Point of care ultrasound: a clinical decision support tool for COVID-19

The COVID-19 global pandemic has overwhelmed health services with large numbers of patients presenting to hospital, requiring immediate triage and diagnosis. Complications include acute respiratory distress syndrome, myocarditis, septic shock, and multiple organ failure. Point of care ultrasound is recommended for critical care triage and monitoring in COVID-19 by specialist critical care societies, however current guidance has mainly been published in webinar format, not a comprehensive review. Important limitations of point of care ultrasound include inter-rater variability and subjectivity in interpretation of imaging findings, as well as infection control concerns. A practical approach to clinical integration of point of care ultrasound findings in COVID-19 patients is presented to enhance consistency in critical care decision making, and relevant infection control guidelines and operator precautions are discussed, based on a narrative review of the literature.

The value of bedside ultrasound and biomarkers in the diagnosis of sepsis-induced myocardial dysfunction and prognosis of septic shock in children / 中国小儿急救医学

Objective:To evaluate the feasibility of using bedside ultrasound and serum biomarkers for the prediction of sepsis-induced myocardial dysfunction(SIMD)and mortality in septic shock patients.Methods:The patients diagnosed as septic shock were enrolled in the study from January 2019 to July 2021 in PICU at Shanghai Children′s Medical Center Affiliated to Shanghai Jiaotong University School of Medicine.Bedside ultrasound results were recorded at day 1, 2, 3, 7 and 10.Blood samples were collected at the same time, markers of myocardial injury were detected, and prognosis was recorded at 28 days.According to the left ventricular ejection fraction (LVEF), children with septic shock were divided into SIMD group and non-SIMD group.Those with LVEF <50% or decreased by ≥10% from baseline level were defined as SIMD.Differences in cardiac ultrasound parameters and biomarkers between two groups were compared.Logistic regression analysis was performed to determine the independent risk factors for SIMD and the independent risk factors for death at 28 days after septic shock.The area under the receiver operating characteristic curve (AUC) was used to evaluate the efficacy of different indicators in predicting SIMD and the death outcome of children with septic shock on 28 days.Results:A total of 57 children were enrolled, including 28 cases in SIMD group and 29 cases in non-SIMD group.Univariate analysis showed that there were statistically significant differences in pediatric critical illness score, N-terminal B-type natriuretic peptide(NT-proBNP), LVEF and left ventricular short axis shortening rate between two groups ( P<0.05). Logistic analysis demonstrated that LVEF( OR=0.890, 95% CI 0.818-0.969, P=0.007)and NT-proBNP ( OR=1.000, 95% CI 1.000-1.000, P=0.015)could independently predict SIMD.There were 42 cases in survival group and 15 in non-survival group according to the prognosis on 28 days.Univariate analysis showed that there were significant differences in pediatric risk mortality score Ⅲ, pediatric sequential organ failure assessment, cardiac troponin I, and mitral annular plane systolic excursion(MAPSE)( P<0.05). Logistic analysis showed that only MAPSE independently predicted mortality( OR=85.670, 95% CI 1.685-4 356.736, P=0.026). Compared with MAPSE(AUC=0.727), MAPSE combined with pediatric risk mortality score Ⅲ, pediatric sequential organ failure assessment, cardiac troponin I(AUC=0.926) could be better to predict the 28 days prognosis of patients with septic shock on 28 days. Conclusion:NT-proBNP increases significantly in the early stage of SIMD.MAPSE shows no difference between SIMD and non-SIMD patients.MAPSE is correlated with the prognosis of patient with septic shock.

Reinforcing the valuable role of gastric ultrasound for volume and content assessment: an observational study

Abstract Background Pulmonary aspiration is one of the most important complications in anesthesiology. Assessment of gastric content by ultrasound is a good method to quantify gastric volume and to determine the risk of intraoperative pulmonary aspiration. The aim of this study is to determine the accuracy of the gastric ultrasonography in the qualitative analysis of gastric content, mainly in the analysis of small amounts of liquid content. Methods Gastric ultrasound was performed to 36 patients before upper gastrointestinal endoscopy (UGI), making two longitudinal scans at the epigastric level, one in supine position and the other in right lateral decubitus position, measuring two diameters and the area of the gastric antrum and assessing the content characteristics determining whether it was an empty stomach or contained fluid or solid content. Subsequently, the ultrasound findings were compared with UGI findings. Results Gastric areas were analyzed by the trace and the lengths of the craniocaudal and anteroposterior axes concluding that there are no significant differences between the two methods. No statistically significant difference was found between UGI and US assessment technics. No statistically significant difference was found between the estimated volume by UGI and US. Conclusions Though our study has some limitations, qualitative analysis of gastric content using ultrasound followed by endoscopy enabled the conclusion that there are no differences in the qualitative assessment regarding these two techniques, supporting the important role of point-of-care gastric ultrasound (POCGUS) in the assessment of pulmonary aspiration risk by the anesthesiologist in the perioperative period.

