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

Role of point-of-care ultrasound (POCUS) in clinical hepatology

Hospitalized patients with cirrhosis frequently require critical care management for sepsis, HE, respiratory failure, acute variceal bleeding, acute kidney injury (AKI), shock, and optimization for liver transplantation, while outpatients have unique care considerations. Point-of-care ultrasonography (POCUS) enhances bedside examination of the hepatobiliary system and relevant extrahepatic sites. POCUS includes cardiac US and is used to assess volume status and hemodynamic parameters like cardiac output, systemic vascular resistance, cardiac contractility, and pulmonary artery pressure, which aid in the early and accurate diagnosis of heart failure, cirrhotic cardiomyopathy, porto-pulmonary hypertension, hepatopulmonary syndrome, arrhythmia, and pulmonary embolism. This also helps in fluid management and vasopressor use in the resuscitation of patients with cirrhosis. Lung ultrasound (LUS) can help in differentiating pneumonia, effusion, and edema. Further, US guides interventions such as line placement, drainage of abdominal collections/abscesses, relief of tension pneumothorax, drainage of pleural and pericardial effusions, and biliary drainage in cholangitis. Additionally, its role is essential to assess liver masses foci of sepsis, for appropriate sites for paracentesis, and to assess for vascular disorders such as portal vein or hepatic vein thrombosis. Renal US can identify renal and postrenal causes of AKI and aid in diagnosis of prerenal AKI through volume assessment. In this review, we address the principles and methods of POCUS in hospitalized patients and in outpatients with cirrhosis and discuss the application of this diverse modality in clinical hepatology.

Emergency Physician Performed Ultrasound-Guided Abdominal Paracentesis: A Retrospective Analysis

BACKGROUND

Emergency physicians commonly perform ultrasound-assisted abdominal paracentesis, using point of care ultrasound (POCUS) to identify ascites and select a site for needle insertion. However, ultrasound-guided paracentesis has the benefit of real-time needle visualization during the entire procedure. Our objective was to characterize the performance of emergency physician-performed ultrasound-guided paracentesis using POCUS, their ability to achieve good in-plane needle visualization, and factors associated with procedural success.

METHODS

A POCUS database was retrospectively reviewed for examinations where abdominal paracentesis was performed by an emergency physician at two academic urban emergency departments over a six-year period. Medical records were reviewed for demographics, presenting history, complications, and hospital course. Descriptive statistics were used to summarize the data.

RESULTS

131 patients were included in the final analysis. The success rate for ultrasound-guided paracentesis was 97.7% (84/86 [95% CI: 92-100%]) compared to 95.6% (43/45 [95% CI: 85-99%]) for ultrasound-assisted paracentesis (p=0.503). 58% (50/86) demonstrated good in-plane needle visualization; 17% (15/86) had partial or out-of-plane visualization; and 24% (21/86) did not demonstrate needle visibility on their saved POCUS images. All four procedural failures were performed by first- or second-year residents using a curvilinear transducer, while all procedures using a linear transducer were successful. The most common complications were ascites leak, infection at the site, and minor bleeding.

CONCLUSIONS

Emergency physicians with training in real-time needle guidance with ultrasound were able to use POCUS to perform ultrasound-guided paracentesis in the emergency department with a high success rate and no fatal complications. Based on our experience, we recommend performing ultrasound-guided paracentesis using a linear transducer, with attention to identifying vessels near the procedure site and maintaining sterile technique.

Haemorrhagic Shock After Iatrogenic Deep Circumflex Iliac Artery Injury During Paracentesis: A Rare Lethal Complication

Abdominal paracentesis is a commonly performed bedside procedure. It serves as a therapeutic and diagnostic tool for a variety of conditions. It is regarded as a safe procedure with a low risk of complications. Rarely, iatrogenic complications such as peritonitis, haemorrhage, and bowel perforation may occur. Intraperitoneal haemorrhage is rare and usually occurs due to bleeding from the intraabdominal venous collateral vessels or mesenteric varices. However, intraperitoneal haemorrhage secondary to injury to the abdominal wall arteries, such as the inferior epigastric artery or deep circumflex iliac artery (DCIA), is very uncommon.  We report on a 64-year-old man with decompensated cardiac failure who underwent paracentesis due to gross ascites. Twenty-four hours post-procedure, he became progressively hypotensive and lethargic. An ecchymosis measuring 3 cm × 2 cm was seen over the puncture site. An urgent CT angiography of the abdomen showed a large left-sided intraperitoneal haematoma with active contrast extravasation from the left DCIA. We performed a successful angioembolisation of the left DCIA. It is important to note that intraperitoneal haemorrhages secondary to DCIA injury may present as occult intraperitoneal haemorrhage. Angioembolisation is a useful tool in the management of uncontrolled intraperitoneal haemorrhage. The recommended puncture site is in the left lower quadrant, 2-4 cm superior and medial to the anterior superior iliac spine (ASIS). This case report serves to emphasise the rare but potentially lethal complication of a commonly performed procedure. A high index of suspicion of intraperitoneal haemorrhage is required for patients with unexplained hypotension post-paracentesis, even if overt abdominal signs are absent. The use of ultrasound guidance will aid in reducing the risk of severe complications and increasing the overall success rate.

