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Lee MS, Sweetnam-Holmes D, Soffer GP, Harel-Sterling M. Updates on the clinical integration of point-of-care ultrasound in pediatric emergency medicine. Curr Opin Pediatr 2024; 36:256-265. [PMID: 38411588 DOI: 10.1097/mop.0000000000001340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
PURPOSE OF REVIEW There is expanding evidence for point-of-care ultrasound (POCUS) use in pediatric emergency medicine - this review highlights the benefits and challenges in the clinical integration of high-yield POCUS applications. Specifically, it will delve into POCUS applications during resuscitations, controversies of Focused Assessment with Sonography for Trauma (FAST) in pediatric trauma, POCUS-guided procedures, and examples of clinical pathways where POCUS can expedite definitive care. RECENT FINDINGS POCUS can enhance diagnostic accuracy and aid in management of pediatric patients in shock and help identify reversible causes during cardiac arrest. The use of the FAST in pediatric blunt abdominal trauma remains nuanced - its proper use requires an integration with clinical findings and an appreciation of its limitations. POCUS has been shown to enhance safety and efficacy of procedures such as nerve blocks, incision & drainage, and intravenous access. Integrating POCUS into pathways for conditions such as intussusception and testicular torsion expedites downstream care. SUMMARY POCUS enhances diagnostic efficiency and management in pediatric patients arriving at the ED with undifferentiated shock, cardiac arrest, or trauma. Additionally, POCUS improves procedural success and safety, and is integral to clinical pathways for expediting definitive care for various pediatric emergencies. Future research should continue to focus on the impact of POCUS on patient outcomes, ensuring user competency, and the expansion of POCUS into diverse settings.
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Affiliation(s)
- Michelle Sin Lee
- Pediatric Emergency Medicine, Hospital for Sick Children, Assistant Professor, University of Toronto, Toronto, ON, Canada
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Healy J, Tzeng CFT, Wolfshohl J, Shedd A, Lin J, Patel C, Chou EH. Point-of-Care Ultrasound in the Emergency Department: Training, Perceptions, Applications, and Barriers from Different Healthcare Professionals. J Acute Med 2024; 14:74-89. [PMID: 38859928 PMCID: PMC11163417 DOI: 10.6705/j.jacme.202406_14(2).0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 07/27/2023] [Accepted: 08/04/2023] [Indexed: 06/12/2024]
Abstract
Background Point-of-care ultrasound (POCUS) is a valuable tool that assists in diagnosis and management of patients in the emergency department (ED) while being cost-efficient and without the use of ionizing radiation. To discern the opinions and perceptions of ED staff about POCUS applications and barriers, we conducted a cross-sectional survey of employees of 12 EDs in North Texas. Methods Participants completed a 20-item online survey about POCUS with questions pertaining to four domains: (1) employee and training information, (2) perceived benefits, (3) common applications, and (4) barriers to use. Out of 805 eligible ED employees, 103 completed the survey (16.1% response rate). Results The results indicated a generally positive perception of POCUS among all employee types. Physician had significant exposure and training of POCUS than non-physician group ( p < 0.001). Physicians tend to find cardiac assessments more useful for clinical management than non-physicians (47% vs. 23%, p = 0.01), while non-physicians find soft tissue/abscess assessments more useful (27% vs. 9%, p = 0.01). Conclusion The most significant barriers to POCUS use were time constraints for physicians and a lack of training for non-physician employees. Our study provides valuable insights into the perceptions of multiple ED professionals, serving as a foundation for promoting POCUS use in the ED.
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Affiliation(s)
- Jack Healy
- Baylor Scott & White All Saints Medical Center Department of Emergency Medicine Fort Worth USA
- Texas Christian University Burnett School of Medicine Fort Worth USA
| | | | - Jon Wolfshohl
- Baylor Scott & White All Saints Medical Center Department of Emergency Medicine Fort Worth USA
| | - Andrew Shedd
- Baylor Scott & White All Saints Medical Center Department of Emergency Medicine Fort Worth USA
| | - Judy Lin
- Baylor Scott & White All Saints Medical Center Department of Emergency Medicine Fort Worth USA
| | - Chinmay Patel
- Baylor Scott & White All Saints Medical Center Department of Emergency Medicine Fort Worth USA
| | - Eric H Chou
- Baylor Scott & White All Saints Medical Center Department of Emergency Medicine Fort Worth USA
- Baylor University Medical Center Department of Emergency Medicine Dallas USA
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Ablordeppey EA, Zhao A, Ruggeri J, Hassan A, Wallace L, Agarwal M, Stickles SP, Holthaus C, Theodoro D. Does Point-of-Care Ultrasound Affect Fluid Resuscitation Volume in Patients with Septic Shock: A Retrospective Review. Emerg Med Int 2024; 2024:5675066. [PMID: 38742136 PMCID: PMC11090677 DOI: 10.1155/2024/5675066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 03/27/2024] [Accepted: 04/13/2024] [Indexed: 05/16/2024] Open
Abstract
Background Fixed, large volume resuscitation with intravenous fluids (IVFs) in septic shock can cause inadvertent hypervolemia, increased medical interventions, and death when unguided by point-of-care ultrasound (POCUS). The primary study objective was to evaluate whether total IVF volume differs for emergency department (ED) septic shock patients receiving POCUS versus no POCUS. Methods We conducted a retrospective observational cohort study from 7/1/2018 to 8/31/2021 of atraumatic adult ED patients with septic shock. We agreed upon a priori variables and defined septic shock as lactate ≥4 and hypotension (SBP <90 or MAP <65). A sample size of 300 patients would provide 85% power to detect an IVF difference of 500 milliliters between POCUS and non-POCUS cohorts. Data are reported as frequencies, median (IQR), and associations from bivariate logistic models. Results 304 patients met criteria and 26% (78/304) underwent POCUS. Cardiac POCUS demonstrated reduced ejection fraction in 15.4% of patients. Lung ultrasound showed normal findings in 53% of patients. The POCUS vs. non-POCUS cohorts had statistically significant differences for the following variables: higher median lactate (6.7 [IQR 5.2-8.7] vs. 5.6], p = 0.003), lower systolic blood pressure (77.5 [IQR 61-86] vs. 85.0, p < 0.001), more vasopressor use (51% vs. 34%, p = 0.006), and more positive pressure ventilation (38% vs. 24%, p = 0.017). However, there were no statistically significant differences between POCUS and non-POCUS cohorts in total IVF volume ml/kg (33.02 vs. 32.1, p = 0.47), new oxygen requirement (68% vs. 59%, p = 0.16), ED death (3% vs. 4%, p = 0.15), or hospital death (31% vs. 27%, p = 0.48). There were similar distributions of lactate, total fluids, and vasopressors in patients with CHF and severe renal failure. Conclusions Among ED patients with septic shock, POCUS was more likely to be used in sicker patients. Patients who had POCUS were given similar volume of crystalloids although these patients were more critically ill. There were no differences in new oxygen requirement or mortality in the POCUS group compared to the non-POCUS group.