Utility of E Point Septal Separation as Screening Tool for Left Ventricular Ejection Fraction in Perioperative Settings by Anesthetists

Background and Aims:Left ventricular (LV) systolic dysfunction is a common cause of hemodynamic disturbance perioperatively and is associated with increased morbidity and mortality. Echocardiographic evaluation of left ventricular systolic function (LVSF) has great clinical utility. This study was aimed to test the hypothesis that LVSF assessed by an anesthetist using mitral valve E Point Septal Separation (EPSS) has a significant correlation with that assessed using modified Simpson’s method perioperatively. Methods: This prospective observational study included 100 patients scheduled for elective surgeries. Transthoracic echocardiography (TTE) was performed preoperatively within 24 hours of surgery by an anesthetist as per American Society of Echocardiography (ASE) guidelines.EPSS measurements were obtained in parasternal long?axis view while volumetric assessment of LV ejection fraction (EF) used apical four?chamber view.Bivariate analysis of EPSS and LV EF was done by testing Pearson correlation coefficient.Receiver Operating Characteristic (ROC) curve constructed to obtain area under curve (AUC) and Youden’s Index. Results: The mean value of mitral valve EPSS was 7.18 ± 3.95 mm. The calculated mean LV EF value using volumetric analysis was 56.31 ± 11.92%. LV dysfunction as per ASE guidelines is present in 28% of patients. EPSS was statistically significantly related to LV EF negatively with a Pearson coefficient of ?0.74 (P < 0.0001).AUC of ROC curve 0.950 (P < 0.0001) suggesting a statistically significant correlation between EPSS and LV EF.Youden’s index of EPSS value 7 mm was obtained to predict LV systolic dysfunction. Conclusion: Mitral valve EPSS shows a significant negative correlation with gold standard LVEF measurement for LVSF estimation. It can very well be used to assess LVSF perioperatively by anesthetists with brief training.

Perioperative POCUS when the heart stops: futility or utility? / POCUS perioperatorio cuando el corazón se detiene: ¿sirve o no sirve?

Abstract: The incidence of cardiac arrest associated with anesthesia is approximately 5.6 per 10,000 cases and the precipitating causes are often known. Transesophageal echocardiography is the modality of choice during unexplained hemodynamic instability or cardiac arrest; but its utility is limited by the need of extensive user training. On the other hand, surface ultrasound has the advantage of simpler user training requirements and offers evaluation of multiple organs. Although its use intraoperatively is limited by poor access to the patient, and postoperatively by dressing and air, it still can be feasible if transesophageal echocardiography is not possible. This manuscript develops a protocol for using POCUS during a cardiac arrest, and emphasizes practical tips for image acquisition and communication of its interpretation.

Resumen: La incidencia de paro cardíaco asociado a la anestesia es de aproximadamente 5.6 por 10,000 casos y las causas son a menudo desconocidas. La ecocardiografía transesofágica es la modalidad de elección durante la inestabilidad hemodinámica no explicada; pero su utilidad es limitada por la necesidad de un entrenamiento extensivo del usuario. Por otra parte, el ultrasonido de superficie tiene la ventaja de requerimientos de entrenamiento más simples y ofrece la evaluación de múltiples órganos. Aunque su uso intraoperatorio es limitado por el pobre acceso al paciente y postoperatoriamente por los apósitos y el aire, ésta puede ser confiable si la ecocardiografía tran-s-esofágica no es posible.

