New pocket echocardiography device is interchangeable with high-end portable system when performed by experienced examiners

Low dialysate sodium and 48-h ambulatory blood pressure in patients with intradialytic hypertension: a randomized crossover study

BACKGROUND

Intradialytic hypertension (IDH) is associated with increased risk for cardiovascular events and mortality. Patients with IDH exhibit higher 48-h blood pressure (BP) levels than patients without this condition. Volume and sodium excess are considered a major factor contributing in the development of this phenomenon. This study evaluated the effect of low (137 mEq/L) compared with standard (140 mEq/L) dialysate sodium concentration on 48-h BP in patients with IDH.

METHODS

In this randomized, single-blind, crossover study, 29 patients with IDH underwent four hemodialysis sessions with low (137 mEq/L) followed by four sessions with standard (140 mEq/L) dialysate sodium, or vice versa. Mean 48-h BP, pre-/post-dialysis and intradialytic BP, pre-dialysis weight, interdialytic weight gain (IDWG) and lung ultrasound B-lines were assessed.

RESULTS

Mean 48-h systolic/diastolic BP (SBP/DBP) were significantly lower with low compared with standard dialysate sodium concentration (137.6 ± 17.0/81.4 ± 13.7 mmHg with low vs 142.9 ± 14.5/84.0 ± 13.9 mmHg with standard dialysate sodium, P = .005/P = .007, respectively); SBP/DBP levels were also significantly lower during the 44-h and different 24-h periods. Low dialysate sodium significantly reduced post-dialysis (SBP/DBP: 150.3 ± 22.3/91.2 ± 15.1 mmHg with low vs 166.6 ± 17.3/94.5 ± 14.9 mmHg with standard dialysate sodium, P < .001/P = .134, respectively) and intradialytic (141.4 ± 18.0/85.0 ± 13.4 mmHg with low vs 147.5 ± 13.6/88.1 ± 12.5 mmHg with standard dialysate sodium, P = .034/P = .013, respectively) BP compared with standard dialysate sodium. Pre-dialysis weight, IDWG and pre-dialysis B lines were also significantly decreased with low dialysate sodium.

CONCLUSIONS

Low dialysate sodium concentration significantly reduced 48-h ambulatory BP compared with standard dialysate sodium in patients with IDH. These findings support low dialysate sodium as a major non-pharmacologic approach for BP management in patients with IDH.

TRIAL REGISTRATION

ClinicalTrials.gov study number NCT05430438.

Evaluation of a Self-Driven Large Animal Point of Care Ultrasound Learning Program for Veterinary Students

Point of care ultrasound (POCUS) has the potential to improve health care outcomes and is increasingly used in veterinary primary care and specialty practice. The aim of this study was to evaluate a self-driven POCUS learning program during clinical rotations in a large animal teaching hospital. A randomized controlled trial of 94 students evaluated the hypotheses that access to a self-driven POCUS program would improve scores on a written test and the quality of subjective, objective, assessment and plan (SOAP) documents. Use of the POCUS devices and perceptions of veterinary students toward POCUS were analyzed. The self-driven POCUS learning program was feasible, and the perception of most students (94%) was that the program was useful for their education. Access to equipment, ability to scan individually, the hands-on learning aspect, and clinicians' help were the most valued aspects of the program. Earlier access to POCUS in the curriculum, hands-on tutorials/labs, and a more structured learning program were identified by students as aspects to improve. Access to the self-driven POCUS program resulted in significantly higher scores on the written test in a subpopulation of students with lower scores. No significant differences in results on the multiple-choice tests in the subpopulation with higher scores or in SOAP scores of the complete group or subpopulations were found. A self-driven POCUS learning program was perceived as beneficial by students, increased POCUS knowledge in students with lower test scores, and was possible to implement in a busy large animal teaching hospital.

Handheld Echocardiography in a Clinical Practice Scenario: Concordances Compared to Standard Echocardiographic Reports

BACKGROUND

The purpose of this study was to assess the utility of a handheld device (HH) used during common daily practice and its agreement with the results of a standard echocardiography study (STD) performed by experienced sonographers and echocardiographer.

METHODS

A prospective follow-up was conducted in an adult outpatient echocardiography clinic. Experienced sonographers performed the STD and an experienced echocardiographer performed the HH. STD included 2-dimensional images, Doppler and hemodynamics analysis. Hemodynamic assessment was not performed with the HH device because the HH does not include such technology. The images were interpreted by blinded echocardiographers, and the agreement between the reports was analyzed.

RESULTS

A total of 108 patients were included; and the concordance for left ventricle (LV) ejection fraction (EF), wall motion score index, LV and right ventricle (RV) function, RV size, and mitral and aortic stenosis was excellent with κ values greater than 0.80. Wall motion abnormalities had good concordance (κ value 0.78). The agreement for LV hypertrophy, mitral and aortic regurgitation was moderate, and tricuspid and pulmonary regurgitation agreements were low (κ values of 0.26 and 0.25, respectively).

CONCLUSIONS

In a daily practice scenario with experienced hands, HH demonstrated good correlation for most echocardiography indications, such as ventricular size and function assessment and stenosis valve lesion analyses.

Impact of simulator-based training on acquisition of transthoracic echocardiography skills in medical students

Introduction:

Due to the expanding role of ultrasound as a diagnostic tool in modern medicine, medical schools rapidly include ultrasound training in their curriculum. The objective of this study was to compare simulator-based training along with classical teaching, using human models, to impart focused transthoracic echocardiography examination.

Subject and Methods:

A total of 22 medical students, with no former transthoracic echocardiography training, undertook a 90-min e-learning module, dealing with focused echocardiography and important echocardiographic pathologies. Subsequently, they had to complete a multiple-choice-questioner, followed by a 120-min practical training session either on the Heartworks™, (Cardiff, UK) and the CAE Vimedix^®, (Québec, Canada) simulator (n = 10) or on a live human model (n = 12). Finally, both groups had to complete a post-test consisting of ten video-based multiple-choice-questions and a time-based, focused echocardiography examination on another human model. Two blinded expert observers scored each acquired loop which recorded 2 s of each standard view. Statistical analysis was performed with SPPS 24 (SPSS™ 24, IBM, USA) using the Mann-Whitney-Test to compare both groups.

Results:

Analysis of measurable outcome skills showed no significant difference between transthoracic echocardiography training on human models and high-fidelity simulators for undergraduate medical students.

Conclusions:

Both teaching methods are effective and lead to the intended level of knowledge and skills.

Offshore telementored ultrasound: a quality assessment study

Background

Telementored ultrasound (US) connects experts to novices through various types of communication and network technologies with the overall aim to bridge the medical imaging gap between patients’ diagnostic needs and on-site user experience. The recurrent theme in previous research on remote telementored US is the limited access to US machines and experienced users. This study was conducted to determine whether telementored US was feasible in a remote offshore setting. The aim was to assess if an onshore US expert can guide an offshore nurse through focused US scanning protocols by connecting an US machine to existing videoconference units at the offshore hospitals and to evaluate the diagnostic quality of the images and cineloops procured.

Results

The diagnostic quality of cineloops was scored on a five-point scale. The percentage of cineloops suitable for interpretation (score 3 ≥) for the FATE and e-FAST protocols was 96.4 and 79.1. Lung sliding and seashore sign could be identified in all volunteers. The scan time for the FAST protocol (n = four scanning positions), FATE protocol (n = six scanning positions) and both lungs (n = two scanning positions) was 1 min 20 s, 4 min 15 s and 32 s, respectively.

Conclusion

A novice US user can be guided by a remote expert through focused US protocols within an acceptable time frame and with good diagnostic quality using existing communication and network systems found onboard offshore oil rigs.

