Implementing point-of-care ultrasonography of the heart and lungs in an anesthesia department

Feasibility of Focused Cardiac Ultrasound Performed by Trainees During Cesarean Delivery

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Prehospital ultrasound in emergency medicine]

Small, portable hand-held ultrasound devices nowadays enable a widespread use of prehospital point-of-care ultrasound (pPOCUS), which has so far only been used hesitantly, especially in ground-based emergency services. Many critical or even life-threatening conditions or internal injuries can often be better diagnosed or ruled out using pPOCUS, which can enable faster and more suitable goal-directed treatment and hospital transport. This article critically discusses relevant data, clinical benefits, limitations and challenges to be overcome when using pPOCUS for the most important life-threatening situations and aims to call for intensifying training and the extensive use of pPOCUS.

Current Use, Training, and Barriers of Point-of-Care Ultrasound in Anesthesiology: A National Survey of Veterans Affairs Hospitals

OBJECTIVES

The purpose of this study was to determine current use, training needs, and barriers to point-of-care ultrasound (POCUS) use among anesthesiologists in practice.

DESIGN

Multicenter, prospective, observational study.

SETTING

Anesthesiology departments in the Veterans Affairs Healthcare System in the United States.

PARTICIPANTS

Chiefs of staff and chiefs of anesthesiology departments.

INTERVENTIONS

A web-based survey was conducted between June 2019 and March 2020. Chiefs of staff answered questions about facility-level POCUS use, training, competency, and policies. Anesthesiology chiefs responded to a follow-up survey with specialty-specific POCUS questions. The results of the 2020 survey were compared with a similar survey conducted by the authors' group in 2015.

MEASUREMENTS AND MAIN RESULTS

All chiefs of staff (n = 130) and 77% of anesthesiology chiefs (n = 96) completed the survey. The most common POCUS applications used were central and peripheral vascular access (69%-72%), peripheral nerve blocks (66%), and evaluation of cardiac function (29%-31%). Compared with 2015, there was a statistically significant increase in desire for training (p = 0.00015), but no significant change in POCUS use (p = 0.31). Training was most desired for volume-status assessment (52%), left ventricular function (47%), pneumothorax (47%), central line placement (40%), peripheral nerve blocks (40%), and pleural effusion (40%). The most common barriers to POCUS use were lack of funding for training (35%), trained providers (33%), and training opportunities (28%).

CONCLUSIONS

A significant increase in desire for POCUS training was seen among anesthesiologists practicing in the Veterans Affairs healthcare system since 2015, and lack of training continues to be a top barrier for POCUS use among anesthesiologists.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Pre-operative point-of-care assessment of left ventricular diastolic dysfunction, an observational study

BACKGROUND

Left ventricular (LV) diastolic dysfunction is an acknowledged peri-operative risk factor that should be identified before surgery. This study aimed to evaluate a simplified echocardiographic method using e' and E/e' for identification and grading of diastolic dysfunction pre-operatively.

METHODS

Ninety six ambulatory surgical patients were consecutively included to this prospective observational study. Pre-operative transthoracic echocardiography was conducted prior to surgery, and diagnosis of LV diastolic dysfunction was established by comprehensive and simplified assessment, and the results were compared. The accuracy of e'-velocities in order to discriminate patients with diastolic dysfunction was established by calculating accuracy, efficiency, positive (PPV) and negative predictive (NPV) values, and area under the receiver operating characteristic curve (AUROC).

RESULTS

Comprehensive assessment established diastolic dysfunction in 77% (74/96) of patients. Of these, 22/74 was categorized as mild dysfunction, 43/74 as moderate dysfunction and 9/74 as severe dysfunction. Using the simplified method with e' and E/e', diastolic dysfunction was established in 70.8% (68/96) of patients. Of these, 8/68 was categorized as mild dysfunction, 36/68 as moderate dysfunction and 24/68 as severe dysfunction. To discriminate diastolic dysfunction of any grade, e'-velocities (mean < 9 cm s^- 1) had an AUROC of 0.901 (95%CI 0.840-0.962), with a PPV of 55.2%, a NPV of 90.9% and a test efficiency of 0.78.

CONCLUSIONS

The results of this study indicate that a simplified approach with tissue Doppler e'-velocities may be used to rule out patients with diastolic dysfunction pre-operatively, but together with E/e' ratio the severity of diastolic dysfunction may be overestimated.

TRIAL REGISTRATION

Clinicaltrials.gov, Identifier: NCT03349593 . Date of registration 21/11/2017. https://clinicaltrials.gov .

