Comparing contamination rates of sterile-covered and uncovered transducers for ultrasound-guided peripheral intravenous lines.

INTRODUCTION: Physicians frequently use point-of-care ultrasound for intravenous access and bloodwork in the ED. Recently, AIUM and ACEP released recommendations on ultrasound-guided peripheral intravenous lines (USPIVs), but there are no agreed upon standardized policies. We sought to determine whether the use of sterile-covered transducers (SCT) decreases the rate of contamination when compared to uncovered transducers (UCT) after standard low-level disinfection (LLD). METHODS: This is a randomized control trial comparing contamination rates of US transducers between SCT and UCT after their use for USPIV by the vascular access team, also known as the "PICC" team, over a 3-month period. A sample of admitted patient with an USPIV order were included and randomized to SCT (experimental) or UCT (control) arms. Transducers were swabbed and inserted into the SystemSURE Plus Adenosine Triphosphate (ATP) Luminometer to calculate Relative Light Units (RLU). We performed a cost analysis of requiring sterile covers for USPIVs. RESULTS: The UCT and SCT arms contained 35 and 38 patients, respectively. The SCT group had a mean of 0.34 compared to the UCT group mean of 2.29. Each sterile cover costs $8.49, and over 3000 USPIVs are placed annually by the "PICC" team. CONCLUSION: Contamination rates were similar among the UCT and SCT groups after LLD. 254 inpatient USPIVs are performed monthly, not including failed attempts or covers used in the ED where USPIV placement is an essential part of ED workflow. This study suggests that the use of SCT does not significantly affect transducer contamination rates. These findings question burdensome regulatory hospital policies that are not evidence-based.

International consensus conference recommendations on ultrasound education for undergraduate medical students.

OBJECTIVES: The purpose of this study is to provide expert consensus recommendations to establish a global ultrasound curriculum for undergraduate medical students. METHODS: 64 multi-disciplinary ultrasound experts from 16 countries, 50 multi-disciplinary ultrasound consultants, and 21 medical students and residents contributed to these recommendations. A modified Delphi consensus method was used that included a systematic literature search, evaluation of the quality of literature by the GRADE system, and the RAND appropriateness method for panel judgment and consensus decisions. The process included four in-person international discussion sessions and two rounds of online voting. RESULTS: A total of 332 consensus conference statements in four curricular domains were considered: (1) curricular scope (4 statements), (2) curricular rationale (10 statements), (3) curricular characteristics (14 statements), and (4) curricular content (304 statements). Of these 332 statements, 145 were recommended, 126 were strongly recommended, and 61 were not recommended. Important aspects of an undergraduate ultrasound curriculum identified include curricular integration across the basic and clinical sciences and a competency and entrustable professional activity-based model. The curriculum should form the foundation of a life-long continuum of ultrasound education that prepares students for advanced training and patient care. In addition, the curriculum should complement and support the medical school curriculum as a whole with enhanced understanding of anatomy, physiology, pathophysiological processes and clinical practice without displacing other important undergraduate learning. The content of the curriculum should be appropriate for the medical student level of training, evidence and expert opinion based, and include ongoing collaborative research and development to ensure optimum educational value and patient care. CONCLUSIONS: The international consensus conference has provided the first comprehensive document of recommendations for a basic ultrasound curriculum. The document reflects the opinion of a diverse and representative group of international expert ultrasound practitioners, educators, and learners. These recommendations can standardize undergraduate medical student ultrasound education while serving as a basis for additional research in medical education and the application of ultrasound in clinical practice.

Empowering the willing: the feasibility of tele-mentored self-performed pleural ultrasound assessment for the surveillance of lung health.

BACKGROUND: SARS-CoV-2 infection, manifesting as COVID-19 pneumonia, constitutes a global pandemic that is disrupting health-care systems. Most patients who are infected are asymptomatic/pauci-symptomatic can safely self-isolate at home. However, even previously healthy individuals can deteriorate rapidly with life-threatening respiratory failure characterized by disproportionate hypoxemic failure compared to symptoms. Ultrasound findings have been proposed as an early indicator of progression to severe disease. Furthermore, ultrasound is a safe imaging modality that can be performed by novice users remotely guided by experts. We thus examined the feasibility of utilizing common household informatic-technologies to facilitate self-performed lung ultrasound. METHODS: A lung ultrasound expert remotely mentored and guided participants to image their own chests with a hand-held ultrasound transducer. The results were evaluated in real time by the mentor, and independently scored by three independent experts [planned a priori]. The primary outcomes were feasibility in obtaining good-quality interpretable images from each anatomic location recommended for COVID-19 diagnosis. RESULTS: Twenty-seven adults volunteered. All could be guided to obtain images of the pleura of the 8 anterior and lateral lung zones (216/216 attempts). These images were rated as interpretable by the 3 experts in 99.8% (647/648) of reviews. Fully imaging one's posterior region was harder; only 108/162 (66%) of image acquisitions was possible. Of these, 99.3% of images were interpretable in blinded evaluations. However, 52/54 (96%) of participants could image their lower posterior lung bases, where COVID-19 is most common, with 99.3% rated as interpretable. CONCLUSIONS: Ultrasound-novice adults at risk for COVID-19 deterioration can be successfully mentored using freely available software and low-cost ultrasound devices to provide meaningful lung ultrasound surveillance of themselves that could potentially stratify asymptomatic/paucisymptomatic patients with early risk factors for serious disease. Further studies examining practical logistics should be conducted. TRIAL REGISTRATION: ID ISRCTN/77929274 on 07/03/2015.

