Clinically integrated multi-organ point-of-care ultrasound for undifferentiated respiratory difficulty, chest pain, or shock: a critical analytic review.
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SUBMITTER: Ha YR
PROVIDER: S-EPMC4983789 | biostudies-literature | 2016
REPOSITORIES: biostudies-literature
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Clinically integrated multi-organ point-of-care ultrasound for undifferentiated respiratory difficulty, chest pain, or shock: a critical analytic review.
Ha Young-Rock YR Toh Hong-Chuen HC
Journal of intensive care 20160815
Rapid and accurate diagnosis and treatment are paramount in the management of the critically ill. Critical care ultrasound has been widely used as an adjunct to standard clinical examination, an invaluable extension of physical examination to guide clinical decision-making at bedside. Recently, there is growing interest in the use of multi-organ point-of-care ultrasound (MOPOCUS) for the management of the critically ill, especially in the early phase of resuscitation. This article will review th ...[more]
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Project description:BackgroundEmergency physicians (EPs) perform critical actions while operating with diagnostic uncertainty. Point-of-care ultrasound (POCUS) is useful in evaluation of dyspneic patients. In prior studies, POCUS is often performed by ultrasound (US) teams without patient care responsibilities.ObjectivesThis study evaluates the effectiveness of POCUS in narrowing diagnostic uncertainty in dyspneic patients when performed by treating EPs vs. separate US teams.MethodsThis multicenter, prospective noninferiority cohort study investigated the effect of a POCUS performing team in patient encounters for dyspnea. Before-and-after surveys assessing medical decision-making were administered to attending physicians. Primary outcome was change in most likely diagnosis after POCUS. This was assessed for noninferiority between encounters where the primary or US team performed POCUS. Secondary outcomes included change in differential diagnosis, confidence in diagnosis, interventions considered, and image quality.ResultsThere were 156 patient encounters analyzed. In the primary team group, most likely diagnosis changed in 40% (95% confidence interval 28-52%) of encounters vs. 32% (95% confidence interval 22-41%) in the US team group. This was noninferior using an a priori specified margin of 20% (p < .0001). Post-POCUS differential decreased by a mean 1.8 diagnoses and was equivalent within a margin of 0.5 diagnoses between performing teams (p = 0.034). Other outcomes were similar between groups.ConclusionPOCUS performed by primary teams was noninferior to POCUS performed by US teams for changing the most likely diagnosis, and equivalent when considering mean reduction in number of diagnoses. POCUS performed by treating EPs reduces cognitive burden in dyspneic patients.
| S-EPMC8578047 | biostudies-literature
Project description:OBJECTIVES:Adequate assessment of fluid responsiveness in shock necessitates correct interpretation of hemodynamic changes induced by preload challenge. This study evaluates the accuracy of point-of-care Doppler ultrasound assessment of the change in carotid corrected flow time induced by a passive leg raise maneuver as a predictor of fluid responsiveness. Noninvasive cardiac output monitoring (NICOM, Cheetah Medical, Newton Center, MA) system based on a bioreactance method was used. DESIGN:Prospective, noninterventional study. SETTING:ICU at a large academic center. PATIENTS:Patients with new, undifferentiated shock, and vasopressor requirements despite fluid resuscitation were included. Patients with significant cardiac disease and conditions that precluded adequate passive leg raising were excluded. INTERVENTIONS:Carotid corrected flow time was measured via ultrasound before and after a passive leg raise maneuver. Predicted fluid responsiveness was defined as greater than 10% increase in stroke volume on noninvasive cardiac output monitoring following passive leg raise. Images and measurements were reanalyzed by a second, blinded physician. The accuracy of change in carotid corrected flow time to predict fluid responsiveness was evaluated using receiver operating characteristic analysis. MEASUREMENTS AND MAIN RESULTS:Seventy-seven subjects were enrolled with 54 (70.1%) classified as fluid responders by noninvasive cardiac output monitoring. The average change in carotid corrected flow time after passive leg raise for fluid responders was 14.1?±?18.7?ms versus -4.0?±?8?ms for nonresponders (p < 0.001). Receiver operating characteristic analysis demonstrated that change in carotid corrected flow time is an accurate predictor of fluid responsiveness status (area under the curve, 0.88; 95% CI, 0.80-0.96) and a 7?ms increase in carotid corrected flow time post passive leg raise was shown to have a 97% positive predictive value and 82% accuracy in detecting fluid responsiveness using noninvasive cardiac output monitoring as a reference standard. Mechanical ventilation, respiratory rate, and high positive end-expiratory pressure had no significant impact on test performance. Post hoc blinded evaluation of bedside acquired measurements demonstrated agreement between evaluators. CONCLUSIONS:Change in carotid corrected flow time can predict fluid responsiveness status after a passive leg raise maneuver. Using point-of-care ultrasound to assess change in carotid corrected flow time is an acceptable and reproducible method for noninvasive identification of fluid responsiveness in critically ill patients with undifferentiated shock.