Graduate Medical Education Can Be an Impetus for Behavior Changes in Physicians in Practice: Point-Of-Care Ultrasound Faculty Development Intervention in Anesthesiology

INTRODUCTION

While there is growing evidence to suggest that point-of-care ultrasound (POCUS) may aid in clinical decision-making in the perioperative setting and there are new requirements that anesthesiology residents must be trained in POCUS, few practicing anesthesiologists use POCUS in their practice. The goal of this investigation is to determine whether a multifaceted faculty development program helps a group of faculty members incorporate POCUS into their practice.

METHODS

This intervention had five parts: (1) online prework, (2) 2-day workshop, (3) follow-up hands-on sessions, (4) regular communication, and (5) equipment acquisition. This is a pretest/posttest, single group, observational study where the main outcome measure is the number of POCUS examinations documented and the number of providers who performed at least one examination. In addition, presurveys and postsurveys were administered to determine whether there was a change in confidence and self-reported use of POCUS.

RESULTS

The number of examinations completed and the number of providers completing examinations by month both seemed to increase over time between May 2017 and October 2018. Between August 2017 and October 2018, the number of examinations completed per month increased by a rate of approximately one examination per month (starting with one examination in May 2017) and the number of providers completing examinations increased by a rate of approximately 0.61 providers per month (staring with one provider in May 2017).

DISCUSSION

This study shows that an intervention that targets interested faculty can increase the use of POCUS in practice and residents' perceptions of teaching.

Learning strategies of general practitioners striving to achieve point-of-care ultrasound competence: a qualitative study

BACKGROUND

Point-of-care ultrasonography (POCUS) is increasingly used in general practice despite the lack of official educational programmes or guidelines for general practitioners (GPs).

AIM

To explore how GPs have learnt to use POCUS and which barriers they have encountered in their learning process.

DESIGN AND SETTING

Qualitative study conducted in office-based general practice in Denmark.

METHODS

Semi-structured interviews were conducted with 13 GPs who had implemented POCUS without supporting guidelines or regulations. Analysis was carried out using systematic text condensation. The interview data for this study were collected along with data used in a previous study.

RESULTS

The participating GPs described having composed their own ultrasound education following a continuous learning process. Basic POCUS competences were achieved through formalized training sessions at hospital departments or courses. The GPs further developed and expanded their scanning skills through additional courses and continuous self-study practice on patients often while consulting internet sources, textbooks or colleagues. Lack of available ultrasound courses, supervision, and clinical guidelines together with time constraints and financial aspects were mentioned as barriers to their ultrasound training.

CONCLUSION

This study showed how GPs had composed their own ultrasound education individually and differently, guided by their own experiences and beliefs about good clinical practice. Formalized ultrasound training was considered a prerequisite for achieving basic ultrasound competences while continuous practice was considered paramount to develop and maintain scanning skills. There were several obstacles to overcome in the learning process including lack of supervision, guidance, and opportunity for practicing skills.Key pointsLittle is known about the educational needs of general practitioners striving to achieve ultrasound competences.General practitioners described using formalized training to achieve basic scanning competences and continuous self-study and practice to further develop their skills.Lack of time, supervision, clinical guidelines and ultrasound courses were considered barriers in the learning process together with financial aspects.

Impact of focused cardiac ultrasound in vascular surgery patients: A prospective observational study

PURPOSE

We aimed to evaluate the diagnostic and logistical consequences of routine preoperative focused cardiac ultrasound (FOCUS) in patients scheduled for elective vascular surgery.

METHODS

In a prospective, observational study, FOCUS was performed in all patients seen in the vascular surgery outpatient clinic from January 14 to May1, 2019, unless a full echocardiography had been conducted in the preceding 12 months or the patient was already referred to an echocardiography by the vascular surgeons. FOCUS followed a stringent protocol and referrals for a full echocardiography followed predefined criteria.

RESULTS

Preoperative FOCUS was performed in 55 (60%) patients. Of these, 12 patients (22%) revealed cardiac pathology and were referred to a full echocardiography. Coronary angiography was subsequently performed in one of these patients but was without a further consequence. All patients underwent surgery.

CONCLUSION

FOCUS disclosed cardiac pathology in the outpatient clinic but with little clinical consequence. This study does not support routine FOCUS as a part of the preoperative patient cardiovascular assessment before vascular surgery. However, larger studies are warranted to further evaluate the relevance of preoperative FOCUS in a larger sample size.