Canadian Internal Medicine Ultrasound (CIMUS) consensus statement: recommendations for mandatory ultrasound competencies for ultrasound-guided thoracentesis, paracentesis, and central venous catheterization

OBJECTIVES

To develop a Canadian Internal Medicine Ultrasound (CIMUS) consensus statement on recommended mandatory point-of-care ultrasound (POCUS) competencies for ultrasound-guided thoracentesis, paracentesis, and central venous catheterizations (CVC) for internal medicine physicians.

METHODS

The 2022 CIMUS group consists of 27 voting members, with representations from all 17 Canadian academic institutions across 8 provinces. Members voted in 3 rounds on 46 procedural competencies as "mandatory, must include", "optional, could include" or "superfluous, do not include". These 46 competencies included 6 general competencies that apply to all POCUS-guided procedures, 11 competencies for thoracentesis, 10 competencies for paracentesis, and 19 competencies for CVC.

RESULTS

In the first round, members reached consensus on 27 competencies (5 general, 6 thoracentesis, 8 paracentesis, 8 CVC). In the second round, 10 competencies (1 general, 2 thoracentesis, 1 paracentesis, 6 CVC) reached consensus. In the third round, 2 additional competencies (1 paracentesis, 1 CVC) reached consensus for being mandatory and 3 as optional (1 thoracentesis and 2 CVC). Overall, a total of 28 competencies reached consensus as mandatory, 3 as optional, while 11 competencies reached consensus as superfluous. Four competencies did not reach consensus for either inclusion or exclusion.

CONCLUSIONS

The CIMUS group recommends 28 competencies be considered mandatory and 3 as optional for internal medicine physicians performing POCUS guided thoracentesis, paracentesis, and CVC placement. National curriculum development and implementation efforts should include training these mandatory competencies.

Point-of-care ultrasound for non-vascular invasive procedures in critically ill neonates and children: current status and future perspectives

Point-of-care ultrasound (POCUS) has been established as an essential bedside tool for real-time image guidance of invasive procedures in critically ill neonates and children. While procedural guidance using POCUS has become the standard of care across many adult medicine subspecialties, its use has more recently gained popularity in neonatal and pediatric medicine due in part to improvement in technology and integration of POCUS into physician training programs. With increasing use, emerging data have supported its adoption and shown improvement in pediatric outcomes. Procedures that have traditionally relied on physical landmarks, such as thoracentesis and lumbar puncture, can now be performed under direct visualization using POCUS, increasing success, and reducing complications in our most vulnerable patients. In this review, we describe a global and comprehensive use of POCUS to assist all steps of different non-vascular invasive procedures and the evidence base to support such approach.

CONCLUSION

There has been a recent growth of supportive evidence for using point-of-care ultrasound to guide neonatal and pediatric percutaneous procedural interventions. A global and comprehensive approach for the use of point-of-care ultrasound allows to assist all steps of different, non-vascular, invasive procedures.

WHAT IS KNOWN

• Point-of-care ultrasound has been established as a powerful tool providing for real-time image guidance of invasive procedures in critically ill neonates and children and allowing to increase both safety and success.

WHAT IS NEW

• A global and comprehensive use of point-of-care ultrasound allows to assist all steps of different, non-vascular, invasive procedures: from diagnosis to semi-quantitative assessment, and from real-time puncture to follow-up.

The Impact of a Point-of-Care Ultrasound (POCUS) Program to Diagnose and Manage Ascites in Home-based Palliative Care

OBJECTIVE

The objective of this study was to examine the impact of a point-of-care ultrasound (POCUS) program among people with ascites receiving home-based palliative care by measuring the association of POCUS with ascites-related days spent out of the home, compared with outcomes before POCUS implementation.

DESIGN

Open cohort study.

SETTING AND PARTICIPANTS

Adults who had an ascites-related procedure (ARP) between January 1, 2014, and December 31, 2015 (ie, pre-POCUS) and January 1, 2019, and December 31, 2020 (ie, POCUS). An ARP was defined as using ultrasound to diagnose suspected ascites or a paracentesis with or without ultrasound guidance to manage ascites.

METHODS

The main outcome was the rate of ascites-related days spent out of the home, defined as days out of the home for either ARPs or because of ascites-related hospital admissions, relative to the time patients were at risk for spending ascites-related days out of the home.

RESULTS

Among the 103 pre-POCUS patients (mean age 68.0; 50.4% female), there were 161 ARPs with 12.4% occurring at home. Among the 127 POCUS patients (mean age 74.0; 52.0% female) there were 193 ARPs with 82.4% occurring at home. POCUS was associated with a significantly lower rate of ascites-related days spent outside the home (pre-POCUS rate of 33 days per 1000 patient days vs POCUS rate of 9 days; unadjusted incidence rate ratio (IRR), 3.86; 95% CI, 2.95-5.12; P < .001; adjusted IRR, 3.83; 95% CI, 1.27-11.54; P = .02). POCUS was also associated with a higher likelihood of ARPs occurring in the home [unadjusted odds ratio (OR), 32.44; 95% CI, 18.15-59.90; P < .001; adjusted OR, 48.99; 95% CI, 21.04-114.10; P < .001].

