 %) preoperatively after SPA and 39 of 40 (97.5%) intraoperatively after ND. Right ventricular function could be assessed in 31 of 40 (77.5 %) after SPA and in 23 of 40 (59%) after ND. We observed a difference in image grading between different trainees in the AP4CH-view (P = .0001). No difference in image grading was found between preoperative and intraoperative FCUs.

CONCLUSIONS

FCU is feasible in the parturient undergoing CD and images of sufficient quality for clinical decision-making were obtained by trainees with limited experience in almost all parturients. Image acquisition and quality in the A4CH view may be impacted by the individual trainee performing the FCU.

Role of point-of-care ultrasound in critical care and emergency medicine: update and future perspective

Point-of-care ultrasound (POCUS) is a rapidly developing technology that has the potential to revolutionize emergency and critical care medicine. The use of POCUS can improve patient care by providing real-time clinical information. However, appropriate usage and proper training are crucial to ensure patient safety and reliability. This article discusses the various applications of POCUS in emergency and critical care medicine, the importance of training and education, and the future of POCUS in medicine.

Identifying commonalities in definition and governance of point-of-care ultrasound within statements from medical organizations in the United States: A scoping review for a shared understanding

This scoping review analyzed statements from 22 medical organizations in the United States to identify commonalities in the definition and governance of point-of-care ultrasound (POCUS). A total of 41 statements were included. The review found that the most commonly used elements in defining POCUS were "focused," "bedside," and "patient care." In terms of governance, consistent requirements included specific training programs, documentation in medical records, continuous quality assurance, and standards for credentialing and privileging. These findings suggest the existence of essential commonalities that could facilitate communication and the development of standardized POCUS programs in the future.

Experimental assessment of cardiovascular physiology in the chick embryo

High resolution assessment of cardiac functional parameters is crucial in translational animal research. The chick embryo is a historically well-used in vivo model for cardiovascular research due to its many practical advantages, and the conserved form and function of the chick and human cardiogenesis programs. This review aims to provide an overview of several different technical approaches for chick embryo cardiac assessment. Doppler echocardiography, optical coherence tomography, micromagnetic resonance imaging, microparticle image velocimetry, real-time pressure monitoring, and associated issues with the techniques will be discussed. Alongside this discussion, we also highlight recent advances in cardiac function measurements in chick embryos.

Perioperative Point of Care Ultrasound for Hemodynamic Assessment: A Narrative Review

While transesophageal echocardiography (TEE) has traditionally been used in perioperative care, there is growing evidence supporting point of care ultrasound (POCUS) for the anesthesiologist in guiding patient care. It is a quick way to non-invasively evaluate hemodynamically unstable patients and ascertain their state of shock, determine volume status, and guide resuscitation in cardiac arrest. In addition, through use of POCUS, the anesthesiologist is able to identify signs of chronic heart disease to provide a more tailored and safer approach to perioperative care.

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

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Machine learning derived echocardiographic image quality in patients with left ventricular systolic dysfunction: insights on the echo views of greatest image quality

We sought to determine the cardiac ultrasound view of greatest quality using a machine learning (ML) approach on a cohort of transthoracic echocardiograms (TTE) with abnormal left ventricular (LV) systolic function. We utilize an ML model to determine the TTE view of highest quality when scanned by sonographers. A random sample of TTEs with reported LV dysfunction from 09/25/2017-01/15/2019 were downloaded from the regional database. Component video files were analyzed using ML models that jointly classified view and image quality. The model consisted of convolutional layers for extracting spatial features and Long Short-term Memory units to temporally aggregate the frame-wise spatial embeddings. We report the view-specific quality scores for each TTE. Pair-wise comparisons amongst views were performed with Wilcoxon signed-rank test. Of 1,145 TTEs analyzed by the ML model, 74.5% were from males and mean LV ejection fraction was 43.1 ± 9.9%. Maximum quality score was best for the apical 4 chamber (AP4) view (70.6 ± 13.9%, p<0.001 compared to all other views) and worst for the apical 2 chamber (AP2) view (60.4 ± 15.4%, p<0.001 for all views except parasternal short-axis view at mitral/papillary muscle level, PSAX M/PM). In TTEs scanned by professional sonographers, the view with greatest ML-derived quality was the AP4 view.

Impact of focused cardiac and lung ultrasound screening performed by a junior doctor during admission to the surgical ward on patients before emergency non-cardiac surgery: A pilot prospective observational study

Purpose

To assess whether pre-operative focused cardiac ultrasound and lung ultrasound screening performed by a junior doctor can change diagnosis and clinical management of patients aged ≥65 years undergoing emergency, non-cardiac surgery.

Method

This pilot prospective observational study included patients scheduled for emergency, non-cardiac surgery. The treating team completed a diagnosis and management plan before and after focused cardiac and lung ultrasound, which was performed by a junior doctor. Changes to diagnosis and management after ultrasound were recorded. Ultrasound images were assessed for image and diagnostic interpretation by an independent expert.

