Is 1 Day of Focused Training in Echocardiographic Assessment Using Subxiphoid-Only (EASy) Examination Enough? A Tertiary Hospital Response to the COVID-19 Crisis and the Use of the EASy Examination to Support Unit-Wide Image Acquisition.

OBJECTIVES: We assessed the efficacy of 1-day training in echocardiography assessment using subxiphoid-only (EASy) followed by supervised image interpretation and decision-making during patient rounds as a novel approach to scaling up the use of point-of-care ultrasound (POCUS) in critically ill patients. DESIGN: Retrospective analysis of medical records and EASy examination images. SETTING: Tertiary care academic hospital. PATIENTS: A total of 14 adults (> 18 yr old) with COVID-19-associated respiratory failure under the care of Albany Medical Center's surge response team from April 6-17, 2020 who received at least one EASy examination. INTERVENTIONS: Residents (previously novice sonographers) were trained in EASy examination using 1 day of didactic and hands-on training, followed by independent image acquisition and supervised image interpretation, identification of hemodynamic patterns, and clinical decision-making facilitated by an echocardiography-certified physician during daily rounds. MEASUREMENTS AND MAIN RESULTS: We recorded the quality of resident-obtained EASy images, scanning time, and frequency with which the supervising physician had to repeat the examination or obtain additional images. A total of 63 EASy examinations were performed; average scanning time was 4.3 minutes. Resident-obtained images were sufficient for clinical decision-making on 55 occasions (87%), in the remaining 8 (13%) the supervising physician obtained further images. CONCLUSIONS: EASy examination is an efficient, valuable tool under conditions of scarce resources. The educational model of 1-day training followed by supervised image interpretation and decision-making allows rapid expansion of the pool of sonographers and implementation of bedside echocardiography into routine ICU patient management.

An Echocardiographic Approach for the Management of Shock: The Subcostal to Apical, Respiratory to Parasternal-Cardiac to Respiratory, Aortic to Stomach Protocol.

Point of care ultrasound has become an integral part of critical care medicine, particularly for recognizing shock etiologies and guiding management. Most of the current ultrasonography guided shock protocols have been tailored towards a qualitative assessment of patients on presentation with shock. Unfortunately, the evolving nature of shock, particularly in the face of resuscitation and physiologic changes, demands a more sophisticated approach. This manuscript serves to present a comprehensive algorithm called the transthoracic Subcostal To Apical, Respiratory to paraSternal and transesophageal Cardiac to Respiratory, Aortic to StomacH ultrasonographic evaluations for the assessment of shock. This protocol is better suited for the critically ill patient in its ability to move beyond pattern recognition and focus on monitoring shock states from their presentation through their evolution. Not only is importance placed on the sequence of the exam, but also the identification of signs of chronic disease, the early incorporation of pulmonary evaluation, and the role for transesophageal imaging in critically ill patients with difficult surface imaging. Given the broad capabilities of bedside ultrasound, the Subcostal To Apical, Respiratory to paraSternal-Cardiac to Respiratory, Aortic to StomacH protocol serves as a multifaceted algorithm allowing for a nuanced and dynamic approach for the resuscitation of critically ill patients in shock.

Assessment of cardiopulmonary point-of-care ultrasound objective structured clinical examinations in graduating anesthesiology residents across multiple residency programs.

STUDY OBJECTIVE: To implement and assess a cardiopulmonary point-of-care ultrasound (POCUS) objective structured clinical examination (OSCE) in a large cohort of graduating anesthesia residents. DESIGN: Observational cohort study. SETTING: University-affiliated hospitals. SUBJECTS: 150 graduating anesthesia residents in their last nine months of training. INTERVENTIONS: A standardized cardiopulmonary OSCE was administered to each resident. MEASUREMENTS: The cardiac views evaluated were parasternal long axis (PLAX), apical 4 chamber (A4C), and parasternal short axis (PSAX). The pulmonary views evaluated were pleural effusion (PLE) and pneumothorax (PTX). In addition, a pre- and post-exam survey scored on a 5-point Likert scale was administered to each resident. MAIN RESULTS: A4C view (mean 0.7 ± 0.3) scored a lower mean, compared to PSAX (mean 0.8 ± 0.3) and PLAX (mean 0.8 ± 0.4). Residents performed well on the PTX exam (mean 0.9 ± 0.3) but more poorly on the PLE exam (mean 0.6 ± 0.4). Structural identification across cardiac and pulmonary views were mostly high (means >0.7), but advanced interpretive skills and maneuvers had lower mean scores. Pre- and post- OSCE survey results were positive with almost all questions scoring >4 on the Likert scale. CONCLUSION: Our study demonstrates that a cardiopulmonary POCUS OSCE can be successfully implemented across multiple anesthesia training programs. While most residents were able to perform basic ultrasound views and identify structures, advanced interpretive skills and maneuvers performed lower.