Application of point-of-care cardiopulmonary ultrasound in mechanical ventilation of neonatal respiratory distress syndrome / 中华超声影像学杂志

Objective:To explore the value of point-of-care cardiopulmonary ultrasound (POCUS) in the evaluation of modifying mechanical ventilation and weaning timing of neonates with respiratory distress syndrome (RDS).Methods:A total of 82 infants with RDS received invasive mechanical ventilation in the neonatal intensive care unit of the First Affiliated Hospital of Nanjing Medical University from January 2019 to October 2020 were enrolled.Endotracheal tube was extubated after getting in line with the clinical weaning standard. According to the results of ventilator withdrawal, infants were divided into successful group and failure group. POCUS were performed within half hour of intubation and extubation. Lung ultrasound score (LUS), left ventricular ejection fraction (LVEF), tricuspid annular plane systolic excursion (TAPSE), left ventricular eccentricity index (LVEI) and pulmonary artery systolic pressure (PASP) were recorded also with the arterial blood gas, ventilator parameters, duration of mechanical ventilation and oxygen therapy. The above indexes were compared between two groups to evaluate the predictive value of POCUS for mechanical ventilation evacuation.Results:The gestational age [(28.6±4.2)W vs (32.5±3.7)W], body weight [(1 289±790)g vs (1 969±771)g], initial ventilation PaO 2 [(41.2±8.5)mmHg vs (50.1±12.2)mmHg], LVEF of ventilator withdrawal[(62.7±3.9)% vs (66.9±3.1)%] of the failed weaning group were lower than those of successful group (all P<0.05). LUS at ventilator withdrawal[(13.7±1.0) points vs (11.1±1.6) points], PASP [(40.5±7.2)mmHg vs (32.9±6.2)mmHg] and the duration of mechanical ventilation [(5.4±4.7)d vs (3.6±2.3)d], duration of oxygen therapy [(48.5±25.0)d vs (24.5±18.5)d] were higher than those of successful group (all P<0.05). The initial LUS of mechanical ventilation was positively correlated with the duration of mechanical ventilation ( r=0.188, P<0.01), and TAPSE was negatively correlated with the duration of mechanical ventilation ( r=-0.344, P<0.01). LUS was positively correlated with X-ray grading and mean airway pressure at the initial and withdrawal time ( rs=0.790, P<0.01 and rs=0.686, P<0.01; r=0.383, P<0.01 and r=0.548, P<0.01). To assess LUS prediction of weaning failure, the area under ROC curve (AUC) was 0.922, and the combined ΔLUS (change of pre- and post-LUS ) ≤7 points and ΔPASP (change of pre- and post-PASP) ≤9.5 mmHg predicted AUC was 0.912. Prediction of AUC by using LUS combining PASP and LVEF was 0.937, Youden index was 0.736, the cut-off value was 0.185, with sensitivity 89.5% and the specificity 84.1%. LUS≥13 points, PASP≥43 mmHg and LVEF≤60% were related to weaning failure by using the Logistic regression analysis (all P<0.05). Conclusions:Bedside POCUS can effectively evaluate the application of mechanical ventilation process and predict the weaning of infants with RDS. POCUS is practical, real-time, accurate, and worthy of clinical application.

Interpretation of International Evidence-based Guideline on Point-of-Care Ultrasound for Critically Ill Neonates and Children Issued by the European Society of Paediatric and Neonatal Intensive Care / 中国小儿急救医学

In 2020, the European Society of Paediatric and Neonatal Intensive Care first issued the international point-of-care ultrasound(POCUS) guideline for the critically ill newborns and children, which provided an evidence-based foundation to standardize the use of POCUS in the critically ill neonates and children.It has been widely recognized by neonatology and pediatric critical physicians worldwide.In order to keep our domestic colleagues updated and promote the POCUS application based on this international standard, the guideline was summarized and interpreted in this review.

New fields and progress of ultrasound imaging used in diagnosis and therapy / 中国医师杂志

With the continuous development of ultrasound equipment and imaging technology, the application of ultrasound imaging technology is more and more wide, and gradually covers the whole process of disease diagnosis and treatment. Focusing on the highlights of ultrasound development, this article briefly introduces the new fields and new progress of clinical application of ultrasound from interventional ultrasound, point-of-care ultrasound, and musculoskeletal ultrasound.