Results

There was a total of 57 patients at age 77 ± 8 years. Cardiopulmonary pathology was suspected after clinical assessment in 28% vs. 72% after ultrasound (including abnormal haemodynamic state in 61%, valvular lesions in 32%, acute pulmonary oedema/interstitial syndrome in 9% and bilateral pleural effusions in 2%). In 67% of patients, the perioperative management was changed. The changes were in fluid therapy in 30%, cardiology consultation in 7%, formal in- or out-patient, transthoracic echocardiography in 11% and 30% respectively.

Discussion

The impact of pre-operative focused cardiac and lung ultrasound on diagnosis and management of patients on the hospital ward before emergency non-cardiac surgery by a junior doctor was comparable to previous studies of anaesthetists experienced in focused ultrasound. However, the ability to recognise when image quality is insufficient for diagnosis is an important consideration for novice sonographers.

Conclusions

Focused cardiac and lung ultrasound examination by a junior doctor is feasible and may change preoperative diagnosis and management in patients of 65 years or older, admitted for emergency non-cardiac surgery.

The Year in Perioperative Echocardiography: Selected Highlights From 2022

THIS SPECIAL article is part of an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the Editorial Board for the opportunity to continue this series, which focuses on the past year's research highlights that pertain to perioperative echocardiography in relation to cardiothoracic and vascular anesthesia. The major selected themes for 2022 include (1) updates on mitral valve assessments and interventions, (2) training and simulation updates, (3) outcomes and complications of transesophageal echocardiography, and (4) point-of-care cardiac ultrasound. The themes selected for this special article are just a sample of the advances in perioperative echocardiography during 2022. An appreciation and understanding of these highlights will help to ensure and improve the perioperative outcomes for patients with cardiovascular disease undergoing cardiac surgery.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

The Evolution of Cardiovascular Ultrasound: A Review of Cardiac Point-of-Care Ultrasound (POCUS) Across Specialties

The use of cardiac point-of-care ultrasound (POCUS) is now widespread in clinics, emergency departments, and all areas of the hospital. Users include medical trainees, advanced practice practitioners, and attending physicians in many specialties and sub-specialties. Opportunities to learn cardiac POCUS and requirements for training vary across specialties as does the scope of the cardiac POCUS examination. In this review, we describe both a brief history of how cardiac POCUS emerged from echocardiography and the state of the art across a variety of medical fields.

Recommendations for Cardiac Point-of-Care Ultrasound in Children: A Report from the American Society of Echocardiography

Cardiac point-of-care ultrasound has the potential to improve patient care, but its application to children requires consideration of anatomic and physiologic differences from adult populations, and corresponding technical aspects of performance. This document is the product of an American Society of Echocardiography task force composed of representatives from pediatric cardiology, pediatric critical care medicine, pediatric emergency medicine, pediatric anesthesiology, and others, assembled to provide expert guidance. This diverse group aimed to identify common considerations across disciplines to guide evolution of indications, and to identify common requirements and infrastructure necessary for optimal performance, training, and quality assurance in the practice of cardiac point-of-care ultrasound in children. The recommendations presented are intended to facilitate collaboration among subspecialties and with pediatric echocardiography laboratories by identifying key considerations regarding (1) indications, (2) imaging recommendations, (3) training and competency assessment, and (4) quality assurance.

Quantification of left ventricular ejection fraction and cardiac output using a novel semi-automated echocardiographic method: a prospective observational study in coronary artery bypass patients

BACKGROUND

Echocardiographic quantification of ejection fraction (EF) by manual endocardial tracing requires training, is time-consuming and potentially user-dependent, whereas determination of cardiac output by pulmonary artery catheterization (PAC) is invasive and carries a risk of complications. Recently, a novel software for semi-automated EF and CO assessment (AutoEF) using transthoracic echocardiography (TTE) has been introduced. We hypothesized that AutoEF would provide EF values different from those obtained by the modified Simpson's method in transoesophageal echocardiography (TOE) and that AutoEF CO measurements would not agree with those obtained via VTI_LVOT in TOE and by thermodilution using PAC.

METHODS

In 167 patients undergoing coronary artery bypass graft surgery (CABG), TTE cine loops of apical 4- and 2-chamber views were recorded after anaesthesia induction under steady-state conditions. Subsequently, TOE was performed following a standardized protocol, and CO was determined by thermodilution. EF and CO were assessed by TTE AutoEF as well as TOE, using the modified Simpson's method, and Doppler measurements via velocity time integral in the LV outflow tract (VTI_LVOT). We determined Pearson's correlation coefficients r and carried out Bland-Altman analyses. The primary endpoints were differences in EF and CO. The secondary endpoints were differences in left ventricular volumes at end diastole (LVEDV) and end systole (LVESV).

