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Leonny S, Bowra J, Davis RA, Zuleta N, Hansen K, Large R, Yeung J. Review article: Telehealth in Emergency Medicine in Australasia: Advantages and barriers. Emerg Med Australas 2024. [PMID: 38649791 DOI: 10.1111/1742-6723.14411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/15/2024] [Accepted: 03/29/2024] [Indexed: 04/25/2024]
Abstract
The COVID-19 pandemic catapulted Telehealth to the forefront of Emergency Medicine (EM) as an alternative way of assessing and managing patients. This challenged the traditional idea that EM can only be practised within brick-and-mortar EDs. Many Emergency Physicians may find the idea of practising Telehealth in Emergency Medicine (TEM) confronting, particularly in the absence of training and clear practice guidelines. The purpose of the present paper is to describe the current use of TEM in Australasia, and outline the advantages and barriers in adopting this practice domain.
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Affiliation(s)
- Sheravika Leonny
- My Emergency Doctor, Sydney, New South Wales, Australia
- Peninsula Health, Melbourne, Victoria, Australia
| | - Justin Bowra
- My Emergency Doctor, Sydney, New South Wales, Australia
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Rebecca A Davis
- Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- RPA Virtual Hospital, Sydney, New South Wales, Australia
| | - Natalia Zuleta
- WA Country Health Service, Perth, Western Australia, Australia
| | - Kim Hansen
- Virtual Emergency Department, Metro North, Brisbane, Queensland, Australia
- Critical Care, Women's and Children's Service Line, Redcliffe Hospital, Redcliffe, Queensland, Australia
| | - Ruth Large
- New Zealand Telehealth Leadership Group, Christchurch, New Zealand
- Whakarongorau Aotearoa//New Zealand Telehealth Services, Auckland, New Zealand
| | - Justin Yeung
- WA Country Health Service, Perth, Western Australia, Australia
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Zhang LF, Duong MT, Bowra J. SLICE: An algorithm for incorporating ultrasonography in the assessment of shocked or breathless patients. Emerg Med Australas 2023; 35:242-245. [PMID: 36333871 DOI: 10.1111/1742-6723.14106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 09/26/2022] [Indexed: 11/08/2022]
Abstract
SLICE is an algorithm for the integration of point-of-care ultrasound in the assessment and resuscitation of the shocked or breathless patient. It aims to determine the patient's fluid status, and identify reversible causes for the patient's clinical picture. SLICE stands for 'In a patient who is Shocked/Short of breath, scan the Lungs, IVC, Cardiac and Extra regions as indicated'. Its key advantages are that it explicitly guides resuscitative fluid management, can be performed rapidly and by clinicians with a broad range of sonographic experience, and can be used in a broad range of clinical scenarios. Its use has been successfully taught and implemented in routine clinical practice at our local institution.
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Affiliation(s)
- Lorena Fy Zhang
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Minh-Tu Duong
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Justin Bowra
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
- The University of Sydney, Sydney, New South Wales, Australia
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Julliard D, Vassiliadis J, Bowra J, Gillett M, Knipp R, Krishnamohan A, Fogg T. Comparison of supine and upright face-to-face cadaver intubation. Am J Emerg Med 2022; 56:87-91. [DOI: 10.1016/j.ajem.2022.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 03/14/2022] [Accepted: 03/15/2022] [Indexed: 11/27/2022] Open
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Bowra J, Duong MT. Point-of-care ultrasound in emergency department: Tips, tricks and controversies. Emerg Med Australas 2020; 32:155-157. [PMID: 31960600 DOI: 10.1111/1742-6723.13460] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 12/23/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Justin Bowra
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Minh-Tu Duong
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia
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Bowra J, Uwagboe V, Goudie A, Reid C, Gillett M. Interrater agreement between expert and novice in measuring inferior vena cava diameter and collapsibility index. Emerg Med Australas 2015; 27:295-9. [PMID: 26072675 DOI: 10.1111/1742-6723.12417] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2015] [Indexed: 12/01/2022]
Abstract
BACKGROUND In critical care medicine, US views of the inferior vena cava (IVC) and its change with respiration are used to estimate the intravascular volume status of unwell patients and, in particular, to answer the question: 'Is this patient likely to be fluid responsive?' Most commonly in the literature, the subxiphisternal (SX) window in the longitudinal plane is utilised. To date, no study has specifically assessed interrater agreement in estimating IVC diameter between emergency medicine specialists (experts) and trainees (learners). OBJECTIVES To determine the interrater agreement between an expert (senior emergency specialist with US qualifications) and learner (emergency medicine trainee) when measuring IVC diameter (IVCD) and IVC collapsibility index (IVCCI) in the SX longitudinal US window in healthy volunteers. METHODS Healthy volunteers (ED staff) were scanned in the supine position using a sector (cardiac) probe of a portable US machine, in the SX longitudinal position. The maximum and minimum diameters of the IVC were measured in each of these positions and the IVCCI calculated. Results were analysed using Bland-Altman plots. RESULTS In the longitudinal SX window, the operators' measurements of maximum IVCD differed by an average of 1.9 mm (95% limits of agreement -9.4 mm to +5.5 mm) and their measurement of IVCCI differed by an average of 4% (95% limits of agreement -30% to 38%). CONCLUSIONS The wide 95% limits of agreement demonstrate a poor interrater agreement between the IVC US measurements obtained by expert and learner users in the assessment of fluid status. These ranges are greater than clinically acceptable.
