New Imaging Protocol to Assess Endotracheal Tube Placement: A Case-control Study.

PURPOSE: After intubation, a frontal chest radiograph (CXR) is obtained to assess the endotracheal tube (ETT) position by measuring the ETT tip-to-carina distance. ETT tip location changes with neck position and can be determined by assessing the position of the mandible. As the mandible is typically not visualized on standard CXRs, we developed a new protocol where the mandible is seen on the CXR, hypothesizing that it will improve the accuracy of the ETT position assessment. PATIENTS AND METHODS: Two groups of intubated patients studied (February 9, 2021 to May 4, 2021): CXR taken in either standard or new protocol (visible mandible required). Two observers independently assessed the images for the neck position (neutral, flexed, and extended) based on the mandible position relative to the vertebral bodies. With the mandible absent (ie, neck position unknown), we established terms: "gray zone" (difficult to assess the ETT position adequately) and "clear zone" (confident recommendation to retract, advance, or maintain ETT position). We compared the rate of confident assessment of the ETT in the standard versus the new protocol. RESULTS: Of 308 patients, 155 had standard CXRs and 153 had the new protocol. Interrater agreements for the distance between the ETT and the carina and mandible height based on vertebral bodies were 0.986 ( P < 0.001) and 0.955 ( P < 0.001), respectively. The mandible was visualized significantly more often ( P < 0.001) with the new protocol (92%; 141/153) than with the standard protocol (21%; 32/155). By visualizing the mandible or the presence of the ETT within the clear zone, a reader could confidently assess the ETT position more often using the new protocol (96.7% vs 51.6%, P < 0.001). CONCLUSIONS: Mandible visibility on postintubation CXR is helpful for assessing the ETT position. The new protocol resulted in a significant increase in both visualizing the mandible and accurately determining ETT position on postintubation CXR.

Workflow of Ultrasound-Guided Arterial Access.

Arterial line cannulations frequently are performed in various clinical settings to facilitate hemodynamic monitoring and metabolic assessments. Palpation-guided technique generally is performed due to the superficial nature of the peripheral arteries; however, this approach may be challenging in patients with obesity, edema, and hypotension. Difficult line placements are a significant contributor of reduced operating room efficiency due to time delays seen in procedural workflow. Real-time ultrasound guidance is shown to improve success rates of arterial cannulation and reduction in multiple attempts, leading to time efficiency and less likelihood of arterial spasms or hematoma formation. In this report, the authors demonstrate the workflow of ultrasound-guided arterial line cannulation, outline the features of their institutional multi-modal training project for quality improvement, and evaluate the possible effect of the initiative on surgical delays seen with difficult line placements.

Ultrasound-Guided Pecto-Intercostal Fascial Block for Postoperative Pain Management in Cardiac Surgery: A Prospective, Randomized, Placebo-Controlled Trial.

OBJECTIVE: To explore the effect of pecto-intercostal fascial plane block (PIFB) on postoperative opioid requirements, pain scores, lengths of intensive care unit and hospital stays and incidence of postoperative delirium in cardiac surgical patients. DESIGN: Single- center, prospective, randomized (1:1), quadruple- blinded, placebo-controlled trial. SETTING: Single center, tertiary- care center. PARTICIPANTS: The study comprised 80 adult cardiac surgical patients (age >18 y) requiring median sternotomy. INTERVENTION: Patients were randomly assigned to receive ultrasound-guided PIFB, with either 0.25% bupivacaine or placebo, on postoperative days 0 and 1. MEASUREMENTS AND MAIN RESULTS: Of the 80 patients randomized, the mean age was 65.78 ± 8.73 in the bupivacaine group and 65.70 ± 9.86 in the placebo group (p = 0.573). Patients receiving PIFB with 0.25% bupivacaine showed a statistically significant reduction in visual analog scale scores (4.8 ± 2.7 v 5.1 ± 2.6; p < 0.001), but the 48-hour cumulative opioid requirement computed as morphine milligram equivalents was similar (40.8 ± 22.4 mg v 49.1 ± 26.9 mg; p = 0.14). There was no difference in the incidence of postoperative delirium between the groups evaluated using the 3-minute diagnostic Confusion Assessment Method (3/40 [7.5%] v 5/40 [12.5%] placebo; p = 0.45). CONCLUSION: Patients who received PIFB with bupivacaine showed a decline in cumulative opioid consumption postoperatively, but this difference between the groups was not statistically significant. Low incidence of complications and improvement in visual analog scale pain scores suggested that the PIFB can be performed safely in this population and warrants additional studies with a larger sample size.

