Critical Ultrasound Journal最新文献

In critical care patients, point of care abdominal ultrasound examination, although it has been practiced for over 30 years, is not as widespread as its cardiac or pulmonary counterparts. We report two cases in which detection of air during abdominal ultrasound allowed the early detection of life-threatening pathologies. In the first case, a patient with severe Clostridium difficile was found to have portal venous gas but its significance was confounded by a recent surgery. Serial ultrasonographic exams triggered a surgical intervention. In the second case, we report what we call the "liver sign" a finding in patients with pneumoperitoneum. These findings, all obtained prior to conventional abdominal imaging, had immediate clinical impact and avoided unnecessary delays and radiation. Detection of abdominal air should be part of the routine-focused ultrasonographic exam and for critically ill patients an algorithm is proposed.

Background: Lung ultrasound (LUS) represents an emerging technique for bedside chest imaging in different clinical settings. A standardized approach allows the diagnosis, the quantification, and the follow-up of different conditions for which acute respiratory failure is the main clinical presentation. The aim of this study was to test what skill targets could be achieved in LUS, with a short-training course offered to 19 Medical Doctors attending the certification board school in Internal Medicine at the University of Verona, Italy.

Methods: The training course (theoretical and practical) consisted of 9 h subdivided in 4 days. Each trainee examined three healthy volunteers during the first day that was also the day of the theoretical lessons. Moreover, they examined nine patients per day (a total of 27 patients). Trainees were tested in the recognition of the basic signs in LUS, the managing of the Bedside Lung Ultrasound Evaluation (the BLUE protocol), and the recognition of the broad clinical scenarios recognized by the LUS. Kappa statistic was used to calculate the inter-observer agreement (trainees/tutor).

Results: Twenty-seven patients were examined by the 19 trainees (ten trainees had previous limited experience in general ultrasound). The agreement among the trainees and the tutor in the recognition of the LUS basic signs and in the recognition of the BLUE protocol profiles ranged from "fair" to "excellent". In particular, the agreement among the trainees and the tutor in the final LUS diagnosis was "excellent" for the recognition of the interstitial syndrome and the pleural effusion, "substantial" for the recognition of the normal lung, and "moderate" for the recognition of consolidation and pneumothorax. LUS outcome gave useful information and drove change in therapy in 16 patients. It affected immediate management in nine patients. The concordance between the previous X chest ray and LUS was observed in 21 patients.

Conclusions: A short training in LUS provided good proficiency in the recognition only of the main signs of the BLUE protocol, but allowed a correct LUS diagnosis in the Internal Medicine most frequent clinical settings of acute respiratory failure. This study supports incorporating LUS into Internal Medicine fellowship training programs.

Background: Emergency point-of-care ultrasound (POC u/s) is an example of a health information technology that improves patient care and time to correct diagnosis. POC u/s examinations should be documented, as they comprise an integral component of physician decision making. Incomplete documentation prevents coding, billing and physician group compensation for ultrasound-guided procedures and patient care. We aimed to assess the effect of directed education and personal feedback through a task force driven initiative to increase the number of POC u/s examinations documented and transferred to medical coders by emergency medicine physicians.

Methods: Three months before a chosen go-live date, departmental leadership, the ultrasound division, and residents formed a task force. Barriers to documentation were identified through brain storming and email solicitation. The total number and application-specific POC u/s examinations performed and transferred to the healthcare record and medical coders were compared for the pre- and post-task force intervention periods. Chi square analysis was used to determine the difference between the number of POC u/s examinations reported before and after the intervention.

Results: A total of 1652 POC u/s examinations were reported during the study period. Successful reporting to the patient care chart and medical coders increased from 41 % pre-task force intervention to 63 % post-intervention (p value 0.000). The number of scans performed during the 3-month periods (pre-intervetion, post-intervention 0-3 months, post-intervention 3-6 months) was similar (521, 594 and 537). When analyzed by specific application, the majority showed a statistically significant increase in the percentage of examinations reported, including those most critical for patient care decision making: (EFAST (41 vs. 64 %), vascular access (26 vs. 61 %), and cardiac (43 vs. 72 %); and those most commonly performed: biliary (44 vs. 61 %) and pelvic (60 vs. 66 %). Of the POC u/s studies coded and reported for reimbursement, 15.9 % were billed before intervention and 32 % were billed after intervention (p value: 0.000).

Conclusions: The formation of a workflow solution task force positively affected emergency physician compliance with POC u/s documentation for coding and billing over a 6-month period. Further investigation should assess the long-term effect of the intervention and whether this translates into increased revenue to the department.

Background: Medical residents' training in ultrasonography usually follows the recommendations of the American College of Emergency Physicians (ACEP), even though these do not provide specific technical guidelines. Adequate training is considered to require 25 practical iterations in the majority of ultrasound procedures. However, the effectiveness of this approach has not been verified experimentally. We set out to determine the number of repetitions required for an acceptable ultrasound procedure of the inferior vena cava (IVC), as an important and emerging ultrasound procedure in cardiology.