Feasibility of Using a Pocket-Sized Ultrasound Device to Measure the Inferior Vena Cava Diameter of Patients With Heart Failure in the Community Setting: A Pilot Study

Background: The incidence of heart failure as well as its treatment costs and rehospitalization rates are increasing worldwide. Physical assessment of elderly patients with heart failure living in their homes is challenging for community nurses. Pocket-sized echocardiographs will be useful for assessing the condition of the patients with heart failure during home-visit care. Objectives: This pilot study aimed to examine the feasibility of measuring the inferior vena cava (IVC) diameter using a pocket-sized ultrasound device. Methods: Nursing students were trained to use the pocket-sized ultrasound device (PUSD) for measuring the inferior vena cava diameter of a healthy subject. We evaluated the accuracy and rapidity of the nursing students' measurements compared with those of an expert sonographer. Results: In total, 83.3% of the participants accurately visualized the IVC using the PSUD. There was no significant difference in the mean IVC diameter between that measured by the students and the sonographer. In total, 25% of the participants accurately measured the IVC diameter. The mean measurement time was 201 seconds. Conclusion: Our training program allowed the participants to accurately visualize the IVC using the PSUD. However, these results on accuracy and measurement time still need to be improved before community nurses can use the PSUD during home visits.

Smartphone interfaced handheld echocardiography for focused assessment of ventricular function and structure in children: A pilot study

INTRODUCTION

Miniaturized echocardiographic machines improve availability and portability and can be particularly useful for underserved and resource-limited settings. The goal of this study was to compare left ventricular fractional shortening (FS) and left ventricular ejection fraction (LVEF) obtained by a newer handheld echo (HHE) machine to standard transthoracic echocardiogram (TTE) in children.

METHODS

Pediatric outpatients (Birth-18 years) undergoing TTE were prospectively enrolled. HHE protocol included 2D and M-mode images from the parasternal long, short, and apical-4 chamber views. HHE and TTE measurements were reviewed for agreement. Kappa statistic was used to analyze qualitative indices while FS and LVEF were analyzed with Lin's concordance correlation coefficient (CCC) and Bland-Altman limits of agreement (loa).

RESULTS

Sixty children were enrolled; 55 were included in the quantitative analysis. Mean age was 7.5 ± 5.5 years; 67% males; median HHE image acquisition duration was 2.3(1-5) minutes. Fractional shortening and EF by HHE showed good agreement with TTE [CCC = 0.82, 95%CI (0.73,0.90), mean bias -3.18%, loa (-7.00,6.44%) vs CCC = 0.81 (0.72,0.90), mean bias -0.87%, loa (-6.94,5.17%], respectively. In children ≤5 years, HHE FS (n = 20) and EF (n = 21) agreed with TTE measurement [0.59 (0.31, 0.88), mean bias 0.30%, loa (-8.5, 9.1%); 0.79 (0.63, 0.96), mean bias 0.10%, loa (-5.99, 6.14)]. Kappa values for RV size, function, and LV function were 1.00 (P < .05); 0.75 for LV size (P < .05) and 0.66 for pericardial effusion (P < .05).

CONCLUSION

Handheld echo demonstrates good correlation with standard TTE for focused assessment of ventricular chamber sizes and function in children.

Focused Cardiac Ultrasonography: Current Applications and Future Directions

Focused cardiac ultrasonography is performed by clinicians at the bedside and is used in time-sensitive scenarios to evaluate a patient's cardiovascular status when comprehensive echocardiography is not immediately available. This simplified cardiac ultrasonography is often performed by noncardiologists using small, portable devices to augment the physical examination, triage patients, and direct management in both critical care and outpatient settings. However, as the use of focused cardiac ultrasonography continues to expand, careful consideration is required regarding training, scope of practice, impact on patient outcomes, and medicolegal implications. In this review, we examine some of the challenges with rapid uptake of this technique and explore the benefits and potential risk of focused cardiac ultrasonography. We propose possible mechanisms for cross-specialty collaboration, quality improvement, and oversight.

Implementation of the modified four-step approach method for teaching echocardiography using the FATE protocol-A pilot study

Introduction

Peyton's four‐step approach is well‐known and commonly used in medical education. It is a practical and useful method which is simple to apply. The study presents the implementation of the modified four‐step approach method to teach how to perform the emergency echocardiographic assessment according to FATE (Focus‐Assessed Transthoracic Echo) protocol. The aim of the study was to determine the feasibility and utility of this method FATE protocol teaching.

Design

We collected students' feedback relating to perception of this way of teaching. Based on a semistructured interview conducted with the students, as well as an evaluation of the electronic survey, it has been demonstrated that the four‐step method is useful for teaching emergency echocardiographic assessment.

Setting

One Polish medical school.

Participants

The classes were run in small groups as part of an elective ultrasound course for the fourth‐ and fifth‐year students of the Faculty of Medicine of the Medical College. Twenty‐two students were trained.

Results

Based on the opinions of the participants of the elective course and the teacher conducting the classes, which involved the use of the modified Peyton's four‐step method in teaching echocardiography in emergency cases according to the FATE protocol, it has been determined that the four‐step method is effective in imaging training. All participants claim that this method is clear and understandable. Advantages of the methodological approach: a slow‐motion demonstration by the instructor, accompanied by the commentary on the activities undertaken and practical exercises performed by the participants, learning through repetition, requirement of constant concentration.

Conclusions

Peyton's approach allows to use of the class time in maximal extend by consolidating new information and facilitating memorization through adequate instructor guidance and observation of the training of the peer students and repetition of the skills acquired.

Effects of Progressive Hypoventilation on Left Ventricular Appearance: An Alternative Etiology of Acute Sonographic Short-Axis D-Shaping

OBJECTIVES

The purpose of this study was to evaluate the effects of progressive hypoventilation on echocardiographic measures of the left ventricular (LV) appearance in a porcine model.

METHODS

Ten piglets were included in the experimental group, and 5 served as controls. The experimental group underwent 3 interventions of progressive hypoventilation (baseline: tidal volume, 240 mL; respiratory frequency, 16 minutes^-1 ; first intervention: tidal volume, 240 mL; respiratory frequency, 8 minutes-1; second intervention: tidal volume, 240 mL; respiratory frequency, 4 minutes^-1 ; and third intervention: tidal volume, 120 mL; respiratory frequency, 4 minutes^-1 ). Respiratory resuscitation was initiated if the MAP decreased to 50% of the baseline level or at the end of the third intervention. Transthoracic sonography and invasive measurements were obtained throughout. The primary end point was the LV end-diastolic eccentricity index, a measure of LV D-shaping.

RESULTS

The median LV end-diastolic eccentricity index increased from 1.1 (interquartile range, 1.0-1.1) at baseline to 1.4 (1.3-1.4) 3 minutes after the third intervention (P < .001) and returned to baseline after resuscitation (P = .093). The MAP declined from 87 mm Hg (81-92 mm Hg) to 50 mmHg (33-66 mm Hg) after initiation of the third intervention (P < .001). The mean pulmonary arterial pressure increased from 20 mm Hg (15-21 mm Hg) to 39 mm Hg (38-40 mm Hg) during the second intervention (P < .001).

CONCLUSIONS

Progressive hypoventilation led to a marked D-configuration of the LV and a sharp decrease in systemic blood pressure. After respiratory resuscitation, sonographic measures normalized. These findings were explainable by the pressure changes observed within the left and right ventricles.

Clinical utility and diagnostic accuracy of palm-held, mini-sized ultrasonocardiographic scanner in congenital heart disease

BACKGROUND/PURPOSE

To investigate whether a palm-held ultrasonocardiographic scanner would be useful for screening and follow-up in congenital heart disease (CHD).

METHODS

We retrospectively reviewed the echocardiographic images from June 1, 2014 to November 1, 2014. All patients underwent two ultrasonographic examinations including palm-held scanner examination and standard echocardiography. To compare the quality of the two instruments, we developed a diagnostic scoring system ranging from 1 point to 10 points, with 10 points indicating the best quality. Two experienced echocardiographers retrospectively reviewed all recorded images blindedly and gave each examination a score. Comparisons of diagnostic score between two equipments were performed.

