Positioning document on incorporating point-of-care ultrasound in Internal Medicine departments

Executive summary of the consensus document for the training and development of clinical ultrasound in Internal Medicine: Recommendations from the Clinical Ultrasound Working Group of the Spanish Society of Internal Medicine (GTECO-SEMI)

INTRODUCTION

Given the increasing adoption of clinical ultrasound in medicine, it is essential to standardize its application, training, and research.

OBJECTIVES AND METHODS

The purpose of this document is to provide consensus recommendations to address questions about the practice and operation of clinical ultrasound units. Nineteen experts and leaders from advanced clinical ultrasound units participated. A modified Delphi consensus method was used.

RESULTS

A total of 137 consensus statements, based on evidence and expert opinion, were considered. The statements were distributed across 10 areas, and 99 recommendations achieved consensus.

CONCLUSIONS

This consensus defines the most important aspects of clinical ultrasound in the field of Internal Medicine, with the aim of standardizing and promoting this healthcare advancement in its various aspects. The document has been prepared by the Clinical Ultrasound Working Group and endorsed by the Spanish Society of Internal Medicine.

The Association Between Intra-abdominal Pressure and Diuretic Response in Heart Failure

PURPOSE OF THE REVIEW

An efficient diuretic response is vital during cardiac decompensation in heart failure (HF) patients. The increase in intra-abdominal pressure (IAP) could be one of the keys for understanding cardiorenal syndrome and guiding diuretic treatment during hospitalization. In this review, we analyze the relationship between IAP and diuretic response in HF patients.

RECENT FINDINGS

Increased IAP is associated with worsening renal function (WRF) in patients with advanced HF. Furthermore, the persistence of a rise in IAP after the first 72 h of intravenous diuretic treatment has been correlated with a worse diuretic response, a higher degree of congestion, and an impaired prognosis. The rise in IAP in HF patients has been associated with impaired renal function and a lower diuretic response. Nonetheless, more studies are needed to elucidate the actual role of IAP in congestive nephropathy and whether it may help guide diuretic therapy during acute decompensations.

Main applications of point-of care ultrasound in palliative care

Combined with a physical examination, clinical ultrasound offers a valuable complement that can help guide clinical decision-making. In various medical and surgical specialties, it is increasingly used for diagnostic and therapeutic purposes. Due to recent technological advances, smaller and more affordable ultrasound machines are now being developed for use in home hospice care. The purpose of this paper is to describe how clinical ultrasound may be applied in Palliative Care, where it can be a valuable tool to assist the clinician in making better clinical decisions and to assist in accurately guiding palliative procedures. Furthermore, it can be used to identify unnecessary hospitalizations and prevent them from occurring. Training programs with specific objectives are necessary to implement clinical ultrasound in Palliative Care, as well as defining learning curves and promoting alliances with scientific societies that recognize the teaching, care and research trajectory for accreditation of competencies.

Point-of-Care Ultrasound (POCUS) as an Extension of the Physical Examination in Patients with Bacteremia or Candidemia

Background: In general, transthoracic echocardiography (TTE) is the first diagnostic test used for patients with bacteremia or candidemia and clinical signs of Infective Endocarditis (IE). Point-of-care ultrasound (POCUS) may be used in addition to physical examination for the detection of structural heart disease and valve abnormalities. Objective: To determine the diagnostic accuracy of POCUS for the detection of signs suggestive of IE, including vegetation, valvular regurgitation, structural heart disease, hepatomegaly, splenomegaly and septic embolisms, in patients with bacteremia or candidemia. Design: Observational, cross-sectional, multicenter study using convenience sampling. Setting: Six Spanish academic hospitals. Patients: Adult patients with bacteremia or candidemia between 1 February 2018 and 31 December 2020. Measurements: The reference test, to evaluate vegetation, valvular regurgitation and structural heart disease, was transesophageal echocardiography (TEE). For patients who did not undergo TEE, transthoracic echocardiography (TTE) was considered the reference test. POCUS was performed by internists, while conventional echocardiography procedures were performed by cardiologists. Results: In 258 patients, for the detection of valvular vegetation, POCUS had sensitivity, specificity, and positive and negative predictive values of 77%, 94%, 82% and 92%, respectively. For valvular regurgitation (more than mild), sensitivity was ≥76% and specificity ≥85%. Sensitivity values for the detection of hepatomegaly and splenomegaly were 92% and 92%, respectively, while those for specificity were 96% and 98%. Conclusion: POCUS could be a valuable tool, as a complement to physical examination, at the hospital bedside for patients with bacteremia or candidemia, helping to identify signs suggestive of IE.

