Ultrasound-guided interventional radiology in critical care

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.

Ultrasonography and procedures in intensive care medicine

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

Handheld interventional ultrasound/photoacoustic puncture needle navigation based on deep learning segmentation

Interventional ultrasound (US) has challenges in accurate localization of the puncture needle due to intrinsic acoustic interferences, which lead to blurred, indistinct, and even invisible needles in handheld linear array transducer-based US navigation, especially the incorrect needle tip positioning. Photoacoustic (PA) imaging can provide complementary image contrast, without additional data acquisition. Herein, we proposed an internal illumination to solely light up the needle tip in PA imaging. Then deep-learning-based feature segmentation alleviates acoustic interferences, enhancing the needle shaft-tip visibility. Further, needle shaft-tip compensation aligned the needle shaft in US image and the needle tip in the PA image. The experiments on phantom, ex vivo chicken breast, preclinical radiofrequency ablation and in vivo biopsy of sentinel lymph nodes were piloted. The target registration error can reach the submillimeter level, achieving precise puncture needle tracking ability with in-plane US/PA navigation.

Introduction to Point-of-Care Ultrasonography

Medical ultrasonography was first used as a diagnostic tool in 1942 by Theodore Karl Dussik to visualize brain structures. Use of ultrasonography broadened to the field of obstetrics in the 1950s and has since expanded to many other medical special-ties owing to ease of use, reproducibility, low cost, and lack of radiation. Advancements in ultrasonography technology have allowed clinicians to perform procedures with greater accuracy and to characterize tissue better than ever before. Piezoelectric crystals used to produce ultrasound waves have been replaced by silicon chips; artificial intelligence can be used to mitigate user variability; and more portable ultrasound probes are available for use with mobile devices. Ultrasonography requires training to be used appropriately, and patient and family education are crucial when performing an examination. Although some data are available regarding the amount of training needed for users to reach proficiency, this topic remains controversial and no standard currently exists.

Pocket-sized, wireless-Bluetooth ultrasound system to perform diagnostic and low-complexity interventional procedures in bedridden patients during the COVID-19 pandemic: from intensive care unit to domiciliary service?

The use of a pocked-sized, wireless-Bluetooth ultrasound portable system with display images presented on a tablet facilitated the work of our radiologists during the first wave of coronavirus disease 2019 (COVID-19) to perform diagnostic and interventional procedures in bedridden patients. The device is equipped with a battery-powered probe without cables that transmits images to a tablet (or a cell phone) through a dedicated App. We hypothesise in future to extend diagnostic and low-complexity interventional procedures from hospitalised patients to at-home patients who are not able to mobilise out of bed or are difficult to transport. This domiciliary service might also reduce the overhead of hospital accesses.

The State of Point-of-Care Ultrasound Training in Undergraduate Medical Education: Findings From a National Survey

PURPOSE

The primary aim of this study was to evaluate the current state of point-of-care ultrasound (POCUS) integration in undergraduate medical education (UME) at MD-granting medical schools in the United States.

METHOD

In 2020, 154 clinical ultrasound directors and curricular deans at MD-granting medical schools were surveyed. The 25-question survey collected data about school characteristics, barriers to POCUS training implementation, and POCUS curriculum details. Descriptive analysis was conducted using frequency and percentage distributions.

RESULTS

One hundred twenty-two (79%) of 154 schools responded to the survey, of which 36 were multicampus. Sixty-nine (57%) schools had an approved POCUS curriculum, with 10 (8%) offering a longitudinal 4-year curriculum. For a majority of schools, POCUS instruction was required during the first year (86%) and second year (68%). Forty-two (61%) schools were teaching fundamentals, diagnostic, and procedural ultrasound. One hundred fifteen (94%) schools identified barriers to implementing POCUS training in UME, which included lack of trained faculty (63%), lack of time in current curricula (54%), and lack of equipment (44%). Seven (6%) schools identified no barriers.

CONCLUSIONS

Over half of the responding medical schools in the United States had integrated POCUS instruction into their UME curricula. Despite this, a very small portion had a longitudinal curriculum and multiple barriers existed for implementation, with the most common being lack of trained faculty. The data from this study can be used by schools planning to add or expand POCUS instruction within their current curricula.