Multi-organ point-of-care ultrasound for COVID-19 (PoCUS4COVID): international expert consensus.

COVID-19 has caused great devastation in the past year. Multi-organ point-of-care ultrasound (PoCUS) including lung ultrasound (LUS) and focused cardiac ultrasound (FoCUS) as a clinical adjunct has played a significant role in triaging, diagnosis and medical management of COVID-19 patients. The expert panel from 27 countries and 6 continents with considerable experience of direct application of PoCUS on COVID-19 patients presents evidence-based consensus using GRADE methodology for the quality of evidence and an expedited, modified-Delphi process for the strength of expert consensus. The use of ultrasound is suggested in many clinical situations related to respiratory, cardiovascular and thromboembolic aspects of COVID-19, comparing well with other imaging modalities. The limitations due to insufficient data are highlighted as opportunities for future research.

RESCUE transesophageal echocardiography for monitoring of mechanical chest compressions and guidance for extracorporeal cardiopulmonary resuscitation cannulation in refractory cardiac arrest.

There is a growing interest in using point-of-care transesophageal echocardiography (TEE) during cardiac arrest. TEE is effective at identifying the etiology of sudden cardiovascular collapse and guiding management during the resuscitation. In selected patients with refractory cardiac arrest, extracorporeal cardiopulmonary resuscitation (ECPR) can be considered. ECPR requires percutaneous vascular access for the implantation of veno-arterial extracorporeal membrane oxygenation circuit. We present a case of prolonged cardiac arrest in which rescue TEE was pivotal in narrowing the differential diagnosis, monitoring of mechanical chest compression performance, and guiding cannulation for ECPR.

An Updated Healthcare System-Wide Clinical Pathway for Managing Patients With Chest Pain and Acute Coronary Syndromes.

Clinical pathways reinforce best practices and help healthcare institutions standardize care delivery. The NewYork-Presbyterian/Columbia University Irving Medical Center has used such a pathway for the management of patients with chest pain and acute coronary syndromes for almost 2 decades. A multidisciplinary panel of stakeholders serially updates the algorithm according to new data and recently published guidelines. Herein, we present the 2019 version of the clinical pathway. We explain the rationale for changes to the algorithm and describe our experience expanding the pathway to all the 8 affiliated institutions within the NewYork Presbyterian healthcare system.

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.

Derivation of a pediatric growth curve for inferior vena caval diameter in healthy pediatric patients: brief report of initial curve development.

BACKGROUND: A validated tool has long been sought to provide clinicians with a uniform and accurate method to assess hydration status in the pediatric emergency medicine population. Outpatient clinicians use CDC height- and weight-based curves for the assessment of physical development. In hospital, daily weights provide objective data; however, these are usually not available at presentation.One of the most promising techniques for the rapid assessment of volume is ultrasound (US) to obtain an indexed inferior vena cava diameter (IVCDi); as previously described. Prior studies have focused on IVCDi in dehydrated patients and have shown that it provides accurate estimates of right atrial pressure and volume status. The objective of this study is to derive an IVC growth curve in healthy pediatric patients. METHODS: Prospective cohort design enrolled healthy children between the ages of 4 weeks and 20 years. Patients presenting with fever, illnesses, or diagnoses known to affect the volume will be excluded. All eligible patients under 21, who have provided self or parental written consent, will undergo a brief ultrasound to obtain transverse and long images of both the IVC and the aorta; all scans will be digitally saved. Image quality will be subjectively rated as poor, fair, or good based on wall clarity. Poor quality images will be recorded but may be omitted from our analysis. Five clinicians completed a 1-h introduction to IVC-US and ten supervised scans prior to enrollment. Still images will be measured in order to determine IVCDi in both transverse and longitudinal planes. To assess inter-rater reliability, in 10% of cases, two clinicians will complete scans. All study scans will be over-read by a fellowship-trained sonologist.IVCDi will be plotted independently as functions of age, gender, BMI, and aortic diameter. Within each group, means with means or medians with 95% CIs will be calculated. Following uni- and bivariate analyses and assessment for colinearity, a variety of parametric and nonparametric regression procedures will be conducted. The smoothed curves will be approximated using a modified LMS estimation procedure. RESULTS: Data for the initial curve derivation includes 25 patients ranging from 13 months to 20 years (mean 102 months or 8.5 years). Sixty-five percent of patients were enrolled from the ED, while 35% were enrolled from well-child clinic visits. When evaluating the size of IVC as a function of time linear growth, increasing size was found to proportionately increase with age of patient in months. CONCLUSIONS: Data suggest a linear correlation between IVC size and age. Such data, when plotted as a new growth curve, may allow clinicians to plot a patient's sonographic measurements in order to assess hydration health.