RESULTS

A total of 262 patients' images were reviewed. All cardiac lesions could be detected with both instruments. The mean diagnostic score of palm-held scanner and standard echocardiography were 8.20±0.53 versus 9.64±0.37 (p<0.05) in color image and 7.00±1.05 versus 8.56±1.14 (p<0.05) in gray-scale two-dimensional image, respectively. When we compared the score between the two instruments in individual CHDs, we found standard echocardiography had better quality except for detecting muscular ventricular septal defect and pulmonary regurgitation.

CONCLUSION

The diagnostic sensitivity of palm-held scanner in detecting CHD was very good. Despite both instruments having a high diagnostic score in detecting CHD, standard echocardiography had better quality. Traditional echocardiography is still the standard tool for CHD evaluation. However, the palm-held scanner can support physical examination for initial screening and follow-up, and offer cardiologists an opportunity to visualize and listen to the heart at any time.

Make it SIMPLE: enhanced shock management by focused cardiac ultrasound

BACKGROUND

Shock is a spectrum of circulatory failure that, if not properly managed, would lead to high mortality. Special diagnostic and treatment strategies are essential to save lives. However, clinical and laboratory findings are always non-specific, resulting in clinical dilemmas.

MAIN CONTENT

Focused cardiac ultrasound (FoCUS) has emerged as one of the power tools for clinicians to answer simple clinical questions and guide subsequent management in hypotensive patients. This article will review the development and utility of FoCUS in different types of shock. The sonographic features and ultrasound enhanced management of hypotensive patients by a de novo "SIMPLE" approach will be described. Current evidence on FoCUS will also be reviewed.

CONCLUSION

Focused cardiac ultrasound provides timely and valuable information for the evaluation of shock. It helps to improve the diagnostic accuracy, narrow the possible differential diagnoses, and guide specific management. SIMPLE is an easy-to-remember mnemonic for non-cardiologists or novice clinical sonographers to apply FoCUS and interpret the specific sonographic findings when evaluating patients in shock.

Diagnosis of Postoperative Urinary Retention Using a Simplified Ultrasound Bladder Measurement

BACKGROUND

In this study, we sought to determine whether a simplified ultrasound measurement of the largest transverse diameter, using a standard ultrasound machine, could be used to diagnose postoperative urinary retention (POUR). This method may replace expensive bladder volume measuring devices or a more complex ultrasound procedure (involving the measurement of 3 bladder diameters).

METHODS

Patients at risk of POUR if unable to void after orthopedic surgery were evaluated in the postanesthesia care unit before discharge. Bladder diameter was first measured using a portable ultrasound device (Vscan®; GE Healthcare, Wauwatosa, WI). An automated evaluation of bladder volume was then performed (Bladderscan® BVI 3000; Diagnostic Ultrasound, Redmond, WA). Finally, when a bladder catheterization was performed, the actual urinary volume was measured. The main outcome was a bladder volume ≥600 mL as measured using the automated ultrasound scanner (Bladderscan BVI 3000) or by catheterization. Correlations between bladder volumes and diameter were studied and receiver operating characteristic curves were constructed to determine the performance in predicting a bladder volume ≥600 mL. A "gray zone" approach was developed because a single cutoff value may not always be clinically significant.

RESULTS

One hundred patients were included and underwent a Bladderscan measurement. Urinary volume after catheterization was obtained in 49 patients. A significant correlation was found between the largest transverse diameter and urinary volumes assessed by the 2 methods (Bladderscan and catheterization). Pearson correlation coefficients were r = 0.80 (95% confidence interval [CI], 0.72-0.86; P < 0.001) and r = 0.79 (95% CI, 0.65-0.88; P < 0.001), respectively. The area under the receiver operating characteristic curves for the prediction of a bladder volume ≥600 mL were 0.94 (95% CI, 0.88-0.98) and 0.91 (95% CI, 0.79-0.97), respectively, for urinary volumes assessed by Bladderscan and catheterization. The optimal cutoff value was 9.7 cm for both methods. The gray zone was narrow, ranging from 9.7 to 10.7 cm thus limiting inconclusive measurements.

CONCLUSIONS

A simple ultrasound measurement of the largest transverse bladder diameter seemed to be helpful to exclude or confirm POUR.

Ultrasound as a tool for fluid status assessment in the trauma and critically ill patient

Resuscitation to euvolemia in trauma as well as in the critically ill patient, continues to be a challenge. Focused cardiac ultrasound has been shown to be a reliable tool to evaluate fluid status and to guide therapy. The present manuscript reviews the evidence supporting the use of this tool and describes the clinical applications for image-based resuscitation using echocardiogram.

Focused cardiac ultrasound: where do we stand?

Focused cardiac ultrasound (FCU) is a bedside examination of the heart performed with a small, portable ultrasound platform by a physician as an adjunct to their physical examination. The goal is to recognize a narrow list of abnormalities that are both detectable by physicians with limited ultrasound training and have high clinical assessment value. Results from the FCU examination are integrated with traditional bedside assessment (physical examination and history) to provide early management plans and patient triage in settings when echocardiography cannot be obtained or is not immediately available.

Does physician experience influence the interpretability of focused echocardiography images performed by a pocket device?

Introduction

The use of focused cardiac ultrasound (FoCUS) in a prehospital setting is recommended. Pocket ultrasound devices (PUDs) appear to be well suited to prehospital FoCUS. The main aim of our study was to evaluate the interpretability of echocardiography performed in a prehospital setting using a PUD based on the experience of the emergency physician (EP).

Methods

This was a monocentric prospective observational study. We defined experienced emergency physicians (EEPs) and novice emergency physicians (NEPs) as echocardiographers if they had performed 50 echocardiographies since their initial university training (theoretical training and at least 25 echocardiographies performed with a mentor). Each patient undergoing prehospital echocardiography with a PUD was included. Four diagnostic items based on FoCUS were analyzed: pericardial effusions (PE), right ventricular dilation (RVD), qualitative left ventricular function assessment (LVEF), and inferior vena cava compliance (IVCC). Two independent experts blindly evaluated the interpretability of each item by examining recorded video loops. If their opinions were divided, then a third expert concluded.

Results

Fourteen EPs participated: eight (57 %) EEPs and six (43 %) NEPs. Eighty-five patients were included: 34 (40 %) had an echocardiography by an NEP and 51 (60 %) by an EEP. The mean number of interpretable items by echocardiography was three [1; 4]; one [0; 2.25] in the NEP group, four [3; 4] in EEP (p < .01). The patient position was also associated with interpretable items: supine three [2; 4], “45°” three [1; 4], sitting two [1; 4] (p = .02). In multivariate analysis, only EP experience was associated with the number of interpretable items (p = .02). Interpretability by NEPs and EEPs was: 56 % vs. 96 % for LVF, 29 % vs. 98 % for PE, 26 % vs. 92 % for RVD, and 21 % vs. 67 % for IVCC (p < .01 for all).

Conclusion

FoCUS with PUD in prehospital conditions was possible for EEPs, It is difficult and the diagnostic yield is poor for NEPs.

Diagnostic influence of routine point-of-care pocket-size ultrasound examinations performed by medical residents

OBJECTIVES

We aimed to investigate the potential benefit of adding goal-directed ultrasound examinations performed by on-call medical residents using a pocket-size imaging device in patients admitted to a medical department.

METHODS

A total of 992 emergency admissions to the medical department at a nonuniversity hospital in Norway were included. Patients admitted on dates with an on-call medical resident randomized to use a pocket-size imaging device were eligible for pocket-size cardiac and abdominal ultrasound examinations or standard care. The cardiac examination included estimation of right and left ventricular sizes and global systolic function and regional left ventricular systolic function, evaluation for pleural and pericardial effusion, and valvular disease. The abdominal examination looked for signs of gross abnormalities of the liver, gallbladder, abdominal aorta, inferior vena cava, and urinary system. Six of 12 medical residents with limited ultrasound experience were randomized to perform the examinations. Diagnostic corrections were made, and findings were confirmed by reference standard diagnostics.