| S-EPMC6774608 | biostudies-literature
Project description:COVID-19 has caused great devastation in the past year. Multi-organ point-of-care ultrasound (PoCUS) including lung ultrasound (LUS) and focused cardiac ultrasound (FoCUS) as a clinical adjunct has played a significant role in triaging, diagnosis and medical management of COVID-19 patients. The expert panel from 27 countries and 6 continents with considerable experience of direct application of PoCUS on COVID-19 patients presents evidence-based consensus using GRADE methodology for the quality of evidence and an expedited, modified-Delphi process for the strength of expert consensus. The use of ultrasound is suggested in many clinical situations related to respiratory, cardiovascular and thromboembolic aspects of COVID-19, comparing well with other imaging modalities. The limitations due to insufficient data are highlighted as opportunities for future research.
| S-EPMC7759024 | biostudies-literature
Project description:IntroductionPoint-of care-ultrasound (POCUS) has become ubiquitous in emergency medicine practice for the management of emergent pathophysiology. There is growing interest in its potential as a diagnostic tool in the prehospital setting. Few studies have examined the feasibility or efficacy of curricula targeted at teaching POCUS to prehospital personnel. Our objective in this study was to investigate a curriculum for the extended focused assessment with sonography in trauma (eFAST) exam in helicopter emergency medical services (HEMS) crews.MethodsThis was a pre/post intervention study of HEMS personnel at a tertiary care center. Subjects were administered a pre-intervention written test and an observed structured clinical evaluation (OSCE). Subsequently, they participated in an educational intervention intended to impart proficiency in performing the eFAST. Subjects underwent post-intervention written exams and OSCEs. We analyzed pre- and post-intervention test performance along with the number and quality of practice ultrasound examinations achieved.ResultsSixteen subjects were enrolled (62.5% male, mean age 44.1). After undergoing the intervention, the mean written test score increased 22.1% (t=3.41; P <0.001) and the mean OSCE score increased by 64.5% (t=6.87, P <0.001). All subjects met "passing" criteria for the written test and OSCE on their post-intervention attempt. Subjects accomplished a mean of 21.1 clinically interpretable eFAST sonographs. Most subjects reported the curriculum was useful (90.1%) and that they would incorporate this skill into clinical practice (90.1%).ConclusionA targeted POCUS curriculum was feasible and effective in establishing clinical proficiency in HEMS crews for performing and interpreting the eFAST exam.