RESULTS

AutoEF and the modified Simpson's method in TOE showed moderate EF correlation (r = 0.38, p < 0.01) with a bias of -12.6% (95% limits of agreement (95%LOA): -36.6 - 11.3%). AutoEF CO correlated poorly both with VTI_LVOT in TOE (r = 0.19, p < 0.01) and thermodilution (r = 0.28, p < 0.01). The CO bias between AutoEF and VTI_LVOT was 1.33 l min^-1 (95%LOA: -1.72 - 4.38 l min^-1) and 1.39 l min^-1 (95%LOA -1.34 - 4.12 l min^-1) between AutoEF and thermodilution, respectively. AutoEF yielded both significantly lower EF (EF_AutoEF: 42.0% (IQR 29.0 - 55.0%) vs. EF_{TOE Simpson}: 55.2% (IQR 40.1 - 70.3%), p < 0.01) and CO values than the reference methods (CO_{AutoEF biplane}: 2.30 l min^-1 (IQR 1.30 - 3.30 l min^-1) vs. CO_{VTI LVOT}: 3.64 l min^-1 (IQR 2.05 - 5.23 l min^-1) and CO_PAC: 3.90 l min^-1 (IQR 2.30 - 5.50 l min^-1), p < 0.01)).

CONCLUSIONS

AutoEF correlated moderately with TOE EF determined by the modified Simpson's method but poorly both with VTI_LVOT and thermodilution CO. A systematic bias was detected overestimating LV volumes and underestimating both EF and CO compared to the reference methods.

TRIAL REGISTRATION

German Register for Clinical Trials (DRKS-ID DRKS00010666, date of registration: 08/07/2016).

Cardiac Point-of-Care Ultrasound and Multi-Disciplinary Improvement Opportunities in Acute Systolic Heart Failure Management in a Pediatric Emergency Center

Cardiac point-of-care ultrasound (POCUS) has the ability to rapidly assess function and identify systolic heart failure (HF), an often-missed diagnosis. POCUS has the potential to expedite medical intervention, improving overall outcomes. There have been limited studies describing pediatric emergency center (EC) utilization of cardiac POCUS and its impact on outcomes in pediatric patients. Authors performed a retrospective chart review at a tertiary children's hospital to identify all patients admitted from the EC to the Cardiac Intensive Care Unit (CICU) with acute systolic HF between January 2017 and August 2019. Outcome measures included EC length of stay (LOS), CICU LOS, and time until first IV HF medicine was administered. A total of 21 patients and 24 encounters meeting criteria were identified. Cardiac POCUS agreed with standard echocardiography in 8 of 9 cases. Patients who had a cardiac POCUS in the EC seemed more likely to receive their first dose of intravenous heart failure medication while in the Emergency Center (70% vs 43%). There was a trend toward significance, but it did not reach statistical significance (p = 0.1). EC and CICU LOS were not significantly different between POCUS and non-POCUS groups. Cardiac POCUS has the potential to have a valuable role in the early diagnosis of acute systolic HF in children. However, early diagnosis by POCUS did not translate into shorter EC or CICU LOS. This pilot data serves as a baseline for efforts to promote earlier clinical recognition of acute HF and more efficient collaboration between clinical services.

FoCUS cardiac ultrasound training for undergraduates based on current national guidelines: a prospective, controlled, single-center study on transferability

INTRODUCTION

In emergency and critical-care medicine, focused cardiac ultrasound (FoCUS) is indispensable for assessing a patient's cardiac status. The aim of this study was to establish and validate a peer-to-peer-supported ultrasound course for learning FoCUS-specific skills during undergraduate studies at a German university.

METHODS

A 1-day, 12 teaching units training course was developed for students in the clinical section of medical college, with content based on the current national guidelines. A total of 217 students participated in the study (97 in the course group and 120 in the control group). The course and the participants' subjective assessment of improved skills were evaluated using a questionnaire (7-point Likert scale; 7 = complete agreement and 1 = no agreement at all). Objective learning gains were assessed by tests before and after the course. These consisted of a test of figural intelligence (eight items) and a test of technical knowledge (13 items).

RESULTS

The course participants experienced significant improvement (P < 0.001) from before to after the course, with a large effect size of η²_part = 0.26. In addition, the course group had significantly better results (P < 0.001) than the control group in the post-test, with a medium to large effect size of η²_part = 0.14. No significant differences (P = 0.27) were detected in the test section on figural intelligence. The evaluations showed that the participants had a high degree of satisfaction with the course approach, teaching materials, and tutors. There was also a positive increase in their subjective assessment of their own skills, including areas such as technical knowledge, ultrasound anatomy, and performance of the examination.

CONCLUSION

The results of both the objective learning assessment and the subjective evaluations suggest that a FoCUS course originally intended for qualified physicians is equally suitable for students. With the development and provision of modern digital teaching media, even more students will be able to benefit from this approach in the future.

