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Scott C, Alade K, Leung SK, Vaughan RM, Riley AF. Cardiac Point-of-Care Ultrasound and Multi-Disciplinary Improvement Opportunities in Acute Systolic Heart Failure Management in a Pediatric Emergency Center. Pediatr Cardiol 2024; 45:1353-1358. [PMID: 36790508 PMCID: PMC9930710 DOI: 10.1007/s00246-023-03125-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 02/02/2023] [Indexed: 02/16/2023]
Abstract
Cardiac point-of-care ultrasound (POCUS) has the ability to rapidly assess function and identify systolic heart failure (HF), an often-missed diagnosis. POCUS has the potential to expedite medical intervention, improving overall outcomes. There have been limited studies describing pediatric emergency center (EC) utilization of cardiac POCUS and its impact on outcomes in pediatric patients. Authors performed a retrospective chart review at a tertiary children's hospital to identify all patients admitted from the EC to the Cardiac Intensive Care Unit (CICU) with acute systolic HF between January 2017 and August 2019. Outcome measures included EC length of stay (LOS), CICU LOS, and time until first IV HF medicine was administered. A total of 21 patients and 24 encounters meeting criteria were identified. Cardiac POCUS agreed with standard echocardiography in 8 of 9 cases. Patients who had a cardiac POCUS in the EC seemed more likely to receive their first dose of intravenous heart failure medication while in the Emergency Center (70% vs 43%). There was a trend toward significance, but it did not reach statistical significance (p = 0.1). EC and CICU LOS were not significantly different between POCUS and non-POCUS groups. Cardiac POCUS has the potential to have a valuable role in the early diagnosis of acute systolic HF in children. However, early diagnosis by POCUS did not translate into shorter EC or CICU LOS. This pilot data serves as a baseline for efforts to promote earlier clinical recognition of acute HF and more efficient collaboration between clinical services.
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Affiliation(s)
- Camille Scott
- Department of Pediatrics, Section of Emergency Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.
- Department of Pediatrics, Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.
| | - Kiyetta Alade
- Department of Pediatrics, Section of Emergency Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
- Department of Pediatrics, Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Stephanie K Leung
- Department of Pediatrics, Section of Emergency Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
- Department of Pediatrics, Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Ruth Morrison Vaughan
- Department of Pediatrics, Section of Emergency Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
- Department of Pediatrics, Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Alan F Riley
- Department of Pediatrics, Section of Emergency Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
- Department of Pediatrics, Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA
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Francisco MJ, de Lira EB, de Queiroz MRG. Point-of-Care in Clinical Practice: Consolidated Reality. Arq Bras Cardiol 2024; 121:e20230688. [PMID: 38451562 PMCID: PMC11081179 DOI: 10.36660/abc.20230688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 11/08/2023] [Accepted: 11/08/2023] [Indexed: 03/08/2024] Open
Affiliation(s)
- Miguel José Francisco
- Faculdade Israelita de Ciências da Saúde Albert EinsteinHospital Albert EinsteinSão PauloSPBrasilFaculdade Israelita de Ciências da Saúde Albert Einstein (FICSAE) - Hospital Albert Einstein, São Paulo, SP – Brasil
| | - Edgar Bezerra de Lira
- Faculdade Israelita de Ciências da Saúde Albert EinsteinHospital Albert EinsteinSão PauloSPBrasilFaculdade Israelita de Ciências da Saúde Albert Einstein (FICSAE) - Hospital Albert Einstein, São Paulo, SP – Brasil
| | - Marcos Roberto Gomes de Queiroz
- Faculdade Israelita de Ciências da Saúde Albert EinsteinHospital Albert EinsteinSão PauloSPBrasilFaculdade Israelita de Ciências da Saúde Albert Einstein (FICSAE) - Hospital Albert Einstein, São Paulo, SP – Brasil
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Cabral NC, Figueira SDANN, Zamith MM, de Oliveira AC, Padrini L, Sanudo A, de Almeida MFB, Guinsburg R. Neonatal performed echocardiography course: Can we face it? J Perinatol 2023; 43:1262-1267. [PMID: 36739361 PMCID: PMC9898855 DOI: 10.1038/s41372-023-01617-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 01/09/2023] [Accepted: 01/16/2023] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate students' qualification after a six-month basic course of Neonatal Performed Echocardiography (NPEcho), adjusted by the motivational profile. STUDY DESIGN Prospective cohort of 16 neonatologists/neonatal fellows who underwent the basic NPEcho course in 2019 (18 h face-to-face theoretical classes; 36 h hands-on training) and 12 in 2020 (18 h online theoretical classes; 36 h hands-on training). Students' qualification was defined as ≥70% in post-test, video test, and practical evaluation in neonates. Academic Motivation Scale was applied. RESULTS Scores in 2019 vs. 2020 were: pre-test -32% vs. 40% (p = 0.029), final theoretical score -78% vs. 69% (p = 0.007), and practical evaluation -88% vs. 65% (p = 0.003), resulting in 68.8% in 2019 vs. 33.3% in 2020 qualified students. Students' motivational profile were similar in 2019 and 2020. CONCLUSION The NPEcho was successful in qualifying students with face-to-face theoretical classes, but the online format was inadequate to achieve the learning goals.
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Affiliation(s)
- Nádia Canale Cabral
- Division of Neonatal Medicine, Department of Pediatrics, Escola Paulista de Medicina-Universidade Federal de São Paulo, São Paulo, SP, Brazil.
| | | | - Marina Maccagnano Zamith
- Department of Internal Medicine, Escola Paulista de Medicina-Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Allan Chiaratti de Oliveira
- Division of Neonatal Medicine, Department of Pediatrics, Escola Paulista de Medicina-Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Lucio Padrini
- Division of Neonatal Medicine, Department of Pediatrics, Escola Paulista de Medicina-Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Adriana Sanudo
- Department of Preventive Medicine, Escola Paulista de Medicina-Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Maria Fernanda Branco de Almeida
- Division of Neonatal Medicine, Department of Pediatrics, Escola Paulista de Medicina-Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Ruth Guinsburg
- Division of Neonatal Medicine, Department of Pediatrics, Escola Paulista de Medicina-Universidade Federal de São Paulo, São Paulo, SP, Brazil
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Fremuth J, Huml M, Pomahacova T, Kobr J, Kormunda S, Sykora J. Stroke Volume Measurements by Echocardiography and Ultrasonic Cardiac Output Monitor in Children: A Prospective Observational Cohort Study. Pediatr Emerg Care 2023; 39:680-684. [PMID: 37478016 PMCID: PMC10487356 DOI: 10.1097/pec.0000000000003018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/23/2023]
Abstract
OBJECTIVES Stroke volume (SV) and cardiac output monitoring is a cornerstone of hemodynamic assessment. Noninvasive technologies are increasingly used in children. This study compared SV measurements obtained by transcutaneous Doppler ultrasound techniques (ultrasonic cardiac output monitor [USCOM]), transthoracic echocardiography jugular (TTE-J), and parasternal (TTE-P) views performed by pediatric intensivists (OP-As) with limited training in cardiac sonography (20 previous examinations) and pediatric cardiologists (OP-Bs) with limited training in USCOM (30 previous examinations) in spontaneously ventilating children. METHODS A single-center study was conducted in 37 children. Each operator obtained 3 sets of USCOM SV measurements within a period of 3 to 5 minutes, followed with TTE measurements from both apical and jugular views. The investigators were blinded to each other's results to prevent visual and auditory bias. RESULTS Both USCOM and TTE methods were applicable in 89% of patients. The intraobserver variability of USCOM, TTE-J, and TTE-P were less than 10% in both investigators. The SV measurements by OP-As using USCOM, TTE-J, and TTE-P were 46.15 (25.48) mL, 39.45 (20.65) mL, and 33.42 (16.69) mL, respectively. The SV measurements by OP-Bs using USCOM, TTE-J, and TTE-P were 43.99 (25.24) mL, 38.91 (19.98) mL, and 37.58 (19.81) mL, respectively.The percentage error in SV with USCOM relative to TTE-J was 36% in OP-As and 37% in OP-Bs. The percentage error in SV with TTE-P was 33% relative to TTE-J in OP-As and 21% in OP-Bs. CONCLUSIONS Our findings show that the methods are not interchangeable because SV values by USCOM are higher in comparison with the SV values obtained by TTE. Both methods have low level of intraobserver variability. The SV measurements obtained by TTE-P were significantly lower compared with the TTE-J for the operator with limited training in echocardiography. The TTE-P requires longer practice compared with the TTE-J; therefore, we recommend to prefer TTE-J to TTE-P for inexperienced operators.
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Mori T, Chor YK, Bui TL, Do HA, Ong GYK. Implementation and Assessment of a Hybrid Training Course on Point-of-Care Pediatric Ultrasound in Vietnam During the COVID-19 Pandemic. Cureus 2023; 15:e45758. [PMID: 37872933 PMCID: PMC10590496 DOI: 10.7759/cureus.45758] [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] [Accepted: 09/21/2023] [Indexed: 10/25/2023] Open
Abstract
Background As point-of-care ultrasound (POCUS) has gained popularity, some educational guidelines have been developed. However, in Vietnam, no training course in pediatric POCUS has yet been developed. This was challenging, especially during the COVID-19 pandemic. Objectives This study aimed to implement a three-month hybrid training course for pediatric POCUS training in Vietnam using both online and face-to-face hands-on sessions and to assess participants' self-efficacy level and change in their attitudes towards pediatric POCUS. Methods A hybrid training course in pediatric POCUS was implemented at a children's hospital in Vietnam. This study developed a standardized training course, including online learning, live lectures, hands-on sessions, and skill assessment based on the POCUS consensus educational guidelines. Physicians interested in pediatric POCUS were recruited for participation. They completed a self-evaluation survey before and after the course using a Likert score to assess their background, self-efficacy in performing POCUS, overall satisfaction with the course, and change in their attitudes towards POCUS three months after the course. Results A total of 19 physicians participated in the course. The mean post-training self-efficacy score was significantly higher than the pre-course assessment score: 73.1 (standard deviation (SD): 7.2) vs. 48.9 (SD: 12.5) (p <0.05). The efficacy level was retained three months after the course. Furthermore, overall satisfaction with the course was high at 9.5 (SD: 0.6). After the course, almost all participants strongly agreed to increase the use of POCUS in their clinical practice. Conclusion A hybrid training course in pediatric POCUS was successfully implemented in Vietnam and found the participants' self-efficacy level to be significantly higher after the course and the effect to be retained after the course. The training course could positively affect the participants' attitudes towards POCUS, encouraging them to use POCUS more frequently in their clinical practice.