Clinical Impact of Point-of-Care Ultrasound in Internal Medicine Inpatients: A Systematic Review

The aim in this systematic review was to determine the effect of point-of-care ultrasound (POCUS) on the clinical decision-making process and patient outcomes in adults admitted to the general medicine ward. A comprehensive search was performed in MEDLINE (Ovid), EMBASE (Ovid), PubMed, the Cochrane Library, ClinicalTrials.gov, Scopus, LILACS and Cinahl. Articles had to fulfill the inclusion criteria of randomised or non-randomised studies assessing the impact of POCUS on the diagnosis, management, length of hospital stay or mortality of patients admitted to the internal medicine ward. Six studies were included involving a total of 1836 patients. The influence of POCUS on the diagnosis was reported as a change in the main diagnosis or the addition of a relevant diagnosis in up to 18% and 24% of the cases, respectively. Impact on the management plan was reported in 37% to 52.1% of the participants. Three studies documented the impact of POCUS on the length of stay. Two of them reported no difference between groups, and the other reported a significant reduction of 1 d of the hospital stay. In conclusion, POCUS appears to have positive effects on the clinical decision-making process with impacts on optimal patient management and possible reduction in the hospital length of stay.

Comparative Anesthesia Effect of Brachial Plexus Block Based on Smart Electronic Medical Ultrasound-Guided Positioning and Traditional Anatomical Positioning

With the intensification of population aging, the improvement of visualization technology, and the concept of accelerated rehabilitation surgery, the anesthesia method of upper extremity surgery is gradually changing. However, these methods are often caused by anatomical variations and often have low block success rates and patient satisfaction. The neuroanatomical position should be accurately located so that the puncture needle is right next to the nerve bundle or in the nerve sheath. This is very important for implementing accurate brachial plexus anesthesia. This article uses ultrasound-guided positioning technology and traditional anatomical positioning technology for brachial plexus block treatment, aiming to explore the anesthesia effect of brachial plexus block with different techniques. This article selects 120 patients undergoing brachial plexus block surgery for forearm or hand surgery and divides these 120 patients into 6 groups with 20 people in each group. The first 3 groups were treated with brachial plexus block using ultrasound-guided positioning technology. The latter 3 groups were treated with brachial plexus block using traditional anatomical positioning technology. Experiments proved that during anesthesia, compared with the ultrasound group, the heart rate of the traditional anatomy group was significantly decreased (P < 0.05), and the average arterial pressure of the six groups of patients at each time point had no statistical difference (P > 0.05). This shows that whether it is ultrasound-guided positioning technology or traditional anatomical positioning technology, it has no effect on the average arterial pressure of the patient at each time point. In addition to intuitive and accurate viewing of needle and nerve contact, ultrasound real-time guidance allows intuitive viewing of anesthesia. This is a special advantage of nerve block under ultrasound guidance.

Emerging applications of clinical ultrasonography

In this work, we introduce the numerous emerging areas and frontiers in the use of point-of-care ultrasonography. Of these, we review the following three: 1) the use of clinical ultrasonography in infectious and tropical diseases (we address its usefulness in the diagnosis and follow-up of the main syndromes, in tropical diseases, and in areas with scarce resources); 2) the usefulness of clinical ultrasonography in the assessment of response to volume infusion in severely ill patients (we review basic concepts and the main static and dynamic variables used for this evaluation); and 3) the use of clinical ultrasonography in the assessment of muscle mass in elderly patients with primary sarcopenia (we review the main muscles and measurements used for it).

Emerging applications of clinical ultrasonography

In this work, we introduce the numerous emerging areas and frontiers in the use of point-of-care ultrasonography. Of these, we review the following three: 1) the use of clinical ultrasonography in infectious and tropical diseases (we address its usefulness in the diagnosis and follow-up of the main syndromes, in tropical diseases, and in areas with scarce resources); 2) the usefulness of clinical ultrasonography in the assessment of response to volume infusion in severely ill patients (we review basic concepts and the main static and dynamic variables used for this evaluation); and 3) the use of clinical ultrasonography in the assessment of muscle mass in elderly patients with primary sarcopenia (we review the main muscles and measurements used for it).

Point-of-care ultrasound in internal medicine: A position paper by the ultrasound working group of the European federation of internal medicine

Point-of-care ultrasound (POCUS) is increasingly used to assess medical patients. It has many uses in daily clinical practice, including improved diagnostic timeliness and accuracy, and providing information about a patient's prognosis and follow-up. It has been integrated into numerous specialities, but remains relatively undefined in internal medicine training programs. Ultrasonography is a useful tool in the standard clinical practice of internists in numerous clinical scenarios (Emergency Department, hospital ward, general and specific consultations, and home care). Although POCUS has been recently included in the European curriculum of internal medicine, there are differences between European internists in its use, ranging from not at all to well structured educational programs. The use of POCUS needs to be widespread in internal medicine departments, and to accomplish this we must encourage structured training. This document details the consensus-based recommendations by the European Federation of Internal Medicine (EFIM) Ultrasound working group. We establish POCUS core competencies and clinical settings for internists in a symptom-based approach. We also propose training requirements, providing a framework for training programs at a national level.