Neonatal & Paediatric Point Of Care Ultrasound (Pocus): A Novel Standard Practice

An ever expanding branch of applications have been developed for ultrasound, including its goal directed use at the bedside, often called point-of-care ultrasound (POCUS). Although neonatologist-performed functional echocardiography has been at the frontline of the worldwide growth of POCUS, a rapidly growing body of evidence has also demonstrated the importance of non-cardiac applications, including guidance of placement of central catheterisation and lumbar puncture, endotracheal tube localisation as well as rapid estimation of the brain, lungs, bladder and bowel. Ultrasonography has become a pivotal adjunct to the care of neonates in the neonatal intensive care unit (NICU); but a full appreciation for its diagnostic capabilities in the NICU is lacking. Ultrasonography (USG) is no longer the exclusive domain of radiologists and cardiologists. With appropriate training, clinician performed ultrasound (CPU) is now practised widely in obstetrics, emergency medicine and adult intensive care .In many developed countries, it is standard practice in neonatology. In this review, we will discuss neonatal & paediatric point of care ultrasound (POCUS) as a novel standard practice & its clinical application for assessment of the head, heart, lung, gut and bladder for vascular line localization & for endotracheal tube placement. As new applications and adoption of point-of-care ultrasound continues to gain acceptance in paediatric and neonatal medicine throughout the world, a rapidly growing body of evidence suggests that the result will be faster, safer and more successful diagnosis and treatment of our patients.

Advance in Point-of-care Ultrasound for Pulmonary Rehabilitation in Critically Ill Patients (review) / 中国康复理论与实践

In addition to primary diseases, critically ill patients often suffered from multiple functional disorders, including pulmonary dysfunction. Pulmonary rehabilitation can effectively improve the lung and overall function of patients, which need assistance of relevant examinations. Point-of-care ultrasound (POCUS) can not only help to diagnose, evaluate, monitor and treat the disease faster, more accurate and safer, but also reduce the adverse events resulting from handling, activities and radiation, which is applied more extensively in critical patients accepting pulmonary rehabilitation.

Impact of point-of-care cardiopulmonary ultrasound on treatment change in critically ill patients: assessment of 1 913 cases in a multicentric, prospective study / 中华超声影像学杂志

Objective:To describe the features of point-of-care cardiopulmonary ultrasound (POCUS) in the critically ill patients and analyze the independent factors associated with treatment changes after POCUS assessment.Methods:This was a prospective multicentric observational study from January to December 2018 in 13 intensive care units (ICU) in China. Consecutive patients admitted to the ICU were enrolled, POCUS were performed within the first 24 h of admission. The POCUS parameters included acute or chronic cardiac abnormality, diameter of inferior vena cava (IVC) at end-expiration, right ventricular systolic function, systolic and diastolic function of left ventricle (LV) and lung ultrasound score. The general features of patients and performers were recorded. Based on the treatment proposed by the performer before and after POCUS assessment, the patients were divided into treatment changed and unchanged groups. Factors associated with treatment changes were identified by multiple logistic regression analysis.Results:Totally 1 913 patients were enrolled including 322 (16.8%) patients with shock, 638 (33.3%) patients with respiratory failure, 139 (7.3%) patients with both shock and respiratory failure and 814 (42.6%) perioperative patients. POCUS had contributed to treatment changes in 1 204 (62.9%) patients, including 867 (72.0%) cases involved fluid management. Univariate analysis showed that there were significant differences in general characteristics of patients, performers and POCUS parameters between groups(all P<0.05). Logistic regression analysis showed that independent factors of treatment changes included ministry of education or university affiliated teaching hospitals (vs.general hospitals, OR=1.891, 95% CI=1.314-2.722, P<0.001 and OR=1.644, 95% CI=1.152-2.347, P=0.006 separately), middle and senior title performers (vs.primary title, OR=2.112, 95% CI=1.358-3.284, P=0.001, OR=3.271, 95% CI=2.129-5.025, P<0.001 separately), mechanical ventilation (vs.without, OR=0.488, 95% CI 0.381-0.626, P<0.001), IVC diameter ≤1 cm (vs.1-2 cm, OR=0.317, 95% CI 0.231-0.434, P<0.001), LV ejecting fraction <50% (vs.≥50%, OR=0.328, 95% CI=0.210-0.512, P<0.001), lung ultrasound score of 6-12 and >12 points(vs.score ≤ 6 points, OR=0.237, 95% CI=0.178-0.315, P<0.001 and OR=0.619, 95% CI=0.457-0.837, P=0.002 separately). Conclusions:POCUS assessment contributes to treatment changes, most of which involves fluid management strategy, in 62.9% critical patients. The independent influencing factors associated with POCUS parameters includes IVC diameter at end-expiratory, LV systolic function and lung ultrasound score. The performers′ title and hospital grade also have a noticeable effect.