Methods: Using three human models, each of eight medical residents in the Emergency Medicine (EM) Program at the Universidad del Rosario performed 25 iterations of the recommended procedure, with image quality evaluation by an EM physician expert in the technique. Logistic regression analysis was used to determine the lowest number of repetitions required to achieve an adjusted probability of success of 80 and 90 %, respectively.

Results: We obtained 200 ultrasound images. The percentage success by each resident ranged from 52 to 96 %. There was no statistical significance in the relation between gender and success (p = 0.83), but there was an association between year of residency and success (p < 0.001). The average time taken for each procedure was 17.3 s (SD 8.1); there was no association between the time taken and either repetition number or image quality. We demonstrate that eleven repetitions are required to achieve acceptable image quality in 80 %, and that 21 repetitions are required to achieve acceptable image quality in 90 %.

Conclusions: This is the first study to formally evaluate the effectiveness of recommended training in ultrasound techniques. Our findings demonstrate that training comprising 25 procedural repetitions is easily sufficient to achieve optimal image quality, and they also provide empiric knowledge toward elucidating the times and minimum repetitions needed to acquire and improve ultrasonographic technique in novice operators to a level which fulfills quality requirements for interpretation.

Background: Optic nerve sheath diameter (ONSD) measurement using ultrasound has been proposed as a rapid, non-invasive, point of care technique to estimate intra-cranial pressure (ICP). Ultrasonic measurement of the optic nerve sheath can be quite challenging and there is limited literature surrounding learning curves for this technique. We attempted to develop a method to estimate the reliability learning curve for ONSD measurement utilizing a unique definition of reliability: a plateau in within-subject variability with unchanged between-subject variability.

Methods: As part of a previously published study, a single operator measured the ONSD in 120 healthy volunteers over a 6-month period. Utilizing the assumption that the four measurements made on each subject during this study should be equal, the relationship of within-subject variance was described using a quadratic-plateau model as assessed by segmental polynomial (knot) regression.

Results: Segmental polynomial (knot) regression revealed a plateau in within-subject variance after the 21st subject. However, there was no difference in overall mean values [3.69 vs 3.68 mm (p = 0.884)] or between-subject variance [14.49 vs 11.92 (p = 0.54)] above or below this cutoff.

Conclusions: This study suggests a significant finite learning curve associated with ONSD measurements. It also offers a unique method of calculating the learning curve associated with ONSD measurement.

The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers.  To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed "how to" and description of individual point-of-care ultrasound examinations.  Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.

Lung collapse is a known complication that affects most of the patients undergoing positive pressure mechanical ventilation. Such atelectasis and airways closure lead to gas exchange and lung mechanics impairment and has the potential to develop an inflammatory response in the lungs. These negative effects of lung collapse can be reverted by a lung recruitment maneuver (RM) i.e. a ventilatory strategy that resolves lung collapse by a brief and controlled increment in airway pressures. However, an unsolved question is how to assess such RM at the bedside. The aim of this paper is to describe the usefulness of lung sonography (LUS) to conduct and personalize RM in a real-time way at the bedside. LUS has favorable features to assess lung recruitment due to its high specificity and sensitivity to detect lung collapse together with its non-invasiveness, availability and simple use.

Background: The use of emergency ultrasonography (EUS) has gained much popularity in the past few decades, and is now a mainstay of diagnostic decision-making. This expanded use is now highlighting the substantial issue of individual hospitals in credentialing its emergency medicine attending physicians in EUS in the United States. This issue is also of importance as more hospitals are now requesting reimbursements for emergency ultrasounds. The objective of this study is to gain an understanding of how many emergency departments are currently credentialing its attending staff in EUS, what the internal structure and staffing are of these emergency departments, and how they are currently performing quality assurance of the ultrasounds performed.

Methods: This was a cross-sectional, web-based survey sent to 160 ACGME-accredited EM residency programs from July 2013 to November 2013. The survey consisted of 23 questions regarding: (1) number of emergency medicine attendings on staff, (2) presence of an EUS fellowship, (3) quality assurance (QA) process, and (4) current US credentialing process.

Results: There was a 50 % response rate. Fifty percent of the total respondents (n = 40) had an EUS fellowship program. Of the sites with an EUS fellowship, 36 had EUS fellowship-trained attendings. Of the sites without an EUS fellowship, 19 had EUS fellowship-trained faculty, p ≤ 0.0001. Sites with an EUS fellowship had a greater percentage of staff credentialed to perform EUS as compared to sites with no EUS fellowship, p = 0.0161. All sites with an EUS fellowship had EUS-credentialed attendings. In sites with an EUS fellowship, 35 conducted a formal QA of ED performed EUS scans versus 22 at sites without an EUS fellowship, p = 0.003.

Conclusions: The survey results support hiring emergency attendings that have completed postgraduate training in emergency ultrasonography to aid in credentialing staff. This also seems to be helpful in completing a timelier QA of all ED ultrasounds.