| S-EPMC9897250 | biostudies-literature
Project description:IntroductionCurrent recommendations for diagnostic imaging for moderately to severely ill patients with suspected coronavirus disease 2019 (COVID-19) include chest radiograph (CXR). Our primary objective was to determine whether lung ultrasound (LUS) B-lines, when excluding patients with alternative etiologies for B-lines, are more sensitive for the associated diagnosis of COVID-19 than CXR.MethodsThis was a retrospective cohort study of all patients who presented to a single, academic emergency department in the United States between March 20 and April 6, 2020, and received LUS, CXR, and viral testing for COVID-19 as part of their diagnostic evaluation. The primary objective was to estimate the test characteristics of both LUS B-lines and CXR for the associated diagnosis of COVID-19. Our secondary objective was to evaluate the proportion of patients with COVID-19 that have secondary LUS findings of pleural abnormalities and subpleural consolidations.ResultsWe identified 43 patients who underwent both LUS and CXR and were tested for COVID-19. Of these, 27/43 (63%) tested positive. LUS was more sensitive (88.9%, 95% confidence interval (CI), 71.1-97.0) for the associated diagnosis of COVID-19 than CXR (51.9%, 95% CI, 34.0-69.3; p = 0.013). LUS and CXR specificity were 56.3% (95% CI, 33.2-76.9) and 75.0% (95% CI, 50.0-90.3), respectively (p = 0.453). Secondary LUS findings of patients with COVID-19 demonstrated 21/27 (77.8%) had pleural abnormalities and 10/27 (37%) had subpleural consolidations.ConclusionAmong patients who underwent LUS and CXR, LUS was found to have a higher sensitivity than CXR for the evaluation of COVID-19. This data could have important implications as an aid in the diagnostic evaluation of COVID-19, particularly where viral testing is not available or restricted. If generalizable, future directions would include defining how to incorporate LUS into clinical management and its role in screening lower-risk populations.
| S-EPMC7390587 | biostudies-literature
Project description:BackgroundAlthough many sepsis treatments have shown efficacy in acute animal models, at present only activated protein C is effective in humans. The likely reason for this discrepancy is that most of the animal models used for preclinical testing do not accurately replicate the complex pathogenesis of human sepsis. Our objective in this study was to develop a clinically applicable model of severe sepsis and gut ischemia/reperfusion (I/R) that would cause multiple organ injury over a period of 48 h.Materials and methodsAnesthetized, instrumented, and ventilated pigs were subjected to a "two-hit" injury by placement of a fecal clot through a laparotomy and by clamping the superior mesenteric artery (SMA) for 30 min. The animals were monitored for 48 h. Wide spectrum antibiotics and intravenous fluids were given to maintain hemodynamic status. FiO(2) was increased in response to oxygen desaturation. Twelve hours following injury, a drain was placed in the laparotomy wound. Extensive hemodynamic, lung, kidney, liver, and renal function measurements and serial measurements of arterial and mixed venous blood gases were made. Bladder pressure was measured as a surrogate for intra-peritoneal pressure to identify the development of the abdominal compartment syndrome (ACS). Plasma and peritoneal ascites cytokine concentration were measured at regular intervals. Tissues were harvested and fixed at necropsy for detailed morphometric analysis.ResultsPolymicrobial sepsis developed in all animals. There was a progressive deterioration of organ function over the 48 h. The lung, kidney, liver, and intestine all demonstrated clinical and histopathologic injury. Acute lung injury (ALI) and ACS developed by consensus definitions. Increases in multiple cytokines in serum and peritoneal fluid paralleled the dysfunction found in major organs.ConclusionThis animal model of Sepsis+I/R replicates the systemic inflammation and dysfunction of the major organ systems that is typically seen in human sepsis and trauma patients. The model should be useful in deciphering the complex pathophysiology of septic shock as it transitions to end-organ injury thus allowing sophisticated preclinical studies on potential treatments.
| S-EPMC3061050 | biostudies-literature
Project description: Not available
| S-EPMC8724081 | biostudies-literature
Project description:IntroductionPoint-of-care ultrasound (POCUS) is accepted as an important tool for evaluating patients presenting to the emergency department (ED) with dyspnea1 and undifferentiated shock.2 Identifying the etiology and type of shock is time-critical since treatments vary based on this information. Clinicians typically rely on the history, exam, and diagnostics tests to identify the etiology of shock. In resource-limited settings where there is reduced access to timely laboratory and diagnostic studies. The use of POCUS enables rapid classification and directed treatment of shock. Additionally, POCUS can aid in the diagnosis of rarer tropical diseases that can be important causes of shock in resource-limited settings.Case reportWe discuss a case of a pediatric patient who presented to an ED in Cusco, Peru, with acute dyspnea and shock. Point-of-care ultrasound was used to expedite the diagnosis of a ruptured pulmonary hydatid cyst, guide proper management of septic and anaphylactic shock, and expedite definitive surgical intervention.ConclusionIn resource-limited settings where there is reduced access to timely laboratory and diagnostic studies, the use of POCUS enables rapid classification and directed treatment of shock.