International evidence-based recommendations on ultrasound-guided vascular access.

PURPOSE: To provide clinicians with an evidence-based overview of all topics related to ultrasound vascular access. METHODS: An international evidence-based consensus provided definitions and recommendations. Medical literature on ultrasound vascular access was reviewed from January 1985 to October 2010. The GRADE and the GRADE-RAND methods were utilised to develop recommendations. RESULTS: The recommendations following the conference suggest the advantage of 2D vascular screening prior to cannulation and that real-time ultrasound needle guidance with an in-plane/long-axis technique optimises the probability of needle placement. Ultrasound guidance can be used not only for central venous cannulation but also in peripheral and arterial cannulation. Ultrasound can be used in order to check for immediate and life-threatening complications as well as the catheter's tip position. Educational courses and training are required to achieve competence and minimal skills when cannulation is performed with ultrasound guidance. A recommendation to create an ultrasound curriculum on vascular access is proposed. This technique allows the reduction of infectious and mechanical complications. CONCLUSIONS: These definitions and recommendations based on a critical evidence review and expert consensus are proposed to assist clinicians in ultrasound-guided vascular access and as a reference for future clinical research.

International evidence-based recommendations for point-of-care lung ultrasound.

BACKGROUND: The purpose of this study is to provide evidence-based and expert consensus recommendations for lung ultrasound with focus on emergency and critical care settings. METHODS: A multidisciplinary panel of 28 experts from eight countries was involved. Literature was reviewed from January 1966 to June 2011. Consensus members searched multiple databases including Pubmed, Medline, OVID, Embase, and others. The process used to develop these evidence-based recommendations involved two phases: determining the level of quality of evidence and developing the recommendation. The quality of evidence is assessed by the grading of recommendation, assessment, development, and evaluation (GRADE) method. However, the GRADE system does not enforce a specific method on how the panel should reach decisions during the consensus process. Our methodology committee decided to utilize the RAND appropriateness method for panel judgment and decisions/consensus. RESULTS: Seventy-three proposed statements were examined and discussed in three conferences held in Bologna, Pisa, and Rome. Each conference included two rounds of face-to-face modified Delphi technique. Anonymous panel voting followed each round. The panel did not reach an agreement and therefore did not adopt any recommendations for six statements. Weak/conditional recommendations were made for 2 statements, and strong recommendations were made for the remaining 65 statements. The statements were then recategorized and grouped to their current format. Internal and external peer-review processes took place before submission of the recommendations. Updates will occur at least every 4 years or whenever significant major changes in evidence appear. CONCLUSIONS: This document reflects the overall results of the first consensus conference on "point-of-care" lung ultrasound. Statements were discussed and elaborated by experts who published the vast majority of papers on clinical use of lung ultrasound in the last 20 years. Recommendations were produced to guide implementation, development, and standardization of lung ultrasound in all relevant settings.

Simple, almost anywhere, with almost anyone: remote low-cost telementored resuscitative lung ultrasound.