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Affiliation(s)
- Takaaki Mori
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, SGP
| | - Yek Kee Chor
- Department of Paediatrics, Sarawak General Hospital, Sarawak, MYS
| | - Thanh Liem Bui
- Department of Pediatrics, University of Medicine and Pharmacy, Ho Chi Minh City, VNM
| | - Hong Anh Do
- Department of Emergency, Critical Care, and Clinical Toxicology, University of Medicine and Pharmacy, Ho Chi Minh City, VNM
| | - Gene Yong-Kwang Ong
- Department of Children's Emergency, KK Women's and Children's Hospital, Singapore, SGP
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Scheier E. Cardiac POCUS in Pediatric Emergency Medicine: A Narrative Review. J Clin Med 2023; 12:5666. [PMID: 37685733 PMCID: PMC10488602 DOI: 10.3390/jcm12175666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/21/2023] [Accepted: 08/28/2023] [Indexed: 09/10/2023] Open
Abstract
PURPOSE OF THIS REVIEW The cardiac point of care ultrasound (POCUS) is among the most impactful examinations in the evaluation of an ill child. This paper will review the English-language literature on cardiac POCUS in the pediatric emergency department (PED), the adult emergency literature with relevance to pediatric emergency, and other pediatric cardiac studies outside pediatric emergency with relevance to PED detection of potentially emergent pediatric cardiac pathology. RECENT FINDINGS Pediatric emergency physicians can reliably detect decreased left-sided systolic function and pericardial effusion using POCUS. Case reports show that pediatric emergency physicians have detected right-sided outflow tract obstruction, aortic root dilatation, and congenital cardiac disease using POCUS. Training for pediatric cardiac POCUS competency is feasible, and cardiac POCUS does not increase the burden on cardiology resources to the PED. SUMMARY While cardiac pathology in children is relatively rare, pediatric cardiac POCUS can incorporate a broad curriculum beyond systolic function and the presence of pericardial fluid. Further research should assess pediatric emergency physician performance in the identification of a broader range of cardiac pathology.
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Affiliation(s)
- Eric Scheier
- Pediatric Emergency, Kaplan Medical Center, Rehovot 76100, Israel; ; Tel.: +972-(8)-944-1275; Fax: +972-(8)-944-1276
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112001, Israel
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Edwards P, Anyaogu C, Mezue K, Baugh D, Goha A, Egbuche O, Nunura F, Madu E. Focused cardiac ultrasound in pregnancy. J Investig Med 2023; 71:81-91. [PMID: 36691704 DOI: 10.1177/10815589221142195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Cardiac disease in pregnancy is an important cause of maternal morbidity and mortality. In many high-income countries, acquired cardiac disease is now the largest cause of maternal mortality. Given its prevalence in low- and middle-income countries (LMICs), rheumatic heart disease is the most common cause of cardiac disease in pregnancy worldwide and is associated with poor maternal outcome. The diagnosis of cardiac disease in pregnancy is often delayed resulting in excess maternal morbidity and mortality. Maternal mortality review committees have suggested that prompt recognition and treatment of heart disease in pregnancy may improve maternal outcome. Given the similarities between symptoms of normal pregnancy and those of cardiac disease, the clinical diagnosis of heart disease in pregnancy is challenging with echocardiography being the primary diagnostic modality. Focused cardiac ultrasound (FOCUS) at the point of care provides supplemental data to the history and physical examination and has been demonstrated to permit early diagnosis and improvement in the management of cardiac disease in emergency medicine, intensive care, and anesthesia. It has also been demonstrated to be useful in surveillance for rheumatic heart disease in LMICs. The use of FOCUS may allow earlier and more accurate diagnosis of cardiac disease in pregnancy with the potential to decrease morbidity and mortality in both developed and developing countries.
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Affiliation(s)
- Paul Edwards
- Heart Institute of the Caribbean, Kingston, Jamaica
| | | | - Kenechukwu Mezue
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Dainia Baugh
- Heart Institute of the Caribbean, Kingston, Jamaica
| | - Ahmed Goha
- Cardiology department, Cardiac Center Hail, Hail, Saudi Arabia
| | - Obiora Egbuche
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wexner Medical Center, Ohio State University, Columbus, OH, USA
| | - Felix Nunura
- Heart Institute of the Caribbean, Kingston, Jamaica
| | - Ernest Madu
- Heart Institute of the Caribbean, Kingston, Jamaica
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Dessie AS, Calhoun AW, Kanjanauptom P, Gilbert GE, Ekpenyong A, Lewiss RE, Rabiner JE, Tsze DS, Kessler DO. Development and Validation of a Point-of-Care-Ultrasound Image Quality Assessment Tool: The POCUS IQ Scale. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:135-145. [PMID: 36165271 DOI: 10.1002/jum.16095] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 08/04/2022] [Accepted: 08/24/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES We aimed to develop a standardized scoring tool to measure point-of-care ultrasound (POCUS) image quality and to determine validity evidence for its use to assess lung ultrasound image quality. METHODS The POCUS Image Quality (POCUS IQ) scale was developed by POCUS-trained physicians to assess sonographers' image acquisition skills by evaluating image quality for any POCUS application. The scale was piloted using lung images of healthy standardized patients acquired by three expert sonographers compared to three novices before and after training. All images (experts, novices pre-training, novices post-training) were scored on the POCUS IQ scale by three blinded POCUS-trained physicians. Reliability was assessed with fully-crossed generalizability and decision studies. Validity was assessed using Messick's framework. RESULTS Content validity was supported by the tool's development process of literature review, expert consensus, and pilot testing. Response process was supported by reviewer training and the blinded scoring process. Relation to other variables was supported by scores relating to sonographer experience: median expert score = 10.5/14 (IQR: 4), median novice pre-training score = 6/14 (IQR: 2.25), and novices' improvement after training (median post-training score = 12/14, IQR: 3.25). Internal structure was supported by internal consistency data (coefficient alpha = 0.84, omega coefficient = 0.91) and the generalizability study showing the main contributor to score variability was the sonographer (51%). The G-coefficient was 0.89, suggesting very good internal structure, however, Gwet's AC2 was 0.5, indicating moderate interrater reliability. The D study projected a minimum of 1 reviewer and 2 patients are needed for good psychometric reliability. CONCLUSIONS The POCUS scale has good preliminary validity evidence as an assessment tool for lung POCUS image acquisition skills. Further studies are needed to demonstrate its utility for other POCUS applications and as a feedback tool for POCUS learners.
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Affiliation(s)
- Almaz S Dessie
- Department of Emergency Medicine, Columbia University Vagelos College of Physicians & Surgeons, New York, New York, USA
| | - Aaron W Calhoun
- University of Louisville, Department of Pediatrics, Louisville, Kentucky, USA
| | - Panida Kanjanauptom
- Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Gregory E Gilbert
- Biostatistics and Medical Writing, ∑igma∑tats™, LLC, Charleston, South Carolina, USA
- ICON, plc, New Wales, Pennsylvania, USA
| | - Atim Ekpenyong
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Resa E Lewiss
- Department of Pediatrics, University of California-San Diego, San Diego, California, USA
| | - Joni E Rabiner
- Department of Emergency Medicine, Columbia University Vagelos College of Physicians & Surgeons, New York, New York, USA
| | - Daniel S Tsze
- Department of Emergency Medicine, Columbia University Vagelos College of Physicians & Surgeons, New York, New York, USA
| | - David O Kessler
- Department of Emergency Medicine, Columbia University Vagelos College of Physicians & Surgeons, New York, New York, USA
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Persson JN, Kim JS, Good RJ. Diagnostic Utility of Point-of-Care Ultrasound in the Pediatric Cardiac Intensive Care Unit. CURRENT TREATMENT OPTIONS IN PEDIATRICS 2022; 8:151-173. [PMID: 36277259 PMCID: PMC9264295 DOI: 10.1007/s40746-022-00250-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/08/2022] [Indexed: 12/26/2022]
Abstract
Purpose of Review Recent Findings Summary Supplementary Information
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Affiliation(s)
- Jessica N. Persson
- Division of Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Children’s Hospital Colorado, 13123 East 16th, Avenue, Box 100, Aurora, CO 80045 USA
- Division of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine, Children’s Hospital Colorado, 13123 East 16th, Avenue, Box 100, Aurora, CO 80045 USA
| | - John S. Kim
- Division of Cardiology, Department of Pediatrics, University of Colorado School of Medicine, Children’s Hospital Colorado, 13123 East 16th, Avenue, Box 100, Aurora, CO 80045 USA
| | - Ryan J. Good
- Division of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine, Children’s Hospital Colorado, 13123 East 16th, Avenue, Box 100, Aurora, CO 80045 USA
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Rajamani A, Galarza L, Sanfilippo F, Wong A, Goffi A, Tuinman P, Mayo P, Arntfield R, Fisher R, Chew M, Slama M, Mackenzie D, Ho E, Smith L, Renner M, Tavares M, Prabu R N, Ramanathan K, Knudsen S, Bhat V, Arvind H, Huang S. Criteria, Processes, and Determination of Competence in Basic Critical Care Echocardiography Training: A Delphi Process Consensus Statement by the Learning Ultrasound in Critical Care (LUCC) Initiative. Chest 2022; 161:492-503. [PMID: 34508739 DOI: 10.1016/j.chest.2021.08.077] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 08/26/2021] [Accepted: 08/31/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND With the paucity of high-quality studies on longitudinal basic critical care echocardiography (BCCE) training, expert opinion guidelines have guided BCCE competence educational standards and processes. However, existing guidelines lack precise detail due to methodological flaws during guideline development. RESEARCH QUESTIONS To formulate methodologically robust guidelines on BCCE training using evidence and expert opinion, detailing specific criteria for every step, we conducted a modified Delphi process using the principles of the validated AGREE-II tool. Based on systematic reviews, the following domains were chosen: components of a longitudinal BCCE curriculum; pass-grade criteria for image-acquisition and image-interpretation; and formative/summative assessment and final competence processes. STUDY DESIGN AND METHODS Between April 2020 and May 2021, a total of 21 BCCE experts participated in four rounds. Rounds 1 and 2 used five web-based questionnaires, including branching-logic software for directed questions to individual panelists. In round 3 (videoconference), the panel finalized the recommendations by vote. During the journal peer-review process, Round 4 was conducted as Web-based questionnaires. Following each round, the agreement threshold for each item was determined as ≥ 80% for item inclusion and ≤ 30% for item exclusion. RESULTS Following rounds 1 and 2, agreement was reached on 62 of 114 items. To the 49 unresolved items, 12 additional items were added in round 3, with 56 reaching agreement and five items remaining unresolved. There was agreement that longitudinal BCCE training must include introductory training, mentored formative training, summative assessment for competence, and final cognitive assessment. Items requiring multiple rounds included two-dimensional views, Doppler, cardiac output, M-mode measurement, minimum scan numbers, and pass-grade criteria. Regarding objective criteria for image-acquisition and image-interpretation quality, the panel agreed on maintaining the same criteria for formative and summative assessment, to categorize BCCE findings as major vs minor and a standardized approach to errors, criteria for readiness for summative assessment, and supervisory options. INTERPRETATION In conclusion, this expert consensus statement presents comprehensive evidence-based recommendations on longitudinal BCCE training. However, these recommendations require prospective validation.