Urgent ultrasound-guided interventional procedures

Interventional radiology procedures have become a fundamental part of radiology, resulting in faster diagnoses and in safer, more effective, and more precise treatments, all of which are important, and even more so when referring to urgent situations, where time is of the essence. In this context, the use of ultrasound to guide interventional procedures enables real-time viewing in multiple planes that can be done at the patient's bedside, which is a great advantage in critical patients. We review the indications and technical aspects of the most common procedures related with radiological care of urgent patients.

Efficacy of an Integrated Hands-On Thyroid Ultrasound Session for Medical Student Education

As ultrasound has gained popularity with improving technology and ease-of-use, a push has been made to integrate ultrasound into the medical school curriculum. Many institutions are reporting one- to four-year integrated ultrasound curricula to augment anatomy and pathophysiology teaching. Our goal was to integrate a thyroid ultrasound scanning session into the endocrinology block of our institution’s medical school curriculum to enhance medical student understanding of thyroid anatomy and pathophysiology. We conducted a prospective, single-center cohort (pre-experimental) study to evaluate student performance and knowledge acquisition using a pretest-posttest design. These multimodal sessions, consisting of a didactic, hands-on scanning sessions, and knowledge integration tests, covered ultrasound technique and thyroid evaluation and advanced to diagnosing an abnormal thyroid and working up a thyroid nodule. There were 26 to 27 second-year medical students per session who rotated between three stations proctored by credentialled physicians. Students participated in hands-on scanning of patients with or without thyroid pathology at each station. Out of the 209 students who participated in the ultrasound sessions, 114 (54.5%) consented to participate in the research project and completed both the pretest and posttest. Test data from the 114 students showed a mean pretest score of 57.5% ± 14.6% and the mean posttest score of 73.9% ± 17.4%. They had a 16.5% ± 19.6% (p < 0.001) increase in score between the two tests. Our study demonstrates that a multimodal thyroid ultrasound scanning session is an effective tool to augment the medical school endocrinology curriculum and to improve students’ knowledge of thyroid anatomy, pathophysiology, and diagnostic workup of thyroid nodules.

Ultrasound Evaluation for Incomplete Carpal Tunnel Release

Background: Ultrasound can provide evaluation of the anatomy of the carpal tunnel in a convenient, noninvasive office setting. This study is intended to determine the accuracy and diagnostic performance of ultrasound, used by surgeons, for the evaluation of completeness of carpal tunnel release (CTR). Methods: Ten cadaver arms underwent randomized sectioning of 0%, 25%, 50%, 75%, or 100% of the transverse carpal ligament. Following a brief training session, a blinded observer used ultrasound to evaluate the percentage of the transverse carpal ligament release. The release amount was then confirmed with an open exposure of the transverse carpal ligament. Results: Cronbach α and Pearson correlation coefficients were 0.92 and 0.87, demonstrating excellent reliability and validity of the technique. Diagnostic performance including sensitivity, specificity, positive predictive value, and negative predictive value was 100%, 75%, 86%, and 100%, respectively, for the diagnosis of incomplete release of the transverse carpal ligament by a novice sonographer orthopedic surgeon. Conclusions: The ultrasound is a highly accurate tool for the diagnosis of incomplete transverse carpal ligament release and requires a minimal amount of training to use for this purpose. It provides a rapid means of diagnosing incomplete release of the transverse carpal ligament following CTR.

Teaching neurological disorders with ultrasound: A novel workshop for medical students

INTRODUCTION

The goal of this study was to assess if a neurological disorder ultrasound workshop for the first-year medical students significantly enhanced the students' ability to retain and apply concepts related to neuroanatomy and neurophysiology.

MATERIALS AND METHODS

We performed a prospective study to evaluate student performance before and after an optional ultrasound workshop. Data were collected through a within-population pretest-posttest design. Purposive sampling was used to recruit first-year medical students for this study. The six stations were transcranial doppler ultrasound, ocular ultrasound, ultrasound-guided external ventricular drain placement, high-intensity focused ultrasound for brain lesions, carotid artery scan with ultrasound, and ultrasound-guided central line placement. We used a pre-post workshop survey to identify opinions and perceptions about ultrasound and a pre-post workshop test to assess knowledge about neuroanatomy, neurophysiology, and related ultrasound topics.