Diagnostic Capacity of Pocket-Sized Ultrasound Devices at Point of Care by a Non-radiologist Resident in Patients with Suspected Abdominal Pathology

Studies have reported the usefulness and tolerability in practice of abdominal ultrasound performed by non-radiologists in various clinical situations. This prospective observational single-center study included 184 patients hospitalized in an internal medicine department who underwent conventional abdominal ultrasound. A medical resident with basic training performed point-of-care clinical ultrasound using a pocket-sized device. The concordance obtained between the researcher and the radiologist was good (k >0.6) for the gallbladder, splenomegaly, longitudinal diameter of the kidney, presence of renal cysts and hydronephrosis. The specificity was >90% for all parameters assessed except normal renal size. A negative predictive value >90% was obtained for all variables studied except the presence of hepatic space-occupying lesions and gallbladder pathology, the negative predictive values for which were >80%. A positive predictive value >80% was obtained for all of these variables, except the presence of adenopathies, hepatomegaly, space-occupying lesions, echogenicity and/or enlargement of the biliary tract, left renal atrophy and right renal masses. We conclude there was a high concordance between a conventional abdominal study and that performed with a pocket-sized ultrasound device after a brief learning curve.

Clinical ultrasonography in systemic autoimmune diseases

Clinical ultrasonography should be considered a complementary examination that can change clinical practice, as well as a tool to add to the medical history. Systemic autoimmune diseases (SAD) can involve numerous structures and organs. Ultrasonography has broad applied utility in detecting complications such as the presence of free intraabdominal, pleural and pericardial fluid in polyserositis, left ventricular systolic dysfunction in myocarditis and deep vein thrombosis in antiphospholipid syndrome. Specifically for SAD, ultrasonography helps examine the salivary glands in Sjögren's syndrome, determines the presence of the halo sign in giant cell arteritis and the presence of tendon or joint inflammation, quantifies pulmonary hypertension in scleroderma and assesses the presence of interstitial pulmonary disease in dermatomyositis. Clinical ultrasonography performed by internists is therefore an extremely useful technique in the diagnosis and follow-up of patients with SAD.

[Usefulness and reliability of point of care ultrasound in Family Medicine: Focused cardiac and lung ultrasound]

The family doctor incorporates clinical ultrasound as an exploration and diagnosis technique in his care activity, the same way as the rest of the specialists. His generalist role makes him a potential user of all possible applications of this technique, which can provide a high impact on his ability to manage, focus and solve a large number of clinical situations. In this article we focus on assessing the usefulness and reliability of clinical ultrasound performed by the family doctor in their most novel aspects such as focused cardiac ultrasound and lung ultrasound.

Implementation of a point-of-care ultrasound skills practicum for hospitalists

Introduction

Point-of-care ultrasound is recognized as a safe and valuable diagnostic tool for patient evaluation. Hospitalists are prime candidates for advancing the point-of-care ultrasound field given their crucial role in inpatient medicine. Despite this, there is a notable lack of evidence-based ultrasound training for hospitalists. Most research focuses on diagnostic accuracy rather than the training required to achieve it. This study aims to improve hospitalists' point-of-care ultrasound knowledge and skills through a hands-on skills practicum.

Methods

Four skill practicums were conducted with pre-course, post-course, and six-month evaluations and knowledge assessments.

Results

The mean pre- vs. post-course knowledge assessment scores significantly improved, 41.7% vs. 75.9% (SD 16.1% and 12.7%, respectively, p < 0.0001). The mean ultrasound skills confidence ratings on a 10-point Likert scale significantly increased post-course (2.60 ± 1.66 vs. 6.33 ± 1.63, p < 0.0001), but decreased at six months (6.33 ± 1.63 vs. 4.10 ± 2.22, p < 0.0001). The greatest limitations to usage pre-course and at six months were knowledge/skills and lack of machine access. While knowledge/skills decreased from pre-course (82.0%) as compared to six-months (64.3%), lack of machine access increased from pre-course (15.8%) to six-months (28.6%) (p = 0.28).

Conclusion

Hospitalists agree that point-of-care ultrasound has utility in the diagnostic and therapeutic management of patients, though the lack of training is a significant limitation. Our study demonstrated that a brief skills practicum significantly improves hospitalists' confidence and knowledge regarding ultrasound image acquisition and interpretation in the short term. Long-term confidence and usage wanes, which appears to be due to the lack of machine access.