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Affiliation(s)
- Enyo A. Ablordeppey
- Department of Anaesthesiology, Washington University School of Medicine, St. Louis, MO, USA
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Amy Zhao
- Washington University School of Medicine, St. Louis, MO, USA
| | - Jeffery Ruggeri
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Ahmad Hassan
- Washington University School of Medicine, St. Louis, MO, USA
| | - Laura Wallace
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Mansi Agarwal
- Division of Biostatistics, Washington University School of Medicine, St. Louis, MO, USA
| | - Sean P. Stickles
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Christopher Holthaus
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel Theodoro
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
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Parra VM, Fita G, Azqueta M, González M, Aranda F, Maestre ML, Silva J, Hortal J, Morales D, Bórquez E, Adasme F, Real MI, Mercadal J, Zelada P, Riobó G, Galdames K, Domenech RJ. Student survey after ten years of continuous blended teaching of echocardiography. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:8-16. [PMID: 37683971 DOI: 10.1016/j.redare.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 05/25/2023] [Indexed: 09/10/2023]
Abstract
OBJECTIVE To analyse the impact of 10 years of blended echocardiography teaching. METHODS AND RESULTS A questionnaire was emailed to all medical doctors who graduated from the blended learning diploma in echocardiography developed by the University of Chile and taught by a team from Chile and Spain. One hundred and forty of the 210 students who graduated from the program between 2011 and 2020 completed the questionnaire: 53.57% were anaesthesiologists, and 26.42% were intensivists. More than 85% of respondents indicated that the online teaching met their expectations, and 70.2% indicated that the hands-on practice fulfilled the stated objectives. In a retrospective analysis using self-reported data, graduates reported that their use of transthoracic and transoesophageal echocardiography has increased from 24.29% to 40.71% and from 13.57% to 27.86%, repectively, after the programme compared to before the programme. They used echocardiography mainly in the perioperative period (56.7%) and during intensive care (32.3%), while only 11% of respondents used it in emergency care units. Nearly all (92.4%) respondents reported that the skills learned was very useful in their professional practice. CONCLUSIONS Ten years after its launch, the blended learning diploma in echocardiography was well rated by graduate specialists, and is associated with a significant increase in the use of echocardiography in the perioperative period and during intensive care. The main challenges are to establish a longer period of practice and achieve greater implantation in emergency medicine.
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Affiliation(s)
- Víctor M Parra
- Echocardiography Unit, Instituto Nacional del Tórax, Santiago, Chile; Faculty of Medicine, Universidad de Chile, Santiago, Chile.
| | - Guillermina Fita
- Department of Anaesthesiology, Hospital Clínic, Barcelona, Spain
| | - Manel Azqueta
- Cardiovascular Institute, Hospital Clínic, Barcelona, Spain
| | - Mauricio González
- Department of Anaesthesiology and Perioperative Medicine, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Fernando Aranda
- Anaesthesia Unit and Surgical Suites, Hospital Dr. Gustavo Fricke, Universidad de Valparaíso, Chile
| | - M Luz Maestre
- Department of Anaesthesiology, Hospital Santa Creu i Sant Pau, Barcelona, Spain
| | - Jorge Silva
- Echocardiography Unit, Instituto Nacional del Tórax, Santiago, Chile
| | - Javier Hortal
- Department of Anaesthesiology and Critical Care, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Daniel Morales
- Echocardiography Unit, Instituto Nacional del Tórax, Santiago, Chile
| | | | - Fabián Adasme
- Cardiovascular Service, Clínica Santa María, Santiago, Chile
| | - María Isabel Real
- Department of Anaesthesiology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Jordi Mercadal
- Department of Anaesthesiology and Critical Care, Surgical Intensive Care Unit, Hospital Clínic, Barcelona, Spain
| | - Pamela Zelada
- Congenital Heart Diseases Unit, Instituto Nacional del Tórax, Paediatric Cardiology, Pontificia Universidad Católica de Chile and Hospital Dr. Sótero del Río, Santiago, Chile
| | - Gonzalo Riobó
- Echocardiography Unit, Instituto Nacional del Tórax, Santiago, Chile
| | - Katia Galdames
- Echocardiography Unit, Instituto Nacional del Tórax, Santiago, Chile; Cardiovascular Institute, Hospital Clínico Universidad de Chile, Santiago, Chile
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Prevalska IG, Tucker RV, England PC, Fung CM. Focused Cardiac Ultrasound Findings of Fluid Tolerance and Fluid Resuscitation in Septic Shock. Crit Care Explor 2023; 5:e1015. [PMID: 38053747 PMCID: PMC10695585 DOI: 10.1097/cce.0000000000001015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023] Open
Abstract
OBJECTIVES Compliance with the fluid bonus component of the SEP-1 (severe sepsis and septic shock management) bundle remains poor due to concerns for iatrogenic harm from fluid overload. We sought to assess whether patients who received focused cardiac ultrasound (FCU) and were found to be fluid tolerant (FT) were more likely to receive the recommended 30 mL/kg fluid bolus within 3 hours of sepsis identification. DESIGN Retrospective, observational cohort study. SETTING University-affiliated, tertiary-care hospital in the United States. PATIENTS Emergency department patients presenting with septic shock from 2018 to 2021. The primary exposure was receipt of FCU with identification of fluid tolerance 3 hours from onset of septic shock. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Two hundred ninety-two of 1,024 patients with septic shock received FCU within 3 hours of sepsis onset. One hundred seventy-seven were determined to be FT. One hundred fifteen patients were determined to have poor fluid tolerance (pFT). FT patients were more likely to reach the recommended 30 mL/kg fluid bolus amount compared with pFT (FT 52.0% vs. pFT 31.3%, risk difference: 20.7%, [95% CI, 9.4-31.9]). Patients who did not receive FCU met the bolus requirement 34.3% of the time. FT patients received more fluid within 3 hours (FT 2,271 mL vs. pFT 1,646 mL, mean difference 625 mL [95% CI, 330-919]). Multivariable logistic regression was used to estimate the association between fluid tolerance FCU findings and compliance with 30 mL/kg bolus after adjustment for patient characteristics and markers of hemodynamic instability. FT with associated with a higher likelihood of meeting bolus requirement (odds ratio 2.17 [1.52-3.12]). CONCLUSIONS Patients found to be FT by FCU were more likely to receive the recommended 30 mL/kg bolus in the SEP-1 bundle when compared with patients found with pFT or those that did not receive FCU. There was no difference between groups in 28-day mortality, vasopressor requirement, or need for mechanical ventilation.
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Affiliation(s)
- Ina G Prevalska
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Ryan V Tucker
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Peter C England
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
- Department of Anesthesiology, Critical Care, University of Michigan, Ann Arbor, MI
| | - Christopher M Fung
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
- Michigan Center for Integrative Research in Critical Care, University of Michigan, Ann Arbor, MI
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Michels G, Greim CA, Krohn A, Ott M, Feuerstein D, Möckel M, Fuchs N, Friemert B, Wolfrum S, Kiefl D, Bernhard M, Reifferscheid F, Bathe J, Walcher F, Dietrich CF, Lechleuthner A, Busch HJ, Sauer D. [Recommendations for Education in Sonography in Prehospital Emergency Medicine (pPOCUS): Consensus paper of DGINA, DGAI, BAND, BV-ÄLRD, DGU, DIVI and DGIIN]. Med Klin Intensivmed Notfmed 2023; 118:39-46. [PMID: 37548658 DOI: 10.1007/s00063-023-01054-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Point-of-care sonography is a precondition in acute and emergency medicine for the diagnosis and initiation of therapy for critically ill and injured patients. While emergency sonography is a mandatory part of the training for clinical acute and emergency medicine, it is not everywhere required for prehospital emergency medicine. Although some medical societies in Germany have already established their own learning concepts for emergency ultrasound, a uniform national training concept for the use of emergency sonography in the out-of-hospital setting is still lacking. Experts of several professional medical societies have therefore joined forces and developed a structured training concept for emergency sonography in the prehospital setting. The consensus paper serves as quality assurance in prehospital emergency sonography.