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Affiliation(s)
- Justin Bowra
- Emergency Department, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Victor Uwagboe
- Emergency Department, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Adrian Goudie
- Emergency Department, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - Cliff Reid
- Emergency Department, Mona Vale Hospital, Sydney, New South Wales, Australia
| | - Mark Gillett
- Emergency Department, Royal North Shore Hospital, St Leonards, New South Wales, Australia
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Bass D, Telfah M, Bowra J. Use of bedside ultrasound to diagnose dislodged gastric band. Australas J Ultrasound Med 2015; 18:33-37. [PMID: 28191239 PMCID: PMC5024957 DOI: 10.1002/j.2205-0140.2015.tb00022.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introduction: Obesity levels mean an increased presentation of patients with Laparoscopic adjustable gastric banding (LAGB). Method: Literature search revealed a paucity of information on ultrasonography to diagnose a slipped LAGB. Conclusion: 2D Ultrasonography with a standard low frequency curvilinear probe proved to be a simple, effective method of diagnosing slipped Laparoscopic adjustable gastric banding (LAGB). We suggest the inclusion of routine abdominal ultrasound (after drinking water to improve sensitivity of the test) as part of the routine workup of suspected LAGB slippage.
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Affiliation(s)
- Dirk Bass
- Emergency Care Unit; Sydney Adventist Hospital; Wahroonga New South Wales Australia
| | - Malek Telfah
- Emergency Care Unit; Sydney Adventist Hospital; Wahroonga New South Wales Australia
| | - Justin Bowra
- Emergency Care Unit; Sydney Adventist Hospital; Wahroonga New South Wales Australia
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Abstract
As in so many other fields, the internet has revolutionised medical education. It has done this by circumventing the traditional constraints of medical education, in particular the availability of local resources such as teachers and textbooks. This "education revolution" has been most successful in the areas of theoretical knowledge. This article explores the available resources, and the challenges that arise when attempting to teach point-of-care ultrasound via the internet, such as the visuomotor and visuospatial skills required to create a diagnostic image. This article also describes the progress to date in this field.
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Affiliation(s)
- J Bowra
- University of Sydney, Australia
- Emergency Care, Sydney Adventist and Royal North Shore Hospital Hospitals, Sydney, Australia
| | | | - A Goudie
- Emergency Department, Fremantle Hospital, Australia
- University of Western Australia, Australia
| | - M Mallin
- University of Utah, USA
- Emergency Department, Salt Lake City Hospital, USA
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Abstract
Right upper quadrant and epigastric abdominal pain are common presenting complaints in the emergency department. With increasing access to point-of-care ultrasound, emergency physicians now have an added tool to help identify biliary problems as a cause of a patient's right upper quadrant pain. Point-of-care ultrasound has a sensitivity of 89.8% (95% CI 86.4-92.5%) and specificity of 88.0% (83.7-91.4%) for cholelithiasis, very similar to radiology-performed ultrasonography. In addition to assessment for cholelithiasis and cholecystitis, point-of-care ultrasound can help emergency physicians to determine whether the biliary system is the source of infection in patients with suspected sepsis. Use of point-of-care ultrasound for the assessment of the biliary system has resulted in more rapid diagnosis, decreasing costs, and shorter emergency department length of stay.
