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The reliability of carotid ultrasound in determining the return of pulsatile flow: A pilot study.

ABSTRACT: Manual palpation of pulses is unreliable in detecting pulsatile flow in human participants, complicating the assessment of return of spontaneous circulation after cardiac arrest. Ultrasound may offer an alternative. This study's objective was to investigate whether return of pulsatile flow in humans can be reliably assessed by common carotid artery ultrasound. We conducted a single-blinded randomised study of common carotid artery ultrasound using 20 cardiopulmonary bypass patients to model the return of pulsatile flow. Synchronised time-stamped videos of radial artery invasive blood pressure and 10 two-dimensional or 10 colour Doppler ultrasounds were recorded. Three independent reviewers recorded the timestamp where they considered pulsatile flow was first visible on ultrasound. Ultrasound times were compared to the onset of arterial line pulsatile flow and reliability assessed by intraclass correlation coefficient. The median difference between radial artery and ultrasound flow time (interquartile range (range)) was 24 seconds (5-40 (0-93)) for two-dimensional and 5 seconds (2-17 (-28 to 188)) for colour Doppler. The intraclass correlation coefficient for two-dimensional ultrasound was 0.86 (95%CI 0.63-0.96) and 0.32 (95%CI -0.01 to 0.71) for colour Doppler. The median (interquartile range (range)) mean arterial pressure where ultrasound flow occurred for two-dimensional ultrasound was 62?mmHg (49-74 (33-82)) and 56?mmHg (52-73 (43-83)) for colour Doppler. In our pilot study, two-dimensional ultrasound was reliable in detecting the return of pulsatile flow. Colour Doppler detected pulsatile flow earlier and at lower mean arterial pressure but was not reliable, although a larger study is needed to determine colour Doppler's utility.

SUBMITTER: Germanoska B

PROVIDER: S-EPMC6042301 | biostudies-literature | 2018 May

REPOSITORIES: biostudies-literature

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The reliability of carotid ultrasound in determining the return of pulsatile flow: A pilot study.

Germanoska Biljana B Coady Matthew M Ng Sheyin S Fermanis Gary G Miller Matthew M

Ultrasound (Leeds, England) 20180129 2

Manual palpation of pulses is unreliable in detecting pulsatile flow in human participants, complicating the assessment of return of spontaneous circulation after cardiac arrest. Ultrasound may offer an alternative. This study's objective was to investigate whether return of pulsatile flow in humans can be reliably assessed by common carotid artery ultrasound. We conducted a single-blinded randomised study of common carotid artery ultrasound using 20 cardiopulmonary bypass patients to model the ...[more]

PMID: 30013612

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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.

Project description:INTRODUCTION:Patients with severe, symptomatic carotid stenosis can have their subsequent stroke risk reduced by surgical intervention if performed soon after a transient ischemic attack (TIA) or stroke. Patients presenting to an emergency department (ED) without computed tomography angiography (CTA) with TIA/stroke, may require transfer to another hospital for imaging to rule out carotid artery stenosis. The objective of this study was to determine the test characteristics of carotid artery point-of-care ultrasound (POCUS) in detecting greater than 50% stenosis in patients presenting with TIA/stroke. METHODS:We conducted a prospective cohort study on a convenience sample of adult patients presenting to a comprehensive stroke centre with TIA or stroke between June-October 2017. Carotid POCUS was performed. Primary outcome measure, stenosis ? 50%, was determined by the final radiology report of CTA. A blinded POCUS expert separately reviewed the archived carotid POCUS scans. We calculated sensitivity and specificity for stenosis ? 50%. RESULTS:We conducted POCUS on 75 patients, of which 70 were included in our analyses. Of those 70, 14.3% were diagnosed with greater than 50% stenosis. Carotid POCUS performed as follows: sensitivity 70.0% (95% confidence interval [CI], 34.8%-93.3%); specificity 86.7% (95% CI, 75.4%-94.1%); positive likelihood ratio (LR +) 5.3 (95% CI, 1.2-9.3); negative likelihood ratio (LR-) 0.4 (95% CI, 0.0-0.7). The inter-rater reliability between POCUS performer interpretation and expert interpretation had moderate agreement (k = 0.68). Scans took a mean 6.2 ± 2.2 minutes to complete. CONCLUSION:Carotid POCUS has low to moderate association with CTA for detection of carotid artery stenosis ? 50%. Further research and investigation is needed prior to widespread use of carotid POCUS in patients with acute cerebral ischemia. Additionally, external validity is likely affected by availability of training, maintenance of competency, and experience in more rural centres.

Dataset Information

The reliability of carotid ultrasound in determining the return of pulsatile flow: A pilot study.

Publications

The reliability of carotid ultrasound in determining the return of pulsatile flow: A pilot study.

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