Role of Point-of-Care Ultrasound in Emergency Airway Management Outside the Operating Room.

Tracheal intubation is one of the most frequently performed procedures in critically ill patients, and is associated with significant morbidity and mortality. Hemodynamic instability and cardiovascular collapse are common complications associated with the procedure, and are likely in patients with a physiologically difficult airway. Bedside point-of-care ultrasound (POCUS) can help identify patients with high risk of cardiovascular collapse, provide opportunity for hemodynamic and respiratory optimization, and help tailor airway management plans to meet individual patient needs. This review discusses the role of POCUS in emergency airway management, provides an algorithm to facilitate its incorporation into existing practice, and provides a framework for future studies.

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.

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.

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.

Focused ultrasonography for septic shock resuscitation.

PURPOSE OF REVIEW: Severe sepsis with septic shock is the most common cause of death among critically ill patients. Mortality has decreased substantially over the last decade but recent data has shown that opportunities remain for the improvement of early and targeted therapy. This review discusses published data regarding the role of focused ultrasonography in septic shock resuscitation. RECENT FINDINGS: Early categorization of the cardiovascular phenotypes with echocardiography can be crucial for timely diagnosis and targeted therapy of patients with septic shock. In the last few years, markers of volume status and volume responsiveness have been investigated, serving as valuable tools for targeting volume therapy in the care of both spontaneously breathing and mechanically ventilated patients. In tandem, investigators have highlighted findings of extravascular volume with ultrasonographic evaluation to compliment de-escalation of resuscitation efforts when appropriate. Furthermore, special attention has been given to resuscitation efforts of patients in septic shock with right ventricular failure. SUMMARY: Severe sepsis with septic shock is an insidious disease process that continues to take lives. In more recent years, data have emerged suggesting the utility of bedside ultrasonography for early cardiovascular categorization, goal directed resuscitation, and appropriate cardiovascular support based on its changing phenotypes.

Perioperative Management of Patients with Sepsis and Septic Shock, Part II: Ultrasound Support for Resuscitation.

Point-of-care ultrasound is capable of identifying the precise causes of hemodynamic failure in patients with septic shock. Patients in shock demonstrate complex alterations in their circulation, including changes in loading conditions (preload and afterload), right and left ventricular function, and development of obstructive physiology, and some of them have a burden of underlying cardiac disease. Knowledge of underlying hemodynamic derangements in such situations allows targeted interventions, that is, fluids, vasoactive, and inotropic medications, to optimize patient's perfusion. One example of competing goals involves a patient with hypertrophic "thick" left ventricle (LV), which is easily identified using point-of-care ultrasound (POCUS). Such patients usually have diastolic dysfunction and commonly require higher filling pressures (mainly grade II and III diastolic dysfunction) to maintain adequate cardiac output. They are vulnerable to the effects of hypovolemia with the potential for dynamic LV outflow tract (LVOT) obstruction. The use of inotrope is harmful under these circumstances and could lead to worsening of the obstructive physiology because of systolic anterior motion of the mitral valve leaflet and mitral regurgitation with rapid progression toward a cardiac arrest. Recognizing the increasingly important role of POCUS in the perioperative arena, in this review, we highlight how POCUS allows anesthesiologists to recognize and manage hemodynamic derangements in patients with sepsis and septic shock. We provide a systematic approach to the evaluation of this patient population using qualitative assessment of myocardial performance, fluid responsiveness, and fluid tolerance. Our approach is based on a limited number of ultrasound views: subcostal, inferior vena cava (IVC), and lung views are obtained in rapid succession. A combination of findings in these views is grouped into distinct hemodynamic phenotypes, each of them requiring their own approach to management.

Perioperative Management of Patients with Sepsis and Septic Shock, Part I: Systematic Approach.

Sepsis and septic shock are medical emergencies, with high associated mortality. The Surviving Sepsis Campaign has developed definitions and management guidelines, emphasizing the use of hour-1 care bundle. Anesthesiologists frequently encounter sepsis when source control is required. The authors summarize expected manifestations of organ dysfunction and state-of-the-art management of patients with sepsis and septic shock. They highlight an increasingly vital role point-of-care ultrasound examination in the recognition and management of hemodynamic derangements in this patient population. Supporting the role of anesthesiologists as perioperative physicians, the authors provide a framework for transitions of care between operating room and intensive care units.