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Affiliation(s)
- Guido Michels
- Notfallzentrum, Krankenhaus der Barmherzigen Brüder Trier, Medizincampus der Universitätsmedizin Mainz, Nordallee 1, 54292, Trier, Deutschland.
| | - Clemens-Alexander Greim
- Klinik für Anästhesiologie, Intensiv- und Notfallmedizin, Klinikum Fulda, Fulda, Deutschland
| | - Alexander Krohn
- Department für interdisziplinäre Akut‑, Notfall- und Intensivmedizin (DIANI), Klinikum Stuttgart, Stuttgart, Deutschland
| | - Matthias Ott
- Department für interdisziplinäre Akut‑, Notfall- und Intensivmedizin (DIANI), Klinikum Stuttgart, Stuttgart, Deutschland
| | - Doreen Feuerstein
- Zentrum für Notfall- und Rettungsmedizin, Universitäts-Notfallzentrum (UNZ), Universitätsklinikum Freiburg, Freiburg, Deutschland
| | - Martin Möckel
- Notfall- und Akutmedizin, Zentrale Notaufnahmen und Chest Pain Units, Campus Virchow-Klinikum/Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Nikola Fuchs
- St.-Antonius-Hospital gGmbH, Klinik für Akut- und Notfallmedizin, Eschweiler, Deutschland
| | - Benedikt Friemert
- Klinik für Unfallchirurgie und Orthopädie, Rekonstruktive und Septische Chirurgie, Sporttraumatologie, Bundeswehrkrankenhaus Ulm, Ulm, Deutschland
| | - Sebastian Wolfrum
- Interdisziplinäre Notaufnahme, Universitätsklinikums Schleswig-Holstein, Kiel, Deutschland
| | | | - Michael Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Heinrich-Heine Universität, Düsseldorf, Deutschland
| | - Florian Reifferscheid
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Kiel, Deutschland
| | - Janina Bathe
- Institut für Rettungs- und Notfallmedizin, Universitätsklinikum Schleswig-Holstein, Kiel, Deutschland
| | - Felix Walcher
- Klinik für Unfallchirurgie, Universitätsmedizin Magdeburg, Magdeburg, Deutschland
| | - Christoph F Dietrich
- Department für Allgemeine Innere Medizin DAIM, Kliniken Hirslanden Beau Site, Salem und Permanence, Bern, Schweiz
| | | | - Hans-Jörg Busch
- Zentrum für Notfall- und Rettungsmedizin, Universitäts-Notfallzentrum (UNZ), Universitätsklinikum Freiburg, Freiburg, Deutschland
| | - Dorothea Sauer
- Zentrale Notaufnahme, Asklepios Klinik Wandsbek, Hamburg, Deutschland
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7
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Jones M, Elrifay A, Amer N, Awad H. Con: Limitations of POCUS Examination: Be Aware of Overdiagnosis and Undertreatment. J Cardiothorac Vasc Anesth 2023; 37:2366-2369. [PMID: 36707381 DOI: 10.1053/j.jvca.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 01/02/2023] [Indexed: 01/09/2023]
Affiliation(s)
- Mikayla Jones
- The Ohio State University College of Medicine, Columbus, OH
| | - Amr Elrifay
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Nourhan Amer
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Hamdy Awad
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH.
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Meisel JL, Chen DCR, Cohen GM, Bernard SA, Carmona H, Petrusa ER, Opole IO, Navedo D, Valtchinov VI, Nahas AH, Eiduson CM, Papps N. Listen Before You Auscultate: An Active-Learning Approach to Bedside Cardiac Assessment. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2023; 19:11362. [PMID: 37915746 PMCID: PMC10615901 DOI: 10.15766/mep_2374-8265.11362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 08/28/2023] [Indexed: 11/03/2023]
Abstract
Introduction Bedside cardiac assessment (BCA) is deficient across a spectrum of noncardiology trainees. Learners not taught BCA well may become instructors who do not teach well, creating a self-perpetuating problem. To improve BCA teaching and learning, we developed a high-quality, patient-centered curriculum for medicine clerkship students that could be flexibly implemented and accessible to other health professions learners. Methods With a constructivist perspective, we aligned learning goals, activities, and assessments. The curriculum used a "listen before you auscultate" framework, capturing patient history as context for a six-step, systematic approach. In the flipped classroom, short videos and practice questions preceded two 1-hour class activities that integrated diagnostic reasoning, pathophysiology, physical diagnosis, and reflection. Activities included case discussions, jugular venous pressure evaluation, heart sound competitions, and simulated conversations with patients. Two hundred sixty-eight students at four US and international medical schools participated. We incorporated feedback, performed thematic analysis, and assessed learners' confidence and knowledge. Results Low posttest data capture limited quantitative results. Students reported increased confidence in BCA ability. Knowledge increased in both BCA and control groups. Thematic analysis suggested instructional design strategies were effective and peer encounters, skills practice, and encounters with educators were meaningful. Discussion The curriculum supported active learning of day-to-day clinical competencies and promoted professional identity formation alongside BCA ability. Feedback and increased confidence on the late-clerkship posttest suggested durable learning. We recommend approaches to confirm this and other elements of knowledge, skill acquisition, or behaviors and are surveying impacts on professional identity formation-related constructs.
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Affiliation(s)
- James L. Meisel
- Associate Chief of Staff for Education, VA Bedford Healthcare System; Associate Professor of Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine
| | - Daniel C. R. Chen
- Assistant Dean of Student Affairs and Clinical Associate Professor of Medicine, General Internal Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine
| | | | - Sheilah A. Bernard
- Associate Professor of Medicine, Cardiovascular Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine
| | - Hugo Carmona
- Assistant Professor of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington School of Medicine
| | - Emil R. Petrusa
- Professor of Surgery, Harvard Medical School, and Department of Surgery, Learning Lab, Massachusetts General Hospital
| | - Isaac O. Opole
- Professor of Internal Medicine, Department of Internal Medicine, University of Kansas Medical Center
| | - Deborah Navedo
- Director of Education, STRATUS Center for Simulation, Brigham and Women's Hospital
| | - Vladimir I. Valtchinov
- Assistant Professor of Radiology, Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, and Department of Biomedical Informatics, Harvard Medical School
| | - Ahmed H. Nahas
- Advanced Geriatric Medicine Fellow, New England Geriatric Research Education and Clinical Center, VA Boston Health Care System, and Harvard Medical School Multicampus Geriatrics Fellowship, Beth Israel Deaconess Medical Center; Family Physician and Geriatrician, Family Medicine Clinic, Yakima Valley Farm Workers Clinic
| | - Carly M. Eiduson
- Fourth-Year Medical Student, University of Rochester School of Medicine & Dentistry
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Michels G, Greim CA, Krohn A, Ott M, Feuerstein D, Möckel M, Fuchs N, Friemert B, Wolfrum S, Kiefl D, Bernhard M, Reifferscheid F, Bathe J, Walcher F, Dietrich CF, Lechleuthner A, Busch HJ, Sauer D. [Recommendations for Education in Sonography in Prehospital Emergency Medicine (pPOCUS): Consensus paper of DGINA, DGAI, BAND, BV-ÄLRD, DGU, DIVI and DGIIN]. DIE ANAESTHESIOLOGIE 2023; 72:654-661. [PMID: 37544933 DOI: 10.1007/s00101-023-01327-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
Point-of-care sonography is a precondition in acute and emergency medicine for the diagnosis and initiation of therapy for critically ill and injured patients. While emergency sonography is a mandatory part of the training for clinical acute and emergency medicine, it is not everywhere required for prehospital emergency medicine. Although some medical societies in Germany have already established their own learning concepts for emergency ultrasound, a uniform national training concept for the use of emergency sonography in the out-of-hospital setting is still lacking. Experts of several professional medical societies have therefore joined forces and developed a structured training concept for emergency sonography in the prehospital setting. The consensus paper serves as quality assurance in prehospital emergency sonography.