Preoperative Point-of-Care Assessment of Left Ventricular Systolic Dysfunction With Transthoracic Echocardiography

BACKGROUND

Left ventricular (LV) systolic dysfunction is an acknowledged perioperative risk factor and should be identified before surgery. Conventional echocardiographic assessment of LV ejection fraction (LVEF) obtained by biplane LV volumes is the gold standard to detect LV systolic dysfunction. However, this modality needs extensive training and is time consuming. Hence, a feasible point-of-care screening method for this purpose is warranted. The aim of this study was to evaluate 3 point-of-care echocardiographic methods for identification of LV systolic dysfunction in comparison with biplane LVEF.

METHODS

One hundred elective surgical patients, with a mean age of 63 ± 12 years and body mass index of 27 ± 4 kg/m2, were consecutively enrolled in this prospective observational study. Transthoracic echocardiography was conducted 1-2 hours before surgery. LVEF was obtained by automatic two-dimensional (2D) biplane ejection fraction (EF) software. We evaluated if Tissue Doppler Imaging peak systolic myocardial velocities (TDISm), anatomic M-mode E-point septal separation (EPSS), and conventional M-mode mitral annular plane systolic excursion (MAPSE) could discriminate LV systolic dysfunction (LVEF <50%) by calculating accuracy, efficiency, correlation, positive (PPV) respective negative predictive (NPV) values, and area under the receiver operating characteristic curve (AUROC) for each point-of-care method.

RESULTS

LVEF<50% was identified in 22% (21 of 94) of patients. To discriminate an LVEF <50%, AUROC for TDISm (mean <8 cm/s) was 0.73 (95% confidence interval [CI], 0.62-0.84; P < .001), with a PPV of 47% and an NPV of 90%. EPSS with a cutoff value of >6 mm had an AUROC 0.89 (95% CI, 0.80-0.98; P < .001), with a PPV of 67% and an NPV of 96%. MAPSE (mean <12 mm) had an AUROC 0.80 (95% CI, 0.70-0.90; P < 0.001) with a PPV of 57% and an NPV of 98%.

CONCLUSIONS

All 3 point-of-care methods performed reasonably well to discriminate patients with LVEF <50%. The clinician may choose the most suitable method according to praxis and observer experience.

Intraoperative Focused Cardiac Ultrasound for Assessment of Hypotension: A Systematic Review

Focused cardiac ultrasound (FoCUS) has become a valuable tool to assess unexplained hypotension in critically ill patients. Due to increasing availability of transthoracic echocardiography (TTE) equipment in the operating room, there is a widespread interest in its usefulness for intraoperative diagnosis of hypotension as an alternative to transesophageal echocardiography (TEE). The objective of this systematic review is to evaluate the utility of intraoperative FoCUS to assess patients experiencing unexplained hypotension while undergoing noncardiac surgery. We performed a systematic literature search of multiple publication databases for studies that evaluated the utility of intraoperative FoCUS for assessment and management of unexplained hypotension in patients undergoing noncardiac surgery, including retro- and prospective clinical studies. A summary of the study findings, study quality, and assessment of level of evidence is presented. We identified 2227 unique articles from the literature search, of which 27 were potentially relevant, and 9 were included in this review. The number of patients pooled from these studies was 255, of whom 228 had intraoperative diagnoses with the aid of intraoperative FoCUS. The level of evidence of all studies included was very low according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) guidelines. This systematic review has demonstrated that FoCUS may be a useful, noninvasive method to differentiate causes of intraoperative hypotension and guide correcting interventions, although the quality of evidence is very low. Further prospective high-quality studies are needed to investigate whether intraoperative FoCUS has a diagnostic utility that is associated with improved outcomes.

Use of Handheld Point-of-Care Ultrasound in Emergency Airway Management

Emergency airway management (EAM) is associated with a high rate of complications, morbidity, and mortality. Handheld point-of-care ultrasound shows promise as an emerging technology to facilitate rapid screening for difficult laryngoscopy, identify the cricothyroid membrane for potential cricothyroidotomy, and assess for increased aspiration risk, as well as provide confirmation of proper endotracheal tube positioning. This review summarizes the available evidence for the use of point-of-care ultrasound in EAM, provides an algorithm to facilitate its incorporation into existing EAM practice to improve patient safety, and serves as a framework for future validation studies.