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Affiliation(s)
- Michael Y Woo
- Department of Emergency Medicine, University of Ottawa and Ottawa Hospital Research Institute, Canada
| | - Mark Taylor
- Department of Emergency Medicine, University of Ottawa and Ottawa Hospital Research Institute, Canada
| | - Osama Loubani
- Department of Emergency Medicine, Dalhousie University, Canada
| | - Justin Bowra
- Department of Emergency Medicine, Sydney Adventist Hospital, Australia; Department of Emergency Medicine, Royal North Shore Hospital, Australia
| | - Paul Atkinson
- Department of Emergency Medicine, Dalhousie University, Canada; Discipline of Emergency Medicine, Memorial University, Canada; Department of Emergency Medicine, Saint John Regional Hospital, Canada
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Abstract
Undifferentiated dyspnoea is a common patient presentation in the intensive care unit, medical and surgical floors, and in the emergency department. Physical examination and chest radiography are notoriously insensitive for detection and differentiation of various lung pathologies while computed tomography consumes significant resources and exposes the patient to ionizing radiation. Point-of-care ultrasound (PoCUS) is a highly sensitive and specific diagnostic tool that, with appropriate operator experience, is capable of diagnosing and differentiating between the various causes of dyspnoea. PoCUS machines are readily available, images are rapidly generated and repeatable, and technical skills are easily taught during short training sessions. Furthermore, the development of PoCUS skills in one specific area enables and enhances the development of skills in other non-related areas. This article describes the benefits, technical aspects, and challenges associated with using PoCUS to examine the lung parenchyma in the acutely dyspnoeic patient.
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Affiliation(s)
- James Milne
- Dalhousie University – Medicine, Saint John, New Brunswick, E2L 4L5, Canada
| | - Paul Atkinson
- Dalhousie University – Medicine, Saint John, New Brunswick, E2L 4L5, Canada
- Saint John Regional Hospital – Emergency Medicine, Saint John, New Brunswick, E2L 3L6, Canada
| | - Justin Bowra
- Sydney Adventist Hospital and Royal North Shore Hospital – Emergency Medicine, Wahroonga, New South Wales, 2076/2065, Australia
| | - Osama Loubani
- Dalhousie University – Emergency Medicine, Halifax, Nova Scotia, B3H 4R2, Canada
| | - Bob Jarman
- Queen Elizabeth Hospital – Emergency Medicine, Gateshead, NE9 6SX, UK
| | - Andrew Smith
- Memorial University – Emergency Medicine, St John's, Newfoundland, A1B 3U6, Canada
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Bowra J. Chest ultrasound in practice: a review of utility in the clinical setting. Intern Med J 2012; 42:1372; author reply 1373. [PMID: 23253010 DOI: 10.1111/imj.12005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2012] [Accepted: 09/29/2012] [Indexed: 11/29/2022]
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Bowra J, Forrest-Horder S, Caldwell E, Cox M, D'Amours SK. Validation of nurse-performed FAST ultrasound. Injury 2010; 41:484-7. [PMID: 19800621 DOI: 10.1016/j.injury.2009.08.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2009] [Revised: 08/09/2009] [Accepted: 08/10/2009] [Indexed: 02/02/2023]
Abstract
BACKGROUND Patients presenting to Emergency Departments (EDs) with abdominal trauma benefit from FAST (Focused Assessment with Sonography in Trauma). Not all doctor members of the trauma team are credentialed in FAST; therefore occasionally no one is available in the hospital to undertake a FAST. Hence, the aim of this study was to determine the accuracy of nurse-performed FAST as a practical alternative where suitably trained doctors are not available. METHODS This was a prospective study of a convenience sample of patients with multisystem trauma in whom abdominal injury was clinically suspected. Senior nurses trained in FAST performed and reported FAST scans for each patient. Accuracy of nurse-performed FAST was determined by comparing results with computerised tomography (CT) scan or operation report. RESULTS 242 indicated nurse-performed FAST scans were included in the study. Nurse-performed FAST demonstrated sensitivity of 84.4% (95% CI 72.1-92.2) and specificity of 98.4% (CI 94.9-99.6), a positive predictive value (PPV) of 94.2% (CI 83.1-98.5) and a negative predictive value (NPV) of 95.3% (91.0-97.7). Overall accuracy of nurse-performed FAST for the detection of free fluid was 95.0% (95% CI 91.3-97.3). CONCLUSION This study demonstrates that, in a convenience sample of injured patients, nurse-performed FAST achieved similar accuracy to previously published results of doctor-performed FAST. Future studies with greater patient numbers would be valuable.