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Affiliation(s)
- Guido Michels
- Notfallzentrum, Krankenhaus der Barmherzigen Brüder Trier, Medizincampus der Universitätsmedizin Mainz, Nordallee 1, 54292, Trier, Deutschland.
| | - Clemens-Alexander Greim
- Klinik für Anästhesiologie, Intensiv- und Notfallmedizin, Klinikum Fulda, Fulda, Deutschland
| | - Alexander Krohn
- Department für interdisziplinäre Akut‑, Notfall- und Intensivmedizin (DIANI), Klinikum Stuttgart, Stuttgart, Deutschland
| | - Matthias Ott
- Department für interdisziplinäre Akut‑, Notfall- und Intensivmedizin (DIANI), Klinikum Stuttgart, Stuttgart, Deutschland
| | - Doreen Feuerstein
- Zentrum für Notfall- und Rettungsmedizin, Universitäts-Notfallzentrum (UNZ), Universitätsklinikum Freiburg, Freiburg, Deutschland
| | - Martin Möckel
- Notfall- und Akutmedizin, Zentrale Notaufnahmen und Chest Pain Units, Campus Virchow-Klinikum/Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Nikola Fuchs
- St.-Antonius-Hospital gGmbH, Klinik für Akut- und Notfallmedizin, Eschweiler, Deutschland
| | - Benedikt Friemert
- Klinik für Unfallchirurgie und Orthopädie, Rekonstruktive und Septische Chirurgie, Sporttraumatologie, Bundeswehrkrankenhaus Ulm, Ulm, Deutschland
| | - Sebastian Wolfrum
- Interdisziplinäre Notaufnahme, Universitätsklinikums Schleswig-Holstein, Kiel, Deutschland
| | | | - Michael Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Heinrich-Heine Universität, Düsseldorf, Deutschland
| | - Florian Reifferscheid
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Kiel, Deutschland
| | - Janina Bathe
- Institut für Rettungs- und Notfallmedizin, Universitätsklinikum Schleswig-Holstein, Kiel, Deutschland
| | - Felix Walcher
- Klinik für Unfallchirurgie, Universitätsmedizin Magdeburg, Magdeburg, Deutschland
| | - Christoph F Dietrich
- Department für Allgemeine Innere Medizin DAIM, Kliniken Hirslanden Beau Site, Salem und Permanence, Bern, Schweiz
| | | | - Hans-Jörg Busch
- Zentrum für Notfall- und Rettungsmedizin, Universitäts-Notfallzentrum (UNZ), Universitätsklinikum Freiburg, Freiburg, Deutschland
| | - Dorothea Sauer
- Zentrale Notaufnahme, Asklepios Klinik Wandsbek, Hamburg, Deutschland
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10
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Michels G, Greim CA, Krohn A, Ott M, Feuerstein D, Möckel M, Fuchs N, Friemert B, Wolfrum S, Kiefl D, Bernhard M, Reifferscheid F, Bathe J, Walcher F, Dietrich CF, Lechleuthner A, Busch HJ, Sauer D. Empfehlungen zur Sonografieausbildung in der prähospitalen Notfallmedizin (pPOCUS): Konsensuspapier von DGINA, DGAI, BAND, BV-ÄLRD, DGU, DIVI und DGIIN. Notf Rett Med 2023. [DOI: 10.1007/s10049-023-01196-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2023]
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11
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Elhassan MG, Grewal S, Nezarat N. Point-of-Care Ultrasonography in Internal Medicine: Limitations and Pitfalls for Novice Users. Cureus 2023; 15:e43655. [PMID: 37600433 PMCID: PMC10436027 DOI: 10.7759/cureus.43655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 08/22/2023] Open
Abstract
Point-of-care ultrasound (POCUS) is increasingly being adopted in the field of internal medicine, leading to the development of POCUS curricula in undergraduate and postgraduate medical education programs. Prominent internal medicine societies and organizations worldwide recognize the expanding utilization of POCUS by internal medicine physicians, emphasizing the need for practitioners to be aware of both its benefits and limitations. Despite the growing enthusiasm for POCUS, clinicians, particularly those with limited clinical experience, must be cautious regarding its inherent limitations and the potential impact on their clinical practice. This review aims to outline the limitations and potential drawbacks of POCUS for medical students, residents, and internists who wish to stay abreast of the escalating use of POCUS in internal medicine and have a desire, or have already commenced, to incorporate POCUS into their practice. Additionally, it provides recommendations for enhancing POCUS proficiency to mitigate these limitations.
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Affiliation(s)
| | - Sarbjot Grewal
- Internal Medicine, Saint Agnes Medical Center, Fresno, USA
| | - Negin Nezarat
- Internal Medicine, Saint Agnes Medical Center, Fresno , USA
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12
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Michels G, Greim CA, Krohn A, Ott M, Feuerstein D, Möckel M, Fuchs N, Friemert B, Wolfrum S, Kiefl D, Bernhard M, Reifferscheid F, Bathe J, Walcher F, Dietrich CF, Lechleuthner A, Busch HJ, Sauer D. Empfehlungen zur Sonografieausbildung in der prähospitalen Notfallmedizin (pPOCUS): Konsensuspapier von DGINA, DGAI, BAND, BV-ÄLRD, DGU, DIVI und DGIIN. NOTARZT 2023; 39:195-203. [DOI: 10.1055/a-2114-7667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2023]
Abstract
ZusammenfassungDie Point-of-Care-Sonografie ist in der Akut- und Notfallmedizin ein fester Bestandteil der Diagnostik und Therapieeinleitung von kritisch kranken und verletzten Patienten. Während die
Notfallsonografie im Rahmen der Zusatzweiterbildung für klinische Akut- und Notfallmedizin vorausgesetzt wird, wird diese für die prähospitale Notfallmedizin lediglich im (Muster-)Kursbuch
Allgemeine und spezielle Notfallbehandlung als Weiterbildungsinhalt definiert. Obwohl einige Fachgesellschaften in Deutschland bereits eigene Lernkonzepte für die Notfallsonografie etabliert
haben, fehlt bis dato ein einheitliches nationales Ausbildungskonzept für den Einsatz der Notfallsonografie im prähospitalem Umfeld. Experten mehrerer Fachgesellschaften haben daher als
Empfehlung für die notfallmedizinische Weiterbildung ein Kurskonzept für die spezielle Ausbildung in der prähospitalen Notfallsonografie erarbeitet, welche gleichermaßen zu deren
Qualitätssicherung beitragen soll.