RESULTS

A total of 199 patients were examined. Median times used were 5.7 minutes for the cardiac examination and 4.7 minutes for the abdominal examination. In 13 patients (6.5%), the examination resulted in a major change in the primary diagnosis. In 21 patients (10.5%), the diagnosis was verified, and in 48 (24.0%), an additional important diagnosis was made.

CONCLUSIONS

By implementing pocket-size ultrasound examinations that took less than 11 minutes to the usual care, we corrected, verified, or added important diagnoses in more than 1 of 3 emergency medical admissions. Point-of-care examinations with a pocket-size imaging device increased medical residents' diagnostic accuracy and capability.

The utility of pocket-sized echocardiography to assess left ventricular systolic function prior to permanent pacemaker implantation

Background

A subset of patients receiving first-time permanent pacemakers (PPM) may also benefit from an implantable cardioverter defibrillator (ICD) based on the presence of left ventricular systolic dysfunction (LVSD). Routine screening using pocket-sized echocardiography (PSE) may be useful in identifying such patients.

Objective

To determine whether PSE can be used by an inexperienced sonographer to adequately screen for LVSD in a patient population receiving a first-time PPM.

Methods

A sonographic trainee (medical student) acquired images using PSE, which were then evaluated by an experienced echocardiologist for both image quality and presence of LVSD. The sensitivity and specificity of assessment by the inexperienced sonographer was compared to the level 3 echocardiologist.

Results

The patient population included 71 individuals (66% male, mean age 77 ± 12 years). Interpretable images where left ventricular ejection fraction (LVEF) could be adequately assessed were obtained in 93% of the patient population. As compared with the echocardiologist, the sonographic trainee had a sensitivity of 60% and a specificity of 98% in detecting LVSD.

Conclusions

For patients receiving first-time PPM, the use of PSE by a sonographic trainee combined with interpretation by an experienced imaging cardiologist can triage for the need to perform standard transthoracic echocardiography (sTTE) by determining the presence of LVSD.

Pocket-sized focused cardiac ultrasound: strengths and limitations

Focused cardiac ultrasound (FCU) has emerged in recent years and has created new possibilities in the clinical assessment of patients both in and out of hospital. The increasing portability of echocardiographic devices, with some now only the size of a smartphone, has widened the spectrum of potential indications and users, from the senior cardiologist to the medical student. However, many issues still need to be addressed, especially the acknowledgment of the advantages and limitations of using such devices for FCU, and the extent of training required in this rapidly evolving field. In recent years, an increasing number of studies involving FCU have been published with variable results. This review outlines the evidence for the use of FCU with pocket-echo to address specific questions in daily clinical practice.

Screening for rheumatic heart disease: evaluation of a focused cardiac ultrasound approach

BACKGROUND

Rheumatic heart disease (RHD) remains a major public health problem worldwide. Although early diagnosis by echocardiography may potentially play a key role in developing active surveillance, systematic evaluation of simple approaches in resource poor settings are needed.

METHODS AND RESULTS

We prospectively compared focused cardiac ultrasound (FCU) to a reference approach for RHD screening in a school children population. FCU included (1) the use of a pocket-sized echocardiography machine, (2) nonexpert staff (2 nurses with specific training), and (3) a simplified set of echocardiographic criteria. The reference approach used standardized echocardiographic examination, reviewed by an expert cardiologist, according to 2012 World Heart Federation criteria. Among the 6 different echocardiographic criteria, first tested in a preliminary phase, mitral regurgitation jet length≥2 cm or any aortic regurgitation was considered best suited to be FCU criteria. Of the 1217 subjects enrolled (mean, 9.6±1 years; 49.6% male), 49 (4%) were diagnosed with RHD by the reference approach. The sensitivity of FCU for the detection of RHD was 83.7% (95% confidence interval, 73.3-94.0) for nurse A and 77.6% (95% confidence interval, 65.9-89.2) for nurse B. FCU yielded a specificity of 90.9% (95% confidence interval, 89.3-92.6) and 92.0% (95% confidence interval, 90.4-93.5) according to users. Percentage of agreement among nurses was 91.4%.

CONCLUSIONS

FCU by nonexperts using pocket devices seems feasible and yields acceptable sensitivity and specificity for RHD detection when compared with the state-of-the-art approach, thereby opening new perspectives for mass screening for RHD in low-resource settings.

International evidence-based recommendations for focused cardiac ultrasound

BACKGROUND

Focused cardiac ultrasound (FoCUS) is a simplified, clinician-performed application of echocardiography that is rapidly expanding in use, especially in emergency and critical care medicine. Performed by appropriately trained clinicians, typically not cardiologists, FoCUS ascertains the essential information needed in critical scenarios for time-sensitive clinical decision making. A need exists for quality evidence-based review and clinical recommendations on its use.

METHODS

The World Interactive Network Focused on Critical UltraSound conducted an international, multispecialty, evidence-based, methodologically rigorous consensus process on FoCUS. Thirty-three experts from 16 countries were involved. A systematic multiple-database, double-track literature search (January 1980 to September 2013) was performed. The Grading of Recommendation, Assessment, Development and Evaluation method was used to determine the quality of available evidence and subsequent development of the recommendations. Evidence-based panel judgment and consensus was collected and analyzed by means of the RAND appropriateness method.

RESULTS

During four conferences (in New Delhi, Milan, Boston, and Barcelona), 108 statements were elaborated and discussed. Face-to-face debates were held in two rounds using the modified Delphi technique. Disagreement occurred for 10 statements. Weak or conditional recommendations were made for two statements and strong or very strong recommendations for 96. These recommendations delineate the nature, applications, technique, potential benefits, clinical integration, education, and certification principles for FoCUS, both for adults and pediatric patients.

CONCLUSIONS

This document presents the results of the first International Conference on FoCUS. For the first time, evidence-based clinical recommendations comprehensively address this branch of point-of-care ultrasound, providing a framework for FoCUS to standardize its application in different clinical settings around the world.

Pocket-sized ultrasound as an aid to physical diagnosis for internal medicine residents: a randomized trial

BACKGROUND

Proficiency and self-confidence in the physical examination is poor among internal medicine residents and interest in ultrasound technology has expanded.

OBJECTIVE

We aimed to determine whether a pocket-sized ultrasound improves the diagnostic accuracy and confidence of residents after a 3-h training session and 1 month of independent practice.

DESIGN

This was a randomized parallel group controlled trial.

PARTICIPANTS

Forty internal medicine residents in a single program at an academic medical center participated in the study.

INTERVENTION

Three hours of training on use of pocket-sized ultrasound was followed by 1 month of independent practice.

MAIN MEASURES

The primary outcome was a comparison of the diagnostic accuracy of a physical exam alone versus a physical examination augmented with a pocket-sized ultrasound. Other outcomes included confidence in exam findings and a survey of attitudes towards the physical exam and the role of ultrasound.

KEY RESULTS

Residents in the intervention group using a pocket-sized ultrasound correctly identified an average of 7.6 of the 17 abnormal findings (accuracy rate of 44.9 %). Those in the control group correctly identified an average of 6.4 abnormal findings (accuracy rate of 37.6 %, p = 0.11). Residents in the intervention group identified on average 15.9 findings as abnormal when no abnormality existed (false positive rate of 16.8 %). Those in the control group incorrectly identified an average of 15.5 positive findings (false positive rate of 16.3 %). There was no difference between groups regarding self-assessed confidence in physical examination. Residents in the intervention group identified 6.1 of 13 abnormal cardiac findings versus the control group's 4.5 of 13, an accuracy rate of 47.0 % versus 34.6 % (p = 0.023).

CONCLUSIONS

The diagnostic ability of internal medicine residents did not significantly improve with use of a pocket-sized ultrasound device after a 3-h training session and 1 month of independent practice.

TRIAL REGISTRATION

clinicaltrials.gov: number NCT01948076; URL http://clinicaltrials.gov/ct2/show/study/NCT01948076?term=ultrasound+physical+exam&rank=2.