RESULTS

Twenty-two 22 first-year medical students consented to participate in this study. The Wilcoxon signed-rank test showed a statistically significant difference in pre- and posttest scores, suggesting that participants demonstrated higher levels of medical knowledge related to neurological physiology, anatomy, and ultrasound after participating in the workshop. The analysis of the pre-post survey showed participants attributed greater value to ultrasound as a useful tool for their future medical practice after participation in the event (Z = -2.45, P = 0.014).

CONCLUSIONS

There is value in integrating experiences with ultrasound into the neurological disorder block of medical school. Future studies, with a larger sample size, are needed to further explore the efficacy of this workshop in enhancing knowledge retention.

Bedside Lung Ultrasound for Postoperative Lung Conditions in Cardiothoracic Intensive Care Unit: Diagnostic Value and Comparison with Bedside Chest Roentgenogram

Background:

The postoperative settings in cardiothoracic intensive care unit (ICU) patients pose a certain risk with pulmonary dysfunction causing morbidity and mortality. Lung ultrasound (LUS) has a potential to supplant or replace Chest X-rays (CXR) in these subset of patients, who will require bed side pulmonary pathology diagnosis and interventions.

Aims and Objectives:

Aim of the study is to compare the diagnosis predicted from LUS to the diagnosis made from routine bedside CXR and to find the degree of agreement in diagnosis made by both modalities in different cardiopulmonary pathologies in ICUs.

Materials and Methods:

Prospective observational study involving 250 postoperative patients, admitted in cardio-thoracic and vascular ICU of a tertiary referral centre. LUS was done in the study patients after the scheduled CXR in the immediate postoperative period and postoperative day one. Findings of pulmonary pathologies by each imaging modality were independently interpreted by two different team of specialist investigators. The findings were evaluated for the degree of agreement between the two imaging modalities using Cohen's kappa statistical test.

Results:

CXR and LUS imaging showed substantial agreement in the diagnosing cardiopulmonary pathologies (κ = 0.652) in the immediate postoperative period as well as on the postoperative day one (κ = 0.740). For specific cardiopulmonary pathologies, the degree of agreement was moderate for pleural effusion (κ = 0.561), substantial for atelectasis (κ = 0.673) and interstitial edema (κ = 0.707) and perfect for pneumothorax (κ = 0.931).

Conclusions:

LUS can effectively replace CXR with reduction in radiation exposure in the immediate postoperative period and also in the follow up period. It can be used as a bedside diagnostic and monitoring tool in postoperative cardiothoracic and ICUs for diagnosing pneumothorax, pleural effusion, atelectasis and interstitial edema.

Point-of-Care Ultrasound in the Intensive Care Unit

Spreading beyond the realm of tertiary academic medical centers, point-of-care ultrasound in the intensive care unit is an important diagnostic tool. The real-time feedback garnered can lead to critical and clinically relevant changes in management and decrease potential complications. Bedside ultrasound evaluation in the intensive care setting with a small, portable equipment is well-suited for placement of central lines, lumbar puncture, thoracentesis or other bedside ICU procedures and in the evaluation of cardiac activity, pleural and abdominal cavity and the overall fluid volume. Formalized curriculums centering on point-of-care ultrasound are emerging that will enhance its applicability and relevance.

Recommendations on the Use of Ultrasound Guidance for Adult Abdominal Paracentesis: A Position Statement of the Society of Hospital Medicine

1. We recommend that ultrasound guidance should be used for paracentesis to reduce the risk of serious complications, the most common being bleeding. 2. We recommend that ultrasound guidance should be used to avoid attempting paracentesis in patients with an insufficient volume of intraperitoneal free fluid to drain. 3. We recommend that ultrasound guidance should be used with paracentesis to improve the success rates of the overall procedure. 4. We recommend that ultrasound should be used to assess the volume and location of intraperitoneal free fluid to guide clinical decision making of where paracentesis can be safely performed. 5. We recommend that ultrasound should be used to identify a needle insertion site based on size of the fluid collection, thickness of the abdominal wall, and proximity to abdominal organs. 6. We recommend that the needle insertion site should be evaluated using color flow Doppler ultrasound to identify and avoid abdominal wall blood vessels along the anticipated needle trajectory. 7. We recommend that a needle insertion site should be evaluated in multiple planes to ensure clearance from underlying abdominal organs and detect any abdominal wall blood vessels along the anticipated needle trajectory. 8. We recommend that a needle insertion site should be marked with ultrasound immediately before performing the procedure, and the patient should remain in the same position between marking the site and performing the procedure. 9. We recommend that using real-time ultrasound guidance for paracentesis should be considered when the fluid collection is small or difficult to access. 10. We recommend that dedicated training sessions, including didactics, supervised practice on patients, and simulation-based practice, should be used to teach novices how to perform ultrasound-guided paracentesis. 11. We recommend that simulation-based practice should be used, when available, to facilitate acquisition of the required knowledge and skills to perform ultrasoundguided paracentesis. 12. We recommend that competence in performing ultrasound-guided paracentesis should be demonstrated prior to independently performing the procedure on patients.

