Lung Ultrasound to Diagnose Pulmonary Congestion Among Patients on Hemodialysis: Comparison of Full Versus Abbreviated Scanning Protocols.

RATIONALE & OBJECTIVE: Pulmonary congestion contributes to morbidity and mortality in patients with kidney failure on hemodialysis, but physical assessment is an insensitive approach to its detection. Lung ultrasound is useful for assessing the presence and severity of pulmonary congestion, but the most widely validated 28-zone study is cumbersome. We sought to compare abbreviated 4-, 6-, and 8-zone studies to 28-zone studies. STUDY DESIGN: Diagnostic test study. SETTING & PARTICIPANTS: Convenience sample of 98 patients with kidney failure on hemodialysis presenting to an emergency department in the United States. TESTS COMPARED: 4-, 6-, and 8-zone lung ultrasound studies versus a 28-zone lung ultrasound. OUTCOME: Prediction of pulmonary congestion and 30-day mortality. RESULTS: All patients completed a 28-zone lung ultrasound. Correlation coefficients (nonparametric Spearman) between each of the studies were high (all values > 0.84). Bland-Altman analysis showed good agreement. Each of the short-form studies discriminated well with area under the receiver-operator characteristic curve > 0.83 for no-to-mild versus moderate-to-severe pulmonary congestion. During a median follow-up period of 778 days, 46 (47%) died. Patients with moderate-to-severe pulmonary congestion on lung ultrasound had a 30-day mortality rate similar to that observed among patients with no-to-mild pulmonary congestion (OR, 0.95 [95% CI, 0.70-1.29]). LIMITATIONS: Single-center study conducted in an emergency care setting, convenience sample of patients, and lack of long-term follow-up data. CONCLUSIONS: Among hemodialysis patients presenting to an emergency department, 4-, 6-, or 8-zone lung ultrasounds were comparable to 28-zone studies for the assessment of pulmonary congestion. The mortality rates did not differ between those with no-to-mild and moderate-to-severe pulmonary congestion.

A Call for Development of Point-of-Care Ultrasound Training Recommendations in Obstetrics and Gynecology Residency.

Point-of-care ultrasound (POCUS) skillsets are now taught throughout training levels from medical school through fellowship given the broad utility in assisting with bedside procedures and triaging clinical presentations for expedited workup. This is reflected in training curricula for emergency medicine, internal medicine, and general surgery residencies. However, these skillsets are not formally taught or required in obstetrics and gynecology residency. We present the opinion that these skillsets and curricula should be developed for obstetrics and gynecology trainees given their exposure to patients with similar clinical presentations in which the clinical management would be aided by POCUS.

Characteristics, Outcomes, and Trends of Patients With COVID-19-Related Critical Illness at a Learning Health System in the United States.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic continues to surge in the United States and globally. OBJECTIVE: To describe the epidemiology of COVID-19-related critical illness, including trends in outcomes and care delivery. DESIGN: Single-health system, multihospital retrospective cohort study. SETTING: 5 hospitals within the University of Pennsylvania Health System. PATIENTS: Adults with COVID-19-related critical illness who were admitted to an intensive care unit (ICU) with acute respiratory failure or shock during the initial surge of the pandemic. MEASUREMENTS: The primary exposure for outcomes and care delivery trend analyses was longitudinal time during the pandemic. The primary outcome was all-cause 28-day in-hospital mortality. Secondary outcomes were all-cause death at any time, receipt of mechanical ventilation (MV), and readmissions. RESULTS: Among 468 patients with COVID-19-related critical illness, 319 (68.2%) were treated with MV and 121 (25.9%) with vasopressors. Outcomes were notable for an all-cause 28-day in-hospital mortality rate of 29.9%, a median ICU stay of 8 days (interquartile range [IQR], 3 to 17 days), a median hospital stay of 13 days (IQR, 7 to 25 days), and an all-cause 30-day readmission rate (among nonhospice survivors) of 10.8%. Mortality decreased over time, from 43.5% (95% CI, 31.3% to 53.8%) to 19.2% (CI, 11.6% to 26.7%) between the first and last 15-day periods in the core adjusted model, whereas patient acuity and other factors did not change. LIMITATIONS: Single-health system study; use of, or highly dynamic trends in, other clinical interventions were not evaluated, nor were complications. CONCLUSION: Among patients with COVID-19-related critical illness admitted to ICUs of a learning health system in the United States, mortality seemed to decrease over time despite stable patient characteristics. Further studies are necessary to confirm this result and to investigate causal mechanisms. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Effect of Machine Settings on Ultrasound Assessment of B-lines.