Pre-operative transthoracic echocardiography in ambulatory surgery-A cross-sectional study

BACKGROUND

Cardiac disease and aberrations in central volume status are risk factors for perioperative complications, and should be identified prior to surgery. This study investigated the benefit of transthoracic echocardiography (TTE) for pre-operative identification of cardiac disease and hypovolemia in ambulatory surgery.

METHODS

Ninety-six patients, with a mean age of 63.5 ± 12.2 years and body mass index of 27.0 ± 4.3 kg/m² , scheduled for ambulatory surgery (breast, thyroid, and minor gastrointestinal), were consecutively enrolled in this prospective observational study. Pre-operative comprehensive TTE was performed in order to assess heart failure (HF), asymptomatic left ventricular dysfunction, valvular disease, and aberrations in central volume status.

RESULTS

Pre-operative TTE identified a total of 28 cases of HF, 13 cases of HF with reduced or moderately reduced, ejection fraction (EF), and 15 cases of HF with preserved EF. Furthermore, 46 cases of asymptomatic left ventricular (LV) dysfunction were identified. 44/96 patients were hypovolemic, 16 of whom in severe hypovolemia. Seven cases of previously unknown obstructive valvular or myocardial disease and six cases of right ventricular systolic dysfunction were identified. A total of 24% (23/96) were classified as potential critical hemodynamic findings. The number needed (NNT) to treat for pre-operative TTE in order to find one critical finding was 4.2.

CONCLUSION

In this ambulatory surgical cohort, a high prevalence of pre-operative LV dysfunction and aberrations in volume status was observed. The results demonstrate that pre-operative TTE contributed valuable hemodynamic information. The standard pre-operative assessment for this cohort might need to be revised.

Improving Clinical Proficiency Using a 3-Dimensionally Printed and Patient-Specific Thoracic Spine Model as a Haptic Task Trainer

BACKGROUND AND OBJECTIVES

Advanced haptic simulators for neuraxial training are expensive, have a finite life, and are not patient specific. We sought to demonstrate the feasibility of developing a custom-made, low-cost, 3-dimensionally printed thoracic spine simulator model from patient computed tomographic scan data. This study assessed the model's practicality, efficiency as a teaching tool, and the transfer of skill set into patient care.

METHODS

A high-fidelity, patient-specific thoracic spine model was used for the study. Thirteen residents underwent a 1-hour 30-minute training session prior to performing thoracic epidural analgesia (TEA) on patients. We observed another group of 14 residents who were exposed to the traditional method of training during their regional anesthesia rotation for thoracic epidural placement. The TEA was placed for patients under the supervision of attending anesthesiologists, who were blinded to the composition of the study and control groups. As a primary outcome, data were collected on successful TEAs, which was defined as a TEA that provided full relief of sensation across the entire surgical area as assessed by both a pinprick and temperature test. Secondary outcomes included whether any assistance from the attending physician was required and failed epidurals.

RESULTS

A total of 27 residents completed the study (14 in the traditional training, 13 in the study group). We found that the residents who underwent training with the simulator had a significantly higher success rate (11 vs 4 successful epidural attempts, P = 0.002) as compared with the traditional training group. The control group also required significantly more assistance from the supervising anesthesiologist compared with the study group (5 vs 1 attempt requiring guidance). The number needed to treat (NNT) for the traditional training group was 1.58 patients over the study period with a 95% confidence interval of 1.55 to 1.61.

CONCLUSIONS

By using patient-specific, 3-dimensionally printed, thoracic spine models, we demonstrated a significant improvement in clinical proficiency as compared with traditional teaching models.

The role of point of care ultrasound in prehospital critical care: a systematic review

Background

In 2011, the role of Point of Care Ultrasound (POCUS) was defined as one of the top five research priorities in physician-provided prehospital critical care and future research topics were proposed; the feasibility of prehospital POCUS, changes in patient management induced by POCUS and education of providers. This systematic review aimed to assess these three topics by including studies examining all kinds of prehospital patients undergoing all kinds of prehospital POCUS examinations and studies examining any kind of POCUS education in prehospital critical care providers.