Feasibility and safety of exclusive echocardiography-guided intravenous temporary pacemaker implantation

BACKGROUND

The standard approach for urgent trans-venous temporary cardiac pacemaker (TVTP) implantation is fluoroscopy guidance. The delay in activation of the fluoroscopy-room and the transfer of unstable patients may be life-threatening. Echocardiography-guided TP implantation may increase the safety of the patients by obviating the need for in-hospital transfer. We examined the feasibility and safety of echocardiography-guided vs. fluoroscopy-guided TVTP implantation.

METHODS

From January 2015 to September 2017 data for consecutive patients who needed emergent TVTP implantation were retrospectively reviewed. Ultrasound-guided TVTP protocol that was introduced in our center in January 2015 involved ultrasound guidance for both central venous access and pacing lead positioning. Access sites included femoral, subclavian, or jugular veins. Electrodes were placed in the right ventricular apex by means of echocardiographic monitoring in intensive care unit or by fluoroscopic guidance. Endpoints were achievement of successful ventricular pacing and procedural complications.

RESULTS

Sixty-six patients (17 echocardiography-guided and 49 fluoroscopy-guided) were included. There were no differences in pacing threshold between the echocardiography-guided group and the fluoroscopy-guided group (0.75 ± 0.58 mA vs. 0.57 ± 0.35 mA, p = 0.24). The access site for implantation was femoral vein in 27% for the fluoroscopy-guided vs. none for the echocardiography-guided approach (p = 0.015). One hematoma and one related infection occurred in the fluoroscopy-guided group. The need for electrode repositioning was observed in 1 patient in each group. There were no procedural-related deaths in either group.

CONCLUSIONS

Echocardiography-guided temporary cardiac pacing is a feasible and safe alternative to fluoroscopy-guided approach and significantly lowers the need for in-hospital transfer.

Point-of-care Ultrasonography in Orthopedic Management of Hemophilia: Multiple Uses of an Effective Tool

Even in our current era of hemophilia prophylaxis, articular complications can arise and there is a growing need for strategies in the prevention, diagnosis, and treatment of hemophilic arthropathy, a significant contributor to disability in patients with hemophilia. One useful tool, point-of-care ultrasonography (POC-US), offers diverse diagnostic and therapeutic possibilities. This article reviews the literature on the uses of POC-US in hemophilia, including early diagnosis of joint damage, differential diagnosis of articular pain, follow-up of joint injury, and guidance for both arthrocentesis and intra-articular injection. Studies show that for patients with hemophilia, POC-US enhances diagnostic accuracy and targeted treatments. Further research is required into the most efficient use of POC-US and the training needed to develop clinicians' skills. The attributes of POC-US should be understood more fully to enable its widespread application.

Complications related to the insertion and maintenance of peripheral venous access central venous catheter

OBJECTIVE

To evaluate the rates and nature of the complications related to the Central Peripheral Access Catheter (CVCAP or PICC) from its insertion to its withdrawal.

METHODS

Prospective observational study. All patients older than 14 years of age with a PICC inserted in the polyvalent intensive care unit (ICU) during the period between May 1, 2015 and April 30, 2016 were included. Data collected included: demographic data, insertion details, reason for insertion and removal, maintenance unit, total dwell time, incidence of complications and related factors and infection rate.