OBJECTIVES: B-lines are a lung ultrasound (LUS) artifact that often indicate pathology. Little is known about the optimal ultrasound machine settings to assess B-lines. We compared settings typically used to evaluate B-lines at our institution with adjusted settings based on recent studies. METHODS: In order to determine typical settings for B-line assessment, we retrospectively reviewed LUS images obtained at our institution. We then prospectively performed LUS with both typical and adjusted settings, using curvilinear and phased array probes, in 20 patients presenting to the emergency department with shortness of breath. The prospectively obtained clips were rated for quality and quantity of B-lines by 14 clinicians with experience in LUS, with 1 assigned for typical settings "much greater," 2 for typical settings "slightly greater," 3 for both settings "similar," 4 for adjusted settings "slightly greater," and 5 for adjusted settings "much greater." RESULTS: Mean ratings and 95% confidence intervals significantly exceeded the null value of 3 for both B line quality (curvilinear probe: 4.68, 4.50-4.85; phased array probe: 4.02, 3.70-4.35) and B line quantity (curvilinear probe: 4.16, 3.84-4.49; phased array probe: 3.68, 3.41-3.96). CONCLUSIONS: B-line quality and quantity were rated higher using adjusted settings based on recently published evidence than when using settings that are typically employed in our institution. Our findings suggest that B-line assessment should be performed with focal zone at the level of the pleura, harmonics off, and gain increased in the far field.

The Cost-Effectiveness of Interventions to Increase Utilization of Prone Positioning for Severe Acute Respiratory Distress Syndrome.

OBJECTIVES: Despite strong evidence supporting proning in acute respiratory distress syndrome, few eligible patients receive it. This study determines the cost-effectiveness of interventions to increase utilization of proning for severe acute respiratory distress syndrome. DESIGN: We created decision trees to model severe acute respiratory distress syndrome from ICU admission through death (societal perspective) and hospital discharge (hospital perspective). We assumed patients received low tidal volume ventilation. We used short-term outcome estimates from the PROSEVA trial and longitudinal cost and benefit data from cohort studies. In probabilistic sensitivity analyses, we used distributions for each input that included the fifth to 95th percentile of its CI. SETTING: ICUs that care for patients with acute respiratory distress syndrome. SUBJECTS: Patients with moderate to severe acute respiratory distress syndrome. INTERVENTIONS: The implementation of a hypothetical intervention to increase the appropriate utilization of prone positioning. MEASUREMENTS AND MAIN RESULTS: In the societal perspective model, an intervention that increased proning utilization from 16% to 65% yielded an additional 0.779 (95% CI, 0.088-1.714) quality-adjusted life years at an additional long-term cost of $31,156 (95% CI, -$158 to $92,179) (incremental cost-effectiveness ratio = $38,648 per quality-adjusted life year [95% CI, $1,695-$98,522]). If society was willing to pay $100,000 per quality-adjusted life year, any intervention costing less than $51,328 per patient with moderate to severe acute respiratory distress syndrome would represent good value. From a hospital perspective, the intervention yielded 0.072 (95% CI, 0.008-0.147) more survivals-to-discharge at a cost of $5,242 (95% CI, -$19,035 to $41,019) (incremental cost-effectiveness ratio = $44,615 per extra survival [95% CI, -$250,912 to $558,222]). If hospitals were willing to pay $100,000 per survival-to-discharge, any intervention costing less than $5,140 per patient would represent good value. CONCLUSIONS: Interventions that increase utilization of proning would be cost-effective from both societal and hospital perspectives under many plausible cost and benefit assumptions.

Emergency Department Patient Perceptions of Transvaginal Ultrasound for Complications of First-Trimester Pregnancy.

