Point-of-Care-Ultrasound in Pediatrics: A Review and Update.

Point-of-Care-Ultrasound (POCUS) has encountered a tremendous expansion in patient care. POCUS has taken a central role during invasive procedures. POCUS has expanded to most subspecialties from adult to pediatric and neonatal health care. POCUS in pediatrics has also become part of specific critical situations such as myocardial function assessment during cardiac arrest, extracorporeal membrane oxygenation deployment and neurological evaluation. In this review we will go over the most important historical aspects of POCUS. We will also review important aspects of POCUS in the intensive care unit, cardiologist evaluation and in the emergency department among others.

A Program of Assessment Model for Point-of-Care Ultrasound Training for Pediatric Critical Care Providers: A Comprehensive Approach to Enhance Competency-Based Point-of-Care Ultrasound Training.

Point-of-care ultrasound (POCUS) is increasingly accepted in pediatric critical care medicine as a tool for guiding the evaluation and treatment of patients. POCUS is a complex skill that requires user competency to ensure accuracy, reliability, and patient safety. A robust competency-based medical education (CBME) program ensures user competency and mitigates patient safety concerns. A programmatic assessment model provides a longitudinal, holistic, and multimodal approach to teaching, assessing, and evaluating learners. The authors propose a fit-for-purpose and modifiable CBME model that is adaptable for different institutions' resources and needs for any intended competency level. This educational model drives and supports learning, ensures competency attainment, and creates a clear pathway for POCUS education while enhancing patient care and safety.

Death and Ultrasound Evidence of the Akinetic Heart in Pediatric Cardiac Arrest.

Point-of-care ultrasound (POCUS) is an expanding noninvasive diagnostic modality used for the management of patients in multiple intensive care and pediatric specialties. POCUS is used to assess cardiac activity and pathology, pulmonary disease, intravascular volume status, intra-abdominal processes, procedural guidance including vascular access, lumbar puncture, thoracentesis, paracentesis, and pericardiocentesis. POCUS has also been used to determine anterograde flow following circulatory arrest when organ donation after circulatory death is being considered. Published guidelines exist from multiple medical societies including the recent guidelines for the use of POCUS in neonatology for diagnostic and procedural purposes.

Prediction of Difficult Laryngoscopy Using Ultrasound: A Systematic Review and Meta-Analysis.

OBJECTIVES: Evaluate associations between ultrasound measures and difficult laryngoscopy. DATA SOURCES: MEDLINE, Embase, Google Scholar, Web of Science, and the Cochrane Library were searched using MeSH terms and keywords. STUDY SELECTION: Studies published in English describing the use of airway ultrasound for identifying difficult laryngoscopy, with sufficient data to calculate sensitivity and specificity using 2 × 2 tables. DATA EXTRACTION: We assigned the described indices of airway dimension to one of three domains based on methodology characteristics: anterior tissue thickness domain, anatomical position domain, and oral space domain. We then performed a bivariate random-effects meta-analysis, deriving pooled sensitivity, specificity, diagnostic odds ratio, positive likelihood ratio, and negative likelihood ratio estimates. We assessed risks of bias using Quality Assessment of Diagnostic Accuracy Studies-2 analysis. DATA SYNTHESIS: Thirty-three studies evaluating 27 unique indices were included in the meta-analysis. The ultrasound protocols of the included studies were heterogeneous. Anterior tissue thickness demonstrated a pooled sensitivity of 76% (95% CI, 71-81%), specificity of 77% (95% CI, 72-81%), and an area under the receiver operating characteristic curve (AUROC) of 0.83 (95% CI, 0.80-0.86). Anatomical position demonstrated a pooled sensitivity of 74% (95% CI, 61-84%), specificity of 86% (95% CI, 78-91%), and an AUROC of 0.87 (95% CI, 0.84-0.90). Oral space demonstrated a pooled sensitivity of 53% (95% CI, 0.36-0.69), specificity of 77% (95% CI, 0.67-0.85), and an AUROC of 0.73 (95% CI, 0.69-0.77). CONCLUSIONS: Airway ultrasound metrics associate with difficult laryngoscopy in three domains: anterior tissue thickness, anatomic position, and oral space. An assessment instrument combining clinical and ultrasound assessments may be an accurate screening tool for difficult laryngoscopy.