Rescue therapy for severe COVID-19-associated acute respiratory distress syndrome with tissue plasminogen activator: A case series.

The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented stresses on modern medical systems, overwhelming the resource infrastructure in numerous countries while presenting a unique series of pathophysiologic clinical findings. Thrombotic coagulopathy is common in critically ill patients suffering from COVID-19, with associated high rates of respiratory failure requiring prolonged periods of mechanical ventilation. Here, we report a case series of five patients suffering from profound, medically refractory COVID-19-associated respiratory failure who were treated with fibrinolytic therapy using tissue plasminogen activator (tPA; alteplase). All five patients appeared to have an improved respiratory status following tPA administration: one patient had an initial marked improvement that partially regressed after several hours, one patient had transient improvements that were not sustained, and three patients had sustained clinical improvements following tPA administration. LEVEL OF EVIDENCE: Therapeutic, Level V.

Tool to improve qualitative assessment of left ventricular systolic function.

Interactive online learning tools have revolutionized graduate medical education and can impart echocardiographic image interpretive skills. We created self-paced, interactive online training modules using a repository of echocardiography videos of normal and various degrees of abnormal left ventricles. In this study, we tested the feasibility of this learning tool. Thirteen anesthesia interns took a pre-test and then had 3 weeks to complete the training modules on their own time before taking a post-test. The average score on the post-test (74.6% ± 11.08%) was higher than the average score on the pre-test (57.7% ± 9.27%) (P < 0.001). Scores did not differ between extreme function (severe dysfunction or hyperdynamic function) and non-extreme function (normal function or mild or moderate dysfunction) questions on both the pre-test (P = 0.278) and post-test (P = 0.093). The interns scored higher on the post-test than the pre-test on both extreme (P = 0.0062) and non-extreme (P = 0.0083) questions. After using an online educational tool that allowed learning on their own time and pace, trainees improved their ability to correctly categorize left ventricular systolic function. Left ventricular systolic function is often a key echocardiographic question that can be difficult to master. The promising performance of this educational resource may lead to more time- and cost-effective methods for improving diagnostic accuracy among learners.

Ultrasound Guidance for Central Venous Access: Current Evidence and Clinical Recommendations.

Ultrasound-guided central line placement has been shown to decrease the number of needle puncture attempts, complication, and failure rates. In order to obtain successful central access, it is important to have adequate cognitive knowledge, workflow understanding, and manual dexterity to safely execute this invasive procedure. The operator should also be familiar with the anatomical variations, equipment operations, and potential complications and their prevention. In this article, we present a detailed review of ultrasound-guided central venous access. It includes a description of anatomy, operative technique, equipment operation, and techniques for specific situations. We describe the use of ultrasound guidance to avoid and identify various complications associated with this procedure. We have also reviewed recent recommendations and guidelines for the use of ultrasound for central venous access and the current evidence pertaining to the recommendations for the expected level of training, methodology, and metrics for establishing competency.

Focused Cardiac Ultrasound in the Pediatric Perioperative Setting.

Focused cardiac ultrasonography (FoCUS) has become an important diagnostic tool for acute care physicians. FoCUS allows real-time visualization of the heart and, in combination with the physical examination, acts as a hemodynamic monitor to manage patient care in acute situations. Most of the available perioperative literature has focused on adult patients. Little has been published on the perioperative application of FoCUS for pediatric patients. This article provides an overview of FoCUS used at the bedside by pediatric anesthesiologists. Variations in clinical applications, technical aspects, and interpretation of FoCUS findings in children are described. Discussion of training and competency is included. Barriers to implementation by pediatric intensivists and emergency medicine physicians include a lack of understanding of indications and training opportunities in pediatric FoCUS. It is likely that similar barriers exist in pediatric anesthesiology resulting in underutilization of FoCUS. The use of FoCUS in the pediatric operating room, however, may positively impact care of infants and children and should be encouraged.

Faculty-Focused Perioperative Ultrasound Training Program: A Single-Center Experience.