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Affiliation(s)
- Arvind Rajamani
- University of Sydney Nepean Clinical School, Intensive Care Medicine, Kingswood, NSW, Australia; Department of Intensive Care Medicine, Nepean Hospital, Kingswood, NSW, Australia.
| | - Laura Galarza
- Department of Intensive Care, Hospital General Universitario de Castellon, Castellon de la Plana, Spain
| | - Filippo Sanfilippo
- Department of Anaesthesia and Intensive Care, A.O.U. "Policlinico-San Marco," Catania, Italy
| | - Adrian Wong
- Department of Critical Care, King's College Hospital, London, UK
| | - Alberto Goffi
- Department of Critical Care Medicine and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto, Toronto, ON, Canada; Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Pieter Tuinman
- Department of Intensive Care Medicine, Amsterdam University Medical Centers VUmc, Amsterdam, The Netherlands; Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences Research Institute, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Paul Mayo
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY; Department of Pulmonary and Critical Care Medicine, Long Island Jewish Medical Center, New Hyde Park, NY
| | - Robert Arntfield
- Division of Critical Care, Department of Medicine, Western University, London, ON, Canada
| | - Richard Fisher
- Department of Critical Care, King's College Hospital, London, UK
| | - Michelle Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Michel Slama
- Medical Intensive Care, DRIME Department, University Hospital of Amiens, Amiens, France
| | - David Mackenzie
- Department of Emergency Medicine, Maine Medical Center, Portland, ME
| | - Eunise Ho
- Department of Intensive Care, Princess Margaret Hospital, Hong Kong, China
| | - Louise Smith
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, NSW, Australia
| | - Markus Renner
- Department of Intensive Care Medicine, Dunedin Hospital, Dunedin, New Zealand; Otago University, New Zealand
| | - Miguel Tavares
- Department of Anesthesiology and Critical Care, Hospital Geral de Santo António, Porto, Portugal
| | - Natesh Prabu R
- Department of Critical Care Medicine, St. John's Medical College Hospital, Bengaluru, Karnataka, India
| | - Kollengode Ramanathan
- Cardiothoracic Intensive Care Unit, National University Hospital, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Vijeth Bhat
- John Hunter Hospital, Intensive Care Unit, New Lambton Heights, NSW, Australia
| | | | - Stephen Huang
- University of Sydney Nepean Clinical School, Intensive Care Medicine, Kingswood, NSW, Australia
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Carotid Doppler Ultrasonography for Hemodynamic Assessment in Critically Ill Children. Pediatr Cardiol 2022; 43:382-390. [PMID: 34518914 DOI: 10.1007/s00246-021-02732-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 09/06/2021] [Indexed: 10/20/2022]
Abstract
An accurate assessment of cardiovascular performance is essential to predict and evaluate hemodynamic response to interventions. The objective of this prospective study was to assess whether point-of-care ultrasonography of the common carotid artery (CCA) can estimate the stroke volume (SV) and cardiac index (Ci) of critically ill children. Participants underwent Doppler ultrasonography of the left CCA and transthoracic echocardiography (TTE). Variables measured by TTE were SV and Ci. Carotid blood flow (CBF) was calculated based on both systolic velocity-time integral (CBF(s)) and total velocity-time integral (CBF(t)). Carotid corrected flow time(CFT)was also determined. A total of 50 children were enrolled. The median age and weight of participants were 36.0 months and 14.2 kg, respectively. Both CBF(s) and CBF(t) correlated very strongly with SV (ρ = 0.98 and 0.97, respectively) and Ci (ρ = 0.96 and 0.92, respectively). Agreement analysis showed low biases and clinically acceptable percentage errors between variables measured by TTE (SV and Ci) and those estimated by Doppler ultrasonography. Linear regression analysis revealed that the Ci of mechanically ventilated children can be estimated by the following equation: [Formula: see text]. CFT did not significantly correlate with SV or Ci (ρ = 0.27 and 0.05, respectively). Doppler ultrasonography of the left CCA is able to estimate the SV and Ci of critically ill children. Therefore, the CDU may be considered as an alternative for estimating Ci in critically ill children when TTE is not feasible or available.
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Miller AF, Arichai P, Gravel CA, Vieira RL, Neal JT, Neuman MI, Monuteaux MC, Levy JA. Use of Cardiac Point-of-Care Ultrasound in the Pediatric Emergency Department. Pediatr Emerg Care 2022; 38:e300-e305. [PMID: 33122503 DOI: 10.1097/pec.0000000000002271] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES We sought to describe the test characteristics of cardiac point-of-care ultrasound (POCUS) performed by pediatric emergency medicine (PEM) physicians after structured cardiac POCUS training. METHODS We evaluated the use of clinically indicated cardiac POCUS by PEM physicians in a single tertiary care pediatric emergency department after implementation of a focused cardiac POCUS training curriculum. The test characteristics of the sonologist interpretation were compared with expert POCUS review, by PEM physicians who have completed PEM POCUS fellowship training, for the assessment of both pericardial effusion and left ventricular systolic dysfunction. RESULTS A total of 1241 cardiac POCUS examinations were performed between July 2015 and December 2017, of which 456 were clinically indicated and underwent expert POCUS review and comprised the study sample. These examinations were performed by 33 different PEM attending sonologists. Chest pain (52%), dyspnea (20%), and tachycardia (18%) were the most common indications for cardiac POCUS. Prevalence of pericardial effusion and global systolic dysfunction based on expert POCUS review were 11% (48/443) and 4% (16/435), respectively. Real-time cardiac POCUS interpretation had a sensitivity and specificity of 100% and 99.5%, respectively, for both pericardial effusion and left ventricular systolic dysfunction when compared with expert POCUS review. CONCLUSIONS Cardiac POCUS is both sensitive and specific for identifying pericardial effusion and left ventricular systolic dysfunction when performed by PEM attendings with focused training.
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Affiliation(s)
- Andrew F Miller
- From the Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Piyawat Arichai
- Department of Pediatrics, Children's National Hospital, Washington, DC
| | - Cynthia A Gravel
- From the Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Rebecca L Vieira
- From the Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Jeffrey T Neal
- From the Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Mark I Neuman
- From the Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Michael C Monuteaux
- From the Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Jason A Levy
- From the Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
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Singh Y, Bhombal S, Katheria A, Tissot C, Fraga MV. The evolution of cardiac point of care ultrasound for the neonatologist. Eur J Pediatr 2021; 180:3565-3575. [PMID: 34125292 DOI: 10.1007/s00431-021-04153-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 06/06/2021] [Accepted: 06/09/2021] [Indexed: 01/22/2023]
Abstract
Cardiac point of care ultrasound (POCUS) is increasingly being utilized in neonatal intensive care units to provide information in real time to aid clinical decision making. While training programs and scope of practice have been well defined for other specialties, such as adult critical care and emergency medicine, there is a lack of structure for neonatal cardiac POCUS. A more comprehensive and advanced hemodynamic evaluation by a neonatologist has previously published its own clinical guidelines and specific rigorous training programs have been established to achieve competency in neonatal hemodynamics. However, it is becoming increasingly evident that access and training for basic cardiac assessment by ultrasound enhances bedside clinical care for specific indications. Recently, expert consensus POCUS guidelines for use in neonatal and pediatric intensive care endorsed by the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) have been published to guide the clinicians in using POCUS for specific indications, though the line between cardiac POCUS and advanced hemodynamic evaluation remains somewhat fluid.Conclusion: This article is focused on neonatal cardiac POCUS and its evolution, value, and limitations in the modern neonatal clinical practice. Cardiac POCUS can provide physiological and hemodynamic information in making clinical decisions while dealing with neonatal emergencies. However, it should be applied only for the specific indications and should be performed by a clinician trained in cardiac POCUS. There is an urgent need of developing cardiac POCUS curriculum and certification to support a widespread and safe use in neonates. What is Known: • International training guidelines and curriculum have been published for neonatologist-performed echocardiography (NPE) or targeted neonatal echocardiography (TNE). • International evidence-based guidelines for use of point of care ultrasound (POCUS) in neonates and children have been recently published. What is New: • Cardiac POCUS is increasingly being incorporated in neonatal practice for emergency situations. However, one must be aware of its specific indications and limitations, especially for the neonatal clinical practice. • Cardiac POCUS and NPE/TNE are continuum of cardiac imaging with different indications and training requirements.