RESULTS

144 PICCs were inserted, of which 94 corresponded to the ICU group (65.28%) and 50 (34.72%) to the non-ICU group. The most important complication was the suspicion of infection: 17.36% (rate of 15.2 per 1000 days of PICC). The total number of confirmed infections was 6.25% (5.5 per 1000 days of PICC), 1.39% (1.2 per 1000 days) being in the ICU group and 4.86% (4.2 per 1000 days) in the non-ICU group. There were 5 bacteraemias, all in the non-ICU group (3 per 1000 days). The most frequent germ was Staphylococcus epidermidis (6 cases). Phlebitis had an incidence of 9.03% (7.9 per 1000 days of PICC).

CONCLUSIONS

PICC, effective device for central venous access due to the minimal incidence of risks in implantation and to its advantages with regard to the classic central venous catheters, is a further nursing technique.

Point of care ultrasonography in the pediatric emergency department

IMPORTANCE

Point-of-care ultrasonography (POCUS) allows to obtain real-time images to correlate with the patient's presenting signs and symptoms. It can be used by various specialties and may be broadly divided into diagnostic and procedural applications.

OBJECTIVE

We aimed at reviewing current knowledge on the use of POCUS in Pediatric Emergency Departments (PEDs).

FINDINGS

US diagnostic capacity in paediatric patients with suspected pneumonia has been studied and debated whereas literature regarding the usefulness of point-of-care echocardiography in the pediatric setting is still limited. Similarly, Focused Assessment with Sonography for Trauma (FAST) has become a standard procedure in adult emergency medicine but it is still not well codified in the pediatric practice. Concerning procedural applications of POCUS we identified 4 main groups: peripheral vascular access, bladder catheterizations, identification and drainage of abnormal fluid collections and foreign body identification.

CONCLUSIONS AND RELEVANCE

Bedside emergency ultrasound is routinely used by adult emergency physicians and in the last 10 years its application is recognized and applied in PED. Pediatric emergency physicians are encouraged to familiarize with POCUS as it is a safe technology and can be extremely helpful in performing diagnosis, managing critical situations and guiding procedures, which results in globally improving pediatric patients care.

Deep Needle Procedures: Improving Safety With Ultrasound Visualization

Promoting patient safety and increasing health care quality have dominated the health care landscape during the last 15 years. Health care regulators and payers are now tying patient safety outcomes and best practices to hospital reimbursement. Many health care leaders are searching for new technologies that not only make health care for patients safer but also reduce overall health care costs. New advances in ultrasonography have made this technology available to health care providers at the patient's bedside. Point-of-care ultrasound assistance now aids providers with real-time diagnosis and with visualization for procedural guidance. This is especially true for common deep needle procedures such as central venous catheter insertion, thoracentesis, and paracentesis.There is now mounting evidence that clinician-performed point-of-care ultrasound improves patient safety, enhances health care quality, and reduces health care cost for deep needle procedures. Furthermore, the miniaturization, ease of use, and the evolving affordability of ultrasound have now made this technology widely available. The adoption of point-of-care ultrasonography has reached a tipping point and should be seriously considered the safety standard for all hospital-based deep needle procedures.

Murine ultrasound-guided transabdominal para-aortic injections of self-assembling type I collagen oligomers

Abdominal aortic aneurysms (AAAs) represent a potentially life-threatening condition that predominantly affects the infrarenal aorta. Several preclinical murine models that mimic the human condition have been developed and are now widely used to investigate AAA pathogenesis. Cell- or pharmaceutical-based therapeutics designed to prevent AAA expansion are currently being evaluated with these animal models, but more minimally invasive strategies for delivery could improve their clinical translation. The purpose of this study was to investigate the use of self-assembling type I collagen oligomers as an injectable therapeutic delivery vehicle in mice. Here we show the success and reliability of a para-aortic, ultrasound-guided technique for injecting quickly-polymerizing collagen oligomer solutions into mice to form a collagen-fibril matrix at body temperature. A commonly used infrarenal mouse AAA model was used to determine the target location of these collagen injections. Ultrasound-guided, closed-abdominal injections supported consistent delivery of collagen to the area surrounding the infrarenal abdominal aorta halfway between the right renal artery and aortic trifurcation into the iliac and tail arteries. This minimally invasive approach yielded outcomes similar to open-abdominal injections into the same region. Histological analysis on tissue removed on day 14 post-operatively showed minimal in vivo degradation of the self-assembled fibrillar collagen and the majority of implants experienced minimal inflammation and cell invasion, further confirming this material's potential as a method for delivering therapeutics. Finally, we showed that the typical length and position of this infrarenal AAA model was statistically similar to the length and targeted location of the injected collagen, increasing its feasibility as a localized therapeutic delivery vehicle. Future preclinical and clinical studies are needed to determine if specific therapeutics incorporated into the self-assembling type I collagen matrix described here can be delivered near the aorta and locally limit AAA expansion.