OBJECTIVE: Comprehensive educational initiatives in ultrasound for practicing physicians are lacking. We developed a perioperative ultrasound training program for faculty to offer a broad orientation to the principles and clinical applications of ultrasound. DESIGN AND SETTING: The program consisted of two phases. Phase one, which introduced ultrasound via didactic and hands-on components, had six live sessions. At the end of each, participants completed a knowledge quiz. During the sixth session, faculty participated in an objective structured clinical examination (OSCE). For phase two, faculty attended two to three sessions (8-10 hours each) of in-depth individualized training and demonstrated supervised performance of ultrasound-related procedures of their choice. PARTICIPANTS: Participants included Anesthesia faculty at Beth Israel Deaconess Medical Center. MEASUREMENTS AND MAIN RESULTS: On average 30 faculty members attended each live session for phase one; 12 completed phase two. There was a significant difference in quiz scores across the six sessions (p < 0.001) with scores for Session 6 being significantly higher than for Session 1 (p < 0.001). The average mean and median scores on the three OSCE stations were 95.63% and 98.33%, respectively. For phase two, the 8 participants who received training in regional anesthesia each performed > 10 blocks on patients over two days; 5 of the 7 participants who received training in transthoracic echocardiography each completed more than 15 examinations on simulators and 10 examinations on patients. CONCLUSION: It is possible to implement a departmental educational program for ultrasound to improve ultrasound knowledge and skills in practicing anesthesiologists.

Ultrasound as a Screening Tool for Central Venous Catheter Positioning and Exclusion of Pneumothorax.

OBJECTIVES: Although real-time ultrasound guidance during central venous catheter insertion has become a standard of care, postinsertion chest radiograph remains the gold standard to confirm central venous catheter tip position and rule out associated lung complications like pneumothorax. We hypothesize that a combination of transthoracic echocardiography and lung ultrasound is noninferior to chest radiograph when used to accurately assess central venous catheter positioning and screen for pneumothorax. SETTING: All operating rooms and surgical and trauma ICUs at the institution. DESIGN: Single-center, prospective noninferiority study. PATIENTS: Patients receiving ultrasound-guided subclavian or internal jugular central venous catheters. INTERVENTIONS: During ultrasound-guided central venous catheter placement, correct positioning of central venous catheter was accomplished by real-time visualization of the guide wire and positive right atrial swirl sign using the subcostal four-chamber view. After insertion, pneumothorax was ruled out by the presence of lung sliding and seashore sign on M-mode. MEASUREMENTS AND MAIN RESULTS: Data analysis was done for 137 patients. Chest radiograph ruled out pneumothorax in 137 of 137 patients (100%). Lung ultrasound was performed in 123 of 137 patients and successfully screened for pneumothorax in 123 of 123 (100%). Chest radiograph approximated accurate catheter tip position in 136 of 137 patients (99.3%). Adequate subcostal four-chamber views could not be obtained in 13 patients. Accurate positioning of central venous catheter with ultrasound was then confirmed in 121 of 124 patients (97.6%) as described previously. CONCLUSIONS: Transthoracic echocardiography and lung ultrasound are noninferior to chest x-ray for screening of pneumothorax and accurate central venous catheter positioning. Thus, the point of care use of ultrasound can reduce central venous catheter insertion to use time, exposure to radiation, and improve patient safety.

Mannitol or hypertonic saline in the setting of traumatic brain injury: What have we learned?

BACKGROUND: Intracranial hypertension, defined as an intracranial pressure (ICP) >20 mmHg for a period of more than 5 min, worsens neurologic outcome in traumatic brain injury (TBI). While several mechanisms contribute to poor outcome, impaired cerebral perfusion appears to be a highly significant common denominator. Management guidelines from the Brain Trauma Foundation recommend measuring ICP to guide therapy. In particular, hyperosmolar therapy, which includes mannitol or hypertonic saline (HTS), is frequently administered to reduce ICP. Currently, mannitol (20%) is considered the gold standard hyperosmolar agent. However, HTS is increasingly used in this setting. This review sought to compare the efficacy of mannitol to HTS in severe TBI. METHODS: The PubMed database was used to systematically search for articles comparing mannitol to HTS in severe TBI. The following medical subject headings were used: HTS, sodium lactate, mannitol, ICP, intracranial hypertension, and TBI. We included both prospective and retrospective randomized controlled studies of adult patients with intracranial hypertension as a result of severe TBI who received hyperosmolar therapy. RESULTS: Out of 45 articles, seven articles were included in our review: 5 were prospective, randomized trials; one was a prospective, nonrandomized trial; and one was a retrospective, cohort study. CONCLUSIONS: While all seven studies found that both mannitol and HTS were effective in reducing ICP, there was heterogeneity with regard to which agent was most efficacious.

The reliability and validity of passive leg raise and fluid bolus to assess fluid responsiveness in spontaneously breathing emergency department patients.