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Affiliation(s)
- Yogen Singh
- Department of Pediatrics - Neonatology and Pediatric Cardiology, Addenbrooke's Hospital, Cambridge University Hospitals, Box 402, NICU, Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK. .,Departmet of Pediatrics, Division of Neonatology, Loma Linda University School of Medicine, Loma Linda, CA, USA.
| | - Shazia Bhombal
- Department of Pediatrics, Division of Neonatal and Behavioral Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Anup Katheria
- Department of Neonatology, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, USA
| | - Cecile Tissot
- Centre de Pediatrie, Clinique des Grangettes, 7 ch des Grangettes, 1224 Chêne-Bougeries, Geneva, Switzerland
| | - María V Fraga
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, USA
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14
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Mori T, Nomura O, Takei H, Fukuhara S, Ichihashi K. Implementation and assessment of a pediatric point-of-care ultrasound training course in Japan: a pilot study. J Med Ultrason (2001) 2021; 49:85-93. [PMID: 34677709 PMCID: PMC8532428 DOI: 10.1007/s10396-021-01155-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/17/2021] [Indexed: 12/02/2022]
Abstract
Purpose The popularity of point-of-care ultrasound (POCUS) has led to the creation of educational guidelines for its use. In Japan, however, a comprehensive training course for POCUS use in pediatric emergency medicine has yet to be developed. The present study aimed to implement a pilot course for pediatric POCUS training in Japan and to compare participants’ self-efficacy level before and after the course. Methods A half-day training course in pediatric POCUS was implemented at a meeting of the Japan Society of Point-of-Care Ultrasound. A standardized training course, including pre-learning materials, live lectures, and hands-on sessions, was developed based on the US consensus educational guidelines. Physicians interested in pediatric POCUS were recruited for participation and completed a self-evaluation survey before and after the course to access their background, self-efficacy in performing selected ultrasound procedures before and after the course, and their overall satisfaction with the course. Results In total, 31 physicians participated. Of these, 25 completed the survey. Ten participants were in post-graduate year (PGY) 1–2, 13 were in PGY 3–5, and eight were in PGY 6 or higher. The post-training self-efficacy score was significantly higher than the pre-course assessment score (86.0 [standard deviation (SD): 19.2] vs. 35.6 [SD 17.6], p = < 0.05, mean difference: 49.6 [95% confidence interval 39.6–61.2]). Furthermore, overall satisfaction with the course was high at 8.6 (SD 1.8). Conclusion The present study implemented a pilot training course in pediatric POCUS and found the participants’ self-efficacy level to be significantly higher after the course.
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Affiliation(s)
- Takaaki Mori
- Division of Pediatric Emergency Medicine, Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan.
| | - Osamu Nomura
- Department of Emergency and Disaster Medicine, Hirosaki University, 5 Zaifu-cho, Hirosaki, Aomori, 035-8562, Japan
| | - Hirokazu Takei
- Department of Emergency Medicine, Hyogo Prefectural Kobe Children's Hospital, 1-6-7 Minatojimaminamicho, Chuo-ku, Kobe, 650-0047, Japan
| | - Shinichi Fukuhara
- Department of Pediatrics, Hyogo Prefectural Awaji Medical Center, 1-1-137 Shioya, Sumoto, Hyogo, 656-0021, Japan
| | - Ko Ichihashi
- Department of Pediatrics, Jichi Medical University Saitama Medical Center, 1-847 Amanuma-cho, Ohmiya-ku, Saitama, 330-8503, Japan
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15
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Watkins LA, Dial SP, Koenig SJ, Kurepa DN, Mayo PH. The Utility of Point-of-Care Ultrasound in the Pediatric Intensive Care Unit. J Intensive Care Med 2021; 37:1029-1036. [PMID: 34632837 DOI: 10.1177/08850666211047824] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Objectives: Point of care ultrasound (POCUS) in adult critical care environments has become the standard of care in many hospitals. A robust literature shows its benefits for both diagnosis and delivery of care. The utility of POCUS in the pediatric intensive care unit (PICU), however, is understudied. This study describes in a series of PICU patients the clinical indications, protocols, findings and impact of pediatric POCUS on clinical management. Design: Retrospective analysis of 200 consecutive POCUS scans performed by a PICU physician. Patients: Pediatric critical care patients who required POCUS scans over a 15-month period. Setting: The pediatric and cardiac ICUs at a tertiary pediatric care center. Interventions: Performance of a POCUS scan by a pediatric critical care attending with advanced training in ultrasonography. Measurement and Main Results: A total of 200 POCUS scans comprised of one or more protocols (lung and pleura, cardiac, abdominal, or vascular diagnostic protocols) were performed on 155 patients over a 15-month period. The protocols used for each scan reflected the clinical question to be answered. These 200 scans included 133 thoracic protocols, 110 cardiac protocols, 77 abdominal protocols, and 4 vascular protocols. In this series, 42% of scans identified pathology that required a change in therapy, 26% confirmed pathology consistent with the ongoing plans for new therapy, and 32% identified pathology that did not result in initiation of a new therapy. Conclusions: POCUS performed by a trained pediatric intensivist provided useful clinical information to guide patient management.
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Affiliation(s)
- Laura A Watkins
- 232890Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- 6923Present Affiliation: University of Rochester, Rochester, NY, USA
| | - Sharon P Dial
- 232890Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Seth J Koenig
- 2006Albert Einstein College of Medicine, Bronx, NY, USA
| | - Dalibor N Kurepa
- 232890Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Paul H Mayo
- 232890Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
- 5799Northwell LIJ/NSUH Hospital, New Hyde Park, NY, USA
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16
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Yildizdas D, Aslan N. A trend skill that makes pediatric intensivists stand out: Critical care echocardiography. Australas J Ultrasound Med 2021; 24:78-81. [PMID: 34765414 PMCID: PMC8412022 DOI: 10.1002/ajum.12233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Recently, the use of point-of-care ultrasonography (POCUS) by pediatricians especially in emergency and intensive care departments has become increasingly popular. Critical care echocardiography (CCE) quickly and accurately identifies cardiac function, allowing intensivists to manage critically ill pediatric patients by manipulating vasoactive-inotrope-fluid treatment based on the echocardiographic results. Training courses for POCUS are increasingly available and more intensivists are learning how to use CCE. In this review, we focus on the importance and utility of CCE in pediatric intensive units and how it assists in the management of hemodynamically unstable pediatric patients. We highlight the common measurements carried out by intensive care specialists and emphasize the role of the CCE methods in PICUs.
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Affiliation(s)
- Dincer Yildizdas
- Department of Pediatric Intensive CareCukurova University Faculty of MedicineAdanaTurkey
| | - Nagehan Aslan
- Department of Pediatric Intensive CareCukurova University Faculty of MedicineAdanaTurkey
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17
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Haroon-Mowahed Y, Cheen Ng S, Barnett S, West S. Ultrasound in paediatric anaesthesia - A comprehensive review. ULTRASOUND (LEEDS, ENGLAND) 2021; 29:112-122. [PMID: 33995558 PMCID: PMC8083139 DOI: 10.1177/1742271x20939260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 06/09/2020] [Indexed: 11/16/2022]
Abstract
The use of ultrasound is becoming more widespread in anaesthesia. In this review, we discuss the use of ultrasound in various aspects of paediatric anaesthesia and how it can be used to assist diagnostic and therapeutic interventions and the evidence available. We explore the use of ultrasound as an adjunct for regional anaesthesia, vascular access, airway management, bedside cardiac, pulmonary and abdominal imaging and intracranial pressure monitoring.
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Affiliation(s)
- Yumna Haroon-Mowahed
- Department of Anaesthetics, Evelina London Children’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London UK
| | - Su Cheen Ng
- Department of Anaesthetics, University College Hospital, London, UK
| | - Sarah Barnett
- Department of Anaesthetics, University College Hospital, London, UK
| | - Simeon West
- Department of Anaesthetics, University College Hospital, London, UK
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18
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Riera A, Weeks B, Emerson BL, Chen L. Evaluation of a Focused Cardiac Ultrasound Protocol in a Pediatric Emergency Department. Pediatr Emerg Care 2021; 37:191-198. [PMID: 29746359 DOI: 10.1097/pec.0000000000001495] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objective of this study was to evaluate the implementation of a focused cardiac ultrasound (FoCUS) protocol in a pediatric emergency department (PED). METHODS We conducted a cross-sectional, observational, quality improvement project in a PED of an urban tertiary care children's hospital. A FoCUS protocol was collaboratively developed by pediatric cardiology and pediatric emergency medicine. This included a reference document with definitions, indications, image acquisition guidelines, and interpretation expectations. We measured physician-sonographer performance against pediatric cardiologist interpretation of stored cine clips as our reference standard. Focused cardiac ultrasound interpretation was dichotomized for the presence or absence of pericardial effusion, depressed left ventricular function, and chamber size abnormalities. Run charts were used to compare the number FoCUS performed each month and the quality of captured cine clips with those from the previous year. RESULTS Ninety-two FoCUSs were performed by 34 different physician-sonographers from January to December 2016. The prevalence of FoCUS abnormalities was 18.5%. For pericardial effusion, sensitivity was 100% (95% confidence interval [CI], 48%-100%) and specificity was 99% (95% CI, 94%-100%). For depressed function, sensitivity was 100% (95% CI, 54%-100%) and specificity was 99% (95% CI, 94%-100%). For chamber size abnormalities, sensitivity was 100% (95% CI, 54%-100%) and specificity was 95% (95% CI, 89%-99%). The median number of monthly FoCUS increased from 1 (preprotocol) to 5 (postprotocol), and the median rate of adequate studies increased from 0% to 55%. CONCLUSIONS We report the collaborative development and successful implementation of a PED FoCUS protocol. Physician-sonographer interpretation of FoCUS yielded acceptable results. Improvements in FoCUS utilization and cine clip adequacy were observed.
