Ultrasound in the surgical intensive care unit

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.

Evaluation of diaphragm thickening by diaphragm ultrasonography: a reproducibility and a repeatability study

PURPOSE

We have focused on the two-dimensional (B-mode) and the time-motion (M-mode) analysis of the zone of apposition to determine the reliability of diaphragm ultrasonography in the clinical environment.

METHODS

Ten healthy volunteers were enrolled and studied by three operators with different skills in ultrasonography. For every volunteer, each operator acquired three images of the diaphragm for each side, both in B-mode and in M-mode. Then a fourth operator calculated the thickening fraction (TF), by means of the formula TF = (TEI - TEE)/TEE (TEI is the thickness at end inspiration and TEE the thickness at end expiration). Afterwards, intraclass correlation coefficients (ICCs) were computed on TF to establish reproducibility and repeatability both in the B- and M-modes. A Coefficient of Repeatability or repeatability (CR) ≤ 0.3 was considered acceptable.

RESULTS

Both B-mode (CRs 0.16-0.26) and M-mode (CRs 0.10-0.15) were sufficiently repeatable to assess TF, except for the less experienced operator (CRs B-Mode 0.20-0.32). Reproducibility was moderate to good between operators with CRs much narrower for the M-Mode (0.13-0.14).

CONCLUSIONS

The results of our study have shown that diaphragm ultrasound is repeatable and reproducible when carried out by a radiologist or an intensivist with a basic curriculum in ultrasonography. The method is more accurate when using the M-mode for less experienced operators, and in this case, repeatability and reproducibility are not sufficient to make clinical decisions. No TF value lower than 36% was obtained using both techniques. This suggests the existence of a cut-off value that could be used as an initial tool to discriminate healthy subjects from those affected by diaphragmatic dysfunction.

CLINICAL TRIAL REGISTRATION

EUDRACT 2015-004635-12.

Critical care ultrasound in geriatric trauma resuscitation leads to decreased fluid administration and ventilator days

BACKGROUND

Geriatric trauma populations respond differently than younger trauma populations. Critical care ultrasound (CCUS) can guide resuscitation, and it has been shown to decrease intravenous fluid (IVF), lower time until operation, and lower mortality in trauma. Critical care ultrasound-guided resuscitation has not yet been studied in geriatric trauma. We hypothesized that incorporation of CCUS would decrease amount of IVF administered, decrease time to initiation of vasopressors, and decrease end organ dysfunction.

METHODS

A PRE-CCUS geriatric trauma group between January 2015 and October 2016 was resuscitated per standard practice. A POST-CCUS group between January 2017 and December 2018 was resuscitated based on CCUS performed by trained intensivist upon admission to the intensive care unit and 6 hours after initial ultrasound. The PRE-CCUS and POST-CCUS groups underwent propensity score matching, yielding 60 enrollees in each arm. Retrospective review was conducted for demographics, clinical outcomes, and primary endpoints, including amount of IVF in the first 48 hours, duration to initiation of vasopressor use, and end organ dysfunction. Wilcoxon two-sample, χ2 tests, and κ statistics were performed to check associations between groups.

RESULTS

There was no statistical difference between PRE-CCUS and POST-CCUS demographics and Injury Severity Scores. Intravenous fluid within 48 hours decreased from median [interquartile range] of 4941 mL [4019 mL] in the PRE-CCUS to 2633 mL [3671 mL] in the POST-CCUS (p = 0.0003). There was no significant difference between the two groups in time to initiation of vasopressors, vasopressor duration, lactate clearance, intensive care unit length of stay, or hospital length of stay. There was a significant decrease in ventilator days, with 26.7% PRE-CCUS with ventilation longer than 2 days, and only 6.7% POST-CCUS requiring ventilation longer than 2 days (p = 0.0033).

CONCLUSION

Critical care ultrasound can be a useful addition to geriatric resuscitation. The POST-CCUS received less IV fluid and had decreased ventilator days. While mortality, lactate clearance, complications, and hospital stay were not statistically different, there was a perception that CCUS was a useful adjunct for assessing volume status and cardiac function.

LEVEL OF EVIDENCE

Therapeutic, level II.

Safety, tolerability, and efficacy evaluation of the SlimME device for circumference reduction

OBJECTIVE

To assess the short- and long-term thermal impact of subclinical and clinical regimens of a single, non-invasive uniform ultrasound treatment session on subcutaneous adipose tissue (SAT).

STUDY DESIGN

Prospective, open-label, single-arm, split-side study.

METHODS

Patients (n = 17) were subjected to uniform ultrasound treatment, delivered in a single session with the SlimME device. The device was set to one of four treatment regimens, which differed in their durations and energy fluences during the raise and maintenance phases. Up to six abdominal regions were treated, with six patients receiving a different treatment on each side of the abdomen. Safety was assessed by measuring skin surface temperature, evaluating expected skin responses immediately and 30 min after treatment and via patient ratings of pain and discomfort. Efficacy of raising and then maintaining SAT temperatures at 48°C, was determined by routinely measuring SAT temperatures during the treatment session and by histological analysis of samples collected 7 (n = 13) or 90 (n = 4) days after treatment.