Focused cardiac ultrasound in pregnancy

Cardiac disease in pregnancy is an important cause of maternal morbidity and mortality. In many high-income countries, acquired cardiac disease is now the largest cause of maternal mortality. Given its prevalence in low- and middle-income countries (LMICs), rheumatic heart disease is the most common cause of cardiac disease in pregnancy worldwide and is associated with poor maternal outcome. The diagnosis of cardiac disease in pregnancy is often delayed resulting in excess maternal morbidity and mortality. Maternal mortality review committees have suggested that prompt recognition and treatment of heart disease in pregnancy may improve maternal outcome. Given the similarities between symptoms of normal pregnancy and those of cardiac disease, the clinical diagnosis of heart disease in pregnancy is challenging with echocardiography being the primary diagnostic modality. Focused cardiac ultrasound (FOCUS) at the point of care provides supplemental data to the history and physical examination and has been demonstrated to permit early diagnosis and improvement in the management of cardiac disease in emergency medicine, intensive care, and anesthesia. It has also been demonstrated to be useful in surveillance for rheumatic heart disease in LMICs. The use of FOCUS may allow earlier and more accurate diagnosis of cardiac disease in pregnancy with the potential to decrease morbidity and mortality in both developed and developing countries.

Concise, Practical Review on Transthoracic Lung Ultrasound in Prehospital Diagnosis of Dyspnea in Adults

Ultrasonography is a relatively young but widely recognized method of imaging parenchymal organs, including the lungs. Our concise, practical review on transthoracic lung ultrasound (LUS) in the prehospital diagnosis of dyspnea in adults attempts to summarize current knowledge in the field. Furthermore, we discussed POCUS protocols in the analyzed context, discussing their usefulness. We concluded that bedside ultrasonography, or point of care (POCUS), is developing rapidly; however, the knowledge about the use of LUS in a pre-hospital setting is scarce, highlighting the need for further research in this field. Additionally, despite the possibility of using various ultrasound protocols in diagnosing a patient with dyspnea, there is no comprehensive and, at the same time, highly sensitive and specific protocol covering a satisfactory saccade of differential diagnosis of this symptom. It seems reasonable to conduct further targeted research to create such a dedicated solution.

Practitioners' views on community implementation of point-of-care ultrasound (POCUS) in the UK: a qualitative interview study

BACKGROUND

Implementing Point-of-care ultrasound (POCUS) in community practice could help to decide upon and prioritise initial treatment, procedures and appropriate specialist referral or conveyance to hospital. A recent literature review suggests that image quality, portability and cost of ultrasound devices are all improving with widening indications for community POCUS, but evidence about community POCUS use is needed in the UK. We aimed to explore views of clinical practitioners, actively using ultrasound, on their experiences of using POCUS and potential facilitators and barriers to its wider implementation in community settings in the UK.

METHODS

We conducted a qualitative interview study with practitioners from community and secondary care settings actively using POCUS in practice. A convenience sample of eligible participants from different clinical specialties and settings was recruited using social media adverts, through websites of relevant research groups and snowball sampling. Individual semi-structured interviews were conducted online using Microsoft Teams. These were recorded, transcribed verbatim, and analysed using a Framework approach supported by NVivo 12.

RESULTS

We interviewed 16 practitioners aged between 40 and 62 years from different professional backgrounds, including paramedics, emergency physicians, general practitioners, and allied health professionals. Participants identified key considerations and facilitators for wider implementation of POCUS in community settings in the UK: resource requirements for deployment and support of working devices; sufficient time and a skilled workforce; attention to training, education and support needs; ensuring proper governance, guidelines and quality assurance; workforce considerations; enabling ease of use in assisting decision making with consideration of unintended consequences; and more robust evidence to support perceptions of improved patient outcomes and experience.

CONCLUSIONS

POCUS could be useful for improving patient journey and health outcomes in community care, but this requires further research to evaluate outcomes. The facilitators identified could help make community POCUS a reality.

New Developments in Continuous Hemodynamic Monitoring of the Critically Ill Patient

Hemodynamic monitoring is a cornerstone in the assessment of patients with circulatory shock. Timely recognition of hemodynamic compromise and proper optimisation is essential to ensure adequate tissue perfusion and maintain renal, hepatic, abdominal, and cerebral functions. Hemodynamic monitoring has significantly evolved since the first inception of the pulmonary artery catheter more than 50 years ago. Bedside echocardiography, when combined with noninvasive and minimally invasive technologies, provides tools to monitor and quantify the cardiac output to promptly react and improve hemodynamic management in an acute care setting. Commonly used technologies include noninvasive pulse-wave analysis, pulse-wave transit time, thoracic bioimpedance and bioreactance, esophageal Doppler, minimally invasive pulse-wave analysis, transpulmonary thermodilution, and pulmonary artery catheter. These monitoring strategies are reviewed here, along with detailed analysis of their operating mode, particularities, and limitations. The use of artificial intelligence to enhance performance and effectiveness of hemodynamic monitoring is reviewed to apprehend future possibilities.