PURPOSE: We investigated the reproducibility of passive leg raise (PLR) and fluid bolus (BOLUS) using the Non-Invasive Cardiac Output Monitor (NICOM; Cheetah Medical, Tel Aviv, Israel) for assessment of fluid responsiveness (FR) in spontaneously breathing emergency department (ED) patients. METHODS: Prospective, observational study of a convenience sample of adult ED patients receiving intravenous fluid bolus. We assessed stroke volume (SV) using NICOM and obtained results from PLR, where the head of the bed was changed from semirecumbent to supine while the patients' legs raised to 45° for 3 minutes. Fluid bolus was defined as 5 mL/kg normal saline infusion. Maximal increase in SV was recorded. Fluid responsiveness was defined as an increase of SV greater than 10% from baseline. We obtained 4 consecutive responses for each patient; PLR1, PLR2, BOLUS1 separated each by 10 minutes, and BOLUS2 initiated immediately after the end of BOLUS1. We calculated κ statistics, correlation coefficients, and odds ratios with 95% confidence interval and Bland-Altman plots. RESULTS: We enrolled 109 patients enrolled in this study. The 2 PLRs were significantly correlated (r = 0.78, P < .001) with κ = 0.46 for FR (P < .001). The 2 BOLUSES less strongly correlated (r = 0.14, P = .001) and κ = 0.06 for FR (P < .001). Patients who were responsive to PLR1 had 9.5 (3.6-25) odds of being FR for PLR2, whereas those responsive to BOLUS1 had a 1.8 (0.76-4.3) increased odds of FR for BOLUS2. CONCLUSION: In conclusion, we have found PLR as measured by the NICOM to be a promising tool for the evaluation of SV responsiveness. It was feasible for use in the ED, and the data suggest that the PLR technique may be more reproducible than the fluid bolus technique for assessing volume responsiveness.

International evidence-based recommendations for focused cardiac ultrasound.

BACKGROUND: Focused cardiac ultrasound (FoCUS) is a simplified, clinician-performed application of echocardiography that is rapidly expanding in use, especially in emergency and critical care medicine. Performed by appropriately trained clinicians, typically not cardiologists, FoCUS ascertains the essential information needed in critical scenarios for time-sensitive clinical decision making. A need exists for quality evidence-based review and clinical recommendations on its use. METHODS: The World Interactive Network Focused on Critical UltraSound conducted an international, multispecialty, evidence-based, methodologically rigorous consensus process on FoCUS. Thirty-three experts from 16 countries were involved. A systematic multiple-database, double-track literature search (January 1980 to September 2013) was performed. The Grading of Recommendation, Assessment, Development and Evaluation method was used to determine the quality of available evidence and subsequent development of the recommendations. Evidence-based panel judgment and consensus was collected and analyzed by means of the RAND appropriateness method. RESULTS: During four conferences (in New Delhi, Milan, Boston, and Barcelona), 108 statements were elaborated and discussed. Face-to-face debates were held in two rounds using the modified Delphi technique. Disagreement occurred for 10 statements. Weak or conditional recommendations were made for two statements and strong or very strong recommendations for 96. These recommendations delineate the nature, applications, technique, potential benefits, clinical integration, education, and certification principles for FoCUS, both for adults and pediatric patients. CONCLUSIONS: This document presents the results of the first International Conference on FoCUS. For the first time, evidence-based clinical recommendations comprehensively address this branch of point-of-care ultrasound, providing a framework for FoCUS to standardize its application in different clinical settings around the world.

Focused critical care echocardiography.

OBJECTIVE: Portable ultrasound is now used routinely in many ICUs for various clinical applications. Echocardiography performed by noncardiologists, both transesophageal and transthoracic, has evolved to broad applications in diagnosis, monitoring, and management of critically ill patients. This review provides a current update on focused critical care echocardiography for the management of critically ill patients. METHOD: Source data were obtained from a PubMed search of the medical literature, including the PubMed "related articles" search methodology. SUMMARY AND CONCLUSIONS: Although studies demonstrating improved clinical outcomes for critically ill patients managed by focused critical care echocardiography are generally lacking, there is evidence to suggest that some intermediate outcomes are improved. Furthermore, noncardiologists can learn focused critical care echocardiography and adequately interpret the information obtained. Noncardiologists can also successfully incorporate focused critical care echocardiography into advanced cardiopulmonary life support. Formal training and proctoring are important for safe application of focused critical care echocardiography in clinical practice. Further outcomes-based research is urgently needed to evaluate the efficacy of focused critical care echocardiography.