Expert Facilitated Development of an Objective Assessment Tool for Point-of-Care Ultrasound Performance in Undergraduate Medical Education

BACKGROUND

With the various applications of point-of-care ultrasound (PoCUS) steadily increasing, many medical schools across North America are incorporating PoCUS training into their undergraduate curricula. The Faculty of Medicine at Memorial University also intends to introduce PoCUS training into its own undergraduate medical program. The proposed approach is to introduce a PoCUS curriculum focusing on anatomy and physiology while developing cognitive and psychomotor skills that are later transferred into clinical applications. This has been the common approach taken by most undergraduate ultrasound programs in the United States. This project highlights the development and the challenges involved in creating an objective assessment tool that meets the unique needs of this proposed undergraduate ultrasound curriculum.

METHODS

After a thorough review of existing literature and input from experts in PoCUS, a prototype global rating scale (GRS) and three exam-specific checklists were created by researchers. The exam-specific checklists include aorta exam, subxiphoid cardiac exam, and focused abdominal exam. A panel of 18 emergency room physicians certified in PoCUS were recruited to evaluate the GRS and three checklists. This was accomplished using a modified Delphi technique. The items were rated on a 5-point Likert scale. If an item received a mean score of less than 4, it was deemed unimportant for the assessment of PoCUS performance in undergraduate medical learners and was excluded. Experts were also encouraged to provide comments and suggest further items to be added to the GRS or checklists. Items were modified according to these comments. All of the edits were then sent back to the experts for revisions.

RESULTS

A consensus was achieved after three rounds of surveys, with the final GRS containing nine items. The final aorta checklist contained nine items, and the subxiphoid cardiac and focused abdominal checklists each contained 11 items.

CONCLUSION

By using a modified Delphi technique, we developed a single GRS and three checklists. A panel of independent PoCUS practitioners supports the content validity of these tools. Research is currently ongoing to evaluate their validity for assessing PoCUS competency in undergraduate medical students.

Integration of Ultrasound in Medical Education at United States Medical Schools: A National Survey of Directors' Experiences

OBJECTIVES

Despite the rise of ultrasound in medical education (USMED), multiple barriers impede the implementation of such curricula in medical schools. No studies to date have surveyed individuals who are successfully championing USMED programs. This study aimed to investigate the experiences with ultrasound integration as perceived by active USMED directors across the United States.

METHODS

In 2014, all allopathic and osteopathic medical schools in the United States were contacted regarding their status with ultrasound education. For schools with required point-of-care ultrasound curricula, we identified the USMED directors in charge of the ultrasound programs and sent them a 27-question survey. The survey included background information about the directors, ultrasound program details, the barriers directors faced toward implementation, and the directors' attitudes toward ultrasound education.

RESULTS

One-hundred seventy-three medical schools were contacted, and 48 (27.7%) reported having a formal USMED curriculum. Thirty-six USMED directors responded to the survey. The average number of years of USMED curriculum integration was 2.8 years (SD, 2.9). Mandatory ultrasound curricula had most commonly been implemented into years 1 and 2 of medical school (71.4% and 62.9%, respectively). The most common barriers faced by these directors when implementing their ultrasound programs were the lack of funding for faculty/ equipment (52.9%) and lack of time in current medical curricula (50.0%).

CONCLUSIONS

Financial commitments and the full schedules of medical schools are the current prevailing roadblocks to implementation of ultrasound education. Experiences drawn from current USMED directors in this study may be used to help programs starting their own curricula.

The Barriers and Facilitators to Transfer of Ultrasound-Guided Central Venous Line Skills From Simulation to Practice: Exploring Perceptions of Learners and Supervisors

PHENOMENON: Ultrasound-guided central venous line insertion is currently the standard of care. Randomized controlled trials and systematic reviews show that simulation is superior to apprenticeship training. The purpose of this study is to explore, from the perspectives of participants in a simulation-training program, the factors that help or hinder the transfer of skills from simulation to practice.

