Ultrasonography in the Critical Care Unit.

PURPOSE OF REVIEW: This article summarizes the utility and evidence supporting the use of ultrasound exams in the intensive care unit. RECENT FINDINGS: Point-of-care ultrasonography (POCUS) is widely used by intensivists managing critically ill patients whereby they can accurately and rapidly assess for many pathologies such as pneumothorax, pulmonary edema, hydronephrosis, hemoperitoneum, and deep vein thrombosis among others. Basic and advanced critical care echocardiography, including transesophageal echocardiography, are routinely performed to determine the etiology of hemodynamic instability in undifferentiated shock and to guide subsequent therapy. The use of POCUS in the assessment of volume status is controversial with studies demonstrating that respiratory variation of the IVC is not reliable and with analysis of aortic blood flow velocity after passive leg raising maneuvers being the most promising. Point-of-care ultrasonography allows frontline clinicians to make real-time diagnoses and treatment decisions. This article will provide the reader with a broad overview of this important topic.

The impact of video laryngoscopy use during urgent endotracheal intubation in the critically ill.

BACKGROUND: The video laryngoscope (VL) has been shown to improve laryngoscopic views and first-attempt success rates in elective operating room and simulated tracheal intubations compared with the direct laryngoscope (DL). However, there are limited data on the effectiveness of the VL compared with the DL in urgent endotracheal intubations (UEIs) in the critically ill. We assessed the effectiveness of using a VL as the primary intubating device during UEI in critically ill patients when performed by less experienced operators. METHODS: We compared success rates of UEIs performed by Pulmonary and Critical Care Medicine (PCCM) fellows in the medical intensive care unit and medical or surgical wards. A cohort of PCCM fellows using GlideScope VL as the primary intubating device was compared with a historical cohort of PCCM fellows using a traditional Macintosh or Miller blade DL. The primary measured outcome was first-attempt intubation success rate. Secondary outcomes included total number of attempts required for successful tracheal intubation, rate of esophageal intubation, need for supervising attending intervention, duration of intubation sequence, and incidence of hypoxemia and hypotension. RESULTS: There were 138 UEIs, with 78 using a VL and 50 using a DL as the primary intubating device. The rate of first-attempt success was superior with the VL as compared with the DL (91% vs 68%, P < 0.01). The rate of intubations requiring ≥3 attempts (4% vs 20%, P < 0.01), unintended esophageal intubations (0% vs 14%, P < 0.01), and the average number of attempts required for successful tracheal intubation (1.2 ± 0.56 vs 1.7 ± 1.1, P < 0.01) all improved significantly with use of the VL compared with the DL. CONCLUSIONS: UEI using a VL as the primary device improved intubation success and decreased complications compared with a DL when PCCM fellows were the primary operators. These data suggest that the VL should be used as the primary device when urgent intubations are performed by less experienced operators.

Role of Gastroesophageal Reflux Disease in Morbidity and Mortality for Patients Admitted With Pulmonary Hypertension.

INTRODUCTION: The association between gastroesophageal reflux disease (GERD) and morbidity and mortality in patients with pulmonary arterial hypertension (PH) is unknown. Our objective was to examine the difference in socio-demographics, comorbidities, and morbidity/mortality in PH patients also diagnosed with GERD, compared to PH patients without GERD. METHODS: We performed a retrospective cross-sectional study of the large U.S. National Inpatient Sample identifying patients with a primary diagnosis of primary pulmonary hypertension (PH). All patients ≥ 18 years old that were admitted with a primary diagnosis of PH from January 1, 2001, to December 31, 2013, in the NIS database were included. We analyzed the socio-demographic and clinical comorbidities in PH patients with and without GERD. We investigated the predictors for complications of PH and differences in hospital utilization in this population. RESULTS: PH patients with GERD were more likely to be older than 18-29 years. They were more likely to be Caucasian and female and less likely to be part of the top 75% median income compared to the bottom 25%. Patients with GERD were more likely insured with Medicare or private insurance but less likely to have Medicaid or be uninsured. Patients were more likely to be obese, and have asthma, chronic bronchitis, obstructive sleep apnea, hypertension, and hypothyroidism but were less likely to have diabetes or a history of alcohol use. PH Patients with GERD were less likely to have myocardial infarctions, cardiac arrests, pulmonary embolisms, pulmonary hemorrhages, cardiac interventions, acute respiratory failure, acute renal failure, or urinary tract infections compared to those without GERD. Patients with GERD were, however, more likely to have acute heart failure exacerbations and aspiration pneumonia. Patients with a diagnosis of GERD had lower mortality, length of stay (LOS), and hospital costs compared to their counterparts. CONCLUSIONS: The concomitant presence of GERD is associated with fewer adverse outcomes in patients with PH. Though it is well understood that treatment of GERD is beneficial for lung disease, the exact role of GERD in PH has not been identified. This study helps characterize the important role appropriately treated GERD may play in preventing morbidity and mortality due to PH.

Point-of-Care Ultrasound in the Intensive Care Unit: Applications, Limitations, and the Evolution of Clinical Practice.

The use of point-of-care ultrasonography in the intensive care unit has been rapidly advancing over the past 20 years. This review will provide a broad overview of the discipline spanning lung ultrasonography to advanced critical care echocardiography. It will highlight new research that questions the utility of the inferior vena cava for determining volume responsiveness and will introduce the reader to cutting-edge technology including artificial intelligence, which is likely to revolutionize ultrasound teaching and image interpretation, increasing the reach of this modality for the frontline clinician.