CONCLUSIONS AND IMPLICATIONS

The use of POCUS may contribute to maximizing time spent at home for palliative care patients with ascites. These findings support the use of POCUS for home-based palliative care programs.

Ultrasonography and procedures in intensive care medicine

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

Troubleshooting Paracentesis Using POCUS

Paracentesis is a procedure routinely performed at the bedside in the evaluation and management of ascites. While point of care ultrasound (POCUS) assistance during paracentesis is known to reduce the risk of procedure-related complications, intraprocedural POCUS to overcome commonly occurring issues, such as obstructed flow through the centesis catheter, remain poorly described. In this report, we present two cases in which bowel adhered to the catheter during paracentesis. POCUS was used in an attempt to restore flow. Based on our literature review and procedural experience, we propose an algorithm to surmount this routinely encountered problem.

Association of Internal Medicine Point of Care Ultrasound (POCUS) with Length of Stay, Hospitalization Costs, and Formal Imaging: a Prospective Cohort Study

Background: Point of care ultrasound (POCUS) use has rapidly expanded among internal medicine (IM) physicians in practice and residency training programs. Many benefits have been established; however, studies demonstrating the impact of POCUS on system metrics are few and mostly limited to the emergency department or intensive care setting. The study objective was to evaluate the impact of inpatient POCUS on patient outcomes and hospitalization metrics. Methods: Prospective cohort study of 12,399 consecutive adult admissions to 22 IM teaching attendings, at a quaternary care teaching hospital (7/1/2011-6/30/2015), with or without POCUS available during a given hospitalization. Multivariable regression and propensity score matching (PSM) analyses compared multiple hospital metric outcomes (costs, length of stay, radiology-based imaging, satisfaction, etc.) between the "POCUS available" vs. "POCUS unavailable" groups as well as the "POCUS available" subgroups of "POCUS used" vs. "POCUS not used". Results: Patients in the "POCUS available" vs. "POCUS unavailable" group had lower mean total and per-day hospital costs ($17,474 vs. $21,803, p<0.001; $2,805.88 vs. $3,557.53, p<0.001), lower total and per-day radiology cost ($705.41 vs. $829.12, p<0.001; $163.11 vs. $198.53, p<0.001), fewer total chest X-rays (1.31 vs. 1.55, p=0.01), but more chest CTs (0.22 vs 0.15; p=0.001). Mean length of stay (LOS) was 5.77 days (95% CI = 5.63, 5.91) in the "POCUS available" group vs. 6.08 95% CI (5.66, 6.51) in the "POCUS unavailable" group (p=0.14). Within the "POCUS available" group, cost analysis with a 4:1 PSM (including LOS as a covariate) compared patients receiving POCUS vs. those that could have but did not, and also showed total and per-day cost savings in the "POCUS used" subgroup ($15,082 vs. 15,746; p<0.001 and $2,685 vs. $2,753; p=0.04). Conclusions: Availability and selected use of POCUS was associated with a meaningful reduction in total hospitalization cost, radiology cost, and chest X-rays for hospitalized patients.

Evaluating Outcomes and Time Delays of a Non-Trainee-Driven Hospitalist Procedure Service

BACKGROUND AND OBJECTIVES

Ultrasound guidance has become standard of care in hospital medicine for invasive bedside procedures, especially central venous catheter placement. Despite ultrasound-guided bedside procedures having a high degree of success, only a few hospitalists perform them. This is because these are usually performed by radiologists or in the setting of trainee-run procedure teams. We sought to determine the impact of a non-trainee driven , hospitalist-run procedure service relative to time from consult to procedure.

METHODS

The University of Alabama at Birmingham Hospital (UAB), Department of Hospital Medicine, trained 8 non-trainee hospitalist physicians (from existing staff) to implement the ultrasound-guided procedure service. This study examines consult to procedure completion time since the implementation of the procedure service (2014 to 2020). Univariate analyses are used to analyze pre-implementation (2012-2014), pilot (2014-2016), and post-implementation data (2016-2018 initial, and 2018-2020 sustained).

RESULTS

Results suggest a 50% reduction in time from consult to procedure completion when compared with the period before implementation of the nontrainee hospitalist procedure service.

CONCLUSIONS

A hospitalist procedure service, which does not include trainees, results in less time lag from consult to procedure completion time, which could increase patient satisfaction and improve throughput. As such, this study has wide generalizability to community hospitals and other nonacademic medical centers that may not have trainees.

Evaluating the perceptions of Canadian urology residents and program directors regarding the current training in genitourinary imaging

INTRODUCTION

Competency in interpreting genitourinary (GU) imaging is an important skill for urologists; however, no nationally accredited GU imaging curriculum exists for Canadian urology residency training programs. The main objectives of our study were to 1) characterize GU imaging training in Canada; (2) evaluate residents' self-perceived competencies in interpreting GU imaging; (3) explore program directors' (PD) and residents' perceptions regarding the current imaging curriculum and suggestions for future directions.

METHODS

From November to December 2022, a survey examining current imaging education in residency, perceived resident imaging knowledge, avenues for improvement in imaging education, and the role of point-of-care ultrasound within urology was distributed to all Canadian urology PDs and residents.