A point-of-care ultrasound education curriculum for pediatric critical care medicine.

BACKGROUND: Diagnostic and procedural point-of-care ultrasound (POCUS) change patient management with the potential to improve outcomes. Pediatric critical care medicine trainees have limited access to education and training opportunities in diagnostic POCUS in the pediatric ICU. A dearth of published pediatric ICU curricular resources restricts these educational opportunities. METHODS: A 7-week longitudinal curriculum including lectures, practical skills sessions, and knowledge assessment covering core modules including (1) machine operation, (2) vascular access, (3) non-vascular procedures, (4) cardiac imaging, (5) hemodynamic assessment, (6) pulmonary imaging, and (7) abdominal imaging, was disseminated to pediatric critical care trainees and faculty at a single tertiary care pediatric hospital. RESULTS: The knowledge of trainees and participating faculty in procedural and diagnostic POCUS improved after implementing the curriculum. Pre-test scores mean and standard deviation (59.30% ± 14.15%) improved significantly (75.60% ± 9.43%) for all learners (p < 0.001). The overall self-reported comfort in diagnostic and procedural ultrasound improved for all learners. 100% of the learners reported utilizing diagnostic POCUS in their clinical practice four months after disseminating the curriculum. DISCUSSION: We describe a single center's approach to POCUS education with improvement in knowledge, self-reported comfort, and attitudes towards procedural and diagnostic POCUS. The curricular resources for adaptation in a similar educational context are provided.

Ultrasound education improves safety for peripheral intravenous catheter insertion in critically ill children.

BACKGROUND: Difficulty in obtaining peripheral vascular access is a common problem in patients admitted to the pediatric intensive care unit (PICU). The use of ultrasound guidance can improve the overall success in obtaining vascular access. This study evaluated the success and longevity of PIV placement by nurses pre- and post-implementation of an USGPIV curriculum. METHODS: PICU nurses participated in a prospective quality improvement study. Each participating nurse attempted 10 PIVs by using landmark (LM) methods. The same nurses then received individual instruction in an USGPIV placement curriculum. Following the educational intervention, each nurse attempted 10 USGPIVs. RESULTS: A total of 150 LM PIVs and 143 USGPIVs were attempted. The first stick success in the post-intervention (USGPIV) group was 85.9% compared to 47.3% in the pre-intervention (LM) group (p < 0.001). Overall success was also superior in the USGPIV group (94.3 versus 57.3%, respectively; p < 0.001). PIVs placed by US lasted longer with a median survival time of 4 ± 3.84 days versus 3 ± 3.51 days for LM PIVs (p < 0.050, log-rank test). CONCLUSIONS: Successful implementation of a standardized curriculum for USGPIV placement for PICU nurses improves first stick, overall success, and longevity of PIV catheter placement. IMPACT: An ultrasound-guided IV curriculum can be successfully implemented resulting in increased first stick success and increased longevity. Registered nurses can be trained in placement of ultrasound-guided IV placement. This study provides a training curriculum for ultrasound-guided IV placement that can be applied to other settings or institutions.

Laryngeal Ultrasound Detects Vocal Fold Immobility in Adults: A Systematic Review.