Methods and results

By a systematic literature search in MEDLINE, EMBASE, and Cochrane databases, we identified and screened titles and abstracts of 3264 studies published from 2012 to 2017. Of these, 65 studies were read in full-text for assessment of eligibility and 27 studies were ultimately included and assessed for quality by SIGN-50 checklists. No studies compared patient outcome with and without prehospital POCUS. Four studies of acceptable quality demonstrated feasibility and changes in patient management in trauma. Two studies of acceptable quality demonstrated feasibility and changes in patient management in breathing difficulties. Four studies of acceptable quality demonstrated feasibility, outcome prediction and changes in patient management in cardiac arrest, but also that POCUS may prolong pauses in compressions. Two studies of acceptable quality demonstrated that short (few hours) teaching sessions are sufficient for obtaining simple interpretation skills, but not image acquisition skills. Three studies of acceptable quality demonstrated that longer one- or two-day courses including hands-on training are sufficient for learning simple, but not advanced, image acquisition skills. Three studies of acceptable quality demonstrated that systematic educational programs including supervised examinations are sufficient for learning advanced image acquisition skills in healthy volunteers, but that more than 50 clinical examinations are required for expertise in a clinical setting.

Conclusion

Prehospital POCUS is feasible and changes patient management in trauma, breathing difficulties and cardiac arrest, but it is unknown if this improves outcome. Expertise in POCUS requires extensive training by a combination of theory, hands-on training and a substantial amount of clinical examinations – a large part of these needs to be supervised.

Electronic supplementary material

The online version of this article (10.1186/s13049-018-0518-x) contains supplementary material, which is available to authorized users.

Focused cardiac ultrasound is feasible in parturients; a prospective observational study

BACKGROUND

In pregnancy, the major causes of morbidity and mortality include diseases that affect circulation profoundly and restoration of normal circulation is a key objective. Focused cardiac ultrasound provides information on the individual determinants of circulation and has a significant impact on patient management. This study aimed to determine the feasibility of focused cardiac ultrasound in term parturients.

METHODS

Forty parturients underwent focused cardiac ultrasound. Parasternal long-axis, parasternal short-axis, 4-chamber and subcostal views were performed in the left-lateral position and the supine position by a novice operator. All images were graded on the following scale: 1 = no image; 2 = poor and insufficient image; 3 = sufficient image quality; 4 = good image quality; 5 = perfect image quality. A cut-off grade of three signified images sufficient for clinical decision-making.

RESULTS

Images sufficient for clinical decision-making were obtained in all patients when including all imaging views. 37/40 (93 %) patients presented images of grade ≥ 4, whereas 10/40 (25%) patients had images of grade 5. Image grades were higher in the left lateral position (all P < 0.001). Parturients with a body mass index ≤ 30 kg/m² did not present different image grades than parturients with a higher body mass index (P = 0.753). Subcostal views could not be obtained.

CONCLUSION

Focused cardiac ultrasound is feasible in the obstetric population and images of sufficient quality for clinical decision-making were obtained in all parturients by an operator with limited experience.

Clinical examination, critical care ultrasonography and outcomes in the critically ill: cohort profile of the Simple Intensive Care Studies-I

PURPOSE

In the Simple Intensive Care Studies-I (SICS-I), we aim to unravel the value of clinical and haemodynamic variables obtained by physical examination and critical care ultrasound (CCUS) that currently guide daily practice in critically ill patients. We intend to (1) measure all available clinical and haemodynamic variables, (2) train novices in obtaining values for advanced variables based on CCUS in the intensive care unit (ICU) and (3) create an infrastructure for a registry with the flexibility of temporarily incorporating specific (haemodynamic) research questions and variables. The overall purpose is to investigate the diagnostic and prognostic value of clinical and haemodynamic variables.

PARTICIPANTS

The SICS-I includes all patients acutely admitted to the ICU of a tertiary teaching hospital in the Netherlands with an ICU stay expected to last beyond 24 hours. Inclusion started on 27 March 2015.

FINDINGS TO DATE

On 31 December 2016, 791 eligible patients fulfilled our inclusion criteria of whom 704 were included. So far 11 substudies with additional variables have been designed, of which six were feasible to implement in the basic study, and two are planned and awaiting initiation. All researchers received focused training for obtaining specific CCUS images. An independent Core laboratory judged that 632 patients had CCUS images of sufficient quality.

FUTURE PLANS

We intend to optimise the set of variables for assessment of the haemodynamic status of the critically ill patient used for guiding diagnostics, prognosis and interventions. Repeated evaluations of these sets of variables are needed for continuous improvement of the diagnostic and prognostic models. Future plans include: (1) more advanced imaging; (2) repeated clinical and haemodynamic measurements; (3) expansion of the registry to other departments or centres; and (4) exploring possibilities of integration of a randomised clinical trial superimposed on the registry.

STUDY REGISTRATION NUMBER

NCT02912624; Pre-results.