Perioperative point-of-care gastric ultrasound.
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ABSTRACT:
SUBMITTER: El-Boghdadly K
PROVIDER: S-EPMC7808010 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:BACKGROUND:Over a million gastric tubes are placed yearly for varying medical reasons including gastric decompression. In the operating room (OR), this is performed blindly, and position is confirmed by auscultation, aspiration, or palpation by a surgeon. Despite the known risks of malpositioned gastric tubes, there is limited data in anesthesia literature about the incidence of intraoperative malpositioned gastric tubes. In this study, we use Point-of-Care ultrasonography (POCUS) to confirm gastric tube placement in the OR. METHODS:Prospective observational study with a total of 149 subjects, all over 18 years of age, undergoing surgery with general endotracheal anesthesia and intraoperative blind placement of a gastric tube by an anesthesia provider. The primary objective of this study is to determine the incidence of malposition of blindly placed gastric tubes. RESULTS:In our analysis, we found that out of 149 patients 110 patients were successfully visualized; the incidence of malposition was 0.14 [95% CI: 0.08-0.21]. We did not find age, Body Mass Index, or sex to be associated with predisposing patients to intraoperative malposition of gastric tube. However, increasing years of experience of anesthesia provider correlated with higher malposition rates. CONCLUSIONS:In summary, we demonstrated that the incidence of malposition of blindly gastric tubes was 14%. Given the attendant risks of malpositioned gastric tubes, this data should inform decision algorithms for the blind placement of gastric tubes.
| S-EPMC7410345 | biostudies-literature
Project description:Purpose: Fluid overload is a common post-operative issue in children following cardiac surgery and is associated with increased morbidity and mortality. There is currently no gold standard for evaluating fluid status. We sought to validate the use of point-of-care ultrasound to measure skin edema in infants and assess the intra- and inter-user variability. Methods: Prospective cohort study of neonates (≤30 d/o) and infants (31 d/o to 12 m/o) undergoing cardiac surgery and neonatal controls. Skin ultrasound was performed on four body sites at baseline and daily post-operatively through post-operative day (POD) 3. Subcutaneous tissue depth was manually measured. Intra- and inter-user variability was assessed using intraclass correlation coefficient (ICC). Results: Fifty control and 22 surgical subjects underwent skin ultrasound. There was no difference between baseline surgical and control neonates. Subcutaneous tissue increased in neonates starting POD 1 with minimal improvement by POD 3. In infants, this pattern was less pronounced with near resolution by POD 3. Intra-user variability was excellent (ICC 0.95). Inter-user variability was very good (ICC 0.82). Conclusion: Point-of-care skin ultrasound is a reproducible and reliable method to measure subcutaneous tissue in infants with and without congenital heart disease. Acute increases in subcutaneous tissue suggests development of skin edema, consistent with extravascular fluid overload. There is evidence of skin edema starting POD 1 in all subjects with no substantial improvement by POD 3 in neonates. Point-of-care ultrasound could be an objective way to measure extravascular fluid overload in infants. Further research is needed to determine how extravascular fluid overload correlates to clinical outcomes.
| S-EPMC8419458 | biostudies-literature
Project description:BackgroundAirway management for nonelective surgical procedures in the setting of trauma, pain, and opioid use can be complicated by the potential for aspiration due to delayed gastric emptying. Point-of-care ultrasound (POCUS) remains a useful tool for evaluating gastric content and volume in various clinical settings. The authors evaluated gastric volume and content in children scheduled for urgent and semi-urgent procedures to assess their aspiration risk.MethodsAfter obtaining consent, gastric POCUS was performed in the preoperative holding area for pediatric patients scheduled for both elective and nonelective surgery. Qualitative and quantitative measurements of the gastric antrum were taken, and the risk of gastric aspiration was calculated. Additional data collected included patient demographics, the type of surgery, nil per os (NPO) status at the time of surgery, NPO status at the time of injury, and administration of opioids.ResultsThe study cohort included 100 patients ranging in age from 3 to 17 years old (mean age 9.2 years). Out of these 100 patients, gastric scanning was successfully conducted in 98 patients. Sixteen of fifty-nine nonelective patients (27%) had received opioids for pain control prior to surgery. Among the 34 patients who had suffered an acute injury, 7 (21%) had been NPO for <8 hours at the time of the injury. Ninety-nine out of hundred patients had been NPO for at least 6 hours at the time of the gastric ultrasound. Based on our gastric ultrasound findings, all patients who were appropriately NPO had either Grade 0 or Grade 1 risk for aspiration, indicating a low risk of aspiration.ConclusionsThe preliminary data show that when patients presenting for nonelective surgery are appropriately NPO, they may have a low risk of aspiration. This information may help guide the choice of anesthetic induction technique, particularly when concerns exist about the safety of a rapid sequence induction. It allows for a more stable and controlled induction of anesthesia.