APPROACH

Purposeful sampling was used to select and study the experience and perspective of novice fellows after they had completed simulation training and then performed ultrasound-guided central venous line in practice. Seven novice pediatric intensive care unit fellows and six supervising faculty in a university-affiliated academic center in a large urban city were recruited between September 2012 and January 2013. We conducted a qualitative study using semistructured interviews as our data source, employing a constructivist, grounded theory methodology.

FINDINGS

Both curricular and real-life factors influence the transfer of skills from simulation to practice and the overall performance of trainees. Clear instructions, the opportunity to practice to mastery, one-on-one observation with feedback, supervision, and further real-life experiences were perceived as factors that facilitated the transfer of skills. Concern for patient welfare, live trouble shooting, complexity of the intensive care unit environment, and the procedure itself were perceived as real-life factors that hindered the transfer of skills. Insights: As more studies confirm the superiority of simulation training versus apprenticeship training for initial student learning, the faculty should gain insight into factors that facilitate and hinder the transfer of skills from simulation to bedside settings and impact learners' performances. As simulation further augments clinical learning, efforts should be made to modify the curricular and bedside factors that facilitate transfer of skills from simulation to practice settings.

Bedside ultrasound procedures: musculoskeletal and non-musculoskeletal

The widespread availability of ultrasound (US) technology has increased its use for point of care applications in many health care settings. Focused (point of care) US is defined as the act of bringing US evaluation to the bedside for real-time performance. These images are collected immediately by the practitioner, allowing for direct integration into the physician's medical decision-making process. The real-time bedside diagnostic ability of US becomes a key tool for the management of patients. The purpose of this review is to (1) provide a general description of the use of focused US for bedside procedures; (2) specify the indications and common techniques used in bedside US procedures; and (3) describe the techniques used for each bedside intervention.

Ultrasound exposure during gross anatomy

BACKGROUND

As medical schools seek to standardize ultrasound training and incorporate clinical correlations into the basic science years, we proposed that ultrasonography should have a greater role in the anatomy curriculum.

OBJECTIVES

To describe the introduction of ultrasound into the curriculum of a first-year medical student anatomy course and evaluate the utility of this introduction.

METHODS

First-year medical students attended two ultrasound lectures and three small-group hands-on sessions that focused on selected aspects of musculoskeletal, thoracic, abdominal, and neck anatomy. Pre and post surveys were administered to assess student perception of their ability to obtain and interpret ultrasound images and the utility of ultrasound in the anatomy course. Understanding of basic ultrasound techniques and imaging was tested in the practical examinations.

RESULTS

Of the 269 first-year medical students who completed the course, 144 students completed both surveys entirely, with a response rate of 53%. Students' interest and self-perceived experience, comfort, and confidence in ultrasound skills significantly increased (p < 0.001) as a result of this early introduction to ultrasonography. Objective evidence, provided by practical examination scores on ultrasound images, is consistent with this self-perceived confidence reported by students.

CONCLUSIONS

Ultrasound can be effectively incorporated into an anatomy course for first-year medical students by utilizing didactics and hands-on exposure. Medical students found the addition of ultrasound training to be valuable, not only in enhancing their understanding of anatomy, but also in increasing their interest and experience in ultrasound imaging.

A comparison of free-hand vs laser-guided long-axis ultrasound techniques in novice users

OBJECTIVE

The increasing use of point-of-care ultrasonography for targeted procedures justifies a device that helps both novices in training and experts perform the long-axis needle approach. The initial success of traditional needle guidance devices in reducing the time of target procedures is not universal and they can be cumbersome. We aim to investigate whether the less bulky and previously untested laser guide can succeed in reducing procedure time in novice ultrasonographers.

METHODS

82 medical students with no ultrasound experience volunteered. Random allocation determined whether, during a targeted procedure in a turkey breast and olive phantom, participants were assisted by the laser guide or not. The time taken to pierce the target was recorded at 1-cm depth.

RESULTS

The mean procedure time in the laser-assisted (LA) group was 25.1 s (14.0 s; 18.0-25.0 s). The mean procedure time in the free-hand group was 45.5 s (23.0 s; 7.0-55.0 s). The procedure time in the LA group was significantly reduced (p<0.01).