Transesophageal Echocardiography in Patients in Cardiac Arrest: The Heart and Beyond

Point of care ultrasound involves different ultrasound modalities and is useful to assist management in emergent clinical situations such as cardiac arrest. The use of point of care ultrasound in cardiac arrest has mainly been described using transthoracic echocardiography as a diagnostic and as a prognostic tool. However, cardiac evaluation using transthoracic echocardiography might be challenging because of patient-related or technical factors. Furthermore, its use during pulse check pauses has been associated with delays in chest compression resumption. Transesophageal echocardiography (TEE) overcomes these limitations by providing reliable and continuous imaging of the heart without interfering with cardiopulmonary resuscitation. In this narrative review we describe the role of TEE during cardiopulmonary resuscitation in 4 different applications: (1) chest compression quality feedback; (2) rhythm characterization; (3) diagnosis of reversible causes; and (4) procedural guidance. Considering its limitations, we propose an algorithm for the integration of TEE in patients with cardiac arrest with a focus on these 4 applications and extend its use to extracardiac applications.

Focused Cardiac Ultrasound to Guide the Diagnosis of Heart Failure in Pregnant Women in India

BACKGROUND

Cardiac complications are a leading cause of maternal death. Cardiac imaging with echocardiography is important for prompt diagnosis, but it is not available in many low-resource settings. The aim of this study was to determine whether focused cardiac ultrasound performed by trained obstetricians and interpreted remotely by experts can identify cardiac abnormalities in pregnant women in low-resource settings.

METHODS

A cross-sectional study was conducted among 301 pregnant and postpartum women recruited from 10 hospitals across three states in India. Twenty-two obstetricians were trained in image acquisition using a portable cardiac ultrasound device following a simplified protocol adapted from focus-assessed transthoracic echocardiography protocol. It included parasternal long-axis, parasternal short-axis, and apical four-chamber views on two-dimensional and color Doppler. Independent image interpretation was performed remotely by two experts, in the United Kingdom and India, using a standard semiquantitative assessment protocol. Interrater agreement between the experts was examined using Cohen's κ. Diagnostic accuracy of the method was examined in a subsample for whom both focused and conventional scans were available.

RESULTS

Cardiac abnormalities identified using the focused method included valvular abnormalities (27%), rheumatic heart disease (6.6%), derangements in left ventricular size (4.7%) and function (22%), atrial dilatation (19.5%), and pericardial effusion (30%). There was substantial agreement on the cardiac parameters between the two experts, ranging from 93.6% (κ = 0.84) for left ventricular ejection fraction to 100% (κ = 1) for valvular disease. Image quality was graded as good in 79% of parasternal long-axis, 77% of parasternal short-axis and 64% of apical four-chamber views. The chance-corrected κ coefficients indicated fair to moderate agreement (κ = 0.28-0.51) for the image quality parameters. There was good agreement on diagnosis between the focused method and standard echocardiography (78% agreement), compared in 36 participants.

CONCLUSIONS

The focused method accurately identified cardiac abnormalities in pregnant women and could be used for screening cardiac problems in obstetric settings.

The Impact of Bedside Cardiac Point-of-Care Ultrasound on the Utilization of Cardiology Subspecialty Resources in a Pediatric Emergency Department

OBJECTIVE

This study sought to determine the impact of cardiac point-of-care ultrasound (cPOCUS) in a pediatric emergency department (ED) on cardiology subspecialty utilization for subjects with chest pain or syncope. Diagnostic yield of cPOCUS and transthoracic echocardiograms (TTEs) for these subjects was also examined.

METHODS

A retrospective chart review of subjects presenting to a tertiary pediatric ED with chest pain or syncope 1 year before (2015, pre-cPOCUS group) and 1 year after (2017, cPOCUS group) introduction of cPOCUS was conducted. Subjects aged 2 to 18 years evaluated for these symptoms were included. Those with known heart defects, prior abnormal TTE, or asthma exacerbation at presentation were excluded. In both groups, cardiology subspecialty utilization was assessed by determining whether cardiology referrals, cardiology consultations, or follow-up TTEs were completed. Results of TTEs were reviewed and classified as incidental (no follow-up needed), minor (follow-up needed, but intervention unlikely), moderate (nonurgent intervention needed), and severe (hospitalization/urgent intervention needed). Cardiac point-of-care ultrasound results were compared with any follow-up TTEs. Data were analyzed using χ 2 or Student t test as appropriate.

RESULTS

A total of 1230 subjects were analyzed: 595 pre-cPOCUS and 635 cPOCUS group. There was no significant difference in TTEs (42 vs 46), cardiology consultations (36 vs 37), or cardiology referrals (47 vs 37) between groups. Of 67 cPOCUS scans performed, 63 were normal, 3 showed small pericardial effusion, and 2 demonstrated left ventricular dysfunction. Of 88 TTEs in both groups (0.7% subjects), 76 were normal, 5 had incidental, 6 had minor, and 1 had a severe finding present on cPOCUS (0.08% subjects; 95% confidence interval, 0%-0.45%).

CONCLUSIONS

The introduction of cPOCUS did not increase cardiology subspecialty utilization in subjects presenting to the pediatric ED with chest pain or syncope. Cardiac point-of-care ultrasound may be useful in evaluating global biventricular systolic function and effusion in this population.