RESULTS

All PDs (13/13) and 40% (72/178) of residents completed the survey. Only two programs had a formal GU imaging curriculum. PDs and residents reported trainees were least comfortable interpreting Doppler ultrasound of renal, gonadal, and penile vessels. PDs reported that residents were most comfortable with non-contrast computed tomography (CT) scans (9.5/10), CT urogram (9.3/10), and retrograde pyelography (9.3/10). All but one PD favored increasing imaging training in their program. PDs highlighted the lack of time in the curriculum (n=3) and lack of educators (n=3) as the primary barriers to increasing imaging training in their program.

CONCLUSIONS

Most PDs and residents believe there needs to be more imaging training offered at their institution; however, addressing this is challenging due to the limited time in the curriculum and the need for available educators.

Point-of-Care Ultrasound: A Multimodal Tool for the Management of Sepsis in the Emergency Department

Sepsis and septic shock are life-threatening emergencies associated with increased morbidity and mortality. Hence, early diagnosis and management of both conditions is of paramount importance. Point-of-care ultrasound (POCUS) is a cost-effective and safe imaging modality performed at the bedside, which has rapidly emerged as an excellent multimodal tool and has been gradually incorporated as an adjunct to physical examination in order to facilitate evaluation, diagnosis and management. In sepsis, POCUS can assist in the evaluation of undifferentiated sepsis, while, in cases of shock, it can contribute to the differential diagnosis of other types of shock, thus facilitating the decision-making process. Other potential benefits of POCUS include prompt identification and control of the source of infection, as well as close haemodynamic and treatment monitoring. The aim of this review is to determine and highlight the role of POCUS in the evaluation, diagnosis, treatment and monitoring of the septic patient. Future research should focus on developing and implementing a well-defined algorithmic approach for the POCUS-guided management of sepsis in the emergency department setting given its unequivocal utility as a multimodal tool for the overall evaluation and management of the septic patient.

Lights and Shadows of Paracentesis: Is an Ultrasound Guided Approach Enough to Prevent Bleeding Complications?

Paracentesis is a validated procedure for diagnosing and managing ascites. Although paracentesis is a safe procedure with a 1–2% risk of complications such as bleeding, it is necessary to inform the patient about the possible adverse events. We would like to share our experience with two cases of bleeding after paracentesis. In our unit, two major hemorrhagic complications occurred in 162 procedures performed over the year 2020 (frequency of bleeding complications: 1.2%). We report two clinical cases of post-paracentesis abdominal wall hematomas. Despite a similar clinical presentation, the management approach was different: in the first case, embolization of the epigastric artery supplying the hematoma was performed. In the second case, conservative treatment was adopted. Our report aims to provide food for thought about a potentially challenging hemorrhagic complication, even with the risk of adverse outcomes.

Use of Point-of-Care Ultrasonography in the NICU for Diagnostic and Procedural Purposes

Point-of-care ultrasonography (POCUS) refers to the use of portable imaging performed by the provider clinician at the bedside for diagnostic, therapeutic, and procedural purposes. POCUS could be considered an extension of the physical examination but not a substitute for diagnostic imaging. Use of POCUS in emergency situations can be lifesaving in the NICU if performed in a timely fashion for cardiac tamponade, pleural effusions, pneumothorax, etc, with potential for enhancing quality of care and improving outcomes.

In the past 2 decades, POCUS has gained significant acceptance in clinical medicine in many parts of the world and in many subspecialties. Formal accredited training and certification programs are available for neonatology trainees as well as for many other subspecialties in Canada, Australia, and New Zealand. Although no formal training program or certification is available to neonatologists in Europe, POCUS is widely available to providers in NICUs. A formal institutional POCUS fellowship is now available in Canada. In the United States, many clinicians have the skills to perform POCUS and have incorporated it in their daily clinical practice. However, appropriate equipment remains limited, and many barriers exist to POCUS program implementation.

Recently, the first international evidence-based POCUS guidelines for use in neonatology and pediatric critical care were published. Considering the potential benefits, a recent national survey of neonatologists confirmed that the majority of clinicians were inclined to adopt POCUS in their clinical practice if the barriers could be resolved.

This technical report describes many potential POCUS applications in the NICU for diagnostic and procedural purposes.

Paracentesis for cancer-related ascites in palliative care: An international, prospective cohort study

BACKGROUND

Paracentesis is commonly undertaken in patients with cancer-related ascites.

AIM

To systematically investigate the symptomatic benefits and harms experienced by patients with cancer undergoing paracentesis using real-world data in the palliative care setting.

DESIGN

Prospective, multisite, observational, consecutive cohort study. Benefits and harms of paracentesis were assessed between 01/07/2018 and 31/02/2021 as part of routine clinical assessments by treating clinicians at four timepoints: (T0) before paracentesis; (T1) once drainage ceased; (T2) 24 h after T1 and (T3) 28 days after T1 or next paracentesis, if sooner.

SETTING/PARTICIPANTS

Data were collected from 11 participating sites across five countries (Australia, England, Hong Kong, Malaysia and New Zealand) on 111 patients undergoing paracentesis via a temporary (73%) or indwelling (21%) catheter: 51% male, median age 69 years, Australia-modified Karnofsky Performance Score 50.