CONCLUSION

The laser guide significantly improved procedure times. It is felt that the cheaper, smaller, easy to integrate, sterile and more user-friendly laser guidance unit may be a better alternative to the needle guide in improving procedure times for the novice ultrasonographer or to assist the expert, during training for, or performance of, ultrasound-guided targeted procedures.

ADVANCES IN KNOWLEDGE

Following from the prototype paper, this is the first study to investigate the effectiveness of attaching a laser-guidance device to an ultrasound probe. The device succeeded in reducing the procedure times of targeted procedures.

Ultrasound for the Detection of Pleural Effusions and Guidance of the Thoracentesis Procedure

Objective. To review the use of ultrasound for the detection of pleural effusions and guidance of the thoracentesis procedure. Methods. Two clinical cases will be presented in which ultrasound proved beneficial in guiding the diagnosis and management of patients with pleural effusions and respiratory distress. The ultrasound techniques for the evaluation of pleural effusions and performance of the thoracentesis procedure are discussed. A review of the most current literature follows to present the known diagnostic and safety benefits of ultrasound guidance for thoracentesis. Conclusions. Ultrasound improves the diagnostic accuracy for the detection of pleural effusions over standard chest radiographs. Ultrasound can also diagnose a complicated pleural effusion that may be at higher risk for an adverse outcome during a thoracentesis. Optimally, thoracentesis should be performed under direct ultrasound guidance to decrease the complication rate and improve patient safety.

Advanced technologies in trauma critical care management

Care of critically injured patients has evolved over the 50 years since Shoemaker established one of the first trauma units at Cook County Hospital in 1962. Modern trauma intensive care units offer a high nurse-to-patient ratio, physicians and midlevel providers who manage the patients, and technologically advanced monitors and therapeutic devices designed to optimize the care of patients. This article describes advances that have transformed trauma critical care, including bedside ultrasonography, novel patient monitoring techniques, extracorporeal support, and negative pressure dressings. It also discusses how to evaluate the safety and efficacy of future advances in trauma critical care.

The use of point-of-care bedside lung ultrasound significantly reduces the number of radiographs and computed tomography scans in critically ill patients

BACKGROUND

Chest radiography has been reported to have low diagnostic accuracy in critically ill intensive care unit (ICU) patients, and chest computed tomography (CT) scans require patients to be transported out of the ICU, putting them at risk of adverse events. In this study we assessed the efficacy of routine bedside lung ultrasound (LUS) in the evaluation of pleural effusions (PE) in the ICU.

METHODS

Three hundred seventy-six patients admitted to the ICU for major trauma (46.3%), medical pathology (41.5%), and postsurgical complications (12.2%) (May 2008 to April 2009) were included in this study. Patients were placed into either the control group (group C) or the study group (group S), on the basis of the introduction of routine LUS performed by a single group of intensivists in 1 tertiary care ICU. To reduce provider bias, the physicians conducting the LUS were not aware of the study. Collected data included patient demographics, clinical course, and number of chest radiographs and CT scans performed. As a secondary goal, we assessed the reliability of Balik's formula in PE estimation.

RESULTS

No significant differences were found between the 2 groups with regard to their demographics and ICU clinical course. Group S had a significant reduction in the total number of chest radiographs obtained (-26%; P < 0.001) and CT scans (-47%; P < 0.001) in comparison with the comparison group C. A 6-month follow-up analysis of the ICU LUS protocol revealed a time-dependent decrease in the number of radiological examinations requested for patients with PE. Lastly, PE volume estimation using the LUS and Balik's formula correlates well with the effective volume drained (r = 0.65; P < 0.0001).

CONCLUSIONS

Routine use of LUS in the ICU setting can be associated with a reduction of the number of chest radiographs and CT scans performed.

"On the other hand ...": the evidence does not support the use of hand-carried ultrasound by hospitalists

In the right hands, ultrasound is a safe and helpful diagnostic imaging tool. However, evidence supporting the use of hand-carried ultrasound (HCU) by hospitalist physicians has not kept pace with expanding application of these devices. In spite of its strategic point-of-care benefit, use of this technology by hospitalists may not ultimately translate into improved efficiency and better clinical outcomes. Optimal levels of training in image acquisition and interpretation remain to be established. Novelty, availability, and the results of a few small studies lacking patient-centered outcomes remain insufficient grounds to justify the expanded clinical utilization of these medical imaging devices by nonspecialists.