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19
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Chen WC, Chaou CH, Ng CJ, Liu YP, Chang YC. Assessing the effectiveness of pediatric emergency medicine education in emergency medicine residency training: A national survey. HONG KONG J EMERG ME 2020. [DOI: 10.1177/1024907920926312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: Evaluating the effectiveness of pediatric emergency medicine training is essential to ensure that emergency physicians and emergency medicine residents have sufficient knowledge, skill, and confidence in optimizing care for acute pediatric visits. Although the field of pediatric emergency medicine has experienced phenomenal growth in past decades, it still faces challenges in how to best implement the curriculums in emergency medicine residency training programs. Objectives: Exploring emergency physicians’ and emergency residents’ perspectives on pediatric emergency medicine training in emergency residency training programs in Taiwan through a nationwide survey. Methods: The survey was distributed to 1281 emergency physicians and emergency medicine residents in 43 teaching hospitals. The survey inquired about demographic data, hospital type, rank of proctored trainers and assessors, and the setting of pediatric emergency medicine training. Participants’ confidence in managing acute pediatric visits and their satisfaction and reflections of their pediatric emergency medicine training were explored. Results: In all, 258 responses were received from 117 residents and 141 emergency physicians. Seventy-seven percent reported working in medical centers. Clinical supervision was primarily performed by pediatric attending physicians and emergency physicians. Fifty-eight percent of participants felt satisfied with their pediatric emergency medicine training. However, only 52.3% felt confident managing acute pediatric visits, which was attributed to inadequate exposure to pediatric patients. Residents noted lack of confidence in managing newborns, infants, and clinical procedures. Therefore, simulation training and point-of-care ultrasound learning were considered advantageous. Conclusion: The pediatric emergency medicine training in emergency medicine residency programs is diverse in intensive care training, supervisors, and assessors. Surveys demonstrate that learning experience in pediatric wards and emergency department rotations is associated with overall satisfaction with pediatric emergency medicine training; inadequate exposure to pediatric patients contributed to learners having less confidence. Emergency medicine residency program reform might focus on adequate hands-on pediatric patient care.
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Affiliation(s)
- Wei-Chen Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chung-Hsien Chaou
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
- Chang Gung Medical Education Research Centre (CGMERC), Taoyuan City, Taiwan
- Chang Gung University College of Medicine, Taoyuan City, Taiwan
| | - Chip-Jin Ng
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Yueh-Ping Liu
- Department of Medical Affairs, Ministry of Health and Welfare, Taiwan
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Che Chang
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
- Chang Gung Medical Education Research Centre (CGMERC), Taoyuan City, Taiwan
- Chang Gung University College of Medicine, Taoyuan City, Taiwan
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20
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Singh Y, Tissot C, Fraga MV, Yousef N, Cortes RG, Lopez J, Sanchez-de-Toledo J, Brierley J, Colunga JM, Raffaj D, Da Cruz E, Durand P, Kenderessy P, Lang HJ, Nishisaki A, Kneyber MC, Tissieres P, Conlon TW, De Luca D. International evidence-based guidelines on Point of Care Ultrasound (POCUS) for critically ill neonates and children issued by the POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC). Crit Care 2020; 24:65. [PMID: 32093763 PMCID: PMC7041196 DOI: 10.1186/s13054-020-2787-9] [Citation(s) in RCA: 291] [Impact Index Per Article: 72.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 02/14/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Point-of-care ultrasound (POCUS) is nowadays an essential tool in critical care. Its role seems more important in neonates and children where other monitoring techniques may be unavailable. POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) aimed to provide evidence-based clinical guidelines for the use of POCUS in critically ill neonates and children. METHODS Creation of an international Euro-American panel of paediatric and neonatal intensivists expert in POCUS and systematic review of relevant literature. A literature search was performed, and the level of evidence was assessed according to a GRADE method. Recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA voting method. AGREE statement was followed to prepare this document. RESULTS Panellists agreed on 39 out of 41 recommendations for the use of cardiac, lung, vascular, cerebral and abdominal POCUS in critically ill neonates and children. Recommendations were mostly (28 out of 39) based on moderate quality of evidence (B and C). CONCLUSIONS Evidence-based guidelines for the use of POCUS in critically ill neonates and children are now available. They will be useful to optimise the use of POCUS, training programs and further research, which are urgently needed given the weak quality of evidence available.
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Affiliation(s)
- Yogen Singh
- Department of Paediatrics - Neonatology and Paediatric Cardiology, Cambridge University Hospitals and University of Cambridge School of Clinical Medicine, Biomedical Campus, Hills Road, Cambridge, CB2 0QQ, UK.
- Addenbrooke's Hospital, Box 402, Cambridge, UK.
| | - Cecile Tissot
- Paediatric Cardiology, Centre de Pédiatrie, Clinique des Grangettes, Geneva, Switzerland
| | - María V Fraga
- Department of Paediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, USA
| | - Nadya Yousef
- Division of Paediatrics and Neonatal Critical Care, APHP - Paris Saclay University Hospitals, "A. Béclère" Medical centre, Paris, France
| | - Rafael Gonzalez Cortes
- Department of Paediatric Intensive Care, Gregorio Marañón General University Hospital, Madrid, Spain
| | - Jorge Lopez
- Department of Paediatric Intensive Care, Gregorio Marañón General University Hospital, Madrid, Spain
| | | | - Joe Brierley
- Department of Paediatric Intensive Care, Great Ormond Street Hospital, London, UK
| | - Juan Mayordomo Colunga
- Department of Paediatric Intensive Care, Hospital Universitario Central de Asturias, Oviedo. CIBER-Enfermedades Respiratorias. Instituto de Salud Carlos III, Madrid. Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
| | - Dusan Raffaj
- Department of Paediatric Intensive Care, Nottingham University Hospitals, Nottingham, UK
| | - Eduardo Da Cruz
- Department of Paediatric and Cardiac Intensive Care, Children's Hospital Colorado, Aurora, USA
| | - Philippe Durand
- Division of Paediatric Critical Care, APHP - Paris Saclay University Hospitals, "Kremlin Bicetre" Medical Centre, Paris, France
| | - Peter Kenderessy
- Department of Paediatric Anaesthesia and Intensive Care, Children's Hospital Banska Bystrica, Banska Bystrica, Slovakia
| | - Hans-Joerg Lang
- Department of Paediatrics, Medicins Sans Frontieres (Suisse), Geneva, Switzerland
| | - Akira Nishisaki
- Department of Anaesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, USA
| | - Martin C Kneyber
- Department of Paediatrics, Division of Paediatric Critical Care Medicine, Beatrix Children's Hospital Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Pierre Tissieres
- Division of Paediatric Critical Care, APHP - Paris Saclay University Hospitals, "Kremlin Bicetre" Medical Centre, Paris, France
| | - Thomas W Conlon
- Department of Anaesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine, Philadelphia, USA
| | - Daniele De Luca
- Division of Paediatrics and Neonatal Critical Care, APHP - Paris Saclay University Hospitals, "A. Béclère" Medical centre, Paris, France
- Physiopathology and Therapeutic Innovation Unit-INSERM Unit U999, South Paris Medical School, Paris Saclay University, Paris, France
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21
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Quinn N, Kalichuran R, Prenderville T, McGuinness J. Point-of-Care Ultrasound echocardiography diagnosis of an atrial myxoma in a child presenting with stroke. Australas J Ultrasound Med 2020; 23:80-83. [PMID: 34760587 PMCID: PMC8411714 DOI: 10.1002/ajum.12201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
We describe a case of paediatric stroke secondary to atrial myxoma, diagnosed in the Emergency Department by Point-of-Care echocardiography. A previously fit and healthy teenage male presented to our paediatric emergency department following a collapse with loss of consciousness. He had suffered a stroke, and had facial paralysis and hemiplegia. His cardiac examination revealed a 3/6 ejection systolic murmur. Whilst his CT was being reported, he had a Point-of-Care echocardiogram in the resuscitation room which showed a very large mass arising from the left atrium and occupying >50% of the chamber. A piece of the myxoma had detached and caused the stroke. The patient was rapidly transferred to a cardiac intensive care unit and underwent emergency surgery the same day. His tumour was successfully completely resected, and he has only a mild residual hemiplegia. Cardiac myxoma should be considered in any child who presents with unexplained acute stroke and a cardiac murmur. Point-of-Care Ultrasound echocardiography in the Paediatric Emergency Department can be used to make a life-saving diagnosis, enabling early surgical management and preventing lifelong complications in children.