RESULTS

Trace to mild erythema was observed in up to 48% of the treated zones, which, in most cases, resolved within 30 minutes. No significant rise in mean skin surface temperature (≤26.5°C) was recorded following any of the four tested regimens. Overall, patients reported tolerability to treatment, with the highest mean pain score registered for the moderate and high intensity regimens (4.4 ± 1.5 and 4.9 ± 1.4, respectively). Mean SAT temperatures did not exceed 48.4 ± 2.5°C and were effectively maintained throughout the maintenance phase of the treatment session. Low-energy fluence led to localized fat coagulative necrotic lesions, surrounded by subacute rim of inflammation, while high-energy fluence induced fat coagulative necrosis alongside granulomatous panniculitis, which resolved within 90 days.

CONCLUSION

The tested uniform ultrasound regimens elicited SAT temperature elevations, with a subsequent energy-dependent increase in degree of fat necrosis. At the same time, the unique design spared the surrounding tissue from thermal damage and was associated with minimal discomfort. Taken together, the SlimME device constitutes an effective tool for destruction of stubborn hypodermal fat deposits. Lasers Surg. Med. © 2018 The Authors. Lasers in Surgery and Medicine Published by Wiley Periodicals, Inc.

Ultrasonography training and utilization in surgical critical care fellowships: a program director's survey

BACKGROUND

Intensivist-performed ultrasound (IPUS) is an adjunctive tool used to assist in resuscitation and management of critically ill patients. It allows clinicians real-time information through noninvasive methods. We aimed to evaluate the types of IPUS performed and the methods surgical critical care (SCC) fellows are trained along with challenges in training.

METHODS

One hundred SCC fellowship directors were successfully sent an email inviting them to participate in a short Web-based survey. We inquired about program characteristics including hospital type, fellowship size, faculty size and training, dedicated surgical critical care beds, and ultrasound equipment availability. The survey contained questions regarding the program directors' perception on importance on cost effectiveness of IPUS, types of IPUS examinations performed, fellows experience with IPUS, challenges to training, and presence and methods of quality assurance (QA) programs.

RESULTS

A total of 38 (38.0%) program directors completed the survey. Using a 100-point Likert scale, the majority of the respondents indicated that IPUS is important to patient care in the SICU and is cost-effective (mean score 85.5 and 84.6, respectively). Most (34, 89.5%) utilize IPUS and conduct a mean of 5.1 different examination types with FAST being the most prevalent examination (33, 86.8%). Thirty-three (86.8%) programs include IPUS in their SCC training with varying amounts of time spent training. Of these programs, 19 (57.6%) have a specific curriculum. The most frequently used modalities for training fellows were informal bedside teaching (28, 84.8%), hands-on lectures (20, 60.6%) and formal lectures (19, 57.6%). The top three challenges program directors cited for IPUS education was time (23, 69.7%), followed by concerns for ongoing QA (19, 57.6%) and lack of faculty trained in IPUS (18, 53.9%). Only 20 (60.6%) programs review images as a part of QA/quality improvement.

CONCLUSIONS

Utilization and training of IPUS is common in SCC fellowships. There is varied education type and training time devoted to IPUS which could lead to gaps in knowledge and care. Development of a standard curriculum for SCC fellowships could assist surgical intensivists in achieving a base of knowledge in IPUS to create a more homogenously trained workforce and standards of care.

Perceived versus Observed Patient Safety Measures in a Critical Care Unit from a Teaching Hospital in Southern Colombia

Introduction. Patient safety is an important topic. The purpose of this study is to evaluate the perceived versus observed patient safety measures (PSM) in critically ill patients in a teaching hospital in Latin America. Materials and Methods. The level of perceived patient safety was evaluated with the patient safety hospital survey. Three months later, a qualitative study was conducted, including video recording of procedures, graded according to adherence to PSM. Levels of adherence were scored during patient mobilization (PM), placement of central catheters (PCC), other invasive procedures (OIP), infection control (IC), and endotracheal intubation (ETI). Results. The perceived adherence of PSM in the prestudy survey was considered fair by 89.1% of the ICU staff. After the survey, 829 ICU procedures were video-recorded. Mean observed adherence for fair patient safety measures was 20.8%. Perceived adherence was higher than the real patient safety protocol measures observed in the videos. Conclusion. Perception of PSM was higher than observed in the management of critically ill patients in a teaching hospital in southern Colombia.

Evaluation of the eZono 4000 with eZGuide for ultrasound-guided procedures

Ultrasound-guided procedures are increasingly common in a variety of acute care settings, such as the operating room, critical care unit and emergency room. However, accurate judgment of needle tip position using traditional ultrasound technology is frequently difficult, and serious injury can result from inadvertently advancing beyond or through the target. Needle navigation is a recent innovation that allows the clinician to visualize the needle position and trajectory in real time as it approaches the target. A novel ultrasound machine has recently been introduced that is portable and designed for procedural guidance. The eZono 4000™ features an innovative needle navigation technology that is simple to use and permits the use of a wide range of commercially available needles, avoiding the inconvenience and cost of proprietary equipment. This article discusses this new ultrasound machine in the context of other currently available ultrasound machines featuring needle navigation.