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Affiliation(s)
- Guido Michels
- Notfallzentrum, Krankenhaus der Barmherzigen Brüder Trier, Medizincampus der Universitätsmedizin Mainz, Trier, Deutschland
- gleichberechtigte Erstautoren
| | - Clemens-Alexander Greim
- Klinik für Anästhesiologie, Intensiv- und Notfallmedizin, Klinikum Fulda, Fulda, Deutschland
- gleichberechtigte Erstautoren
| | - Alexander Krohn
- Department für interdisziplinäre Akut-, Notfall- und Intensivmedizin (DIANI), Klinikum Stuttgart, Stuttgart, Deutschland
| | - Matthias Ott
- Department für interdisziplinäre Akut-, Notfall- und Intensivmedizin (DIANI), Klinikum Stuttgart, Stuttgart, Deutschland
| | - Doreen Feuerstein
- Zentrum für Notfall- und Rettungsmedizin, Universitäts-Notfallzentrum (UNZ), Universitätsklinikum Freiburg, Freiburg, Deutschland
| | - Martin Möckel
- Notfall- und Akutmedizin, Zentrale Notaufnahmen und Chest Pain Units, Campus Virchow-Klinikum/Campus Charité Mitte, Charité – Universitätsmedizin Berlin
| | - Nikola Fuchs
- St.-Antonius-Hospital gGmbH, Klinik für Akut- und Notfallmedizin, Eschweiler, Deutschland
| | - Benedikt Friemert
- Klinik für Unfallchirurgie und Orthopädie, Rekonstruktive und Septische Chirurgie, Sporttraumatologie, Bundeswehrkrankenhaus Ulm, Ulm, Deutschland
| | - Sebastian Wolfrum
- Interdisziplinäre Notaufnahme, Universitätsklinikums Schleswig-Holstein, Kiel, Deutschland
| | | | - Michael Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Heinrich-Heine Universität, Düsseldorf, Deutschland
| | - Florian Reifferscheid
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Kiel, Deutschland
| | - Janina Bathe
- Institut für Rettungs- und Notfallmedizin Universitätsklinikum Schleswig-Holstein, Kiel, Deutschland
| | - Felix Walcher
- Klinik für Unfallchirurgie, Universitätsmedizin Magdeburg, Magdeburg, Deutschland
| | - Christoph F. Dietrich
- Department für Allgemeine Innere Medizin DAIM, Kliniken Hirslanden Beau Site, Salem und Permanence, Bern, Schweiz
| | | | - Hans-Jörg Busch
- Zentrum für Notfall- und Rettungsmedizin, Universitäts-Notfallzentrum (UNZ), Universitätsklinikum Freiburg, Freiburg, Deutschland
- gleichberechtigte Letztautoren
| | - Dorothea Sauer
- Zentrale Notaufnahme, Asklepios Klinik Wandsbek, Hamburg, Deutschland
- gleichberechtigte Letztautoren
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13
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Polyzogopoulou E, Velliou M, Verras C, Ventoulis I, Parissis J, Osterwalder J, Hoffmann B. Point-of-Care Ultrasound: A Multimodal Tool for the Management of Sepsis in the Emergency Department. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1180. [PMID: 37374384 DOI: 10.3390/medicina59061180] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 06/15/2023] [Accepted: 06/17/2023] [Indexed: 06/29/2023]
Abstract
Sepsis and septic shock are life-threatening emergencies associated with increased morbidity and mortality. Hence, early diagnosis and management of both conditions is of paramount importance. Point-of-care ultrasound (POCUS) is a cost-effective and safe imaging modality performed at the bedside, which has rapidly emerged as an excellent multimodal tool and has been gradually incorporated as an adjunct to physical examination in order to facilitate evaluation, diagnosis and management. In sepsis, POCUS can assist in the evaluation of undifferentiated sepsis, while, in cases of shock, it can contribute to the differential diagnosis of other types of shock, thus facilitating the decision-making process. Other potential benefits of POCUS include prompt identification and control of the source of infection, as well as close haemodynamic and treatment monitoring. The aim of this review is to determine and highlight the role of POCUS in the evaluation, diagnosis, treatment and monitoring of the septic patient. Future research should focus on developing and implementing a well-defined algorithmic approach for the POCUS-guided management of sepsis in the emergency department setting given its unequivocal utility as a multimodal tool for the overall evaluation and management of the septic patient.
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Affiliation(s)
- Effie Polyzogopoulou
- Emergency Medicine Department, Attikon University Hospital, 12462 Athens, Greece
| | - Maria Velliou
- Emergency Medicine Department, Attikon University Hospital, 12462 Athens, Greece
| | - Christos Verras
- Emergency Medicine Department, Attikon University Hospital, 12462 Athens, Greece
- National Centre of Emergency Care (EKAB), 11527 Athens, Greece
| | - Ioannis Ventoulis
- Department of Occupational Therapy, University of Western Macedonia, 50200 Ptolemaida, Greece
| | - John Parissis
- Emergency Medicine Department, Attikon University Hospital, 12462 Athens, Greece
| | | | - Beatrice Hoffmann
- Department of Emergency Medicine BIDMC, One Deaconess Rd, WCC2, Boston, MA 02215, USA
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Kula R, Popela S, Klučka J, Charwátová D, Djakow J, Štourač P. Modern Paediatric Emergency Department: Potential Improvements in Light of New Evidence. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10040741. [PMID: 37189990 DOI: 10.3390/children10040741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 05/17/2023]
Abstract
The increasing attendance of paediatric emergency departments has become a serious health issue. To reduce an elevated burden of medical errors, inevitably caused by a high level of stress exerted on emergency physicians, we propose potential areas for improvement in regular paediatric emergency departments. In an effort to guarantee the demanded quality of care to all incoming patients, the workflow in paediatric emergency departments should be sufficiently optimised. The key component remains to implement one of the validated paediatric triage systems upon the patient's arrival at the emergency department and fast-tracking patients with a low level of risk according to the triage system. To ensure the patient's safety, emergency physicians should follow issued guidelines. Cognitive aids, such as well-designed checklists, posters or flow charts, generally improve physicians' adherence to guidelines and should be available in every paediatric emergency department. To sharpen diagnostic accuracy, the use of ultrasound in a paediatric emergency department, according to ultrasound protocols, should be targeted to answer specific clinical questions. Combining all mentioned improvements might reduce the number of errors linked to overcrowding. The review serves not only as a blueprint for modernising paediatric emergency departments but also as a bin of useful literature which can be suitable in the paediatric emergency field.
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Affiliation(s)
- Roman Kula
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Physiology, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
| | - Stanislav Popela
- Emergency Department, University Hospital Olomouc and Faculty of Medicine, Palacký University, I.P. Pavlova 185/6, 779 00 Olomouc, Czech Republic
- Emergency Medical Service of the South Moravian Region, Kamenice 798, 625 00 Brno, Czech Republic
| | - Jozef Klučka
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
| | - Daniela Charwátová
- Department of Surgery, Vyškov Hospital, Purkyňova 235/36, 682 01 Vyškov, Czech Republic
| | - Jana Djakow
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Paediatric Intensive Care Unit, NH Hospital Inc., 268 01 Hořovice, Czech Republic
| | - Petr Štourač
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
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15
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Verras C, Ventoulis I, Bezati S, Matsiras D, Parissis J, Polyzogopoulou E. Point of Care Ultrasonography for the Septic Patient in the Emergency Department: A Literature Review. J Clin Med 2023; 12:jcm12031105. [PMID: 36769753 PMCID: PMC9917776 DOI: 10.3390/jcm12031105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 01/17/2023] [Accepted: 01/28/2023] [Indexed: 02/04/2023] Open
Abstract
The point-of-care ultrasound (POCUS) has been effectively used in intensive care units for the management of septic patients. Since it is a time- and cost-effective non-invasive imaging modality, its use in the emergency department (ED) has been advocated for by medical experts. This review summarizes the existing literature regarding the breadth of POCUS as a supplementary tool to the holistic approach of septic patients in the ED setting. A literature search was conducted via PubMed (MEDLINE), Cochrane Library, and Scopus databases, analyzing studies which examined the use of POCUS in the ED for non-traumatic, septic, and/or undifferentiated hypotensive patients, resulting in 26 studies. The first cluster of studies investigates the efficiency of POCUS protocols in the differential diagnosis and its reliability for distributive/septic shock and sepsis management. In the second cluster, POCUS use results in faster sepsis cause identification and improves therapeutic management. The third cluster confirms that POCUS aids in the accurate diagnosis and management, even in rare and complicated cases. The results of the present review support the well-documented utility of POCUS and highlight the importance of POCUS incorporation in the comprehensive management of the septic patient in the ED setting.