| S-EPMC8610475 | biostudies-literature
Project description:Background Circulatory failure is classified into four types of shock (obstructive, cardiogenic, distributive, and hypovolemic) that must be distinguished as each requires a different treatment. Point-of-care ultrasound (POCUS) is widely used in clinical practice for acute conditions, and several diagnostic protocols using POCUS for shock have been developed. This study aimed to evaluate the diagnostic accuracy of POCUS in identifying the etiology of shock.MethodsWe conducted a systematic literature search of MEDLINE, Cochrane Central Register of Controlled Trials, Embase, Web of Science, Clinicaltrial.gov, European Union Clinical Trials Register, WHO International Clinical Trials Registry Platform, and University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR) until June 15, 2022. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and assessed study quality using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Meta-analysis was conducted to pool the diagnostic accuracy of POCUS for each type of shock. The study protocol was prospectively registered in UMIN-CTR (UMIN 000048025).ResultsOf the 1553 studies identified, 36 studies were full-text reviewed, and 12 studies with 1132 patients were included in the meta-analysis. Pooled sensitivity and specificity were 0.82 [95% confidence interval (CI) 0.68-0.91] and 0.98 [95% CI 0.92-0.99] for obstructive shock, 0.78 [95% CI 0.56-0.91] and 0.96 [95% CI 0.92-0.98] for cardiogenic shock, 0.90 [95% CI 0.84-0.94] and 0.92 [95% CI 0.88-0.95] for hypovolemic shock, and 0.79 [95% CI 0.71-0.85] and 0.96 [95% CI 0.91-0.98] for distributive shock, respectively. The area under the receiver operating characteristic curve for each type of shock was approximately 0.95. The positive likelihood ratios for each type of shock were all greater than 10, especially 40 [95% CI 11-105] for obstructive shock. The negative likelihood ratio for each type of shock was approximately 0.2.Conclusions The identification of the etiology for each type of shock using POCUS was characterized by high sensitivity and positive likelihood ratios, especially for obstructive shock.
| S-EPMC10214599 | biostudies-literature
Project description:BACKGROUND:In 2011, the role of Point of Care Ultrasound (POCUS) was defined as one of the top five research priorities in physician-provided prehospital critical care and future research topics were proposed; the feasibility of prehospital POCUS, changes in patient management induced by POCUS and education of providers. This systematic review aimed to assess these three topics by including studies examining all kinds of prehospital patients undergoing all kinds of prehospital POCUS examinations and studies examining any kind of POCUS education in prehospital critical care providers. METHODS AND RESULTS:By a systematic literature search in MEDLINE, EMBASE, and Cochrane databases, we identified and screened titles and abstracts of 3264 studies published from 2012 to 2017. Of these, 65 studies were read in full-text for assessment of eligibility and 27 studies were ultimately included and assessed for quality by SIGN-50 checklists. No studies compared patient outcome with and without prehospital POCUS. Four studies of acceptable quality demonstrated feasibility and changes in patient management in trauma. Two studies of acceptable quality demonstrated feasibility and changes in patient management in breathing difficulties. Four studies of acceptable quality demonstrated feasibility, outcome prediction and changes in patient management in cardiac arrest, but also that POCUS may prolong pauses in compressions. Two studies of acceptable quality demonstrated that short (few hours) teaching sessions are sufficient for obtaining simple interpretation skills, but not image acquisition skills. Three studies of acceptable quality demonstrated that longer one- or two-day courses including hands-on training are sufficient for learning simple, but not advanced, image acquisition skills. Three studies of acceptable quality demonstrated that systematic educational programs including supervised examinations are sufficient for learning advanced image acquisition skills in healthy volunteers, but that more than 50 clinical examinations are required for expertise in a clinical setting. CONCLUSION:Prehospital POCUS is feasible and changes patient management in trauma, breathing difficulties and cardiac arrest, but it is unknown if this improves outcome. Expertise in POCUS requires extensive training by a combination of theory, hands-on training and a substantial amount of clinical examinations - a large part of these needs to be supervised.
| S-EPMC6019293 | biostudies-literature