Pathophysiology of fluid administration in critically ill patients

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

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

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

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

The effects of preoperative focused cardiac ultrasound in high-risk patients: A randomised controlled trial (PREOPFOCUS)

BACKGROUND

Surgery is the third most common cause of mortality worldwide. Focused cardiac ultrasound (FOCUS) yields information on cardiac status and discloses the presence of unknown pathology. Preoperative FOCUS changes patient treatment, allowing for a patient-tailored anaesthesia. We hypothesised that preoperative FOCUS would reduce the proportion of patients who were either admitted to hospital for more than 10 days or who were dead within 30 days after high-risk, non-cardiac surgery.

METHODS

This was a randomised, controlled, multi-center study. Patients ≥65 years of age, admitted for urgent orthopaedic- or abdominal surgery, scheduled for general- or neuraxial anaesthesia and with ASA 3/4 were eligible for inclusion. Patients were randomised in a 1:1 ratio to preoperative FOCUS or no preoperative FOCUS performed in accordance with a predefined protocol. Primary endpoint was the proportion of patients admitted more than 10 days or who were dead within 30 days. Secondary endpoints included major complications, days of admission and changes in anaesthesia handling.

RESULTS

During the second COVID-19 wave the study monitoring committee terminated the study prematurely. We included 338 patients of which 327 were included in the final analysis. In the FOCUS group, 41/163 (25%) patients met the criteria for the primary endpoint versus 35/164 (21%) for the control group, adjusted odds ratio 1.37 (95% CI 0.86-2.30), p = .36. The proportions of patients who developed major complications did not differ significantly between groups. Length of hospital stay was 4 (3-8) days in the FOCUS group and 4 (3-7) days on the control group (adjusted p = .24).

CONCLUSION

The routine availability of preoperative FOCUS assessment in this cohort does not appear to reduce the risk for hospitalisation exceeding 10 days or 30-day mortality, although study enrolment was prematurely terminated.

A prospective randomized study to compare standard versus intensive training strategies on long-term improvement in critical care ultrasonography proficiency

BACKGROUND

Critical care ultrasonography (CCUS) has become a daily diagnostic tool for intensivists. While the effective training measures for ultrasound novices are discussed widely, the best curriculum for the novices to retain a long-term proficiency is yet to be determined.

METHODS

Critical care medicine fellows who underwent an introductory CCUS workshop were randomly allocated into the standard training (ST) or the intensive training (IT) group. The IT group received an 8-h training besides the standardized fellowship education that the ST group received. Participant improvement in CCUS proficiency tests (maximum score, 200) after a 6-month training intervention was compared between the groups. CCUS examinations performed in patient care were observed over 2 years.

RESULTS

Twenty-one fellows were allocated into the ST (n = 10) or the IT (n = 11) group. No statistically significant difference was observed in the median (interquartile range [IQR]) improvement in CCUS proficiency tests between the ST group and the IT group: 18 (3.8-38) versus 31 (21-46) (P = .09). Median (IQR) test scores were significantly higher in postintervention than preintervention for both groups: ST, 103 (87-116) versus 124 (111-143) (P = .02), and IT, 100 (87-113) versus 143 (121-149) (P < .01). Participating fellows performed 226 examinations over the 2 years of observation.

CONCLUSIONS

Fellows improved their CCUS proficiency significantly after 6-month training intervention. However, an additional 8-h training did not provide further benefits.

Point-of-Care Ultrasound Diagnosis of Tetralogy of Fallot Causing Cyanosis: A Case Report

INTRODUCTION

Tetralogy of Fallot (TOF) is a congenital heart defect with characteristic features leading to unique physical exam and ultrasound findings. In settings where there is limited prenatal screening, TOF can present with cyanosis at any time from the neonatal period to adulthood depending on the degree of obstruction of the right ventricular outflow tract.

CASE REPORT

This case describes a pediatric patient who presented with undifferentiated dyspnea and cyanosis, for whom point-of-care ultrasound (POCUS) supported the diagnosis of TOF. We highlight the important role POCUS can play in a setting with limited access to formal echocardiography or consultative pediatric cardiology services.

CONCLUSION

This report highlights the utility of POCUS as an inflection point in the diagnostic and management pathway of this patient, which is particularly important when working in a limited-resource or rural setting.

Real-time automatic quantification of left ventricular function by hand-held ultrasound devices in patients with suspected heart failure: a feasibility study of a diagnostic test with data from general practitioners, nurses and cardiologists

OBJECTIVES

To evaluate the feasibility and reliability of hand-held ultrasound (HUD) examinations with real-time automatic decision-making software for ejection fraction (autoEF) and mitral annular plane systolic excursion (autoMAPSE) by novices (general practitioners), intermediate users (registered cardiac nurses) and expert users (cardiologists), respectively, compared to reference echocardiography by cardiologists in an outpatient cohort with suspected heart failure (HF).

DESIGN

Feasibility study of a diagnostic test.