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Affiliation(s)
- Christos Verras
- Emergency Department, National and Kapodistrian University of Athens, Attikon University Hospital, 12462 Athens, Greece
- Correspondence: ; Tel.: +30-6936585677
| | - Ioannis Ventoulis
- Department of Occupational Therapy, University of Western Macedonia, 50100 Kozani, Greece
| | - Sofia Bezati
- Emergency Department, National and Kapodistrian University of Athens, Attikon University Hospital, 12462 Athens, Greece
| | - Dionysis Matsiras
- Emergency Department, National and Kapodistrian University of Athens, Attikon University Hospital, 12462 Athens, Greece
| | - John Parissis
- Emergency Department, National and Kapodistrian University of Athens, Attikon University Hospital, 12462 Athens, Greece
| | - Effie Polyzogopoulou
- Emergency Department, National and Kapodistrian University of Athens, Attikon University Hospital, 12462 Athens, Greece
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16
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Rahsepar S, Sanie Jahromi MS, Abiri S, Akhavan R, Akhavan H, Abbasi B, Maleki F, Ahmadnezhad S, Rezvani Kakhki B, Kalani N, Adibi P. Point-of-Care Tests' Role in Time Metrics of Urgent Interventions in Emergency Department; a Systematic Review of Literature. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2022; 10:e82. [PMID: 36426166 PMCID: PMC9676698 DOI: 10.22037/aaem.v10i1.1817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
INTRODUCTION Point-of-Care Testing (POCT) could be helpful in clinical decisions, treatment selection, monitoring, prognostication, operational decision-making, and resource utilization. This study aimed to review the role of POCT in time metrics of performing urgent interventions in the emergency department (ED) or disposition time to proper care. METHODS This was a systematic review of the literature based on the PRISMA statement. PubMed, Scopus, Web of Science, and EMBASE databases were searched for studies reporting the application of the POCT in the ED with outcomes of the time to intervention or disposition. RESULTS After reviewing 3708 articles, 16 studies with 100,224 participants were included in this systematic review. There were 5 randomized clinical trials (RCTs), 5 retrospective cohorts, 2 prospective cohorts, and 4 before-after studies. All studies were performed in an ED setting except for one study of prehospital EMS air medical transport. Different panels, ultrasound, cardiac parameters, echocardiography, and polymerase chain reaction (PCR) POCTs were used in the studies. Regarding the outcome measures, studies with many types of patients referring to ED used different indices of time to intervention or time to disposition. Studies on different shock circumstances used the time to the first bolus of hydration or vasopressor or intravenous antibiotics for septic shock patients and central venous catheterization (CVC) placement time in one study. Time to imaging was considered as the outcome in some studies. Overall, there was a high risk of bias, especially in case of the randomization methods, and non-blinded designs in RCTs. There was lower possibility of bias in non-randomized studies but the studies did not have enough follow-ups and in case of studies using advanced panels of POCT, results do not seem to be easily applicable to public health care in many countries. CONCLUSION In synthesis of the evidence, all included studies were reporting the benefits of the POCT in decreasing the time to proper interventions and increasing the time to negative interventions in the last lines of critical care as well as the intubation and CVC placement.
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Affiliation(s)
- Sara Rahsepar
- Department of Dermatology, Mashhad University of Medical sciences, Mashhad, Iran
| | | | - Samaneh Abiri
- Research Center for Non-Communicable Diseases, Jahrom University of Medical Sciences, Jahrom, Iran
| | - Reza Akhavan
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical sciences, Mashhad, Iran
| | - Hossein Akhavan
- Department of Pediatrics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Bita Abbasi
- Department of Radiology, Faculty of Medicine, Mashhad University of Medical sciences, Mashhad, Iran
| | - Fatemeh Maleki
- Department of Emergency Medicine, School of Medicine, Birjand University of Medical Sciences, Birjand, Iran
| | - Somayyeh Ahmadnezhad
- Department of Emergency Medicine, Ramsar Campus, Mazandaran University of Medical Sciences, Ramsar, Iran
| | - Behrang Rezvani Kakhki
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical sciences, Mashhad, Iran
| | - Navid Kalani
- Research Center for Social Determinants of Health, Jahrom University of Medical Sciences, Jahrom, Iran
| | - Pourya Adibi
- Anesthesiology, Critical Care and Pain Management Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
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17
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Lau YH, See KC. Point-of-care ultrasound for critically-ill patients: A mini-review of key diagnostic features and protocols. World J Crit Care Med 2022; 11:70-84. [PMID: 35433316 PMCID: PMC8968483 DOI: 10.5492/wjccm.v11.i2.70] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 12/08/2021] [Accepted: 02/10/2022] [Indexed: 02/06/2023] Open
Abstract
Point-of-care ultrasonography (POCUS) for managing critically ill patients is increasingly performed by intensivists or emergency physicians. Results of needs surveys among intensivists reveal emphasis on basic cardiac, lung and abdominal ultrasound, which are the commonest POCUS modalities in the intensive care unit. We therefore aim to describe the key diagnostic features of basic cardiac, lung and abdominal ultrasound as practised by intensivists or emergency physicians in terms of accuracy (sensitivity, specificity), clinical utility and limitations. We also aim to explore POCUS protocols that integrate basic cardiac, lung and abdominal ultrasound, and highlight areas for future research.
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Affiliation(s)
- Yie Hui Lau
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore 308433, Singapore
| | - Kay Choong See
- Division of Respiratory & Critical Care Medicine, National University Hospital, Singapore 119074, Singapore
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18
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Berg I, Walpot K, Lamprecht H, Valois M, Lanctôt JF, Srour N, van den Brand C. A Systemic Review on the Diagnostic Accuracy of Point-of-Care Ultrasound in Patients With Undifferentiated Shock in the Emergency Department. Cureus 2022; 14:e23188. [PMID: 35444920 PMCID: PMC9009815 DOI: 10.7759/cureus.23188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 11/05/2022] Open
Abstract
Early identification of the shock type and correct diagnosis is associated with better outcomes. Previous studies have suggested that point-of-care ultrasound (POCUS) increases the diagnostic accuracy of patients in undifferentiated shock. However, a complete overview of the diagnostic accuracy of POCUS and the related treatment changes when compared to standard care is still limited. Our objective was to compare POCUS against standard practice regarding the diagnostic accuracy and specific therapeutic management changes (fluid volume administration and vasopressor use) in patients with undifferentiated shock in the emergency department (ED). We conducted a systematic review in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. A systematic search was performed using Embase, PubMed, Cochrane Central Register for Controlled Trials, and clinicaltrials.gov. Two physicians independently selected the articles and assessed the quality of the studies independently with the Quadas-2 tool. All included studies used POCUS in adult patients in undifferentiated shock and described diagnostic accuracy or specific therapeutic management changes (fluid volume administration or vasopressor use) and compared this to standard care. The primary outcome was diagnostic accuracy. Secondary outcomes were the amount of fluid administered and vasopressor use in the ED. Only articles published after 1996 were included. There were 10,805 articles found of which 6 articles were included. Four out of six studies reported diagnostic accuracy, three reported on fluid administration and vasopressors. We found that the diagnostic accuracy improved through the use of POCUS when compared to the standard care group, increasing overall diagnostic accuracy from 45-60% to 80-89% when combined with clinical information. There was no significant difference in fluid administration or vasopressor use between the groups. In our systematic review, we found that the use of POCUS in patients that presented with undifferentiated shock in the ED improved the diagnostic accuracy of the shock type and final diagnosis. POCUS resulted in no changes in fluid administration or vasopressor use when compared to standard care. However, the results should be interpreted within the limitations of some of the studies that were included in the review.