RESULTS

At T1 (n = 100), symptoms had improved for most patients (81%), specifically abdominal distension (61%), abdominal pain (49%) and nausea (27%), with two-thirds experiencing improvement in ⩾2 symptoms. In the remaining patients, symptoms were unchanged (7%) or worse (12%). At least one harm occurred in 32% of patients, the most common being an ascitic leak (n = 14). By T3, 89% of patients had experienced some benefit and 36% some harm, including four patients who experienced serious harm, one of which was a fatal bowel perforation.

CONCLUSION

Most patients obtained rapid benefits from paracentesis. Harms were less frequent and generally mild, but occasionally serious and fatal. Our findings help inform clinician-patient discussions about the potential outcomes of paracentesis in this frail population.

Current use, training, and barriers in point-of-care ultrasound in hospital medicine: A national survey of VA hospitals

BACKGROUND

Point-of-care ultrasound (POCUS) can reduce procedural complications and improve the diagnostic accuracy of hospitalists. Currently, it is unknown how many practicing hospitalists use POCUS, which applications are used most often, and what barriers to POCUS use exist.

OBJECTIVE

This study aimed to characterize current POCUS use, training needs, and barriers to use among hospital medicine groups (HMGs).

DESIGN, SETTING, AND PARTICIPANTS

A prospective observational study of all Veterans Affairs (VA) medical centers was conducted between August 2019 and March 2020 using a web-based survey sent to all chiefs of HMGs. These data were compared to a similar survey conducted in 2015.

RESULT

Chiefs from 117 HMGs were surveyed, with a 90% response rate. There was ongoing POCUS use in 64% of HMGs. From 2015 to 2020, procedural POCUS use decreased by 19%, but diagnostic POCUS use increased for cardiac (8%), pulmonary (7%), and abdominal (8%) applications. The most common barrier to POCUS use was lack of training (89%), and only 34% of HMGs had access to POCUS training. Access to ultrasound equipment was the least common barrier (57%). The proportion of HMGs with ≥1 ultrasound machine increased from 29% to 71% from 2015 to 2020. An average of 3.6 ultrasound devices per HMG was available, and 45% were handheld devices.

CONCLUSION

From 2015 to 2020, diagnostic POCUS use increased, while procedural use decreased among hospitalists in the VA system. Lack of POCUS training is currently the most common barrier to POCUS use among hospitalists.

Development of a Point-of-Care Ultrasound Track for Internal Medicine Residents

BACKGROUND

Point-of-care ultrasound (POCUS) training has been increasing among internal medicine (IM) residency programs, but few programs can provide longitudinal training due to barriers such as lack of trained faculty.

AIM

Describe the development of a longitudinal POCUS track for IM residents using local and external resources, including a national POCUS certificate program.

SETTING

University-based IM residency program affiliated with a public and veterans affairs hospital.

PARTICIPANTS

Twelve IM residents from 2018 to 2021.

PROGRAM DESCRIPTION

Residents complete a national POCUS certificate program by attending live courses and completing online modules, an image portfolio, and final knowledge/skills assessments. Locally, residents participate in 1-month procedure and diagnostic POCUS rotations and provide peer-to-peer POCUS teaching of residents and medical students.

PROGRAM EVALUATION

The POCUS track increased residents' use and comfort with diagnostic and procedural applications. All residents rated being satisfied or very satisfied with the track and would recommend it to prospective applicants (100%). The most commonly reported barriers to utilizing POCUS per residents were time constraints (83%), lack of available ultrasound equipment (83%), and lack of trained faculty (58%).

DISCUSSION

IM residency programs with limited faculty expertise in POCUS can leverage external resources to provide longitudinal POCUS training to its residents.

Multimodal Diagnostic Approaches to Advance Precision Medicine in Sarcopenia and Frailty

Sarcopenia, defined as the loss of muscle mass, strength, and function with aging, is a geriatric syndrome with important implications for patients and healthcare systems. Sarcopenia increases the risk of clinical decompensation when faced with physiological stressors and increases vulnerability, termed frailty. Sarcopenia develops due to inflammatory, hormonal, and myocellular changes in response to physiological and pathological aging, which promote progressive gains in fat mass and loss of lean mass and muscle strength. Progression of these pathophysiological changes can lead to sarcopenic obesity and physical frailty. These syndromes independently increase the risk of adverse patient outcomes including hospitalizations, long-term care placement, mortality, and decreased quality of life. This risk increases substantially when these syndromes co-exist. While there is evidence suggesting that the progression of sarcopenia, sarcopenic obesity, and frailty can be slowed or reversed, the adoption of broad-based screening or interventions has been slow to implement. Factors contributing to slow implementation include the lack of cost-effective, timely bedside diagnostics and interventions that target fundamental biological processes. This paper describes how clinical, radiographic, and biological data can be used to evaluate older adults with sarcopenia and sarcopenic obesity and to further the understanding of the mechanisms leading to declines in physical function and frailty.

Motivations, barriers, and professional engagement: a multisite qualitative study of internal medicine faculty's experiences learning and teaching point-of-care ultrasound

BACKGROUND

Point-of-care ultrasound (POCUS) graduate medical education is expanding across many specialties, but a lack of trained faculty is a common barrier. Even well-designed faculty development programs struggle with retention, yet little is known about the experiences of practicing physicians learning POCUS. Our objective is to explore the experiences of clinician-educators as they integrate POCUS into their clinical and teaching practices to help inform curriculum design.