Clinical value of point of care ultrasound on cardiac output and volume responsiveness in patients with septic shock / 中华危重病急救医学

Objective:To assess the value of point of care ultrasound on cardiac output (CO) and volume responsiveness in patients with septic shock.Methods:A prospective investigation study was conducted. Twenty-four mechanical ventilation patients with septic shock who needed pulse-indicated continuous cardiac output (PiCCO) monitoring in the department of critical care medicine of Zhengzhou University People's Hospital, Henan Provincial People's Hospital from November 25, 2020 to April 30, 2021 were selected as the subjects, the patient's basic information and laboratory test results were recorded. PiCCO was used as standard to monitor CO and stroke volume variability (SVV) at 0, 2, 6, 12, 24 and 48 hours. At the same time, point of care transthoracic echocardiography (TTE) was used to measure velocity time integral (VTI) and inferior vena cava diameter (dIVC), the CO, VTI variation rate (△VTI) and dIVC variation rate (△dIVC) were calculated. Then, using the value monitored by PiCCO as the standard, the consistency and correlation analysis were carried out between point of care ultrasound with PiCCO.Results:Twenty-two out of 24 patients obtained satisfactory ultrasound Doppler images, the heart rate (HR), mean arterial pressure (MAP) and body temperature of the enrolled patients were consistent with the pathophysiological characteristics of septic shock. With the extension of treatment time, HR and CO both gradually decreased, and MAP gradually increased, reaching a peak or trough at 48 hours after admission. The difference were statistically significant compared with the time of admission [HR (bpm): 90.36±15.35 vs. 116.82±19.82, MAP (mmHg, 1 mmHg = 0.133 kPa): 87.82±11.06 vs. 58.82±9.85, CO (L/min): 4.80±0.56 vs. 6.78±1.31, all P < 0.05]. The CO obtained by PiCCO and point of care ultrasound had good agreement [5.36 (4.78, 6.33) L/min and 5.21 (4.88, 6.35) L/min, respectively], the average difference value at each time point was (-0.02±0.69) L/min, the 95% agreement limit range was -1.35-1.34, and there was a high degree of correlation ( rs = 0.800, P < 0.001); The SVV by PiCCO and the △dIVC by point of care ultrasound were in good agreement [18.00% (14.00%, 24.00%) and 21.00% (14.00%, 25.75%), respectively], the average difference value at the time point was (-3.16±6.89)%, the 95% agreement limit range was -16.89-10.54, and there was a moderate correlation ( rs = 0.702, P < 0.001); The SVV by PiCCO and the △VTI by point of care ultrasound were in good agreement [18.00% (14.00%, 24.00%) and 16.00% (11.25%, 20.75%), respectively], the average difference value at each time point was (13.03±14.75)%, and the 95% agreement limit range was 1.72-27.78, and there was a high correlation ( rs = 0.918, P < 0.001). Conclusion:Point of care ultrasound can accurately assess CO and volume responsiveness of patients with septic shock, and the △VTI is better than the △dIVC in assessing volume responsiveness.

What is the ideal approach for emergent pericardiocentesis using point-of-care ultrasound guidance? / 世界急诊医学杂志（英文）

@#BACKGROUND: Traditionally performed using a subxiphoid approach, the increasing use of point-of-care ultrasound in the emergency department has made other approaches (parasternal and apical) for pericardiocentesis viable. The aim of this study is to identify the ideal approach for emergency-physician-performed ultrasound-guided pericardiocentesis as determined by ultrasound image quality, distance from surface to pericardial fluid, and likely obstructions or complications. METHODS: A retrospective review of point-of-care cardiac ultrasound examinations was performed in two urban academic emergency departments for the presence of pericardial effusions. The images were reviewed for technical quality, distance of effusion from skin surface, and predicted complications. RESULTS: A total of 166 pericardial effusions were identified during the study period. The mean skin-to-pericardial fluid distance was 5.6 cm (95% confidence interval [95% CI] 5.2-6.0 cm) for the subxiphoid views, which was significantly greater than that for the parasternal (2.7 cm [95% CI 2.5-2.8 cm], P<0.001) and apical (2.5 cm [95% CI 2.3-2.7 cm], P<0.001) views. The subxiphoid view had the highest predicted complication rate at 79.7% (95% CI 71.5%-86.4%), which was significantly greater than the apical (31.9%; 95% CI 21.4%-44.0%, P<0.001) and parasternal (20.2%; 95% CI 12.8%-29.5%, P<0.001) views. CONCLUSIONS: Our results suggest that complication rates with pericardiocentesis will be lower via the parasternal or apical approach compared to the subxiphoid approach. The distance from skin to fluid collection is the least in both of these views.