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Affiliation(s)
- Justin Bowra
- Department of Emergency Medicine, Liverpool Hospital, Sydney, NSW 2170, Australia.
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Watkins S, Bowra J, Sharma P, Holdgate A, Giles A, Campbell L. Validation of emergency physician ultrasound in diagnosing hydronephrosis in ureteric colic. Emerg Med Australas 2007; 19:188-95. [PMID: 17564683 DOI: 10.1111/j.1742-6723.2007.00925.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Patients presenting to the ED with obstructive nephropathies benefit from early detection of hydronephrosis. Out of hours radiological imaging is expensive and disruptive to arrange. Emergency physician ultrasound (EPU) could allow rapid diagnosis and disposition. If accurate it might avert the need for formal radiological imaging, exclude an obstruction and improve patient flow through the ED. METHODS This was a prospective study of a convenience sample of all adult non-pregnant patients with presumed ureteric colic attending the ED with prior ethics committee approval. An emergency physician or registrar performed a focused ultrasound scan and were blinded to the patient's other management. A computerized tomography scan was also performed for all patients while in the ED or within 24 h of the EPU. The accuracy of EPU detection of hydronephrosis was determined; using computerized tomography scans reported by a senior radiologist as the 'gold-standard'. RESULTS Sixty-three patients with suspected ureteric colic were enrolled of whom 57 completed both EPU and computerized tomography imaging. Forty-nine had confirmed nephrolithiasis by computerized tomography with 39 having evidence of hydronephrosis. Overall prevalence of hydronephrosis was 68% (95% confidence interval [CI] 56-79%); compared with computerized tomography, EPU had a sensitivity of 80% (95% CI 65-89%); specificity of 83% (95% CI 61-94%); positive predictive value of 91% (95% CI 75-98%) and negative predictive value of 65% (95% CI 43-83%). The overall accuracy was 81% (95% CI 69-89%). CONCLUSION Although the accuracy of detection of hydronephrosis after focused training in EPU is encouraging, further experience and training might improve the accuracy of EPU and allow its use as a screening tool.
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Affiliation(s)
- Stuart Watkins
- Department of Emergency Medicine, Liverpool Hospital, Liverpool, NSW, Australia.
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Bowra J. Validation of Emergency Department Physician Ultrasound in Diagnosing Hydronephrosis in Ureteric Colic. Acad Emerg Med 2006. [DOI: 10.1197/j.aem.2006.09.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Abstract
OBJECTIVES To evaluate the relationship between Trendelenburg tilt and internal jugular vein (IJV) diameter, and to examine any cumulative effects of tilt on the IJV diameter. METHODS Using a tilt table, healthy volunteers were randomised to Trendelenburg tilts of 10 degrees, 15 degrees, 20 degrees, 25 degrees, and 30 degrees. Ultrasound was used to measure and record the lateral diameter of the right IJV at the level of the cricoid cartilage. Following each reading the table was returned to the supine position. Balanced randomisation was used to assess cumulative tilt effects. RESULTS A total of 20 healthy volunteers were recruited (10 men, 10 women). Mean supine IJV diameter was 13.5 mm (95% CI 12.8 to 14.1) and was significantly greater at 10 degrees (15.5 mm, 95% CI 14.9 to 16.1). There was no significant difference between 10 degrees and greater angles of tilt. The effect of the previous angle of tilt did not prove to be statistically significant. CONCLUSION Increasing the degree of Trendelenburg tilt increases the lateral diameter of the IJV. Even a 10 degrees tilt is effective. The cumulative effect of tilt (that is, the effect of the previous angle) is not significant. Ultrasound guided cannulation is ideal, but in its absence Trendelenburg tilt will increase IJV diameter and improve the chance of successful cannulation. While 25 degrees achieved optimum distension, this may not be practical and may be detrimental (for example, risk of raised intracranial pressure).