Point-of-care cardiac ultrasound in acute medicine--the quick scan

The optimum management of acute medical patients requires prompt and accurate diagnosis, monitoring and treatment. The clinical history and physical examination remain central to diagnosis, but often need supplementation by laboratory testing or imaging. Echocardiographic assessment of cardiac structure and function provides valuable information that can aid diagnosis and assess clinical progress. It has many advantages as an imaging modality, and recent technological advances have resulted in hand-held, battery-powered ultrasound devices that provide high-quality images. Three broad applications of cardiac ultrasound now exist: conventional echocardiography, focussed echocardiography and the quick-scan. A quick-scan using a hand-held ultrasound device is readily integrated into the bedside clinical assessment, providing information that can be used immediately in diagnostic reasoning; it can also guide pericardiocentesis. Hand-held ultrasound devices can also be used in acute situations, as well as geographically remote areas or special situations (eg disaster zones) where other imaging is not available. However, the diagnostic yield of echocardiography is user dependent, and training is required for its benefits to be realised, adding to the hardware costs. More data are needed on the incremental value of hand-held ultrasonography and a quick-scan over conventional methods of assessment, their impact on clinical outcomes, and cost effectiveness.

Routine pre-operative focused ultrasonography by anesthesiologists in patients undergoing urgent surgical procedures

BACKGROUND

Unexpected cardiopulmonary complications are well described during surgery and anesthesia. Pre-operative evaluation by focused cardiopulmonary ultrasonography may prevent such mishaps. The aim of this study was to determine the frequency of unexpected cardiopulmonary pathology with focused ultrasonography in patients undergoing urgent surgical procedures.

METHODS

We performed pre-operative focused cardiopulmonary ultrasonography in patients aged 18 years or above undergoing urgent surgical procedures at pre-defined study days. Known and unexpected cardiopulmonary pathology was recorded, and subsequent changes in the anesthesia technique or supportive actions were registered.

RESULTS

A total of 112 patients scheduled for urgent surgical procedures were included. Their mean age (standard deviation) was 62 (21) years. Of these patients, 24% were American Society of Anesthesiologists (ASA) class 1, 39% were ASA class 2, 32% were ASA class 3, and 4% were ASA class 4. Unexpected cardiopulmonary pathology was disclosed in 27% [95% confidence interval (CI) 19-36] of the patients and led to a change in anesthesia technique or supportive actions in 43% (95% CI 25-63) of these. Unexpected pathology leading to changes in anesthesia technique or supportive actions was only disclosed in a group of patients above the age of 60 years and/or in ASA class ≥ 3.

CONCLUSION

Focused cardiopulmonary ultrasonography disclosed unexpected pathology in patients undergoing urgent surgical procedures and induced changes in the anesthesia technique or supportive actions. Pre-operative focused ultrasonography seems feasible in patients above 60 year and/or with physical limitations but not in young, healthy individuals.

A futuristic vision of pocket ultrasound machines: watch this space

Introduction: Australian medical ultrasound started in 1959 with the establishment of the Ultrasonics Institute. Since then the technology has advanced tremendously. We are now not only able to obtain clearer images on high specification ultrasound machines but also on pocket-sized ultrasound machines that are compact, lightweight and affordable. Method: The following descriptive review will examine the indication for use of pocket ultrasound machines in different clinical settings as well as provide evidence of its image clarity and accuracy. Potentially eligible studies were sought primarily through searches of the electronic databases PubMed, Medline (1996-Present), Embase (1996-Present) and Cochrane Library. Conclusion: Pocket ultrasound machines, with appropriate ultrasound knowledge and training, can be incorporated successfully in patient management. The addition of point-of-care ultrasound has been shown to improve management recommendations and outcomes.

Point-of-care ultrasonography changes patient management following open heart surgery

OBJECTIVES

Although pericardial effusions (PE) and pleural effusions (PLE) may lead to life-threatening respiratory and circulatory deterioration following open heart surgery the postoperative frequency is not fully recognized. The diagnosis is typically based on ultrasonography, X-ray or computer tomography and often disclosed when circulatory collapse is evident. Point-of-care (POC) ultrasonography protocols constitute a noninvasive evaluation of the cardiopulmonary status. We hypothesized that POC ultrasonography could diagnose unknown PE and PLE.

DESIGN

Patients scheduled for open heart surgery were eligible for inclusion. Baseline evaluation including POC examination and dyspnea score was performed one day prior to surgery and repeated on the 4th and 30th postoperative day.

RESULTS

Eighty patients were included and complete follow-up was 80%. Thirteen patients (19%) had PE on the 4th day postsurgery and 19 patients (30%) had PE on the 30th day. Ultrasonography facilitated change in management in one patient with PE requiring drainage. Forty-nine patients (70%) had PLE on the 4th day following surgery and 19 patients (30%) had PLE on the 30th postoperative day. Ultrasonography facilitated a change in management in seven patients with PLE requiring drainage.

CONCLUSION

POC ultrasonography detected pathology, otherwise undisclosed, and was responsible for a change in management in a considerable number of cases.

Feasibility and accuracy of point-of-care pocket-size ultrasonography performed by medical students

BACKGROUND

Point-of-care ultrasound performed by clinicians is a useful supplement in the treatment and assessment of patients. We aimed to investigate whether medical students with minimal training were able to successfully acquire and interpret ultrasound images using a pocket-size imaging device (PSID) as a supplement to their clinical practice.

METHODS

Thirty 5th year (of six) medical students volunteered to participate. They were each given a personal PSID device to use as a supplement to their physical examination during their allocated hospital terms. Prior to clinical placement the students were given three evenings of hands-on training with PSID by a board certified radiologist/cardiologist, including three short lectures (<20 min). The students were shown basic ultrasound techniques and taught to assess for basic, clinically relevant pathology. They were specifically instructed to assess for the presence or absence of reduced left ventricular function (assessed as mitral annular excursion < 10 mm), pericardial effusion, pleural effusion, lung comets, hydronephrosis, bladder distension, gallstones, abdominal free-fluid, cholecystitis, and estimate the diameter of abdominal aorta and inferior vena cava.

RESULTS

A total of 211 patients were examined creating 1151 ultrasound recordings. Acceptable organ presentation was 73.8% (95% CI 63.1-82.6) for cardiovascular and 88.4% (95% CI: 80.6-93.6) for radiological structures. Diagnostic accuracy was 93.5% (95% CI: 89.0-96.2) and 93.2% (95% CI: 87.4-96.5) respectively.

CONCLUSION

Medical students with minimal training were able to use PSID as a supplement to standard physical examination and successfully acquire acceptable relevant organ recordings for presentation and correctly interpret these with great accuracy.

Can hospital rounds with pocket ultrasound by cardiologists reduce standard echocardiography?

BACKGROUND

Frequently, hospitalized patients are referred for transthoracic echocardiograms. The availability of a pocket mobile echocardiography device that can be incorporated on bedside rounds by cardiologists may be a useful and frugal alternative.

METHODS

This was a cross-sectional study designed to compare the accuracy of pocket mobile echocardiography images with those acquired by transthoracic echocardiography in a sample of hospitalized patients. Each patient referred for echocardiography underwent pocket mobile echocardiography acquisition and interpretation by a senior cardiology fellow with level II training in echocardiography. Subsequently, transthoracic echocardiography was performed by skilled ultrasonographers and interpreted by experienced echocardiographers. Both groups were blinded to the results of the alternative imaging modality. Visualizability and accuracy for all key echocardiographic parameters (ejection fraction, wall motion abnormalities, left ventricular end-diastolic dimension, inferior vena cava size, aortic and mitral valve pathology, and pericardial effusion) were determined and compared between imaging modalities.