METHODS

Qualitative study using instrumental case study design to analyze interview data from 18 internal medicine clinician-educators at 3 academic health centers. Interviewees were recruited by program directors at each site to include participants with a range of POCUS use patterns. Interviews took place from July-August 2019.

RESULTS

Analysis yielded 6 themes: teaching performance, patient care, curriculum needs, workflow and access, administrative support, and professional engagement. Participants felt POCUS enhanced their teaching skills, clinical decision making, and engagement with patients. The themes highlighted the importance of longitudinal supervision and feedback, streamlined integration of POCUS into clinical workflow, and administrative support of time and resources. Interviewees reported learning and teaching POCUS helped combat burn-out and enhance their sense of professional engagement.

CONCLUSIONS

Learning POCUS as a practicing clinician-educator is a complicated endeavor that must take into account mastery of psychomotor skills, existing practice habits, and local institutional concerns. Based upon the themes generated from this study, we make recommendations to help guide POCUS faculty development curriculum design. Although this study focused on internists, the findings are likely generalizable to other specialties with growing interest in POCUS education.

Interprofessional Point-of-Care Ultrasound Training of Resident Physicians by Sonography Student-Coaches

INTRODUCTION

Point-of-care ultrasound (POCUS) education is growing throughout medical education, but many institutions lack POCUS-trained faculty. Interprofessional education offers a strategy for expanding the pool of available teachers while providing an opportunity for collaboration between health professional students.

METHODS

Six students enrolled in the diagnostic medical sonography (DMS) program participated in a case-based, train-the-trainer session to practice a standardized approach for POCUS instruction. They then served as coaches to 25 first-year internal medicine residents learning to perform ultrasound exams of the kidneys, bladder, and aorta. Course assessment included an objective structured exam (OSCE), coaching evaluations, and course evaluations.

RESULTS

Residents scored an average of 81% (71.3 out of 88 points, SD = 7.5) on the OSCE. Residents rated the DMS student-coaches positively on all teacher evaluation questions. Both the residents and DMS student-coaches gave positive course evaluations scores.

DISCUSSION

An interprofessional workshop with DMS students coaching internal medicine residents was an effective strategy for teaching POCUS skills. This approach may offer a solution for programs wanting to implement POCUS training with limited faculty expertise or time.

Point-of-care ultrasound in a pandemic: Practical guidance in COVID-19 units

The coronavirus disease 2019 (COVID-19) pandemic has stretched our healthcare system to the brink, highlighting the importance of efficient resource utilization without compromising healthcare provider safety. While advanced imaging is a great resource for diagnostic purposes, the risk of contamination and infection transmission is high and requires extensive logistical planning for intrahospital patient transport, healthcare provider safety, and post-imaging decontamination. This dilemma has necessitated the transition to more bedside imaging. More so than ever, during the current pandemic, the clinical utility and importance of point-of-care ultrasound (POCUS) cannot be overstressed. It allows for safe and efficient beside procedural guidance and provides front line providers with valuable diagnostic information that can be acted upon in real-time for immediate clinical decision-making. The authors have been routinely using POCUS for the management of COVID-19 patients both in the emergency department and in intensive care units turned into “COVID-units.” In this article, we review the nuances of using POCUS in a pandemic situation and maximizing diagnostic output from this bedside technology. Additionally, we review various methods and diagnostic uses of POCUS which can replace conventional imaging and bridge current literature and common clinical practices in critically ill patients. We discuss practical guidance and pertinent review of the literature for the most relevant procedural and diagnostic guidance of respiratory illness, hemodynamic decompensation, renal failure, and gastrointestinal disorders experienced by many patients admitted to COVID-units.

An Automatic Biopsy Needle Detection and Segmentation on Ultrasound Images Using a Convolutional Neural Network

Needle visualization in the ultrasound image is essential to successfully perform the ultrasound-guided core needle biopsy. Automatic needle detection can significantly reduce the procedure time, false-negative rate, and highly improve the diagnosis. In this paper, we present a CNN-based, fully automatic method for detection of core needle in 2D ultrasound images. Adaptive moment estimation optimizer is proposed as CNN architecture. Radon transform is applied to locate the needle. The network's model was trained and tested on the total of 619 2D images from 91 cases of breast cancer. The model has achieved an average weighted intersection over union (the weighted Jaccard Index) of 0.986, F1 Score of 0.768, and angle RMSE of 3.73°. The obtained results exceed the other solutions by at least 0.27 and 7° in case of F1 score and angle RMSE, respectively. Finally, the needle is detected in a single frame averagely in 21.6 ms on a modern PC.

Malignant Ascites in Ovarian Cancer: Cellular, Acellular, and Biophysical Determinants of Molecular Characteristics and Therapy Response

Ascites refers to the abnormal accumulation of fluid in the peritoneum resulting from an underlying pathology, such as metastatic cancer. Among all cancers, advanced-stage epithelial ovarian cancer is most frequently associated with the production of malignant ascites and is the leading cause of death from gynecologic malignancies. Despite decades of evidence showing that the accumulation of peritoneal fluid portends the poorest outcomes for cancer patients, the role of malignant ascites in promoting metastasis and therapy resistance remains poorly understood. This review summarizes the current understanding of malignant ascites, with a focus on ovarian cancer. The first section provides an overview of heterogeneity in ovarian cancer and the pathophysiology of malignant ascites. Next, analytical methods used to characterize the cellular and acellular components of malignant ascites, as well the role of these components in modulating cell biology, are discussed. The review then provides a perspective on the pressures and forces that tumors are subjected to in the presence of malignant ascites and the impact of physical stress on therapy resistance. Treatment options for malignant ascites, including surgical, pharmacological and photochemical interventions are then discussed to highlight challenges and opportunities at the interface of drug discovery, device development and physical sciences in oncology.