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Affiliation(s)
- Nuala Quinn
- Department of Paediatric Emergency MedicineChildren's Health Ireland at Temple StreetDublinIreland
- Emergency Research GroupMurdoch Children's Research InstituteMelbourneVictoriaAustralia
| | - Rohan Kalichuran
- Department of Paediatric Emergency MedicineChildren's Health Ireland at Temple StreetDublinIreland
| | | | - Jonathan McGuinness
- Department of Cardiothoracic SurgeryChildren's Health Ireland at CrumlinDublinIreland
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22
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Dessie A, Leung S, D'Amico B, Fischer KA, Binder Z, Abo A. Focused cardiac ultrasound to expedite diagnosis of pulmonary hypertension in children in the emergency department. Am J Emerg Med 2019; 38:629-637. [PMID: 31924439 DOI: 10.1016/j.ajem.2019.11.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 11/05/2019] [Accepted: 11/06/2019] [Indexed: 10/25/2022] Open
Affiliation(s)
- Almaz Dessie
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University Vagelos College of Physicians & Surgeons and New York-Presbyterian Morgan Stanley Children's Hospital, 3959 Broadway, CHN1-116, New York, NY 10032, United States.
| | - Stephanie Leung
- Department of Pediatrics, Section of Emergency Medicine, Baylor College of Medicine, 6621 Fannin St, Suite A2210, Houston, TX 77030, United States.
| | - Beth D'Amico
- Department of Pediatrics, Section of Emergency Medicine, Baylor College of Medicine, 6621 Fannin St, Suite A2210, Houston, TX 77030, United States.
| | - Kayleigh A Fischer
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Washington University School of Medicine, 660 S Euclid Ave, Campus Box 8116, St Louis, MO 63110, United States.
| | - Zachary Binder
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Boston Medical Center, Boston University School of Medicine, 88 E. Newton St., Vose 529, Boston, MA 02118, United States.
| | - Alyssa Abo
- Division of Emergency Medicine, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, 111 Michigan Ave NW, Washington, DC 20010, United States.
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23
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Adler AC, Brown KA, Conlin FT, Thammasitboon S, Chandrakantan A. Cardiac and lung point-of-care ultrasound in pediatric anesthesia and critical care medicine: Uses, pitfalls, and future directions to optimize pediatric care. Paediatr Anaesth 2019; 29:790-798. [PMID: 31211472 DOI: 10.1111/pan.13684] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 06/09/2019] [Accepted: 06/10/2019] [Indexed: 12/20/2022]
Abstract
Point-of-care ultrasound (POCUS) has found many relevant applications in pediatric anesthesia and critical care medicine. Specifically, the cardiac and pulmonary POCUS examinations provide a wealth of information from physical examination assistance to diagnostic evaluation and assessment of treatment response. However, as with any adjunct, potentially dangerous pitfalls exist when POCUS is performed, interpreted, and applied by the novice sonographer. Using case illustrations, we highlight the clinical application of POCUS in addition to potential dangers. Additionally, suggestions for learning POCUS, assessing competency and credentialing are reviewed.
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Affiliation(s)
- Adam C Adler
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Houston, Texas.,Section of Pediatric Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Houston, Texas
| | - Kyle A Brown
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Houston, Texas.,Baylor College of Medicine, Houston, Texas
| | - Frederick T Conlin
- Department of Anesthesiology and Pain Medicine, Baystate Medical Center, Springfield, Massachusetts.,University of Massachusetts School of Medicine, Worcester, Massachusetts
| | - Satid Thammasitboon
- Section of Pediatric Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Houston, Texas.,Baylor College of Medicine, Houston, Texas
| | - Arvind Chandrakantan
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Houston, Texas.,Section of Pediatric Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Houston, Texas
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Thomas-Mohtat R, Sable C, Breslin K, Weinberg JG, Prasad A, Zinns L, Cohen JS. Interpretation errors in focused cardiac ultrasound by novice pediatric emergency medicine fellow sonologists. Crit Ultrasound J 2018; 10:33. [PMID: 30536155 PMCID: PMC6286908 DOI: 10.1186/s13089-018-0113-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 10/26/2018] [Indexed: 01/24/2023] Open
Abstract
Background Focused cardiac ultrasound (FOCUS) is a core competency for pediatric emergency medicine (PEM) fellows. The objectives of this study were (1) to evaluate test characteristics of PEM-fellow-performed FOCUS for pericardial effusion and diminished cardiac function and (2) to assess image interpretation independent of image acquisition. Methods PEM fellows performed and interpreted FOCUS on patients who also received cardiology service echocardiograms, the reference standard. Subsequently, eight different PEM fellows remotely interpreted a subset of the PEM-acquired and cardiology-acquired echocardiograms. Results Eight PEM fellows performed 54 FOCUS exams, of which two had pericardial effusion and four had diminished function. PEM fellow FOCUS had a sensitivity of 50.0% (95% CI 9.19–90.8) and specificity of 100.0% (95% CI 91.1–100.0) for detecting diminished function, and sensitivity of 50.0% (95% CI 2.67–97.33) and specificity of 98.1% (95% CI 88.42–99.9) for detecting pericardial effusions. When PEM fellows remotely interpreted 15 echocardiograms, the sensitivity was 81.3% (95% CI 70.7–88.8) and specificity 75% (95% CI 67.0–81.0) for detecting diminished function, and sensitivity of 76.3% (95% CI 65.0–85.0) and specificity 94.4% (95% CI 89.0–97.0) for detecting pericardial effusion. There were no differences in sensitivity and specificity of PEM fellows’ interpretation of FOCUS studies compared to their interpretation of cardiology echocardiograms. Interrater reliability for interpretation of remote images (kappa) was 0.66 (95% CI 0.59–0.73) for effusion and 0.31 (95% CI 0.24–0.38) for function among the fellows. Conclusion Novice PEM fellow sonologists (a physician who performs and interprets ultrasound) in the majority of instances were able to acquire and remotely interpret FOCUS images with limited training. However, they made real-time interpretation errors and likely need further training to incorporate real-time image acquisition and interpretation into their practice. Electronic supplementary material The online version of this article (10.1186/s13089-018-0113-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rosemary Thomas-Mohtat
- Department of Emergency Medicine and Trauma Services, Children's National Medical Center, Washington, DC, USA. .,Faculty, George Washington University School of Medicine, Washington, DC, USA.
| | - Craig Sable
- Department of Cardiology, Children's National Medical Center, Washington, DC, USA.,Faculty, George Washington University School of Medicine, Washington, DC, USA
| | - Kristen Breslin
- Department of Emergency Medicine and Trauma Services, Children's National Medical Center, Washington, DC, USA.,Faculty, George Washington University School of Medicine, Washington, DC, USA
| | | | - Aparna Prasad
- Department of Cardiology, Goryeb Children's Hospital, Morristown, NJ, USA
| | - Lauren Zinns
- Department of Emergency Medicine, Icahn School of Medicine at Mt. Sinai, New York, NY, USA
| | - Joanna S Cohen
- Department of Emergency Medicine and Trauma Services, Children's National Medical Center, Washington, DC, USA.,Faculty, George Washington University School of Medicine, Washington, DC, USA
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Adler AC. Perioperative Point-of-Care Ultrasound in Pediatric Anesthesiology: A Case Series Highlighting Intraoperative Diagnosis of Hemodynamic Instability and Alteration of Management. J Cardiothorac Vasc Anesth 2018; 32:1411-1414. [DOI: 10.1053/j.jvca.2017.04.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Indexed: 11/11/2022]
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Abstract
PURPOSE OF REVIEW The diagnostic capability, efficiency and versatility of point-of-care ultrasound (POCUS) have enabled its use in paediatric emergency medicine (PEM) and paediatric critical care (PICU). This review highlights the current applications of POCUS for the critically ill child across PEM and PICU to identify areas of progress and standardized practice and to elucidate areas for future research. RECENT FINDINGS POCUS technology continues to evolve and advance bedside clinical care for critically ill children, with ongoing research extending its use for an array of clinical scenarios, including respiratory distress, trauma and dehydration. Rapidly evolving and upcoming applications include diagnosis of pneumonia and acute chest syndrome, identification of intra-abdominal injury via contrast-enhancement, guidance of resuscitation, monitoring of increased intracranial pressure and procedural guidance. SUMMARY POCUS is an effective and burgeoning method for both rapid diagnostics and guidance for interventions and procedures. It has clinical application for a variety of conditions that span PEM and PICU settings. Formal POCUS training is needed to standardize and expand use of this valuable technology by PICU and PEM providers alike.
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Abstract
INTRODUCTION Limited transthoracic echocardiogram (LTTE) has been shown to be a useful tool in guiding resuscitation in adult trauma patients. Our hypothesis is that image-guided resuscitation in pediatric trauma patients with LTTE is feasible. METHODS A retrospective chart review was performed on highest level pediatric trauma alerts (age 18 years or younger) at our level I trauma center during a 6-month period. Patients were divided into 2 groups as follows: those who had LTTE performed (LTTE group) and those who did not have LTTE performed (non-LTTE group). RESULTS A total of 31 charts were reviewed; 4 patients were excluded because they died on arrival to the emergency department. Fourteen patients had LTTE performed (LTTE group); 13 patients did not have LTTE performed (non-LTTE group). There was no difference in mechanism of injury, age, injury severity score, weight, or intensive care unit admission between the groups. The LTTE group received significantly less intravenous fluid than the non-LTTE group (1.2 vs 2.3 L, P = 0.0013).Within the LTTE group, 8 patients had "full" inferior vena cava (IVC) and 6 patients had "empty" IVC. There was no difference in injury severity score between these subgroups (P = 0.1018). Less fluid was given in the group labeled with full IVC [1.1 L (0.8-1.2)] than the group with empty IVC [2.4 L (1.7-2.6)], P = 0.0005. Four of the 6 patients with "empty" IVC had a confirmed source of bleeding. CONCLUSIONS Limited transthoracic echocardiogram can limit the amount of unnecessary crystalloid resuscitation given to pediatric trauma patients who are not hypovolemic.