RESULTS

A total of 240 hospitalized patients underwent echocardiography with pocket mobile echocardiography and transthoracic echocardiography. The mean age was 71 ± 17 years. Pocket mobile echocardiography imaging time was 6.3 ± 1.5 minutes. Sensitivity of pocket mobile echocardiography varied by parameter and was highest for aortic stenosis (97%) and lowest for aortic insufficiency (76%). Specificity also varied by parameter and was highest for mitral regurgitation (100%) and lowest for left ventricular ejection fraction (92%). Equivalence testing revealed the pocket mobile echocardiography outcomes to be significantly equivalent to the transthoracic echocardiography outcomes with no discernible differences in image quality between pocket mobile echocardiography and transthoracic echocardiography (P = 7.22 × 10(-7)). All outcomes remain significant after correcting for multiple testing using the false discovery rate.

CONCLUSIONS

The results from rapid bedside pocket mobile echocardiography examinations performed by experienced cardiology fellows compared favorably with those from formal transthoracic echocardiography studies. For hospitalized patients, this finding could shift the burden of performing and interpreting the echocardiogram to the examining physician and reduce the number and cost associated with formal echocardiography studies.

Pocket echocardiography system for detection of patent ductus arteriosus in neonates

BACKGROUND

Neonates are commonly referred for a cardiology consult and an echocardiogram to rule out patent ductus arteriosus (PDA).

OBJECTIVES

Evaluate the usefulness of current pocket echocardiography system (PES) in PDA detection compared to traditional full-featured echo system (FFES).

HYPOTHESIS

The determination of the presence of a PDA in neonates can be done using PES.

METHODS

Fifty newborns with orders for echo evaluation were included in this study. A 5-minute PES scan was performed first. Then a full echo study was performed on a traditional FFES. Images were evaluated by three pediatric cardiologists blinded to the patients and the FFES results.

RESULTS

The overall accuracy of reviewers rating PES versus FFES to rule in PDA had low false-positive rates 9.5% (95% CI: 1.2-30%), 11.8% (95% CI: 1.5-36%), 11.1% (95% CI: 1.4-35%) and the false-negative rate to rule out PDA was 0% (95% CI: 0-18%), 5.5% (95% CI: 0.14-27%), 0% (95% CI: 0-26%) for each reviewer 1, 2, and 3, respectively. Upon further analysis, PES scan was shown not to be accurate on infants with body weight below 1000 g with encouraging results for infants above 1000 g and those >37 weeks gestational age.

CONCLUSIONS

Our results suggest that the current PES could potentially be used in larger and near-term infants but has less than acceptable performance in low birth weight and premature infants in determining who should undergo a FFES study for persistent PDA diagnosis. Improvements in the technology along with developing limited training protocols for noncardiology personnel should make it possible for PES scan to be used as a screening tool and as an extension of physical examination especially in limited resource settings.

Diagnostic capability of comprehensive handheld vs transthoracic echocardiography

OBJECTIVE

To assess the diagnostic capability of handheld echocardiography (HHE) compared with transthoracic echocardiography (TTE) performed and evaluated by experienced sonographers and expert echocardiographers.

PATIENTS AND METHODS

We conducted a prospective study of adult outpatients undergoing comprehensive TTE between July 9, 2012, and April 3, 2013. Experienced sonographers performed a detailed, standardized examination using a handheld ultrasound device that included 2-dimensional and color Doppler images from standard imaging windows. Images from TTE and HHE were independently interpreted by expert echocardiographers to whom the other study was masked. Agreement between the standard TTE and the HHE reports was analyzed.

RESULTS

The study group contained 190 patients (mean ± SD age, 62 ± 17 years; 49% male [n=93]). The κ values were 0.52 for left ventricular (LV) enlargement, 0.52 for right ventricular enlargement, 0.62 for regional wall motion abnormalities, 0.73 for aortic stenosis, and 0.61 for mitral regurgitation. Lin concordance correlation coefficients ranged from 0.89 for LV end-systolic diameter to 0.78 for LV end-diastolic diameter. In 51 patients (27%), echocardiographic findings were discordant between HHE and standard TTE. The most common discordant finding was the presence vs absence of any regional wall motion abnormalities. In discordant cases, HHE tended to underestimate, rather than overestimate, the severity of abnormal findings.

CONCLUSION

In experienced hands, HHE shows moderate correlation with standard TTE, but discordant findings were present in 27% of patients. Even when performed and interpreted by experienced operators, HHE should not be used as a surrogate for standard TTE.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01558518.

Pocket-size echocardiograph--a valuable tool for nonexperts or just a portable device for echocardiographers?

PURPOSE

The diagnostic value of examinations performed with the use of pocket-size echocardiograph by medical professionals with different levels of experience remains to be determined. The aim of this study was to assess the diagnostic value of bedside echocardiographic examinations performed with the use of pocket-size echocardiograph by experienced cardiologist and medical students.

MATERIAL/METHODS

The study group comprised 90 patients (63 men, 27 women; mean age 64±14 years) admitted to the cardiac intensive care unit and 30 patients from an out-patient clinic (21 men, 9 women; mean age 62±17 years). All patients underwent bedside echocardiographic examination performed with pocket-size echocardiograph by two briefly trained medical students (n=90 patients) or cardiologist (n=30 patients). Major findings were recorded using a simplified questionnaire. Within 24 hours standard echocardiographic examination was performed in all patients by another cardiologist using a full sized echocardiograph. The study group was divided into 4 subgroups: A / B - first / second half of in-patients examined by students, group C - inpatients examined by cardiologist, group D- out-patients examined by students.

RESULTS

The agreement between standard transthoracic echocardiography (sTTE) and major findings on bedside transthoracic echocardiography (bTTE) was fair to moderate (kappa 0.293-0.57) in group A, moderate to very good (kappa 0.535-1.00) in group B, good to very good (kappa 0.734-1.00) in group C and moderate to very good (kappa 0.590-1.00) in group D.

CONCLUSIONS

Pocket-size echocardiograph enables an expert echocardiographer to perform reliable bedside examinations. When used by briefly trained medical students it provides an acceptable diagnostic value with notable learning curve effect.

Does the integration of personalized ultrasound change patient management in critical care medicine? Observational trials

Objective. To test the influence of personalized ultrasound (PersUS) on patient management in critical care. Design of the Study. Prospective, observational, and critical care setting. Four substudies compared PersUS and mobile ultrasound, work distribution, and diagnostic and procedural quality. Patients and Interventions. 640 patient ultrasound exams including 548 focused diagnostic exams and 92 interventional procedures. Main Outcome Measures. Number of studies, physician's judgement of feasibility, time of usage per patient, and referrals to echo lab. Results. Randomized availability of PersUS increased its application in ICU work shifts more than twofold from 33 to 68 exams mainly for detection and therapy of effusions. Diagnostic and procedural quality was rated as excellent/very good in PersUS-guided puncture in 95% of cases. Integrating PersUS within an initial physical examination of 48 randomized cases in an emergency department, PersUS extended the examination time by 100 seconds. Interestingly, PersUS integration into 53 randomized regular ward rounds of 1007 patients significantly reduced average contact time per patient by 103 seconds from 8.9 to 7.2 minutes. Moreover, it lowered the patient referral rate to an echo lab from 20% to 2% within the study population. Conclusions. We propose the development of novel ultrasound-based clinical pathways by integration of PersUS.

Assessment of cardiac pathology by point-of-care ultrasonography performed by a novice examiner is comparable to the gold standard

Background

The aim of the study was to compare the diagnostic accuracy of point-of-care cardiac ultrasonography performed by a novice examiner against results from a specialist in cardiology with expert skills in echocardiography, with regard to the assessment of six clinically relevant cardiac conditions in a population of ward patients from the Department of Cardiology or the Department of Cardiothoracic Surgery.

Methods

Cardiac ultrasonography was performed by a novice examiner at the bedside and images were interpreted in a point-of-care context with dichotomous outcomes (yes/no). Six outcome categories were defined: 1) pericardial effusion (≥10 mm), 2) left ventricular dilatation (≥62 mm), 3) right ventricular dilatation (≥42 mm or ≥ left ventricular diameter), 4) left ventricular hypertrophy (≥13 mm), 5) left ventricular failure (EF ≤ 40%), 6) aortic stenosis (maximum flow velocity ≥3 m/s). The examiner was blinded to the patients’ medical history and results from previous echocardiographic examinations. Results from the interpreted point-of-care ultrasonography examination were compared with echocardiographic diagnosis made by a specialist in cardiology.