OBJECTIVES: Emergency department (ED) transvaginal ultrasound (US) is underused in clinical practice. This study assessed pregnant women's perceptions of ED transvaginal US in terms of pain, embarrassment, anxiety, and willingness to receive the procedure. Secondary variables include physicians' perceptions of patients' experiences. METHODS: Women undergoing US examinations for complications of first-trimester pregnancy were prospectively surveyed before any US and after ED and/or radiology transvaginal US. Patients' and physicians' assessments of pain, embarrassment, and anxiety were measured with visual analog scales (0-100). RESULTS: A total of 398 women were enrolled. In the pre-US survey, the median anxiety score was 14 (interquartile range, 3-51), and 96% of patients were willing to have an ED transvaginal US if necessary. Of those who had ED transvaginal US, 96% would agree to have another examination. Patients reported minimal pain/embarrassment, and there was no difference if performed in the ED versus radiology (median pain, 11.5 versus 13; P = .433; median embarrassment, 7 versus 4; P = .345). Of the 48 who had both ED and radiology transvaginal US, 85% thought the ED transvaginal US was worthwhile. Physicians accurately assessed patient's embarrassment and pain (mean differences, 3.5 and -1.9, respectively; P > .25 for both); however, they overestimated them relative to the pelvic examination (mean difference for embarrassment, 12.8; P < .0001; pain, 8.0; P = .01). CONCLUSIONS: Pregnant ED patients report low levels of anxiety, pain, and embarrassment, and after ED transvaginal US, 96% would agree to have the examination again. There is no difference in pain/embarrassment between ED and radiology transvaginal US. Emergency department physicians accurately assessed patients' pain and embarrassment with ED transvaginal US but overestimated them compared to the pelvic examination.

Training, Competency, and Interdisciplinary Collaboration in Point-of-Care Ultrasound.

Point-of-care ultrasound can provide critical diagnostic information and add to procedural safety. As with any clinical skill, however, it must be applied by an adequately trained provider, with systems to ensure safety. Training can include a mix of hands-on training with traditional didactics, online coursework, and simulation, but each carries its own costs and benefits worth of review. Following training it is essential to think about assessment of competency in point-of-care ultrasound to reflect the combination of cognitive and procedural skills that makes up the practice. Within the frameworks described, expansion can be expected across specialty and professional boundaries.

Trends in Point of Care Ultrasound Familiarity Among Undergraduate Medical Clerkship Educators.

OBJECTIVES: Despite growing use of point of care ultrasound (POCUS), there remains a paucity of data about familiarity with POCUS among educators who dictate curricular content in undergraduate medical education. This paper aims to longitudinally characterize the level of comfort and frequency of POCUS use among faculty involved in undergraduate clerkship education. METHODS: A web-based cross-sectional survey assessing comfort, frequency of use, and awareness of indications for POCUS among faculty involved in Internal Medicine, Family Medicine, and Surgery undergraduate clerkship education in a single urban academic medical center in 2016 and again in 2022. RESULTS: A total of 45 responses from 2016 and 30 responses from 2022 are included. The percentage of faculty "not comfortable" with performing POCUS decreased from 78% to 46%, although the overall change in comfort was not statistically significant. Comfort interpreting POCUS images, frequency of POCUS use, and familiarity with the clinical applications of POCUS all improved. Faculty identified multiple barriers to more frequent POCUS use. CONCLUSIONS: Over a six-year period at one urban, academic medical center, comfort with POCUS and frequency of use have increased slightly but remain low among core faculty responsible for clerkship education. There are still large gaps in knowledge and very few faculty regularly use POCUS, which can be attributed to multiple different barriers.

Best Practices for Point of Care Ultrasound: An Interdisciplinary Expert Consensus.

Despite the growing use of point of care ultrasound (POCUS) in contemporary medical practice and the existence of clinical guidelines addressing its specific applications, there remains a lack of standardization and agreement on optimal practices for several areas of POCUS use. The Society of Point of Care Ultrasound (SPOCUS) formed a working group in 2022 to establish a set of recommended best practices for POCUS, applicable to clinicians regardless of their training, specialty, resource setting, or scope of practice. Using a three-round modified Delphi process, a multi-disciplinary panel of 22 POCUS experts based in the United States reached consensus on 57 statements in domains including: (1) The definition and clinical role of POCUS; (2) Training pathways; (3) Credentialing; (4) Cleaning and maintenance of POCUS devices; (5) Consent and education; (6) Security, storage, and sharing of POCUS studies; (7) Uploading, archiving, and reviewing POCUS studies; and (8) Documenting POCUS studies. The consensus statements are provided here. While not intended to establish a standard of care or supersede more targeted guidelines, this document may serve as a useful baseline to guide clinicians, leaders, and systems considering initiation or enhancement of POCUS programs.