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De Marchi L, Meineri M. POCUS in perioperative medicine: a North American perspective. Crit Ultrasound J 2017; 9:19. [PMID: 28993991 PMCID: PMC5633585 DOI: 10.1186/s13089-017-0075-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 09/26/2017] [Indexed: 11/10/2022] Open
Abstract
Ultrasound (US) performed at the point of care has found fertile ground in perioperative medicine. In the hands of anesthesiologists, transesophageal echocardiography (TEE) has become established as a powerful diagnostic and monitoring tool in the perioperative care of cardiac and non-cardiac patients. A number of point-of-care US (POCUS) applications are relevant to perioperative care, including airway, cardiac, lung and gastric US. Although guidelines exist to define the scope of practice for basic and advanced TEE, there remains a lack of such guidelines for perioperative point-of-care ultrasound (POCUS), despite a number of recent calls for action in the academic anesthesia community. POCUS training has been integrated into anesthesia residency curricula in Canada and the United States of America (USA). However, a nation-wide curriculum is still lacking. Many limitations to the development of perioperative POCUS curricula exist, including the need to define the scope of practice and design integrated longitudinal learning approaches. The main anesthesiologist societies in both the USA and Canada are promoting the development of guidelines and have introduced POCUS courses into their national conferences. Although bedside US imaging has been integrated into the curricula of many medical schools in North America, the need for specific national guidelines for the training and practice of POCUS in the perioperative setting by anesthesiologists is crucial to the further development of POCUS in perioperative medicine.
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Affiliation(s)
- Lorenzo De Marchi
- Department of Anesthesia, Georgetown University, MedStar Georgetown University Hospital, 3800 Reservoir Road NW, CCC Building, Lower Level, Washington, DC, USA
| | - Massimiliano Meineri
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 200 Elizabeth Street EN 3-400, Toronto, ON, M5G 2C4, Canada.
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Clinical impact and efficacy of bedside echocardiography on patient management in pediatric intensive care units (PICUs): A prospective study. Anatol J Cardiol 2017. [PMID: 28639944 PMCID: PMC5731263 DOI: 10.14744/anatoljcardiol.2017.7659] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Objective: To determine the indication and necessity of echocardiographic assessment and therapeutic interventions in critically ill children. Methods: A total of 140 children, including 75 mechanically ventilated (MV) and 65 spontaneously breathing (SB) children, who were admitted consecutively from March to August 2013 were evaluated prospectively. Data regarding the indication for echocardiography and therapeutic approaches used were documented. For evaluating disease severity, the Pediatric Risk of Mortality Score III (PRISM) was ascertained. The correlation between PRISM score and the requirement of echocardiographic evaluations were analyzed. Results: Patients ages were between 45 days to 18 years. The male-to-female ratio was 1.33. In 35.4% patients who underwent echocardiographic evaluation, no definitive alteration occurred in treatment approach, whereas in the remaining 64.6% patients, decisive or supplemental information was gathered. Echocardiography was indicated in 88% MV children and 46.2% SB children. Echocardiographic evaluation was necessary in MV children and there was a positive correlation between the PRISM score and the requirement of echocardiographic assessment (p<0.001). Conclusion: Echocardiographic evaluation is an invaluable tool especially in MV children and the requirement of echocardiographic assessment increases according to clinical severity. Basic training for intensivists in this procedure is crucial and needs to be improved and supported in critically ill.
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Zhang Z. Echocardiography for patients undergoing extracorporeal cardiopulmonary resuscitation: a primer for intensive care physicians. J Intensive Care 2017; 5:15. [PMID: 28168038 PMCID: PMC5288871 DOI: 10.1186/s40560-017-0211-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 01/26/2017] [Indexed: 02/07/2023] Open
Abstract
Echocardiography is an invaluable tool in the management of patients with extracorporeal cardiopulmonary resuscitation (ECPR) and subsequent extracorporeal membrane oxygenation (ECMO) support and weaning. At the very beginning, echocardiography can identify the etiology of cardiac arrest, such as massive pulmonary embolism and cardiac tamponade. Eliminating these culprits saves life and may avoid the initiation of extracorporeal cardiopulmonary resuscitation. If the underlying causes are not identified or intrinsic to the heart (e.g., such as those caused by cardiomyopathy and myocarditis), conventional cardiopulmonary resuscitation (CCPR) will continue to maintain cardiac output. The quality of CCPR can be monitored, and if cardiac output cannot be maintained, early institution of extracorporeal cardiopulmonary resuscitation may be reasonable. Cannulation is sometimes challenging for extracorporeal cardiopulmonary resuscitation patients. Fortunately, with the help of ultrasonography procedures including localization of vessels, selecting a cannula of appropriate size and confirmation of catheter tip may become easy under sophisticated hand. Monitoring of cardiac function and complications during extracorporeal membrane oxygenation support can be done with echocardiography. However, the cardiac parameters should be interpreted with understanding of hemodynamic configuration of extracorporeal membrane oxygenation. Thrombus and blood stasis can be identified with ultrasound, which may prompt mechanical and pharmacological interventions. The final step is extracorporeal membrane oxygenation weaning. A number of studies investigated the accuracy of some echocardiographic parameters in predicting success rate and demonstrated promising results. Parameters and threshold for successful weaning include aortic VTI ≥ 10 cm, LVEF > 20-25%, and lateral mitral annulus peak systolic velocity >6 cm/s. However, the effectiveness of echocardiography in ECPR patients cannot be determined in observational studies and requires randomized controlled trials in the future. The contents in this review are well known to echocardiography specialists; thus, it should be used as an educational material for emergency or intensive care physicians. There is a trend that focused echocardiography is performed by intensivists and emergency physicians.
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Affiliation(s)
- Zhongheng Zhang
- 0000 0004 1759 700Xgrid.13402.34Department of Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, No 3, East Qingchun Road, Hangzhou, 310016 Zhejiang Province China
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Singh Y. Echocardiographic Evaluation of Hemodynamics in Neonates and Children. Front Pediatr 2017; 5:201. [PMID: 28966921 PMCID: PMC5605552 DOI: 10.3389/fped.2017.00201] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 08/31/2017] [Indexed: 11/13/2022] Open
Abstract
Hemodynamic instability and inadequate cardiac performance are common in critically ill children. The clinical assessment of hemodynamic status is reliant upon physical examination supported by the clinical signs such as heart rate, blood pressure, capillary refill time, and measurement of the urine output and serum lactate. Unfortunately, all of these parameters are surrogate markers of cardiovascular well-being and they provide limited direct information regarding the adequacy of blood flow and tissue perfusion. A bedside point-of-care echocardiography can provide real-time hemodynamic information by assessing cardiac function, loading conditions (preload and afterload) and cardiac output. The echocardiography has the ability to provide longitudinal functional assessment in real time, which makes it an ideal tool for monitoring hemodynamic assessment in neonates and children. It is indispensable in the management of patients with shock, pulmonary hypertension, and patent ductus arteriosus. The echocardiography is the gold standard diagnostic tool to assess hemodynamic stability in patients with pericardial effusion, cardiac tamponade, and cardiac abnormalities such as congenital heart defects or valvar disorders. The information from echocardiography can be used to provide targeted treatment in intensive care settings such as need of fluid resuscitation versus inotropic support, choosing appropriate inotrope or vasopressor, and in providing specific interventions such as selective pulmonary vasodilators in pulmonary hypertension. The physiological information gathered from echocardiography may help in making timely, accurate, and appropriate diagnosis and providing specific treatment in sick patients. There is no surprise that use of bedside point-of-care echocardiography is rapidly gaining interest among neonatologists and intensivists, and it is now being used in clinical decision making for patients with hemodynamic instability. Like any other investigation, it has certain limitations and the most important limitation is its intermittent nature. Sometimes acquiring high quality images for precise functional assessment in a ventilated child can be challenging. Therefore, it should be used in conjunction with the existing tools (physical examination and clinical parameters) for hemodynamic assessment while making clinical decisions.
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Affiliation(s)
- Yogen Singh
- Department of Neonatology and Pediatric Cardiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.,University of Cambridge Clinical School of Medicine, Cambridge, United Kingdom
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Marin JR, Abo AM, Arroyo AC, Doniger SJ, Fischer JW, Rempell R, Gary B, Holmes JF, Kessler DO, Lam SHF, Levine MC, Levy JA, Murray A, Ng L, Noble VE, Ramirez-Schrempp D, Riley DC, Saul T, Shah V, Sivitz AB, Tay ET, Teng D, Chaudoin L, Tsung JW, Vieira RL, Vitberg YM, Lewiss RE. Pediatric emergency medicine point-of-care ultrasound: summary of the evidence. Crit Ultrasound J 2016; 8:16. [PMID: 27812885 PMCID: PMC5095098 DOI: 10.1186/s13089-016-0049-5] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 09/01/2016] [Indexed: 12/19/2022] Open
Abstract
The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers. To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed "how to" and description of individual point-of-care ultrasound examinations. Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.