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Affiliation(s)
- Ingvar Berg
- Emergency Medicine Department, Haaglanden Medical Centre, The Hague, NLD
| | - Kris Walpot
- Emergency Medicine Department, University Hospital Leuven, Leuven, BEL
| | - Hein Lamprecht
- Division of Emergency Medicine, Stellenbosch University, Cape Town, ZAF
| | - Maxime Valois
- Emergency Medicine Department, Hôpital Charleslemoyne, Montreal, CAN
| | | | - Nadim Srour
- Respiratory Medicine Department, Hôpital Charleslemoyne, Montreal, CAN
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19
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Outcomes of CMS-mandated fluid administration among fluid-overloaded patients with sepsis: A systematic review and meta-analysis. Am J Emerg Med 2022; 55:157-166. [DOI: 10.1016/j.ajem.2022.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 02/22/2022] [Accepted: 03/04/2022] [Indexed: 12/20/2022] Open
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20
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Shehata I, Diab S, Kweon J, Farrag O. The role of ultrasonography in anesthesia for bariatric surgery. Saudi J Anaesth 2022; 16:347-354. [PMID: 35898531 PMCID: PMC9311175 DOI: 10.4103/sja.sja_80_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 01/30/2022] [Accepted: 02/03/2022] [Indexed: 11/30/2022] Open
Abstract
Bariatric surgeries are effective long-term management for morbid obesity with its adverse sequelae. Anesthesia of bariatric surgeries poses unique challenges for the anesthesiologist in every step starting with vascular access till tracheal extubation. The usage of ultrasound in anesthesia is becoming more prevalent with a variety of benefits, especially in the obese population. Ultrasound is successfully used for obtaining vascular access, with more than 15 million catheters placed in the United States alone. Ultrasound can also be used to predict difficult intubation, as it can confirm the tracheal intubation and assess the gastric content to prevent pulmonary aspiration. Ultrasound is also used in the management of mechanically ventilated patients to monitor lung aeration and to identify respiratory complications during positive pressure ventilation. Moreover, intraoperative echocardiography helps to discover the pulmonary embolism and guides the fluid therapy. Finally, ultrasound can be used to perform neuraxial and fascial plane block with a less overall time of the procedures and minimal complications. The wide use of ultrasound in bariatric anesthesia reflects the learning curve of the anesthesiologists and their mounting efforts to provide safe anesthesia utilizing the updated technology. In this review, we highlight the role of ultrasonography in anesthesia of bariatric surgery and discuss the recent guidelines.
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21
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Mayo PH, Chew M, Douflé G, Mekontso-Dessap A, Narasimhan M, Vieillard-Baron A. Machines that save lives in the intensive care unit: the ultrasonography machine. Intensive Care Med 2022; 48:1429-1438. [PMID: 35941260 PMCID: PMC9360728 DOI: 10.1007/s00134-022-06804-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 06/23/2022] [Indexed: 02/04/2023]
Abstract
This article highlights the ultrasonography machine as a machine that saves lives in the intensive care unit. We review its utility in the limited resource intensive care unit and some elements of machine design that are relevant to both the constrained operating environment and the well-resourced intensive care unit. As the ultrasonography machine can only save lives, if is operated by a competent intensivist; we discuss the challenges of training the frontline clinician to become competent in critical care ultrasonography followed by a review of research that supports its use.
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Affiliation(s)
- Paul H. Mayo
- Division of Pulmonary, Critical Care, and Sleep Medicine, Northwell Health LIJ/NSUH Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY USA
| | - Michelle Chew
- Department of Anaesthesiology and Intensive Care Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Ghislaine Douflé
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Canada ,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Armand Mekontso-Dessap
- AP-HP Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, 94010 Créteil, France ,Univ Paris Est Créteil, CARMAS, 94010 Créteil, France ,Univ Paris Est Créteil, INSERM, IMRB, 94010 Créteil, France
| | - Mangala Narasimhan
- Division of Pulmonary, Critical Care, and Sleep Medicine, Northwell Health LIJ/NSUH Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY USA
| | - Antoine Vieillard-Baron
- Intensive Care Medicine, University Hospital Ambroise Paré, Assistance Publique-Hôpitaux de Paris, 92100 Boulogne-Billancourt, France
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22
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Chiem AT, Shibata J, Lim G, Liu YT. Pick Up Your Probes: A Call for Clinically Oriented Point-of-Care Ultrasound Research in COVID-19. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:391-396. [PMID: 32686851 PMCID: PMC7405186 DOI: 10.1002/jum.15394] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 06/07/2020] [Indexed: 05/14/2023]
Affiliation(s)
- Alan T. Chiem
- Department of Emergency MedicineOlive View–UCLA Medical CenterSylmarCaliforniaUSA
| | - Jacqueline Shibata
- Department of Emergency MedicineOlive View–UCLA Medical CenterSylmarCaliforniaUSA
| | - George Lim
- Ronald Reagan UCLA Medical CenterCaliforniaLos AngelesUSA
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Subramaniam K, Boisen ML, Yehushua L, Esper SA, Philips DP, Howard-Quijano K. Perioperative Transthoracic Echocardiography Practice By Cardiac Anesthesiologists-Report of a "Start-Up" Experience. J Cardiothorac Vasc Anesth 2020; 35:222-232. [PMID: 32888802 DOI: 10.1053/j.jvca.2020.06.046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 06/10/2020] [Accepted: 06/12/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVE In this paper, the authors report their experience of perioperative transthoracic echocardiography (TTE) practice and its impact on perioperative patient management. DESIGN Retrospective case series. SETTING Single institution, tertiary university hospital. PARTICIPANTS A total of 101 adult ASA II-V male and female patients >18 years old who were scheduled for or having surgery were included in this retrospective case series. INTERVENTIONS All patients underwent a focused perioperative TTE exam performed by cardiac anesthesiologists with significant TTE experience, and further clinical management was based on echocardiography findings discussed with the anesthesia care team. MEASUREMENTS Significant echocardiographic findings and changes in patient management were reported. Step-up management was a new intervention that was executed based on echocardiographic findings (volume infusion, inotropic therapy, cardiology consultation, and other interventions), and step-down management was avoidance of an unnecessary intervention based on echocardiographic findings (proceeding to surgery without cancellation, delay, cardiology consultation, and additional investigations/interventions). MAIN RESULTS Fifty-three percent of TTEs were performed in the preoperative setting, 34% were intra-operative, and 13% were postoperative. No significant findings were detected in 38 patients, leading to step-down management in all of them. Among patients with positive findings, left ventricular dysfunction (12.8%), hypovolemia (10.8%), and right ventricular dysfunction (7.9%) were the most common. Step-up therapy included inotropic/vasopressor therapy (24.8%), intensive care admission after surgery for further management (13.8%), volume infusion (12.8%), and other interventions (additional monitoring, surgical delay, cardiology consultation, and modification of surgical technique). CONCLUSION Perioperative focused TTE examination is useful in the diagnosis of new cardiac conditions for anesthesia management (intraoperative monitoring and hemodynamic therapy) and postoperative care (intensive care unit admissions). Perioperative TTE performed by anesthesiologists can also help avoid procedural delays and unnecessary consults.
