Carotid Ultrasound in Assessing Fluid Responsiveness in Patients with Hypotension and Suspected Sepsis.

PURPOSE: We sought to assess whether ultrasound (US) measurements of carotid flow time (CFTc) and carotid blood flow (CBF) predict fluid responsiveness in patients with suspected sepsis. METHODS: This was a prospective observational study of hypotensive (systolic blood pressure < 90) patients "at risk" for sepsis receiving intravenous fluids (IVF) in the emergency department. US measurements of CFTc and CBF were performed at time zero and upon completion of IVF. All US measurements were repeated after a passive leg raise (PLR) maneuver. Fluid responsiveness was defined as normalization of blood pressure without persistent hypotension or need for vasopressors. RESULTS: A convenience sample of 69 patients was enrolled. The mean age was 65; 49% were female. Fluid responders comprised 52% of the cohort. CFTc values increased significantly with both PLR (P = 0.047) and IVF administration (P = 0.003), but CBF values did not (P = 0.924 and P = 0.064 respectively). Neither absolute CFTc or CBF measures, nor changes in these values with PLR or IVF bolus, predicted fluid responsiveness, mortality, or the need for intensive care unit admission. CONCLUSION: In patients with suspected sepsis, a fluid challenge resulted in a significant change in CFTc, but not CBF. Neither absolute measurement nor delta measurements with fluid challenge predicted clinical outcomes.

A novel measure for characterizing ultrasound device use and wear.

Point-of-care ultrasound (POCUS) equipment management is critical in optimizing daily clinical operations in emergency departments (EDs). Traditional consultative ultrasound laboratories are well practiced at operations management, but this is not the case for POCUS programs, because machine upgrade and replacement metrics have not been developed or tested. We present a data-driven method for assessment of POCUS equipment maintenance and replacement named the ULTrA (a data-driven approach to point-of-care ultrasound upgrade) score. This novel model of assessing each ultrasound machine by quantitative scoring in each of four mostly objective categories: use (U), likeability (L), trustworthiness (Tr), and age (A). We propose the ULTrA model as a method to identify underperforming devices which could be upgraded or eliminated, and to compare relative performance amongst a group of departmental ultrasound machines. This composite score may be a useful objective tool that could replace individual proxies for clinical effectiveness, such as age, use, or individual provider preference. Additional research in multiple centers would be needed to refine and validate the ULTrA score. Once fully developed, the ULTrA score could be deployed in EDs and other clinical settings where POCUS is used to help streamline resources to maintain a functional and state-of-the-art fleet of ultrasound machines over time.

Clinical Integration of Point-of-care Ultrasound by Emergency Medicine Residents: A Single-center Mixed-methods Study.

BACKGROUND: Point-of-care ultrasound (POCUS) competence consists of image acquisition, image interpretation, and clinical integration. Limited data exist on POCUS usage patterns and clinical integration by emergency medicine (EM) residents. We sought to determine actual POCUS usage and clinical integration patterns by EM residents and to explore residents' perspectives on POCUS clinical integration. METHODS: We conducted an explanatory sequential mixed-methods study at a 4-year EM residency program. In phase 1, EM ultrasound (US) attendings observed PGY-4 EM residents' clinical integration of POCUS in real time while on shift in the emergency department (ED). EM US attendings evaluated residents on their intent to perform POCUS, actual POCUS usage, and competence per patient encounter. We used logistic regression to analyze these parameters. In phase 2, we conducted semi-structured interviews with the observed PGY-4 residents regarding POCUS usage and clinical integration in the ED. We analyzed qualitative data for themes. RESULTS: Emergency medicine US attendings observed 10 PGY-4 EM residents during 254 high-acuity patient encounters from December 2018 to March 2019. EM US attendings considered POCUS indicated for 26% (66/254) of patients, possibly indicated for 12% (30/254) and not indicated for 62% (158/254). Of the 66 patients for whom EM US attendings considered POCUS indicated, PGY-4s intended to perform POCUS for patient management 61% (40/66) of the time. PGY-4s subsequently incorporated POCUS into patient management 73% (48/66) of the time. EM US attendings considered PGY-4s entrustable to perform POCUS independently 81% (206/254) of the time. We did not find a statistically significant association between shift volume, shift type, or POCUS application, and resident intent to perform POCUS nor competence. Interviews identified three factors that influence PGY-4's POCUS clinical integration: motivations to use POCUS, barriers to utilization, and POCUS educational methods. CONCLUSIONS: This mixed-methods study identified a significant gap in POCUS utilization and clinical integration by PGY-4 EM residents for clinically indicated cases identified by EM US attendings. As clinical integration is a cornerstone of POCUS competence, it is important to ensure that EM resident POCUS curricula emphasize training on clinical utilization and indications for POCUS while on shift in the ED.