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Affiliation(s)
- Jennifer R. Marin
- Children’s Hospital of Pittsburgh, 4401 Penn Ave, AOB Suite 2400, Pittsburgh, PA 15224 USA
| | - Alyssa M. Abo
- Children’s National Medical Center, Washington DC, USA
| | | | | | | | | | | | | | | | | | | | | | | | - Lorraine Ng
- Morgan Stanley Children’s Hospital, New York, NY USA
| | | | | | | | | | | | | | | | - David Teng
- Cohen Children’s Medical Center, New Hyde Park, USA
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Hemodynamic Bedside Ultrasound Image Quality and Interpretation After Implementation of a Training Curriculum for Pediatric Critical Care Medicine Providers. Pediatr Crit Care Med 2016; 17:598-604. [PMID: 27124564 DOI: 10.1097/pcc.0000000000000737] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Bedside ultrasound for hemodynamic evaluation in critically ill children is increasingly recognized as an important skill for pediatric critical care medicine providers. Our institution implemented a training curriculum leading to institutional credentialing for pediatric critical care providers in nonprocedural bedside ultrasound core applications. We hypothesized that hemodynamic studies performed or supervised by credentialed providers (credentialed providers group) have better image quality and greater accuracy in interpretation than studies performed by non-credentialed providers without supervision (non-credentialed providers group). DESIGN Retrospective descriptive study. SETTING Single-center tertiary non-cardiac 55-bed PICU in a children's hospital. PATIENTS Patients from October 2013 to January 2015, with hemodynamic bedside ultrasound performed and interpreted by pediatric critical care providers exposed to bedside ultrasound training. INTERVENTIONS A cardiologist blinded to performer scored hemodynamic bedside ultrasound image quality for five core cardiac views (excellent = 3, good = 2, fair = 1, unacceptable = 0; median = quality score) and interpretation within 5 hemodynamic domains (agreement = 3, minor disagreement = 2, major disagreement = 1; median = interpretation score), as well as a global assessment of interpretation. MEASUREMENTS AND MAIN RESULTS Eighty-one studies (45 in the credentialed providers group and 36 in the non-credentialed providers group) were evaluated. There was no statistically significant difference in quality score between groups (median: 1.4 [interquartile range: 0.8-1.8] vs median: 1.2 [interquartile range: 0.75-1.6]; p = 0.14]. Studies in the credentialed providers group had higher interpretation score than those in the non-credentialed providers group (median: 3 [interquartile range: 2.5-3) vs median: 2.67 [interquartile range: 2.25-3]; p = 0.04). Major disagreement between critical care provider and cardiology review occurred in 25 of 283 hemodynamic domains assessed (8.8%), with no statistically significant difference between credentialed providers and non-credentialed providers groups (6.1% vs 11.9%; p = 0.12). CONCLUSION Hemodynamic bedside ultrasound performed or supervised by credentialed pediatric critical care providers had more accurate interpretation than studies performed by unsupervised non-credentialed providers. A rigorous pediatric critical care medicine bedside ultrasound credentialing program can train intensivists to attain adequate images and interpret those images appropriately.
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Hempel D, Haunhorst S, Sinnathurai S, Seibel A, Recker F, Heringer F, Michels G, Breitkreutz R. Social media to supplement point-of-care ultrasound courses: the "sandwich e-learning" approach. A randomized trial. Crit Ultrasound J 2016; 8:3. [PMID: 26968408 PMCID: PMC4788673 DOI: 10.1186/s13089-016-0037-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 01/20/2016] [Indexed: 11/18/2022] Open
Abstract
Background Point-of-care ultrasound (POC-US) is gaining importance in almost all specialties. E-learning has been used to teach theoretical knowledge and pattern recognition. As social media are universally available, they can be utilized for educational purposes. We wanted to evaluate the utility of the sandwich e-learning approach defined as a pre-course e-learning and a post-course learning activity using Facebook after a one-day point-of-care ultrasound (POC-US) course and its effect on the retention of knowledge. Methods A total of 62 medial students were recruited for this study and randomly assigned to one of four groups. All groups received an identical hands-on training and performed several tests during the study period. The hands-on training was performed in groups of five students per instructor with the students scanning each other. Group 1 had access to pre-course e-learning, but not to post-course e-learning. Instead of a pre-course e-learning, group 2 listened to presentations at the day of the course (classroom teaching) and had access to the post-course learning activity using Facebook. Group 3 had access to both pre- and post-course e-learning (sandwich e-learning) activities, while group 4 listened classroom presentations only (classroom teaching only). Therefore only groups 2 and 3 had access to post-course learning via Facebook by joining a secured group. Posts containing ultrasound pictures and videos were published to this group. The students were asked to “like” the posts to monitor attendance. Knowledge retention was assessed 6 weeks after the course. Results After 6 weeks, group 3 achieved comparable results when compared to group 2 (82.2 % + −8.2 vs. 84.3 + −8.02) (p = 0.3). Students who participated in the post-course activity were more satisfied with the overall course than students without post-course learning (5.5 vs. 5.3 on a range from 1 to 6). Conclusions In this study, the sandwich e-learning approach led to equal rates of knowledge retention compared to classroom lectures and post-course learning. Students appreciate new media for learning experiences and are more satisfied with their learning activity. The sandwich e-learning can be used to maximize hands-on training during courses. Electronic supplementary material The online version of this article (doi:10.1186/s13089-016-0037-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Dorothea Hempel
- Department of Cardiology, Angiology and Intensive Care, University Medical Center Mainz, Mainz, Germany.
| | - Stephanie Haunhorst
- Department of Anesthesiology and Intensive Care Medicine, Kliniken Maria Hilf, Moenchengladbach, Germany
| | - Sivajini Sinnathurai
- Department of Anesthesiology and Intensive Care Medicine, Kliniken Maria Hilf, Moenchengladbach, Germany
| | - Armin Seibel
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Diakonie Klinikum Jung Stilling, Siegen, Germany.,Ultrasound Network in Acute and Critical Care, SonoABCD, Frankfurt am Main, Germany
| | | | - Frank Heringer
- FINeST Frankfurt Institute of Interdisciplinary Emergency Medicine and und Simulation Training, Johann Wolfgang Goethe University, Frankfurt am Main, Germany
| | - Guido Michels
- Department III of Internal Medicine, Heartcenter, University Hospital of Cologne, Cologne, Germany
| | - Raoul Breitkreutz
- Ultrasound Network in Acute and Critical Care, SonoABCD, Frankfurt am Main, Germany.,Emergency Department, Hospital of the City of Frankfurt (Höchst), Gotenstr. 6-8, 65929, Frankfurt am Main, Germany
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Still a Way to Go: The Substitution of the x-Ray as the Gold Standard to Locate the Right Placement of Central Venous Catheter. Pediatr Crit Care Med 2016; 17:184. [PMID: 26841037 DOI: 10.1097/pcc.0000000000000584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Cowie B. The Preoperative Patient With a Systolic Murmur. Anesth Pain Med 2015; 5:e32105. [PMID: 26705529 PMCID: PMC4688819 DOI: 10.5812/aapm.32105] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 09/04/2015] [Indexed: 01/16/2023] Open
Abstract
Context: Patients with undifferentiated systolic murmurs present commonly during the perioperative period. Traditional bedside assessment and auscultation has not changed significantly in almost 200 years and relies on interpreting indirect acoustic events as a means of evaluating underlying cardiac pathology. This is notoriously inaccurate, even in expert cardiology hands, since many different valvular and cardiac diseases present with a similar auditory signal. Evidence Acquisition: The data on systolic murmurs, physical examination, perioperative valvular disease in the setting of non-cardiac surgery is reviewed. Results: Significant valvular heart disease increases perioperative risk in major non-cardiac surgery and increases long term patient morbidity and mortality. We propose a more modern approach to physical examination that incorporates the use of focused echocardiography to allow direct visualization of cardiac structure and function. This improves the diagnostic accuracy of clinical assessment, allows rational planning of surgery and anaesthesia technique, risk stratification, postoperative monitoring and appropriate referral to physicians and cardiologists. Conclusions: With a thorough preoperative assessment incorporating focused echocardiography, anaesthetists are in the unique position to enhance their role as perioperative physicians and influence short and long term outcomes of their patients.
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Affiliation(s)
- Brian Cowie
- Department of Anaesthesia, St. Vincent’s Hospital, Melbourne, Australia
- Corresponding author: Brian Cowie, Department of Anaesthesia, St. Vincent’s Hospital, 41 Victoria Parade, Fitzroy 3065, Melbourne, Australia. Tel: +61-39288 2211, E-mail:
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The Role of Focused Echocardiography in Pediatric Intensive Care: A Critical Appraisal. BIOMED RESEARCH INTERNATIONAL 2015; 2015:596451. [PMID: 26605333 PMCID: PMC4641179 DOI: 10.1155/2015/596451] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 09/15/2015] [Accepted: 10/18/2015] [Indexed: 01/22/2023]
Abstract
Echocardiography is a key tool for hemodynamic assessment in Intensive Care Units (ICU). Focused echocardiography performed by nonspecialist physicians has a limited scope, and the most relevant parameters assessed by focused echocardiography in Pediatric ICU are left ventricular systolic function, fluid responsiveness, cardiac tamponade and pulmonary hypertension. Proper ability building of pediatric emergency care physicians and intensivists to perform focused echocardiography is feasible and provides improved care of severely ill children and thus should be encouraged.
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Mozzini C, Garbin U, Fratta Pasini AM, Cominacini L. Short training in focused cardiac ultrasound in an Internal Medicine department: what realistic skill targets could be achieved? Intern Emerg Med 2015; 10:73-80. [PMID: 25492052 DOI: 10.1007/s11739-014-1167-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 11/27/2014] [Indexed: 12/21/2022]
Abstract
The importance of focused cardiac ultrasound (FCU) in Internal Medicine care has been recognized by the American Society of Echocardiography. The aim of this study was to test what realistic skill targets could be achieved in FCU, with a relatively short training (theoretical and practical) of 9 h offered to Internal Medicine certification board attending students, and if the addition of further 9 h of training could significantly improve the level of competence. Kappa statistic was used to calculate the inter-observer agreement (trainees/tutor). The agreement between the trainees (who completed the entire training) and the tutor was, respectively, "substantial" (k = 0.71) for the identification of pericardial effusion, "moderate" (k = 0.56-0.54) for the identification of marked right ventricular and left ventricular enlargement, "substantial" (k = 0.77) for the assessment of global cardiac systolic function by visual inspection and "fair" (k = 0.35) for the assessment of size and respiratory change in the diameter of the inferior cave vein (IVC). 18 h training in FCU provided proficiency in obtaining adequate images from the parasternal window without providing the ability to correctly master the apical and subcostal windows. As concerns the interpretative skills, only pericardial effusion and visual estimation of global systolic function could be correctly identified, while ventricular enlargement and IVC prove to be more difficult to evaluate. This study supports incorporating FCU into Internal Medicine fellowship training programs, and should facilitate the design of other similar training courses.
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Affiliation(s)
- Chiara Mozzini
- Section of Internal Medicine, Department of Medicine, University of Verona, 10, Piazzale L.A. Scuro, 37134, Verona, Italy,
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