Comparison of qualitative information obtained with the echocardiographic assessment using subcostal-only view and focused transthoracic echocardiography examinations: a prospective observational study.

PURPOSE: To evaluate whether echocardiographic assessment using the subcostal-only window (EASy) compared with focused transthoracic echocardiography (FTTE) using three windows (parasternal, apical, and subcostal) can provide critical information to serve as an entry-point technique for novice sonographers. METHODS: We conducted a retrospective study to compare diagnostic information acquired during EASy and FTTE examinations on qualitative left ventricular (LV) size, LV contractility, right ventricular (RV) size, RV contractility, interventricular septal position, and the presence of a significant pericardial effusion. Anesthesiology residents (novice users) performed FTTE for hemodynamic instability and/or respiratory distress or to define volume status in the perioperative setting, and later collected images were grouped into EASy and FTTE examinations. Both examinations were reviewed independently by a board-certified cardiologist and an anesthesiologist proficient in critical care echocardiography. FTTE and EASy findings were compared utilizing Gwet's AC1 coefficient to consider disagreement due to chance. RESULTS: We reviewed 102 patients who received FTTE over a period of 14 months. Of those, 82 had usable subcostal views and were included in the analysis. There was substantial agreement for qualitatively evaluating RV size (Gwet's AC1, 0.70; 95% confidence interval [CI], 0.54 to 0.85), LV size (Gwet's AC1, 0.73; 95% CI, 0.58 to 0.88), and LV contractility (Gwet's AC1, 0.73; 95% CI, 0.58 to 0.88) utilizing EASy and FTTE. Additionally, there was an almost perfect agreement when assessing the presence of pericardial effusion (Gwet's AC1, 0.98; 95% CI, 0.95 to 1.0) and RV contractility (Gwet's AC1, 0.84; 95% CI, 0.74 to 0.95) and evaluating the motion of the interventricular septum (Gwet's AC1, 0.92; 95% CI, 0.85 to 0.99). CONCLUSIONS: When images could be obtained from the subcostal window (the EASy examination), qualitative diagnostic information was sufficiently accurate compared with information obtained during FTTE examination. Our findings suggest that the EASy examination can serve as the entry point technique to FTTE for novice clinicians.

RéSUMé: OBJECTIF: Déterminer si l'évaluation échocardiographique se fondant sur la fenêtre unique sous-costale (EASy) par rapport à une échocardiographie transthoracique ciblée (ETTC) fondée sur trois fenêtres (parasternale, apicale et sous-costale) pouvait fournir des informations critiques et servir de technique de départ pour enseigner l'échographie aux novices. MéTHODE: Nous avons réalisé une étude rétrospective afin de comparer les informations diagnostiques acquises lors des examens échocardiographiques EASy et ETTC concernant la taille qualitative du ventricule gauche (VG), la contractilité du VG, la taille du ventricule droit (VD), la contractilité du VD, la position septale interventriculaire et la présence d'un épanchement péricardique significatif. Les résidents en anesthésiologie (utilisateurs novices) ont réalisé une ETTC pour détecter une instabilité hémodynamique et / ou une détresse respiratoire ou pour définir l'état volémique dans un contexte périopératoire; par la suite les images colligées ont été regroupées en examens EASy et ETTC. Les deux examens ont été indépendamment passés en revue par un cardiologue certifié et un anesthésiologiste formé en échocardiographie de soins intensifs. Les résultats des examens d'ETTC et d'EASy ont été comparés en utilisant le coefficient AC1 de Gwet pour tenir compte des désaccords dus au hasard. RéSULTATS: Nous avons passé en revue 102 patients ayant reçu une ETTC sur une période de 14 mois. De ce nombre, 82 ont présenté des vues sous-costales utilisables qui ont été incluses dans l'analyse. Il y avait une importante concordance entre les examens EASy et ETTC pour évaluer qualitativement la taille du VD (AC1 de Gwet, 0,70; intervalle de confiance [IC] à 95 %, 0,54 à 0,85), la taille du VG (AC1 de Gwet, 0,73; IC 95 %, 0,58 à 0,88) et la contractilité du VG (AC1 de Gwet, 0,73; IC 95 %, 0,58 à 0,88). De plus, il y avait une concordance quasi parfaite lors de l'évaluation de la présence d'épanchement péricardique (AC1 de Gwet, 0,98; IC 95 %, 0,95 à 1,0) et de la contractilité du VD (AC1 de Gwet, 0,84; IC 95 %, 0,74 à 0,95) et de l'évaluation du mouvement du septum interventriculaire (AC1 de Gwet, 0,92; IC 95 %, 0,85 à 0,99). CONCLUSION: Lorsque les images pouvaient être obtenues à partir de la fenêtre sous-costale (examen EASy), les informations diagnostiques qualitatives étaient suffisamment précises par rapport aux informations obtenues lors de l'examen d'ETTC. Nos résultats suggèrent que l'examen EASy peut servir de technique d'apprentissage précédant l'ETTC pour les cliniciens novices.

Effect of Sickle Cell Anemia Therapies on the Natural History of Growth and Puberty Patterns.