Pragmatic assessment of resident performed cardiac point of care ultrasound using a validated scoring metric.

Background: Cardiac point of care ultrasound (POCUS) is increasingly utilized by trainees across various specialties and can rapidly assess the cardiac status of unstable patients. However, the quality of trainee performed cardiac examinations has been reported only in controlled studies. In this study we aimed to assess the quality of all cardiac POCUS performed by internal medicine trainees at a major academic medical center over a three-year period. Methods: 256 studies were included and were graded by experts blinded to postgraduate year (PGY) using a previously validated scoring metric. Results: We found significant improvement in overall quality of resident performed cardiac POCUS from PGY 1 to 3 (10.8, 10.2, 13.2, p = 0.012). Assessment of left ventricular function was possible in 82% of studies and increased from PGY 1 to PGY 3 (77%, 76%, 88%, p = 0.025). Similar trends were seen in the assessment of the pericardial space (67%, 71%, 84%, p = 0.012). Images sufficient for right ventricular and volume status assessment were less commonly found (65%, 60%, 75% and 60%, 49%, 57%, respectively). Conclusions: This study provides a real world experience of the level of diagnostic accuracy that can be expected from IM trainees with minimal hands-on supervision.

Interrater reliability of quantitative ultrasound measures of muscle in critically ill patients.

BACKGROUND: Quantitative neuromuscular ultrasound is increasingly used to study muscle pathology and changes in muscle mass during critical illness. Advantages of ultrasound are high axial resolution, low procedural risks, no ionizing radiation, and ease of use early in the course of disease. However, ultrasound is known to be an operator dependent imaging modality and the intensive care unit setting poses additional challenges to obtaining reliable measurements. There is limited evidence validating the feasibility and reliability of its application in this setting. OBJECTIVE: To conduct a standardized protocol for measuring muscle linear depth and cross-sectional area in critically ill populations with a high degree of interrater agreement and feasibility. DESIGN: Prospective observational cohort study of interrater reliability. SETTING: Medical intensive care unit at an academic medical center and a level one trauma and burn center. PATIENTS: Fifteen critically ill patients were evaluated using a standardized ultrasound protocol measuring total elbow flexor, knee extensor, and tibialis anterior depth, as well as rectus femoris cross-sectional area. Each site was independently scanned by two investigators. Reliability of measurements between observers was determined by calculating intraclass correlation coefficients (ICCs) using a two-way random effects model and absolute agreement. An ICC > 0.75 was considered good and >0.90 was considered excellent. RESULTS: In critically ill patients, interrater reliability of linear depth measured at elbow flexor, knee extensor, tibialis anterior, and cross-sectional area of rectus femoris sites was good to excellent with ICC between 0.87 (0.54-0.97) and 0.99 (0.97-1.00). Interrater reliability was improved by creating a summary index of measures resulting in an ICC of 0.99 (0.98-1.00). Feasibility, as definite by the percentage of each measure that was obtainable, ranged from 75%-100%. CONCLUSIONS: Using a standardized protocol, ultrasound measures obtained in critically ill patients demonstrated high levels of interrater agreement with good to excellent feasibility.

Virtual, Augmented, and Alternate Reality in Medical Education: Socially Distanced but Fully Immersed.

BACKGROUND: Advancements in technology continue to transform the landscape of medical education. The need for technology-enhanced distance learning has been further accelerated by the coronavirus disease (COVID-19) pandemic. The relatively recent emergence of virtual reality (VR), augmented reality (AR), and alternate reality has expanded the possible applications of simulation-based education (SBE) outside of the traditional simulation laboratory, making SBE accessible asynchronously and in geographically diverse locations. OBJECTIVE: In this review, we will explore the evidence base for use of emerging technologies in SBE as well as the strengths and limitations of each modality in a variety of settings. METHODS: PubMed was searched for peer-reviewed articles published between 1995 and 2021 that focused on VR in medical education. The search terms included medical education, VR, simulation, AR, and alternate reality. We also searched reference lists from selected articles to identify additional relevant studies. RESULTS: VR simulations have been used successfully in resuscitation, communication, and bronchoscopy training. In contrast, AR has demonstrated utility in teaching anatomical correlates with the use of diagnostic imaging, such as point-of-care ultrasound. Alternate reality has been used as a tool for developing clinical reasoning skills, longitudinal patient panel management, and crisis resource management via multiplayer platforms. CONCLUSION: Although each of these modalities has a variety of educational applications in health profession education, there are benefits and limitations to each that are important to recognize prior to the design and implementation of educational content, including differences in equipment requirements, cost, and scalability.