Puncture needle with a hard plastic sheath and plastic wings minimizes repuncture attempts in ultrasound-guided paracentesis

Background

This study was performed to evaluate periprocedural factors, complications, and repuncture rate of the newly developed puncture needle and compare it with the routinely used puncture needle for ultrasound (US)-guided paracentesis.

Methods

We retrospectively identified 137 patients who underwent US-guided paracentesis between July 2018 and March 2019. Among them, 82 patients underwent US-guided paracentesis with a newly developed puncture needle. The other 55 patients underwent US-guided paracentesis with a routinely used puncture needle. The periprocedural factors, complications, and repuncture rate were compared between the two groups using the Mann-Whitney U test and Fisher exact test. The repuncture-associated factors were assessed using logistic regression analysis.

Results

There were no major or minor complications in either group. The rate of repuncture was significantly lower in the group using the newly developed puncture needle compared with the group using the routinely used puncture needle (p=0.01). The duration of the procedure was significantly shorter with the newly developed puncture needle compared with the routinely used puncture needle (p=0.01). In univariate analysis, the thickness of the abdominal wall (p=0.04) and the use of the newly developed puncture needle (p=0.01) were significantly associated with the rate of repuncture. In multivariate analysis, only the use of the newly developed puncture needle was significantly associated with the rate of repuncture.

Conclusion

Using this novel puncture needle with a hard plastic sheath and plastic wings, the rate of repuncture and the duration of the procedure were decreased without complications of US-guided paracentesis.

A survey demonstrating that the procedural experience of residents in internal medicine, critical care and emergency medicine is poor: training in ultrasound is required to rectify this

BACKGROUND

Training in procedural skills is often suboptimal. The aim of this study was to quantify the needs of residents in internal medicine (IM), critical care (CC), and emergency medicine (EM) for instruction in ultrasound-guided procedures.

METHODS

All IM, EM and CC residents (n = 200) at King Abdulaziz Medical City, Riyadh, Saudi Arabia, were invited to participate in a questionnaire-based survey to identify skill and experience gaps. The contribution of procedural skills to patient care (i.e. applicability) and proficiency in the sterile technique required to perform ultrasound-guided procedures were rated on Likert scales. Data on training, accreditation, and experience with and without ultrasound were collected.

RESULTS

The overall response rate was 72% (IM 91%, CC 100%, EM 40%). Although the sample reported that procedural skills were very applicable, 19% (IM n = 25, EM n = 2) had not performed any procedures. However, five residents were accredited in point-of-care ultrasound, 61% of the sample had performed ultrasound-guided procedures and 65% had used landmark techniques. Whilst more internists had performed procedures using landmark techniques, CC and EM residents had performed more ultrasound-guided procedures. Whilst CC residents had not missed any opportunities to perform procedures because supervisors were less available, EM (6) and IM (89) residents had. Whilst skill gaps were only identified in the IM residency programme, experience gaps were present in all three residency programmes. The IM residency programme had larger experience gaps than the CC and EM programmes for all procedural skills.

DISCUSSION

Residents in IM, CC and EM perceive that ultrasound-guided procedures are relevant to their practice. However, the IM residents performed fewer procedures than CC residents and EM residents at least partly because internists also lack skills in ultrasound. Training in ultrasound-guided procedures may reduce the use of landmark techniques and improve patient safety. Residents in IM, CC and EM therefore require training in ultrasound-guided procedures.

Procedural Competency Among Hospitalists: A Literature Review and Future Considerations

BACKGROUND

As general internists practicing in the inpatient setting, hospitalists at many institutions are expected to perform invasive bedside procedures, as defined by professional standards. In reality, hospitalists are doing fewer procedures and increasingly are referring to specialists, which threatens their ability to maintain procedural skills. The discrepancy between expectations and reality, especially when hospitalists may be fully credentialed to perform procedures, poses significant risks to patients because of morbidity and mortality associated with complications, some of which derive from practitioner inexperience.

METHODS

We performed a structured search of the peer-reviewed literature to identify articles focused on hospitalists performing procedures.

RESULTS

Our synthesis of the literature characterizes contributors to hospitalists' procedural competency and discusses: (1) temporal trends for procedures performed by hospitalists and their associated referral patterns, (2) data comparing use and clinical outcomes of procedures performed by hospitalists compared with specialists, (3) the lack of nationwide standardization of hospitalist procedural training and credentialing, and (4) the role of medical procedure services, although limited in supportive evidence, in concentrating procedural skill and mitigating risk in the hands of a few well-trained hospitalists.

CONCLUSION

We conclude with recommendations for hospital medicine groups to ensure the safety of hospitalized patients undergoing bedside procedures.