Laryngeal ultrasound (US) is becoming widely accepted for assessing true vocal fold immobility (TVFI), a potential complication of laryngeal and thyroid surgery. The objective of this project is to perform a systematic review and meta-analysis of pooled evidence surrounding laryngeal US as a modality for diagnosing TVFI in adults at risk for the condition in comparison to laryngoscopy as a gold standard. Medical subject heading terms were used to search MEDLINE, Embase, Google Scholar, Web of Science, and the Cochrane Library for relevant citations from January 1, 2000, to June 30, 2020. Studies were included if they involved patients 16 years and older, where laryngeal US was compared to laryngoscopy for TVFI. Studies were excluded if there were insufficient data to compute a sensitivity/specificity table after attempting to contact the authors. Case reports, and case series were also excluded. The initial search returned 1357 citations. Of these, 109 were selected for review utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Thirty citations describing 6033 patients were included in the final meta-analysis. A bivariate random effects meta-analysis was performed, revealing a pooled sensitivity for laryngeal US of 0.95 (95% confidence interval [CI] 0.88-0.98), a specificity of 0.99 (95% CI 0.97-0.99), and a diagnostic odds ratio of 1328.2 (95% CI 294.0-5996.5). The area under the curve of the hierarchical summary receiver operating characteristic curve was 0.99 (95% CI 0.98-1.00). Laryngeal US demonstrates high sensitivity and specificity for detecting VFI in the hands of clinicians directly providing care to patients.

Pulmonary Embolism as the Initial Presentation of Coronavirus Disease 2019 in Adolescents.

The current coronavirus disease 2019 pandemic has been particularly challenging for the clinician because of the unclear nature of the underlying disease mechanisms. One of the hallmarks of the disease involves an increased risk of thrombosis and hypercoagulable state. Here, we describe 2 cases of patients admitted with submassive pulmonary embolism in the setting of positive tests for severe acute respiratory syndrome coronavirus 2.

Assessment of Vocal Cord Motion Using Laryngeal Ultrasound in Children: A Systematic Review and Meta-Analysis.

OBJECTIVES: Laryngeal ultrasound is a nonirradiating, noninvasive method for assessing the upper airway in children. This systematic review and meta-analysis examine available evidence for accuracy of laryngeal ultrasound in diagnosing vocal cord immobility in infants and children after surgery and trauma affecting the vocal cords. DESIGN: Medical subject heading terms were used to search MEDLINE, Embase, Google Scholar, Web of Science, and the Cochrane Library for relevant citations. Publications from January 1, 2000, to June 30, 2020 were included in the search strategy. Study inclusion criteria consisted of randomized control trials and nonrandomized retrospective or prospective observational studies where vocal cord motion was evaluated by laryngeal ultrasound and compared with a reference test. Studies were excluded if there was insufficient data to compute a sensitivity/specificity table. Case reports, case series less than 10, and manuscripts not published in English were also excluded. PATIENTS: Studies which included subjects younger than or equal to 18 years were considered for full article review. SETTINGS: No restrictions on study settings were imposed in this systematic review. MEASUREMENTS AND MAIN RESULTS: The initial search returned 1,357 citations. After de-duplication, abstract, and full review, eight citations were included in the final meta-analysis. A bivariate random-effects meta-analysis was performed, which revealed a pooled sensitivity for laryngeal ultrasound in detecting vocal cord immobility of 91% (95% CI, 83-95%), specificity of 97% (95% CI, 82-100%), diagnostic odds ratio 333.56 (95% CI, 34.00-3,248.71), positive likelihood ratio 31.58 (95% CI, 4.50-222.05), and negative likelihood ratio 0.09 (95% CI, 0.05-0.19). CONCLUSIONS: Laryngeal ultrasound demonstrates high sensitivity and specificity for detecting vocal cord motion in children in a wide range of clinical settings. Laryngeal ultrasound offers a low-risk imaging option for assessing vocal cord function in children compared with the current gold standard of laryngoscopy.

Regulating Critical Care Ultrasound, It Is All in the Interpretation.

Point-of-care ultrasound (POCUS) use is rapidly expanding as a practice in adult and pediatric critical care environments. In January 2020, the Joint Commission endorsed a statement from the Emergency Care Research Institute citing point-of-care ultrasound as a potential hazard to patients for reasons related to training and skill verification, oversight of use, and recordkeeping and accountability mechanisms for clinical use; however, no evidence was presented to support these concerns. Existing data on point-of-care ultrasound practices in pediatric critical care settings verify that point-of-care ultrasound use continues to increase, and contrary to the concerns raised, resources are becoming increasingly available for point-of-care ultrasound use. Many institutions have recognized a successful approach to addressing these concerns that can be achieved through multispecialty collaborations.