Results

A total of 102 medical and surgical patients were included. Assessments were made in six categories totalling 612 assessments. There was agreement between the novice examiner and the specialist in 95.6% of the cases; overall sensitivity was 0.91 and specificity was 0.97. Positive predictive value was 0.92 and negative predictive value was 0.97. Kappa statistics showed good agreement between observers (κ=0.88).

Conclusions

This study showed that a novice examiner was able to detect common and significant heart pathology in six different categories with good accuracy using POC ultrasonography.

Focused critical care echocardiography

OBJECTIVE

Portable ultrasound is now used routinely in many ICUs for various clinical applications. Echocardiography performed by noncardiologists, both transesophageal and transthoracic, has evolved to broad applications in diagnosis, monitoring, and management of critically ill patients. This review provides a current update on focused critical care echocardiography for the management of critically ill patients.

METHOD

Source data were obtained from a PubMed search of the medical literature, including the PubMed "related articles" search methodology.

SUMMARY AND CONCLUSIONS

Although studies demonstrating improved clinical outcomes for critically ill patients managed by focused critical care echocardiography are generally lacking, there is evidence to suggest that some intermediate outcomes are improved. Furthermore, noncardiologists can learn focused critical care echocardiography and adequately interpret the information obtained. Noncardiologists can also successfully incorporate focused critical care echocardiography into advanced cardiopulmonary life support. Formal training and proctoring are important for safe application of focused critical care echocardiography in clinical practice. Further outcomes-based research is urgently needed to evaluate the efficacy of focused critical care echocardiography.

Intra-arrest formation of right-heart thrombi -- a case illustrated by real-time ultrasonography

The presence of free-floating right-heart thrombus has been reported in a cardiac arrest patient in the periarrest period. Free-floating right atrial thrombus is a rare phenomenon seen in patients developing severe pulmonary embolism, and is associated with increased mortality. However, there have been no previously reported cases of right-heart thrombus formation during a resuscitated cardiac arrest. We present the pre-hospital case of a woman in the clinical setting of cardiogenic shock due to acute myocardial infarction who developed asystolic cardiac arrest on the scene. Recent implementation of ultrasonography into the regional pre-hospital care protocol enabled sonographic investigation before and during cardiac arrest. This allowed detection of right atrial septal thrombus formation in the course of advanced life support and its migration through the tricuspid valve. The pathophysiological consequences, clinical significance and potential therapeutic options are discussed.

Observations during development of an internal medicine residency training program in cardiovascular limited ultrasound examination

BACKGROUND

Despite the future potential of using ultrasound stethoscopes to augment the bedside cardiac physical, few data exist on a general cardiovascular imaging protocol that can be taught to physicians on a perpetual basis as a curriculum in graduate medical education.

METHODS

During the past decade, we developed and integrated a cardiovascular limited ultrasound training program within the confines of an internal medicine residency. The evidence-based rationale for the exam, the teaching methods, and curriculum are delineated, and subsequent observations regarding program requirements, proficiency, and academic outcomes are explored. Analysis of variance and linear regression assessed for relationships between academic scores, chief resident selection, and gender to proficiency in ultrasound.

RESULTS

A brief, 5-minute cardiovascular limited ultrasound exam (CLUE) was taught using both didactic and bedside methods, and practiced primarily within the cardiology consult, outpatient clinic, and intensive care rotations. Program costs were minimized by employing readily available institutional resources. After a 2-year lead-in training phase, the subsequent 4 years of senior resident performance (n = 41 residents) showed an 81% pass rate in CLUE competency. Resident ultrasound performance did not relate to academic scores (r = 0.05, P = 0.75), chief resident selection, nor gender. Observations regarding resident pitfalls in CLUE practice and increased participation in extracurricular research are described.

CONCLUSIONS

We report our initial experience in developing and implementing a training program for bedside cardiovascular ultrasound examination that employed evidence-based techniques, set proficiency goals, and assessed resident performance. It may be feasible to teach future internist-hospitalists the technique of bedside ultrasound during residency.

Limited intervention improves technical skill in focus assessed transthoracic echocardiography among novice examiners

BACKGROUND

Previous studies addressing teaching and learning in point-of-care ultrasound have primarily focussed on image interpretation and not on the technical quality of the images. We hypothesized that a limited intervention of 10 supervised examinations would improve the technical skills in Focus Assessed Transthoracic Echocardiography (FATE) and that physicians with no experience in FATE would quickly adopt technical skills allowing for image quality suitable for interpretation.

METHODS

Twenty-one physicians with no previous training in FATE or echocardiography (Novices) participated in the study and a reference group of three examiners with more than 10 years of experience in echocardiography (Experts) was included. Novices received an initial theoretical and practical introduction (2 hours), after which baseline examinations were performed on two healthy volunteers. Subsequently all physicians were scheduled to a separate intervention day comprising ten supervised FATE examinations. For effect measurement a second examination (evaluation) of the same two healthy volunteers from the baseline examination was performed.

RESULTS

At baseline 86% of images obtained by novices were suitable for interpretation, on evaluation this was 93% (p = 0.005). 100% of images obtained by experts were suitable for interpretation. Mean global image rating on baseline examinations was 70.2 (CI 68.0-72.4) and mean global image rating after intervention was 75.0 (CI 72.9-77.0), p = 0.0002. In comparison, mean global image rating in the expert group was 89.8 (CI 88.8-90.9).

CONCLUSIONS

Improvement of technical skills in FATE can be achieved with a limited intervention and upon completion of intervention 93% of images achieved are suitable for clinical interpretation.

Pleural effusion decreases left ventricular pre-load and causes haemodynamic compromise: an experimental porcine study

BACKGROUND

Although pleural effusion is a common complication in critically ill patients, detailed knowledge is missing about the haemodynamic impact and the underlining mechanisms. The aim of this study was to evaluate the haemodynamic effect of incremental pleural effusion by means of invasive haemodynamic parameters and transthoracic echocardiography.

METHODS

This experimental interventional study was conducted using 22 female piglets (17.5-21.5 kg) randomized for right-side (n = 9) and left-side (n = 9) pleural effusion, or sham operation (n = 4). Pleural effusion was induced by infusing incremental volumes of saline into the pleural cavity. Invasive haemodynamic measurements and echocardiographical images were obtained at baseline, a volume of 45 ml/kg, a volume of 75 ml/kg and 45 min after drainage.

RESULTS

No difference (all P > 0.147) was found between right- and left-side pleural effusion, and the groups were thus pooled. At 45 ml/kg cardiac output, mean arterial pressure, stroke volume and mixed venous saturation decreased (all P < 0.003); central venous pressure and pulmonary arterial pressure increased (both P > 0.003) at this point. The changes accelerated at 75 ml/kg. At 45 ml/kg left ventricular pre-load in terms of end-diastolic area decreased significantly (P < 0.001). The effect on haemodynamics and cardiac dimensions changed dramatically at 75 ml/kg. Cardiac output, mean arterial pressure, central venous pressure and left ventricular end-diastolic area returned to normal during a recovery period of 45 min (all P > 0.061).

CONCLUSION

Incremental volumes of unilateral pleural effusion induced a significant haemodynamic impact fully reversible after drainage. Pleural effusion causes a significant decrease of left ventricular pre-load in a diverse picture of haemodynamic compromise.

Evaluation of a new pocket echoscopic device for focused cardiac ultrasonography in an emergency setting

Introduction

In the emergency setting, focused cardiac ultrasound has become a fundamental tool for diagnostic, initial emergency treatment and triage decisions. A new ultra-miniaturized pocket ultrasound device (PUD) may be suited to this specific setting. Therefore, we aimed to compare the diagnostic ability of an ultra-miniaturized ultrasound device (Vscan™, GE Healthcare, Wauwatosa, WI) and of a conventional high-quality echocardiography system (Vivid S5™, GE Healthcare) for a cardiac focused ultrasonography in patients admitted to the emergency department.