| S-EPMC10833037 | biostudies-literature
Project description:IntroductionPoint-of-care ultrasound (POCUS) use is increasing in pediatric clinical settings. However, gastric POCUS is rarely used, despite its potential value in optimizing the diagnosis and management in several clinical scenarios (i.e., assessing gastric emptying and gastric volume/content, gastric foreign bodies, confirming nasogastric tube placement, and hypertrophic pyloric stenosis). This review aimed to assess how gastric POCUS may be used in acute and critically ill children.Materials and methodsAn international expert group was established, composed of pediatricians, pediatric intensivists, anesthesiologists, radiologists, nurses, and a methodologist. A scoping review was conducted with an aim to describe the use of gastric POCUS in pediatrics in acute and critical care settings. A literature search was conducted in three databases, to identify studies published between 1998 and 2022. Abstracts and relevant full texts were screened for eligibility, and data were extracted, according to the JBI methodology (Johanna Briggs Institute).ResultsA total of 70 studies were included. Most studies (n = 47; 67%) were conducted to assess gastric emptying and gastric volume/contents. The studies assessed gastric volume, the impact of different feed types (breast milk, fortifiers, and thickeners) and feed administration modes on gastric emptying, and gastric volume/content prior to sedation or anesthesia or during surgery. Other studies described the use of gastric POCUS in foreign body ingestion (n = 6), nasogastric tube placement (n = 5), hypertrophic pyloric stenosis (n = 8), and gastric insufflation during mechanical ventilatory support (n = 4). POCUS was performed by neonatologists, anesthesiologists, emergency department physicians, and surgeons. Their learning curve was rapid, and the accuracy was high when compared to that of the ultrasound performed by radiologists (RADUS) or other gold standards (e.g., endoscopy, radiography, and MRI). No study conducted in critically ill children was found apart from that in neonatal intensive care in preterms.DiscussionGastric POCUS appears useful and reliable in a variety of pediatric clinical settings. It may help optimize induction in emergency sedation/anesthesia, diagnose foreign bodies and hypertrophic pyloric stenosis, and assist in confirming nasogastric tube placement, avoiding delays in obtaining confirmatory examinations (RADUS, x-rays, etc.) and reducing radiation exposure. It may be useful in pediatric intensive care but requires further investigation.
| S-EPMC9298849 | biostudies-literature
Project description:Introduction No consensus exists on how to define enteral nutrition tolerance in critically ill children, and the relevance of gastric residual volume (GRV) is currently debated. The use of point-of-care ultrasound (POCUS) is increasing among pediatric intensivists, and gastric POCUS may offer a new bedside tool to assess feeding tolerance and pre-procedural status of the stomach content. Materials and Methods A prospective observational study was conducted in a tertiary pediatric intensive care unit. Children on mechanical ventilation and enteral nutrition were included. Gastric POCUS was performed to assess gastric contents (empty, full of liquids or solids), and gastric volume was calculated as per the Spencer formula. Then, GRV was aspirated and measured. The second set of gastric POCUS measurements was performed, similarly to the first one performed prior to GRV measurement. The ability of GRV measurement to empty the stomach was compared to POCUS findings. Both GRV and POCUS gastric volumes were compared with any clinical signs of enteral feeding intolerance (vomiting). Results Data from 64 children were analyzed. Gastric volumes were decreased between the POCUS measurements performed pre- and post-GRV aspiration [full stomach, n = 59 (92.2%) decreased to n = 46 (71.9%), p =0.001; gastric volume: 3.18 (2.40–4.60) ml/kg decreased to 2.65 (1.57–3.57), p < 0.001]. However, the stomach was not empty after GRV aspiration in 46/64 (71.9%) of the children. There was no association between signs of enteral feeding intolerance and the GRV obtained, nor with gastric volume measured with POCUS. Discussion Gastric residual volume aspiration failed to empty the stomach and appeared unreliable as a measure of gastric emptiness. Gastric POCUS needs further evaluation to confirm its role.