BACKGROUND: Apnea (APN) and pneumothorax (PTX) are common immediately life-threatening conditions. Ultrasound is a portable tool that captures anatomy and physiology as digital information allowing it to be readily transferred by electronic means. Both APN and PTX are simply ruled out by visualizing respiratory motion at the visceral-parietal pleural interface known as lung sliding (LS), corroborated by either the M-mode or color-power Doppler depiction of LS. We thus assessed how economically and practically this information could be obtained remotely over a cellular network. METHODS: Ultrasound images were obtained on handheld ultrasound machines streamed to a standard free internet service (Skype) using an iPhone. Remote expert sonographers directed remote providers (with variable to no ultrasound experience) to obtain images by viewing the transmitted ultrasound signal and by viewing the remote examiner over a head-mounted webcam. Examinations were conducted between a series of remote sites and a base station. Remote sites included two remote on-mountain sites, a small airplane in flight, and a Calgary household, with base sites located in Pisa, Rome, Philadelphia, and Calgary. RESULTS: In all lung fields (20/20) on all occasions, LS could easily and quickly be seen. LS was easily corroborated and documented through capture of color-power Doppler and M-mode images. Other ultrasound applications such as the Focused Assessment with Sonography for Trauma examination, vascular anatomy, and a fetal wellness assessment were also demonstrated. CONCLUSION: The emergent exclusion of APN-PTX can be immediately accomplished by a remote expert economically linked to almost any responder over cellular networks. Further work should explore the range of other physiologic functions and anatomy that could be so remotely assessed.

A randomized controlled trial of self-management education for asthma patients in the emergency department.

STUDY OBJECTIVE: Patients using the emergency department (ED) for asthma may benefit from self-management education. Our goal is to test an educational intervention in 296 asthma ED patients. METHODS: This was a randomized controlled trial with concealed allocation. Controls received instruction from an asthma knowledge test, peak flowmeter training, and asthma brochures. Intervention patients received these plus a self-management workbook, a behavioral contract, inhaler training, and telephone reinforcements. The main outcome was change in Asthma Quality of Life Questionnaire (AQLQ) score at 8 weeks (a change of 1.5 is a marked clinically important difference). Secondary outcomes were repeated ED visits and change in AQLQ scores at 4, 12, and 16 weeks and 1 year. RESULTS: Mean age of patients was 44 years, and 93% had the 8-week follow-up. Enrollment AQLQ scores were comparable and increased at 8 weeks by more than a marked clinically important difference in both groups. For controls, the change in score was 1.95 (95% confidence interval [CI] 1.74 to 2.16; P<.001), for intervention patients the change in score was 1.83 (95% CI 1.64 to 2.03; P<.001), and the difference between groups was 0.11 (95% CI -0.17 to 0.40; P=.43). Patients who improved more (ie, change was above the group mean) were more likely to be high school graduates (odds ratio=1.9; 95% CI 1.0 to 3.8), previous or current smokers at enrollment (odds ratio=2.2; 95% CI 1.3 to 3.5), and to have been admitted to the hospital from the ED (odds ratio=1.7; 95% CI 1.0 to 2.8). Similar variables were associated with AQLQ outcomes in hierarchic analyses during 16 weeks. Repeated ED visits occurred for 12% of patients at 8 weeks and in multivariate analysis were associated with no hospitalization for the index ED visit, difficult access to outpatient care, and previous ED visits. Fewer patients (16%) had an ED visit at 12 weeks compared with a similar time before enrollment (36%). CONCLUSION: Patients in both groups had marked sustained improvements in clinical status 16 weeks after an ED visit for asthma. A self-management education intervention delivered in the ED and reinforced by telephone was successfully implemented, with high retention rates, but did not provide incremental benefit for quality of life and short-term repeated ED visit outcomes.

Transtracheal 2-d ultrasound for identification of esophageal intubation.

This prospective, blinded, observational, efficacy study is one of the first to evaluate ultrasound in detecting esophageal intubation, a significant source of morbidity and mortality. We utilized a convenience sample of patients undergoing elective surgery during July 2004 in an urban teaching hospital. Trained Emergency Physician sonographers performed transtracheal ultrasounds of intubations to identify esophageal intubation. In 35 of the 40 patients enrolled, there was intubation of the trachea, whereas esophageal intubation occurred in five patients. Sonographers correctly identified all five esophageal intubations, for a sensitivity of 100% (95% confidence interval [CI] 48-100). Ultrasound correctly identified 34 of 35 tracheal intubations and misidentified one resulting in a specificity of 97% (95% CI 90-100). It seems that transtracheal ultrasound may be an efficacious adjunct for detecting esophageal intubation.

Randomized controlled clinical trial of point-of-care, limited ultrasonography for trauma in the emergency department: the first sonography outcomes assessment program trial.