Diaphragm Ultrasound in Weaning From Mechanical Ventilation.

A 65-year-old man was admitted to the ICU for septic shock due to pneumonia. He remained on mechanical ventilation for 96 hours. His shock resolved, and he no longer required IV vasopressor therapy. His vital signs included a BP of 105/70 mm Hg, heart rate 85 beats/min, respiratory rate 22 breaths/min, and oxygen saturation 95%. His ventilator settings were volume control/assist control with a positive end-expiratory pressure of 5 and an Fio2 set to 40%. On these setting his blood gas showed an Pao2 of 75 mm Hg. He was following simple commands and had minimal tracheobronchial secretions. He was placed on a spontaneous breathing trial with a spontaneous mode of ventilation and pressure support of 7/5. He remained hemodynamically stable and showed no distress through the procedure, so he was extubated to 6 L oxygen by nasal cannula. Eighteen hours later, the patient was found to have increased work of breathing, with use of accessory respiratory muscles. A blood gas showed an elevated level of CO2, so the patient was reintubated. After intubation, the patient again appeared comfortable on minimal ventilator settings. Chest radiography before reintubation showed no new parenchymal process, but an elevated left diaphragm. After a thorough workup, it was determined that diaphragmatic weakness was the most likely reason for respiratory failure. The team questioned whether there was a way to have detected this before extubation.

Critical Care Echocardiography: A Primer for the Nephrologist.

Critical care echocardiography (CCE) refers to the goal-directed use of transthoracic or transesophageal echocardiography and represents one of the most common applications of critical care ultrasound. CCE can be performed at the point of care, is easily repeated following changes in clinical status, and does not expose the patient to ionizing radiation. Nephrologists who participate in the care of patients in the intensive care unit will regularly encounter CCE as part of the decision-making and bedside management of ICU patients. The four primary indications for CCE are the characterization of shock, evaluation of preload tolerance, evaluation of volume responsiveness, and serial hemodynamic assessment to evaluate response to therapeutic interventions. This article provides an overview of the anatomical structures that are routinely assessed in basic CCE, describes how these findings are incorporated into the clinical assessment of critically ill patients, and introduces some common applications of advanced CCE.

Focused Cardiac Ultrasound Curriculum for Internal Medicine Residents.

Background: Focused cardiac ultrasound (FCU) is a safe and efficient diagnostic intervention for internal medicine physicians. FCU is a highly teachable skill, but is used in routine cardiac assessment in only 20% of surveyed training programs.We developed an FCU curriculum for internal medicine residents and an assessment tool to evaluate the impact of the curriculum on trainee knowledge and confidence. Methods: Internal medicine residents rotating through clinical cardiology services underwent 30 minutes of didactic and 60 minutes of hands-on teaching on acquisition and interpretation of FCU. A 20 item pre and post-curriculum online survey was administered (November 2018-December 2019) to assess confidence and knowledge in FCU. Results: 79 of 116 (68%) residents completed the pre-survey and 50 completed the post-survey, of whom 34 received the curriculum. The mean change in confidence score in those who received versus did not receive the curriculum was 0.99 versus 0.39 (p=0.046) on a 5-point Likert scale. Among 33 residents who had paired pre- and post-surveys the mean change in confidence score was 1.2 versus 0.85 (p<0.001) in those who received versus did not receive the curriculum. The mean increase in knowledge score was 13% versus 7% respectively (p<0.0001). Conclusions: We instituted a novel curriculum for internal medicine residents to gain experience in image acquisition and interpretation. Both confidence and knowledge in FCU improved following the curriculum, indicating that this is a highly teachable skill. Additional analysis of the of the FCU study images will be useful for informing future interventions.