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Affiliation(s)
- Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, UPMC (University of Pittsburgh Medical Center), Pittsburgh, PA.
| | - Michael L Boisen
- Department of Anesthesiology and Perioperative Medicine, UPMC (University of Pittsburgh Medical Center), Pittsburgh, PA
| | - Liora Yehushua
- Department of Anesthesiology and Perioperative Medicine, UPMC (University of Pittsburgh Medical Center), Pittsburgh, PA
| | - Stephen A Esper
- Department of Anesthesiology and Perioperative Medicine, UPMC (University of Pittsburgh Medical Center), Pittsburgh, PA
| | - Dennis P Philips
- Department of Anesthesiology and Perioperative Medicine, UPMC (University of Pittsburgh Medical Center), Pittsburgh, PA
| | - Kimberly Howard-Quijano
- Department of Anesthesiology and Perioperative Medicine, UPMC (University of Pittsburgh Medical Center), Pittsburgh, PA
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Jones TW, Smith SE, Van Tuyl JS, Newsome AS. Sepsis With Preexisting Heart Failure: Management of Confounding Clinical Features. J Intensive Care Med 2020; 36:989-1012. [PMID: 32495686 DOI: 10.1177/0885066620928299] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Preexisting heart failure (HF) in patients with sepsis is associated with worse clinical outcomes. Core sepsis management includes aggressive volume resuscitation followed by vasopressors (and potentially inotropes) if fluid is inadequate to restore perfusion; however, large fluid boluses and vasoactive agents are concerning amid the cardiac dysfunction of HF. This review summarizes evidence regarding the influence of HF on sepsis clinical outcomes, pathophysiologic concerns, resuscitation targets, hemodynamic interventions, and adjunct management (ie, antiarrhythmics, positive pressure ventilatory support, and renal replacement therapy) in patients with sepsis and preexisting HF. Patients with sepsis and preexisting HF receive less fluid during resuscitation; however, evidence suggests traditional fluid resuscitation targets do not increase the risk of adverse events in HF patients with sepsis and likely improve outcomes. Norepinephrine remains the most well-supported vasopressor for patients with sepsis with preexisting HF, while dopamine may induce more cardiac adverse events. Dobutamine should be used cautiously given its generally detrimental effects but may have an application when combined with norepinephrine in patients with low cardiac output. Management of chronic HF medications warrants careful consideration for continuation or discontinuation upon development of sepsis, and β-blockers may be appropriate to continue in the absence of acute hemodynamic decompensation. Optimal management of atrial fibrillation may include β-blockers after acute hemodynamic stabilization as they have also shown independent benefits in sepsis. Positive pressure ventilatory support and renal replacement must be carefully monitored for effects on cardiac function when HF is present.
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Affiliation(s)
- Timothy W Jones
- Department of Clinical and Administrative Pharmacy, 15506University of Georgia College of Pharmacy, Augusta, GA, USA
| | - Susan E Smith
- Department of Clinical and Administrative Pharmacy, 15506University of Georgia College of Pharmacy, Athens, GA, USA
| | - Joseph S Van Tuyl
- Department of Pharmacy Practice, 14408St Louis College of Pharmacy, St Louis, MO, USA
| | - Andrea Sikora Newsome
- Department of Clinical and Administrative Pharmacy, 15506University of Georgia College of Pharmacy, Augusta, GA, USA.,Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
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Abstract
Purpose of Review To briefly review epidemiology and pathophysiology of SICM and provide a more extensive review of the data on diagnostic and management strategies. Recent Findings SICM is likely underdiagnosed and that has mortality implications. Current evidence supports speckle tracking echocardiography to identify decreased contractility irrespective of left ventricular ejection fraction for the diagnosis of SICM. There continues to be a dearth of large clinical trials evaluating the treatment of SICM and current consensus focuses on supportive measures such as vasopressors and inotropes. Summary Sepsis is a significant cause of mortality, and sepsis-induced cardiomyopathy has both prognostic and management implications for these patients. Individualized work-up and management of these patients is crucial to improving outcomes.
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Affiliation(s)
- Michael L'Heureux
- Division of Pulmonary Disease & Critical Care Medicine, Virginia Commonwealth University, P.O. Box 980050, Richmond, VA, 23298-0050, USA.
| | - Michael Sternberg
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Lisa Brath
- Division of Pulmonary Disease & Critical Care Medicine, Virginia Commonwealth University, P.O. Box 980050, Richmond, VA, 23298-0050, USA
| | - Jeremy Turlington
- Division of Cardiology, Virginia Commonwealth University, Richmond, VA, USA
| | - Markos G Kashiouris
- Division of Pulmonary Disease & Critical Care Medicine, Virginia Commonwealth University, P.O. Box 980050, Richmond, VA, 23298-0050, USA
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Javali RH, Loganathan A, Srinivasarangan M, Patil A, Siddappa GB, Satyanarayana N, Bheemanna AS, Jagadeesh S, Betkerur S. Reliability of Emergency Department Diagnosis in Identifying the Etiology of Nontraumatic Undifferentiated Hypotension. Indian J Crit Care Med 2020; 24:313-320. [PMID: 32728321 PMCID: PMC7358855 DOI: 10.5005/jp-journals-10071-23429] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Introduction Nontraumatic undifferentiated hypotension is one of the common and challenging critical presentations in the emergency department (ED) due to the difficulty in diagnosing the etiology of shock. In the present study, an attempt was made to test point-of-care ultrasound (PoCUS) as an early approach to improve the accuracy of diagnosis and to narrow the differentials in cases of nontraumatic undifferentiated hypotension. Materials and methods This is a prospective explorative study conducted in the ED of a tertiary care hospital over a period of 18 months. A total of 100 patients were included in the study. All patients >18 years of age with systolic blood pressure <90 mm Hg with at least one sign or symptom of hypoperfusion were included in the study. Patients referred from another hospital as shock, history of trauma, and history suggestive of orthostatic hypotension and presented with symptomatic postural hypotension as the only chief complaint were excluded. All the patients who met the inclusion/exclusion criteria underwent detailed clinical and multi-organ PoCUS evaluation by two different observers. Assessment of the lungs, cardia, abdomen, aorta, inferior vena cava (IVC), and leg veins during the PoCUS examination was done. A third observer combined the clinical evaluation and the PoCUS findings. All patients were followed through for their final diagnosis at the time of discharge. First, the diagnosis after clinical evaluation alone was compared to the final diagnosis. Then the diagnoses based on the findings of PoCUS alone were compared with the final diagnosis. Last, the diagnosis obtained on combining the data of clinical evaluation with that of PoCUS was compared to the final diagnosis. The data were analyzed based on their reliability indices, accuracy, and the Cohen’s kappa coefficient. Results Diagnoses based on clinical evaluation alone and POCUS alone were found to be accurate in 45% and 47% of patients, respectively. But on combining the findings of clinical evaluation with PoCUS, the accuracy increased to 89%. The most common etiology of shock was found to be distributive shock present in 38% of patients with sepsis being the most common subtype. In patients with obstructive shock, combined clinical evaluation with PoCUS was in perfect agreement with Cohen’s kappa coefficient (κ) = 1 and those with distributive shock were in substantial agreement with Cohen’s kappa coefficient (κ) = 0717. The overall kappa correlation of the combined evaluation with PoCUS was 0.89, which shows an almost perfect agreement with the final diagnosis. Conclusion This study demonstrates the accuracy and reliability of PoCUS as an easy and valuable bedside tool when added to the clinical evaluation. It helps in narrowing the differentials and thereby guiding early goal-directed therapy in nontraumatic, undifferentiated hypotension patients presenting to the ED. How to cite this article Javali RH, Loganathan A, Srinivasarangan M, Akkamahadevi P, Ganesha BS, Nisarg S, et al. Reliability of Emergency Department Diagnosis in Identifying the Etiology of Nontraumatic Undifferentiated Hypotension. Indian J Crit Care Med 2020;24(5):313–320.
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Affiliation(s)
- Rameshbabu H Javali
- Department of Emergency Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
| | - Arpitha Loganathan
- Department of Emergency Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
| | - Madhu Srinivasarangan
- Department of Emergency Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
| | - Akkamahadevi Patil
- Department of Anesthesia, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
| | | | - Nisarg Satyanarayana
- Department of Emergency Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
| | - Adarsh S Bheemanna
- Department of Emergency Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
| | - Sriharsha Jagadeesh
- Department of Emergency Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
| | - Sagarika Betkerur
- Department of Emergency Medicine, JSS Medical College, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
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Deciphering the Effects of Performing Ultrasound on Critically Ill Emergency Department Patients. Crit Care Explor 2019; 1:e0048. [PMID: 32166229 PMCID: PMC7063894 DOI: 10.1097/cce.0000000000000048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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