STUDY OBJECTIVE: Annually, 38 million people are evaluated for trauma, the leading cause of death in persons younger than 45 years. The primary objective is to assess whether using a protocol inclusive of point-of-care, limited ultrasonography (PLUS), compared to usual care (control), among patients presenting to the emergency department (ED) with suspected torso trauma decreased time to operative care. METHODS: The study was a randomized controlled clinical trial conducted during a 6-month period at 2 Level I trauma centers. The intervention was PLUS conducted by verified clinician sonographers. The primary outcome measure was time from ED arrival to transfer to operative care; secondary outcomes included computed tomography (CT) use, length of stay, complications, and charges. Regression models controlled for confounders and analyzed physician-to-physician variability. All analyses were conducted on an intention-to-treat basis. Results are presented as mean, first-quartile, median, and third-quartile, with multiplicative change and 95% confidence intervals (CIs), or percentage with odds ratio and 95% CIs. RESULTS: Four hundred forty-four patients with suspected torso trauma were eligible; 136 patients lacked consent, and attending physicians refused enrollment of 46 patients. Two hundred sixty-two patients were enrolled: 135 PLUS patients and 127 controls. There were no important differences between groups. Time to operative care was 64% (48, 76) less for PLUS compared to control patients. PLUS patients underwent fewer CTs (odds ratio 0.16) (0.07, 0.32), spent 27% (1, 46) fewer days in hospital, and had fewer complications (odds ratio 0.16) (0.07, 0.32), and charges were 35% (19, 48) less compared to control. CONCLUSION: A PLUS-inclusive protocol significantly decreased time to operative care in patients with suspected torso trauma, with improved resource use and lower charges.

Randomized controlled trial of single-operator vs. two-operator ultrasound guidance for internal jugular central venous cannulation.

OBJECTIVES: Use of ultrasound guidance for central line placement generally requires two operators: one to hold the transducer and the other to guide the needle. The authors propose a single-operator technique and compare it with the two-operator technique for placement of internal jugular central lines. METHODS: This was a randomized clinical trial conducted from June to September 2004 in a U.S. urban teaching hospital. Enrollment packets were randomized to dynamic single operator (D1) and dynamic two operator (D2). The procedure was performed under ultrasound visualization in the transverse plane. The primary outcome measure was cannulation success. A complete Bayesian analysis using noninformative priors to estimate the probability of similarity of outcomes for D1 and D2 was performed. All variables are reported with 95% confidence intervals (CIs) where appropriate. RESULTS: Forty-four patients were enrolled from the emergency department and intensive care unit. Twenty-three patients were randomized to D1, and 21 to D2. Cannulation success was 96% (95% CI = 85% to 100%) for D1 and 95% (95% CI = 83% to 100%) for D2. There was a 90% probability that the success rates of these two groups differed by less than 10% of each other. CONCLUSIONS: This one-person technique appears to be equivalent to the standard two-person technique for successful ultrasound-guided internal jugular central venous catheterization with respect to overall success.

Randomized, controlled clinical trial of point-of-care limited ultrasonography assistance of central venous cannulation: the Third Sonography Outcomes Assessment Program (SOAP-3) Trial.

CONTEXT: A 2001 Agency for Healthcare Research and Quality Evidence Report on patient safety addressed point-of-care limited ultrasonography guidance for central venous cannulation and strongly recommended real-time, dynamic guidance for all central cannulas. However, on the basis of one limited study, the report dismissed static assistance, a "quick look" with ultrasound to confirm vein location before preparing the sterile field, as unhelpful. OBJECTIVE: The objective of this trial was to compare the overall success rate of central cannula placement with use of dynamic ultrasound (D), static ultrasound (S), and anatomical landmarks (LM). DESIGN AND SETTING: A concealed, randomized, controlled, clinical trial conducted from September 2003 to February 2004 in a U.S. urban teaching hospital. PATIENTS: Two-hundred one patients undergoing internal jugular vein central venous cannulation. INTERVENTIONS: Patients were randomly assigned to three groups: 60 to D, 72 to S, and 69 to LM. An iLook25 SonoSite was used for all imaging. MEASUREMENTS AND MAIN RESULTS: Cannulation success, first-attempt success, and number of attempts were noted. Other measures were vein size and clarity of LM. Results, controlled for pretest difficulty assessment, are stated as odds improvement (95% confidence interval) over LM for D and S. D had an odds 53.5 (6.6-440) times higher for success than LM. S had an odds 3 (1.3-7) times higher for success than LM. The unadjusted success rates were 98%, 82%, and 64% for D, S, and LM. For first-attempt success, D had an odds 5.8 (2.7-13) times higher for first success than LM, and S had an odds 3.4 (1.6-7.2) times higher for first success than LM. The unadjusted first-attempt success rates were 62%, 50%, and 23% for D, S, and LM. CONCLUSIONS: Ultrasound assistance was superior to LM techniques. D outperformed S but may require more training and personnel. All central cannula placement should be conducted with ultrasound assistance. The 2001 Agency for Healthcare Research and Quality Evidence Report dismissing static assistance was incorrect.