Endovascular electrocardiography to guide placement of totally implantable central venous catheters in oncologic patients

PURPOSE

Appropriate tip position of totally implantable central venous catheters is essential in order to prevent catheter-related complications, in particular thrombosis. Endovascular electrocardiography is an economic and safe method to guide placement of catheters into the central veins. Although widely utilized, there is still lack of conclusive evidence about its efficacy. The aim of the study was to assess the efficacy and safety of endovascular electrocardiographic guided placement compared to the anthropometric method.

METHODS

Endovascular ECG was employed to guide electrocardiographic placement of a central venous catheter in a cohort of oncologic patients. The rate of correct placement and the incidence of catheter-related thrombosis were considered. Patients in which central venous catheters were inserted with the anthropometric technique were considered as control group.

RESULTS

The rate of correct placement was 91% and 50% for ECG-guided and anthropometric catheters (p<0.0001) respectively. None of the patients suffered from early insertion-related complications. The rate of catheter-related vascular thrombosis was lower for ECG-guided catheters (3.6% vs. 9.6%, n.s.), in particular for left-inserted catheters (0% vs. 33.3%, p=0.02).

CONCLUSION

Endovascular electrocardiography was more effective than the anthropometric technique in placement of implantable central venous catheters and was associated with a lower incidence of catheter-related thrombosis, in particular for those inserted from the left-side.

Ultrasound-guided arterial line catheterization in the critically ill: technique and review

Arterial line catheterization in the critically ill patient is often an arduous task. Here we identify risk factors in the critical care patient that may predict a more difficult arterial catheter insertion. We also describe our ultrasound technique and review of the literature with regard to location of access, complications, and the use of ultrasound guidance.

Ultrasonography versus chest radiography after chest tube removal for the detection of pneumothorax

BACKGROUND

Bedside ultrasound technology is an innovative, cost-effective, safe, and reproducible method used to make efficient decisions that directly affect the care of critical care patients.

PURPOSE

To validate the use of ultrasound technology when compared with the use of standard chest radiography for the detection of pneumothorax following chest tube removal.

METHODS

A prospective observational comparison study of 50 cardiothoracic patients with surgically placed pleural chest tubes was conducted. The accuracy of bedside ultrasound technology was compared with standard chest radiography to detect pneumothorax.

RESULTS

The sample kappa statistic was 1.000, indicating a perfect agreement between bedside ultrasonography and chest radiography in the detection of pneumothorax. Completion of the bedside ultrasound procedure took significantly less time than chest radiography.

CONCLUSIONS

Bedside ultrasound technology is as accurate as chest radiography in detecting pneumothorax following chest tube removal and can save institutions' time and money.

Use of echocardiography and modalities of patient monitoring of trauma patients

PURPOSE OF REVIEW

Trauma patients require evaluation of the anatomic structure as well as the hemodynamic profile of the heart to improve effectiveness of resuscitation. They are prone to hemodynamic instability and must be monitored with various modalities to detect deterioration early. Newer, less invasive ultrasound technologies are replacing familiar 'gold standard' modalities of the past. This article reviews the indications, roles, imaging approaches, and limitations of modern echocardiography. A brief review of other ICU monitoring modalities is also presented.

RECENT FINDINGS

Echocardiography has emerged as a first-line diagnostic tool for assessment of trauma patients, especially those with hemodynamic compromise. It yields crucial information about structural damage as well as the hemodynamic profile and can be performed through either the transesophageal or transthoracic route. Quick and systematic use of echocardiography for diagnosis and management of critically injured patients may lead to improved outcomes.

SUMMARY

Echocardiography plays an important role in the trauma bay for diagnosis of thoracic injury and at the bedside in the ICU for evaluation of the hemodynamic profile.

Focused transthoracic echocardiography

Caring for critically ill patients requires rapid and accurate diagnosis followed by prompt interventions. The physical examination remains an important part of the assessment of such patients, but it has been shown to have a low sensitivity and specificity in judging left ventricular function and intravascular volume. Invasive hemodynamic monitoring has similarly been shown to have significant limitations and has failed to demonstrate a mortality benefit in several recent studies. In some studies, it has been shown to be harmful. Focused transthoracic echocardiography (TTE) has emerged as a noninvasive and portable imaging technique that is capable of providing rapid and accurate information about the heart at the bedside. It can be used to complement the physical examination and result in marked improvement in diagnostic accuracy. Focused TTE can be used as a screening and monitoring tool. Studies have shown that clinicians can be trained to determine left ventricular function, detect pericardial effusions, predict intravenous fluid responsiveness, and identify important valvular defects in a relatively short period. This article describes the indications for focused TTE, provides evidence that clinicians can be rapidly taught the technique, reviews how the focused studies affect management, and discusses the advantages and limitations of this tool.