As pediatric patients with sickle cell anemia (SCA) have impaired growth and puberty patterns, we studied the effect of disease-modifying therapies on growth and puberty patterns for patients with SCA receiving hydroxyurea (HU), transfusions, or no therapy. We performed a retrospective study of children with SCA in whom anthropometric measurements and therapy type were recorded. Penalized smoothing splines were fitted to estimate growth curves and growth velocity, and linear mixed models were used to examine differences across treatment groups. Across group analyses were divided into early childhood (4.0 to 7.9 y) and peripubertal (8.0 to 12.0 y). We analyzed growth data on 157 SCA patients. From 8.0 to 12.0 years, girls on transfusion therapy were significantly taller than girls on HU (range, 5.7 to 7.2 cm; P-value range 0.002 to 0.01). From 10.0 to 12.0 years, boys on transfusion therapy were significantly taller than boys on HU (range, 4.1 to 9.4 cm; P-value range <0.0001 to 0.04). In addition, boys on transfusion therapy had an earlier peak height velocity as compared with boys on either HU or no therapy. In conclusion, children receiving transfusions tended to be taller than children on HU or no therapy. Children on HU did not demonstrate superior growth pattern when compared with children on no therapy in the peripubertal years.

Outcomes of febrile events in pediatric patients with sickle cell anemia.

BACKGROUND: Limited evidence exists to create institutional admission criteria guidelines for febrile sickle cell patients. In addition, evidence is lacking to understand readmission rates for febrile sickle cell patients discharged from the emergency department (ED) or hospital. PROCEDURES: We conducted a 16-year retrospective study of bacteremia outcomes for febrile sickle cell patients. Risk variables analyzed included fever (either ≥ 39.5°C or ≥40°C), abnormal white blood cell (WBC) (>30,000 or <5,000/mcL), tachycardia and hypotension, or "ill appearing." Fourteen-day readmission rates were analyzed to determine outcomes for febrile sickle cell patients discharged from the ED or discharged within 72 h. RESULTS: Bacteremia was identified in 17 (2.6%) of 653 febrile events that are presented to the ED. "Ill-appearing" patients had an 8.5-fold increased odds of being diagnosed with bacteremia. Models using WBC count, "ill appearing," and hypotension have the highest sensitivity and specificity (AUC > 0.75). Among 427 patients discharged from the ED or within 72 h of hospitalization, only 10 (2.3%) were readmitted for a new sickle cell complication. CONCLUSIONS: Institutions can develop admission criteria based on WBC count, hypotension, and "ill appearance." Persistently febrile, well-appearing patient can be discharged at 48 h with minimal risk for new complications.

Focused Cardiac Ultrasound and the Periresuscitative Period: A Case Series of Resident-Performed Echocardiographic Assessment Using Subcostal-Only View in Advanced Life Support.

When incorporated into the 10-second pulse/rhythm check of the advanced life support (ALS) protocol, focused cardiac ultrasound is a useful adjunct to cardiopulmonary resuscitation. In this case series, we demonstrated the feasibility of echocardiographic assessment using subcostal-only view in ALS (EASy-ALS) performed by anesthesiology residents during the periresuscitative period after structured training. Residents obtained diagnostic quality images in 100% of the self-reported cases, which enabled them to identify cardiac motion and potentially reversible causes of hemodynamic instability. Implementation of EASy-ALS into practice requires system-wide changes in cardiac arrest management for consistency, quality, and further evaluation of patient outcomes.

Point-of-Care Ultrasound Before and After Transfemoral Transcatheter Aortic Valve Implantation.

OBJECTIVE: Surgical aortic valve replacement requires a comprehensive transoesophageal echocardiography (TEE) assessment before and after the intervention by cardiac anaesthesiologists. For patients undergoing transfemoral transcatheter aortic valve implantation (TF-TAVI), TEE is not routinely used. We started using transthoracic echocardiography (TTE) as a diagnostic and monitoring modality during TF-TAVI procedures. The aim of this study is to examine the usefulness of TTE before and after TF-TAVI. We hypothesised that TTE can serve as a screening tool in TF-TAVI patients and help rule out significant paravalvular leaks (PVLs), and serve as a monitoring tool. METHODS: A retrospective, observational study of 24 patients who underwent TF-TAVI with perioperative TTE over a 3-month period was conducted. Intraoperatively, two TTE examinations were performed. The first was a baseline pre-procedural TTE examination after anaesthetic induction, and the second was performed after TAVI valve implantation. Both pre- and post-procedural examinations included five focused TTE views. PVLs were graded as none, non-significant (trace or mild) or significant (moderate or severe). RESULTS: The average age and median body mass index of the patients were 82 years and 28.5 kg m-2, respectively. The average time recorded for the pre- and post-TAVI TTE examinations were approximately 4 and 5.5 min, respectively. Non-significant PVL was detected in 6 (25%) patients, and no leak was detected in 18 (75%) patients. CONCLUSION: A focused TTE examination was found to be a useful adjunct during TF-TAVI for a cardiac anaesthesiologist in the absence of TEE, and useful in ruling out significant PVLs.