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McLaughlin RE, Lee A, Clenaghan S, McGovern S, Martyn C, Bowra J. Survey of attitudes of senior emergency physicians towards the introduction of emergency department ultrasound. Emerg Med J 2005; 22:553-5. [PMID: 16046754 PMCID: PMC1726863 DOI: 10.1136/emj.2004.018713] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Emergency department ultrasound (EDU) is widely practised in the USA, Australia, parts of Europe, and Asia. EDU has been used in the UK since the late 1990s but as yet, few areas have established a practice. OBJECTIVES To assess the current climate of opinion with respect to the practice, constraints, and establishment of EDU among emergency department (ED) consultants on the island of Ireland. METHODS A postal questionnaire was formulated, piloted, and assessed for ambiguity by a sample of ED consultants and an independent non-ED consultant, prior to being mailed to all ED consultants in Ireland. RESULTS Of the 58 consultants canvassed 46 (79%) responded. Of the respondents, 40 (87%) strongly agreed/agreed that EDU is appropriate and should be performed in the ED. Of these, 3 (7%) are currently performing EDU; 37 (80%) have not had formal training in EDU, however 42 (91%) support the establishment of national guidelines for training in focused ultrasound in the ED. Problems instituting EDU were often multifactorial. Commonly highlighted difficulties included financial issues (24 respondents, 52%) and radiology department support (16 respondents, 34%). Other cited problems include varying interdepartmental practices (15 respondents, 33%) and (for some EDs) low numbers of patients requiring EDU, with projected difficulties in skills maintenance. CONCLUSION Despite the vast majority of ED consultants being in favour of EDU, very few actually perform it on a regular basis or have had any formal training. Highlighted difficulties in EDU implementation included financial constraints, lack of support from radiology departments, and lack of formal training.
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Abstract
BACKGROUND Emergency department ultrasound (EDU) is a physician performed ultrasound service aimed at improving patient flow and diagnosis in the emergency department. METHODS This paper describes the initial phase of the introduction of EDU with three illustrative case reports and a discussion on the pitfalls and benefits of EDU. RESULTS AND DISCUSSION In three cases discussed here, the use of EDU facilitated treatment and reduced the need for formal radiological scanning. While there are drawbacks to EDU, we believe these are far outweighed by the advantages, and in a recent survey of emergency medicine consultants throughout Ireland, the vast majority were in favour of its introduction. CONCLUSION EDU has become a routine part of our clinical practice, and although we are still on a learning curve with regard to its use, we have experienced significant benefits in patient care. With technological advances (such as improved image resolution and teleradiology) the potential for EDU will continue to expand, but training, practice, accreditation, and audit are essential.
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Abstract
Despite the risk of propofol infusion syndrome, a rare but often fatal complication of propofol infusion in ventilated children and possibly adults, propofol infusion remains in use in paediatric intensive care units (PICU). This questionnaire study surveys the current pattern of use of this sedative infusion in Australian and New Zealand PICUs. Thirty-three of the 45 paediatric intensive care physicians surveyed (73%), from 12 of the 13 intensive care units, returned completed questionnaires. The majority of practitioners (82%) use propofol infusion in children in PICU, the main indication being for short-term sedation in children requiring procedures. 39% of respondents consider propofol infusion useful in ventilated children requiring longer-term sedation. 67% of paediatric intensivists use maximum infusion doses that may be considered dangerously high (> or = 10 mg/kg/h). Nineteen per cent use propofol infusion for prolonged periods (> 72 hours). A smaller proportion (15%) of respondents indicate that they may use both higher doses and prolonged periods of infusion, a practice likely to lead to a greater chance of serious adverse events. Knowledge of local protocols for the use of propofol infusion is associated with a significantly greater level of monitoring for possible adverse events. We suggest that national guidelines for the use of propofol infusion in children should be developed. These should include clear indications and contraindications to its use, a maximum dose rate and maximum period of infusion, with a ceiling placed on the cumulative dose given and clearly stated minimum monitoring requirements.
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Affiliation(s)
- M Festa
- Department of Paediatric Intensive Care, Children's Hospital at Westmead, Locked Bag 4001, Westmead, N.S.W. 2124
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