SETTING AND PARTICIPANTS

166 patients with suspected HF underwent HUD examinations with autoEF and autoMAPSE measurements by five novices, three intermediate-skilled users and five experts. HUD results were compared with a reference echocardiography by experts. A blinded cardiologist scored all HUD recordings with automatic measurements as (1) discard, (2) accept, but adjust the measurement or (3) accept the measurement as it is.

PRIMARY OUTCOME MEASURE

The feasibility of automatic decision-making software for quantification of left ventricular function.

RESULTS

The users were able to run autoEF and autoMAPSE in most patients. The feasibility for obtaining accepted images (score of ≥2) with automatic measurements ranged from 50% to 91%. The feasibility was lowest for novices and highest for experts for both autoEF and autoMAPSE (p≤0.001). Large coefficients of variation and wide coefficients of repeatability indicate moderate agreement. The corresponding intraclass correlations (ICC) were moderate to good (ICC 0.51-0.85) for intra-rater and poor (ICC 0.35-0.51) for inter-rater analyses. The findings of modest to poor agreement and reliability were not explained by the experience of the users alone.

CONCLUSION

Novices, intermediate and expert users were able to record four-chamber views for automatic assessment of autoEF and autoMAPSE using HUD devices. The modest feasibility, agreement and reliability suggest this should not be implemented into clinical practice without further refinement and clinical evaluation.

TRIAL REGISTRATION NUMBER

NCT03547076.

Evaluation of an advanced critical care echocardiography program: a mixed methods study

PURPOSE

Limited data exist on advanced critical care echocardiography (CCE) training programs for intensivists. We sought to describe a longitudinal echocardiography program and investigate the effect of distributed conditional supervision vs predefined en-bloc supervision, as well as the effect of an optional echocardiography laboratory rotation, on learners' engagement.

METHODS

In this mixed methods study, we enrolled critical care fellows and faculty from five University of Toronto-affiliated intensive care units (ICU) between July 2015 and July 2018 in an advanced training program, comprising theoretical lectures and practical sessions. After the first year, the program was modified with changes to supervision model and inclusion of a rotation in the echo laboratory. We conducted semistructured interviews and investigated the effects of curricular changes on progress toward portfolio completion (150 transthoracic echocardiograms) using a Bayesian framework.

RESULTS

Sixty-five learners were enrolled and 18 were interviewed. Four (9%) learners completed the portfolio. Learners reported lack of time and supervision, and skill complexity as the main barriers to practicing independently. Conditional supervision was associated with a higher rate of submitting unsupervised echocardiograms than unconditional supervision (rate ratio, 1.11, 95% credible interval, 1.08 to 1.14). After rotation in the echocardiography laboratory, submission of unsupervised echocardiograms decreased.

CONCLUSION

Trainees perceived lack of time and limited access to supervision as major barriers to course completion. Nevertheless, successful portfolio completion was related to factors other than protected time in the echocardiography laboratory or unconditional direct supervision in ICU. Further research is needed to better understand the factors promoting success of CCE training programs.

Focused Cardiac Ultrasound Training for Non-cardiologists: An Overview and Recommendations for a Lower Middle-Income Country

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.

Medical instrument detection in ultrasound: a review

Medical instrument detection is essential for computer-assisted interventions, since it facilitates clinicians to find instruments efficiently with a better interpretation, thereby improving clinical outcomes. This article reviews image-based medical instrument detection methods for ultrasound-guided (US-guided) operations. Literature is selected based on an exhaustive search in different sources, including Google Scholar, PubMed, and Scopus. We first discuss the key clinical applications of medical instrument detection in the US, including delivering regional anesthesia, biopsy taking, prostate brachytherapy, and catheterization. Then, we present a comprehensive review of instrument detection methodologies, including non-machine-learning and machine-learning methods. The conventional non-machine-learning methods were extensively studied before the era of machine learning methods. The principal issues and potential research directions for future studies are summarized for the computer-assisted intervention community. In conclusion, although promising results have been obtained by the current (non-) machine learning methods for different clinical applications, thorough clinical validations are still required.

Point-of-care ultrasound in pediatric nephrology

Point-of-care ultrasound (POCUS) has evolved in recent years in clinical practice, helping in early bedside diagnosis of important etiologies. Many medical schools and training programs are integrating POCUS into their curriculum. Especially with the technological advances of newer handheld ultrasound devices, POCUS has now become a component adjunct to clinical examination, in the clinic and bedside in critical care units. The diagnostic utility of POCUS lies both in early identification of critical kidney disease, and also extra-renal pathologies from a focused cardiac ultrasound, lung ultrasound, and integrated fluid assessment. There is a need to incorporate POCUS in training in pediatric nephrology and establish competency standard criteria. This review shall cover how POCUS helps in enhancing patient care in pediatric kidney disorders and critical children, and the recent advances.

Feasibility, diagnostic performance and clinical value of an abbreviated echocardiography protocol in an out-patient cardiovascular setting: a pilot study

Background

There has been a growing demand for echocardiography services over the last 5 years, with this supply–demand mismatch exacerbated by the COVID-19 pandemic. Prior studies have suggested a high proportion of normal findings among echocardiograms requested for patients without known cardiovascular disease, particularly in low-risk cohorts. This pilot study investigates the role of an abbreviated echocardiography protocol in improving access to echocardiography services in a low-risk outpatient setting within the rapid access chest pain (RACP) clinic.