Hemodynamic Instability in Emergency Department: Giant Rectus Sheath Hematoma and Point-of-Care Ultrasonography

Iatrogenic rectus sheath hematoma (RSH) developed after paracentesis is a rare but life-threatening complication. Mortality rates of patients may increase due to delays in treatment and comorbid conditions. In this article, we present the case of a patient who was unstable in the emergency department and was diagnosed with RSH using point-of-care ultrasonography (POCUS). The importance of POCUS has increased as hematoma manifestations of patients with severe ascites tend to be obscured. POCUS has varied uses in the emergency department, and in this article we emphasize the use of POCUS in a life-threatening case of RSH.

Guidelines on the management of ascites in cirrhosis

The British Society of Gastroenterology in collaboration with British Association for the Study of the Liver has prepared this document. The aim of this guideline is to review and summarise the evidence that guides clinical diagnosis and management of ascites in patients with cirrhosis. Substantial advances have been made in this area since the publication of the last guideline in 2007. These guidelines are based on a comprehensive literature search and comprise systematic reviews in the key areas, including the diagnostic tests, diuretic use, therapeutic paracentesis, use of albumin, transjugular intrahepatic portosystemic stent shunt, spontaneous bacterial peritonitis and beta-blockers in patients with ascites. Where recent systematic reviews and meta-analysis are available, these have been updated with additional studies. In addition, the results of prospective and retrospective studies, evidence obtained from expert committee reports and, in some instances, reports from case series have been included. Where possible, judgement has been made on the quality of information used to generate the guidelines and the specific recommendations have been made according to the 'Grading of Recommendations Assessment, Development and Evaluation (GRADE)' system. These guidelines are intended to inform practising clinicians, and it is expected that these guidelines will be revised in 3 years' time.

Focus on PoCUS or hocus pocus? Integrating point-of-care ultrasound into residency and clinical practice

Point-of care ultrasound (PoCUS) is a new clinical diagnostic paradigm that plays an instrumental role in the ongoing anesthesiologist’s evolving role towards a perioperative physician. Currently, there are few approved curricula that incorporate a PoCUS program into anesthesia residency. This article examines relevant PoCUS applications for anesthesiologists, presents an overview of existing international guidelines for education and training, and reflects on the need for specialty-wide standards. We present a possible framework, that could offer a first move towards a structured PoCUS pathway for Belgian anesthesia residents and facilitate its incorporation into national anesthesia practice.

Barriers to learning and using point-of-care ultrasound: a survey of practicing internists in six North American institutions

Background

Point-of-care ultrasound (POCUS) is increasingly used in internal medicine, but a lack of trained faculty continues to limit the spread of POCUS education. Using a framework based on organizational change theories, this study sought to identify barriers and enablers for hospital-based practicing internists to learn and use POCUS in clinical practice.

Methods

We invited practicing internists at six North American institutions to participate in an electronic survey on their opinions regarding 39 barriers and enablers.

Results

Of the 342 participants invited, 170 participated (response rate 49.3%). The top barriers were lack of training (79%), lack of handheld ultrasound devices (78%), lack of direct supervision (65%), lack of time to perform POCUS during rounds (65%), and lack of quality assurance processes (53%). The majority of participants (55%) disagreed or strongly disagreed with the statement “My institution provides funding for POCUS training.” In general, participants’ attitudes towards POCUS were favourable, and future career opportunities and the potential for billing were not considered significant factors by our participants in the decision to learn or use POCUS.

Conclusions

This survey confirms the perceived importance of POCUS to practicing internists. To assist in closing faculty development gap, interventions should address training, supervision, quality assurance processes, availability of handheld devices, as well as dedicated time to perform POCUS during clinical care.

The development of a provincial multidisciplinary framework of consensus-based standards for Point of Care Ultrasound at the University of Saskatchewan

OBJECTIVES

The development and adoption of Point-of-Care Ultrasound (POCUS) across disciplines have created challenges and opportunities in implementing training and utilization standards. Within the context of a large, geographically disparate province, we sought to develop a multidisciplinary POCUS framework outlining consensus-based standards.

METHODS

A core working group of local POCUS leaders from Anesthesia, Emergency Medicine, Family Medicine, Intensive Care, Internal Medicine, Pediatrics, and Trauma, in collaboration with western Canadian colleagues, developed a list of key domains for the framework along with a range of potential standards for each area. The members of the working group and the registrants for a multidisciplinary Roundtable discussion at the University of Saskatchewan's annual POCUS conference (SASKSONO19, Saskatoon, Saskatchewan, March 2nd, 2019) were invited to complete a survey on POCUS standards for each domain. The survey results were presented to and discussed by participants at the Roundtable discussion at SASKSONO19 who reached consensus on modified standards for each domain. The modified standards were considered for endorsement by all conference attendees using an audience-response system.

RESULTS

The working group proposed standards in eight domains: scope of use, credentialing and privileges, documentation, quality assurance, leadership and governance, teaching, research, and equipment maintenance. Consensus on modified standards was achieved in the 18 participant Roundtable. Each standard was then endorsed by > 90% of conference respondents.

CONCLUSION

The resulting framework will inform the utilization of POCUS within Saskatchewan. Both this process and its outcomes could inform the development of multidisciplinary POCUS standards within other jurisdictions.