| S-EPMC9240217 | biostudies-literature
Project description:A 49-year-old male presented to the emergency department with abdominal pain and generalized weakness. The physical examination was positive for right upper quadrant tenderness and positive Murphy's sign. Point-of-care biliary ultrasound revealed signs of emphysematous cholecystitis. Emphysematous cholecystitis is a rare biliary pathology with a high mortality rate. It differs from acute cholecystitis is many ways. It has unique ultrasound characteristics. This case highlights the use of point-of-care ultrasound to diagnose a rare biliary condition.
| S-EPMC7012538 | biostudies-literature
Project description:Case presentationA 34-year-old woman presented to the emergency department with bilateral lower extremity edema and shortness of breath. She had been seen by her primary care provider. Lab work and a follow-up with endocrinology had been unrevealing. Using point-of-care ultrasound we identified a cystic mass in the right upper quadrant prompting further imaging.DiscussionAbdominal and pelvic computed tomography confirmed a mass in the right posterior liver, which was later identified as an adrenocortical carcinoma. Ultrasound is an important diagnostic tool in the setting of lower extremity edema and can be used to assess for heart failure, liver failure, obstructive nephropathy, venous thrombosis, and soft tissue infection. In this case, ultrasound helped expedite the diagnosis and treatment of a rare malignancy.
| S-EPMC8610486 | biostudies-literature
Project description: Not available
| S-EPMC9979868 | biostudies-literature
Project description:ObjectiveEmerging evidence suggests that chest radiography (CXR) following central venous catheter (CVC) placement is unnecessary when point-of-care ultrasound (POCUS) is used to confirm catheter position and exclude pneumothorax. However, few providers have adopted this practice, and it is unknown what contributing factors may play a role in this lack of adoption, such as ultrasound experience. The objective of this study was to evaluate the diagnostic accuracy of POCUS to confirm CVC position and exclude a pneumothorax after brief education and training of nonexperts.MethodsWe performed a prospective cohort study in a single academic medical center to determine the diagnostic characteristics of a POCUS-guided CVC confirmation protocol after brief training performed by POCUS nonexperts. POCUS nonexperts (emergency medicine senior residents and critical care fellows) independently performed a POCUS-guided CVC confirmation protocol after a 30-minute didactic training. The primary outcome was the diagnostic accuracy of the POCUS-guided CVC confirmation protocol for malposition and pneumothorax detection. Secondary outcomes were efficiency and feasibility of adequate image acquisition, adjudicated by POCUS experts.ResultsTwenty-six POCUS nonexperts collected data on 190 patients in the final analysis. There were five (2.5%) CVC malpositions and six (3%) pneumothoraxes on CXR. The positive likelihood ratios of POCUS for malposition detection and pneumothorax were 12.33 (95% confidence interval [CI] = 3.26 to 46.69) and 3.41 (95% CI = 0.51 to 22.76), respectively. The accuracy of POCUS for pneumothorax detection compared to CXR was 0.93 (95% CI = 0.88 to 0.96) and the sensitivity was 0.17 (95% CI = 0.00 to 0.64). The median (interquartile range) time for CVC confirmation was lower for POCUS (9 minutes [8.5-9.5 minutes]) compared to CXR (29 minutes [1-269 minutes]; Mann-Whitney U, p < 0.01). Adequate protocol image acquisition was achieved in 76% of the patients.ConclusionThirty-minute training of POCUS in nonexperts demonstrates adequate diagnostic accuracy, efficiency, and feasibility of POCUS-guided CVC position confirmation, but not exclusion of pneumothorax.
| S-EPMC8173448 | biostudies-literature
Project description:Undifferentiated abdominal pain is a common presentation often requiring immediate medical or surgical intervention. Providing an accurate diagnosis involves a detailed patient history and thorough physical exam. Point of care ultrasound is gaining acceptance as a rapid diagnostic tool that can be used to accurately detect life-threatening conditions while potentially avoiding unnecessary radiation exposure and facilitating rapid treatment. Detection of pneumoperitoneum with point-of-care ultrasound is a simple procedure that relies heavily on the experience of the investigating practitioner. Standard technique involves placing a high-frequency linear-array transducer in the right upper quadrant, where abdominal free air is most likely to accumulate. Detection of the 'gut point', which is the transition of abdominal wall sliding to lack thereof in a single image, is the pathognomonic finding of pneumoperitoneum. If visualization is difficult, moving the patient to the left lateral decubitus position or using the scissors technique can provide additional image views. This representative case report and review highlights the use of abdominal POCUS for the diagnosis of pneumoperitoneum. Ultrasound should continue to be explored by clinicians to narrow the differential diagnosis of acute abdominal pain.
| S-EPMC7721848 | biostudies-literature