Methods

During 4 months, patients admitted to our emergency department and requiring transthoracic echocardiography (TTE) were included in this single-center, prospective and observational study. Patients underwent TTE using a PUD and a conventional echocardiography system. Each examination was performed independently by a physician experienced in echocardiography, unaware of the results found by the alternative device. During the focused cardiac echocardiography, the following parameters were assessed: global cardiac systolic function, identification of ventricular enlargement or hypertrophy, assessment for pericardial effusion and estimation of the size and the respiratory changes of the inferior vena cava (IVC) diameter.

Results

One hundred fifty-one (151) patients were analyzed. With the tested PUD, the image quality was sufficient to perform focused cardiac ultrasonography in all patients. Examination using PUD adequately qualified with a very good agreement global left ventricular systolic dysfunction (κ = 0.87; 95%CI: 0.76-0.97), severe right ventricular dilation (κ = 0.87; 95%CI: 0.71-1.00), inferior vena cava dilation (κ = 0.90; 95%CI: 0.80-1.00), respiratory-induced variations in inferior vena cava size in spontaneous breathing (κ = 0.84; 95%CI: 0.71-0.98), pericardial effusion (κ = 0.75; 95%CI: 0.55-0.95) and compressive pericardial effusion (κ = 1.00; 95%CI: 1.00-1.00).

Conclusions

In an emergency setting, this new ultraportable echoscope (PUD) was reliable for the real-time detection of focused cardiac abnormalities.

Left ventricular longitudinal function assessed by speckle tracking ultrasound from a single apical imaging plane

Background. Transthoracic ultrasonography of the heart is valuable in monitoring and treatment of critically ill patients. Speckle tracking ultrasound (STU) has proven valid in estimating left ventricular systolic deformation. The aims of the study were to compare conventional and automated STU and to determine whether left ventricular systolic deformation could be estimated from one single imaging plane. Methods. 2D-echocardiography cine-loops were obtained from 20 patients for off-line speckle tracking analysis, consisting of manually tracing of the endocardial border (conventional method) or automatically drawn boundaries (automated method). Results. We found a bias of 0,6 (95% CI −2.2−3.3) for global peak systolic strain comparing the automated and the conventional method. Comparing global peak systolic strain of apical 4-chamber cine-loops with averaged Global Peak Strain obtained from apical 4, 2 and long axis cine-loops, showed a bias of 0.1 (95% CI −3.9−4.0). The agreement between subcostal 4-chamber and apical 4-chamber global peak systolic strain was 4.4 (95% CI −3.7−12.5). Conclusion. We found good agreement between the conventional and the automated method. STU applied to single apical 4-chamber cine-loops is in excellent agreement with overall averaged global peak systolic strain, while subcostal 4-chamber cine-loops proved less compliant with speckle tracking ultrasound.

Advances in imaging: ultrasound in every physician's pocket

Advances in medical ultrasound have made the modality widely applicable and the new cart-based and pocket size devices have allowed for relevant point-of-care (POC) ultrasound examinations in many medical specialties. POC ultrasonography is performed as a real-time examination assisting the physician in diagnosis, procedure or screening of the patient without life threatening delays. The examination can be performed at the bedside or wherever the patient may be present. Structured and focused protocols for simple clinical questions have been developed and implemented in the following specialties: Anesthesiology, Cardiology, Critical Care Medicine, Dermatology, Emergency Medicine, Neonatology, Gynecology and Rheumatology and many others. POC ultrasound, as well as ultrasound in general, is very user dependent and the need for quality assurance, formal education and practical training is obvious. With this in mind, POC ultrasound now really has the potential for becoming the physician's new personal universal examination tool. Patients admitted to emergency departments will be able to receive organ or symptom-guided initial focused ultrasound triage as part of the physician's first encounter with the patient. This will allow for more accurate referral, correct diagnosis and relevant screening in turn leading to better overall treatment results.

Routinely adding ultrasound examinations by pocket-sized ultrasound devices improves inpatient diagnostics in a medical department

BACKGROUND

We aimed to investigate the potential benefit of adding a routine cardiac and abdominal diagnostic examination by pocket-sized ultrasound device in patients admitted to a medical department.

METHODS

A random sample of 196 patients admitted to the medical department at a non-university hospital in Norway between March and September 2010 was studied. The patients underwent cardiac and abdominal screening with a pocket-sized ultrasound device with B-mode and color flow imaging after a principal diagnosis was set. Three internists/cardiologists experienced in ultrasonography performed the examinations. Diagnostic corrections were made and findings were confirmed by high-end echocardiography and examinations at the radiologic department.

RESULTS

196 patients were included (male=56.6%, mean±SD; 68.1±15.0 years old). The time spent doing the ultrasound screening was mean±SD 4.3±1.6 min for the cardiac screening and 2.5±1.1 min for the abdominal screening. In 36 (18.4%) patients this examination resulted in a major change in the primary diagnosis. In 38 (19.4%) patients the diagnosis was verified and in 18 (9.2%) patients an important additional diagnosis was made.

CONCLUSION

By adding a pocket-sized ultrasound examination of <10 min to usual care, we corrected the diagnosis in almost 1 of 5 patients admitted to a medical department, resulting in a completely different treatment strategy without delay in many of the patients. Routinely adding a cardiac and abdominal ultrasound screening has the potential to rearrange inpatients workflow and diagnosis.

Assessment of left ventricular ejection fraction using an ultrasonic stethoscope in critically ill patients

INTRODUCTION

Assessment of cardiac function is key in the management of intensive care unit (ICU) patients and frequently relies on the use of standard transthoracic echocardiography (TTE). A commercially available new generation ultrasound system with two-dimensional imaging capability, which has roughly the size of a mobile phone, is adequately suited to extend the physical examination. The primary endpoint of this study was to evaluate the additional value of this new miniaturized device used as an ultrasonic stethoscope (US) for the determination of left ventricular (LV) systolic function, when compared to conventional clinical assessment by experienced intensivists. The secondary endpoint was to validate the US against TTE for the semi-quantitative assessment of left ventricular ejection fraction (LVEF) in ICU patients.

METHODS

In this single-center prospective descriptive study, LVEF was independently assessed clinically by the attending physician and echocardiographically by two experienced intensivists trained in critical care echocardiography who used the US (size: 135×73×28 mm; weight: 390 g) and TTE. LVEF was visually estimated semi-quantitatively and classified in one of the following categories: increased (LVEF>75%), normal (LVEF: 50 to 75%), moderately reduced (LVEF: 30 to 49%), or severely reduced (LVEF<30%). Biplane LVEF measured using the Simpson's rule on TTE loops by an independent investigator was used as reference.

RESULTS

A total of 94 consecutive patients were studied (age: 60±17 years; simplified acute physiologic score 2: 41±15), 63 being mechanically ventilated and 36 receiving vasopressors and/or inotropes. Diagnostic concordance between the clinically estimated LVEF and biplane LVEF was poor (Kappa: 0.33; 95% CI: 0.16 to 0.49) and only slightly improved by the knowledge of a previously determined LVEF value (Kappa: 0.44; 95% CI: 0.22 to 0.66). In contrast, the diagnostic agreement was good between visually assessed LVEF using the US and TTE (Kappa: 0.75; CI 95%: 0.63 to 0.87) and between LVEF assessed on-line and biplane LVEF, regardless of the system used (Kappa: 0.75; CI 95%: 0.64 to 0.87 and Kappa: 0.70; CI 95%: 0.59 to 0.82, respectively).

CONCLUSIONS

In ICU patients, the extension of physical examination using an US improves the ability of trained intensivists to determine LVEF at bedside. With trained operators, the semi-quantitative assessment of LVEF using the US is accurate when compared to standard TTE.