Method

A retrospective review of electronic medical records and transthoracic echocardiography (TTE) studies for 212 patients from RACP clinic in 2019 (cohort A), prior to the introduction of the abbreviated echocardiography protocol, and 175 patients seen in the RACP clinic in 2021 (cohort B) was performed. The outcomes measured include the echocardiography referral burden from RACP clinic, waiting time for a TTE and echocardiography findings.

Results

33% and 45% of patients seen in the RACP clinic in 2019 and 2021, respectively, were referred for a TTE. The most common indications include chest pain (50%), dyspnoea (19%) and palpitations (11%). Abnormal findings were identified in 36% of TTEs performed in cohort A and 13% in cohort B. The median echocardiogram study time was significantly shorter in cohort B (7 min vs 13 min, p < 0.00001), with a lower number of images acquired (43 vs. 62, p < 0.00001). The median waiting time for an echocardiography in cohort B was significantly shorter (median: 14 days vs. 42 days in 2019, p < 0.00001). No major pathologies were missed on a retrospective review of these images.

Conclusion

Our study demonstrates that an abbreviated echocardiography protocol has potential to improve access to echocardiography services through increasing scheduling capacity, without compromising diagnostic performance in a low-risk outpatient population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s44156-022-00009-2.

Mixed Machine Learning Approach for Efficient Prediction of Human Heart Disease by Identifying the Numerical and Categorical Features

Heart disease is a danger to people’s health because of its prevalence and high mortality risk. Predicting cardiac disease early using a few simple physical indications collected from a routine physical examination has become difficult. Clinically, it is critical and sensitive for the signs of heart disease for accurate forecasts and concrete steps for future diagnosis. The manual analysis and prediction of a massive volume of data are challenging and time-consuming. In this paper, a unique heart disease prediction model is proposed to predict heart disease correctly and rapidly using a variety of bodily signs. A heart disease prediction algorithm based on the analysis of the predictive models’ classification performance on combined datasets and the train-test split technique is presented. Finally, the proposed technique’s training results are compared with the previous works. For the Cleveland, Switzerland, Hungarian, and Long Beach VA heart disease datasets, accuracy, precision, recall, F1-score, and ROC-AUC curves are used as the performance indicators. The analytical outcomes for Random Forest Classifiers (RFC) of the combined heart disease datasets are F1-score 100%, accuracy 100%, precision 100%, recall 100%, and the ROC-AUC 100%. The Decision Tree Classifiers for pooled heart disease datasets are F1-score 100%, accuracy 98.80%, precision 98%, recall 99%, ROC-AUC 99%, and for RFC and Gradient Boosting Classifiers (GBC), the ROC-AUC gives 100% performance. The performances of the machine learning algorithms are improved by using five-fold cross validation. Again, the Stacking CV Classifier is also used to improve the performances of the individual machine learning algorithms by combining two and three techniques together. In this paper, several reduction methods are incorporated. It is found that the accuracy of the RFC classification algorithm is high. Moreover, the developed method is efficient and reliable for predicting heart disease.

Prevalence of Cardiac Dysfunction in Malawian Children With Severe Febrile Illness

OBJECTIVES

To investigate the prevalence of left ventricular systolic dysfunction (LVSD) in Malawian children with severe febrile illness and to explore associations between LVSD and mortality and lactate levels.

DESIGN

Prospective observational study.

SETTING

Pediatric ward of a tertiary government referral hospital in Malawi.

PATIENTS

Children between 60 days and 10 years old with severe febrile illness (fever with at least one sign of impaired perfusion plus altered mentation or respiratory distress) were enrolled at admission from October 2017 to February 2018.

INTERVENTIONS

Focused cardiac ultrasound (FoCUS) was performed, and serum lactate was measured for each child at enrollment, with repeat FoCUS the following day. LV systolic function was later categorized as normal, reduced, severely reduced, or hyperdynamic by two pediatric cardiologists blinded to clinical course and outcomes.

MEASUREMENTS AND MAIN RESULTS

Fifty-four children were enrolled. LVSD was present in 14 children (25.9%; 95% CI, 15.4-40.3%), of whom three had severely reduced function. Thirty patients (60%) had a lactate greater than 2.5 mmol/L, of which 20 (40%) were markedly elevated (>5 mmol/L). Ten children died during admission (18.5%). Of children who survived, 22.7% had decreased LV systolic function versus 40% of those who died. Dysfunction was not associated with mortality or elevated lactate.

CONCLUSIONS

Cardiac dysfunction may be present in one in four Malawian children with severe febrile illness, and mortality in these patients is especially high. Larger studies are needed to further clarify the role cardiac dysfunction plays in mortality and integrate practical bedside assessments for decision support around individualized resuscitation strategies.