Caso clínico. Ultrasonografía pulmonar en paciente Covid-19 en hospital de baja complejidad / Lung ultrasound in covid-19 patient in a low complexity hospital: Case report

In the current SARS-CoV-2 pandemic, it has become imperative to develop instruments for lung evaluation that are fast and efficient; in this sense, lung ultrasonography is presented as an effective instrument that can be extrapolated to low complexity centers that allow to guide management of Covid-19 patients.

En la pandemia por SARS-CoV-2 que vivimos actualmente se ha hecho imperante desarrollar instrumentos para la evaluación pulmonar que sean rápidos y eficientes, en este sentido la ultrasonografía pulmonar se presenta como un instrumento eficaz extrapolable a centros de baja complejidad que permitan guiar manejo de pacientes Covid-19.

Focused cardiac ultrasound in anesthetic practice: technique and indications / Ultrassom cardíaco focado na prática anestésica: técnica e indicações

Abstract The use of ultrasonography is well established in several anesthesia sub-specialties. Recently, there has been a major expansion of the POC (Point-Of-Care) ultrasound technique in intensive care, surgery, and emergency medicine, corroborating that USPOC in perioperative medicine has a much more comprehensive capability for both providing improved hemodynamic monitoring and early diagnosis of complications. The objective of the present article was to describe the use of a USPOC modality (focused cardiac US) that can be used for bedside assessment of unstable patients. Within a specific list of diagnoses, clinical treatment for a given situation can be tailored according to ultrasound findings, and by using binary and simple questions. Perioperative focused cardiac US use by the anesthesiologist has been related to lower rates of complications and mortality in high-risk patients.

Resumo O uso da ultrassonografia na prática anestésica já é bem estabelecido com a sua utilização em diversas subespecialidades. Recentemente, houve uma grande disseminação da técnica de ultrassonografia POC (point-of-care) nas áreas de medicina intensiva, cirurgia e medicina de urgência, confirmando que o seu uso em medicina perioperatória tem um potencial muito mais abrangente tanto para melhor monitorização hemodinâmica, como também para diagnóstico precoce de complicações. O objetivo deste artigo é descrever a utilização de uma modalidade de USPOC (ultrassom cardíaco focado) que pode ser utilizado à beira do leito com o objetivo de avaliar o paciente instável e, dentro de uma lista específica de diagnósticos, individualizar o tratamento clínico para determinada situação com base nos achados ultrassonográficos utilizando-se de questões de caráter binário e simples, sendo que o seu uso pelo anestesiologista no período perioperatório está relacionado a menores taxas de complicações e mortalidade em pacientes de alto risco.

Retrospective analysis of eFAST ultrasounds performed on trauma activations at an academic level-1 trauma center / 世界急诊医学杂志（英文）

BACKGROUND@#Point-of-care ultrasound (POCUS) has become increasingly integrated into the practice of emergency medicine. A common application is the extended focused assessment with sonography in trauma (eFAST) exam. The American College of Emergency Physicians has guidelines regarding the scope of ultrasound in the emergency department and the appropriate documentation. The objective of this study was to conduct a review of performed, documented and billed eFAST ultrasounds on trauma activation patients.@*METHODS@#This was a retrospective review of all trauma activation patients during a 10-month period at an academic level-one trauma center. A list comparing all trauma activations was crossreferenced with a list of all billed eFAST scans. Medical records were reviewed to determine whether an eFAST was indicated, performed, and appropriately documented.@*RESULTS@#We found that 1,507 of 1,597 trauma patients had indications for eFAST, but 396 (27%) of these patients did not have a billed eFAST. Of these 396 patients, 87 (22%) had documentation in the provider note that an eFAST was performed but there was no separate procedure note. The remaining 309 (78%) did not have any documentation of the eFAST in the patient’s chart although an eFAST was recorded and reviewed during ultrasound quality assurance.@*CONCLUSION@#A significant proportion of trauma patients had eFAST exams performed but were not documented or billed. Lack of documentation was multifactorial. Emergency ultrasound programs require appropriate reimbursement to support training, credentialing, equipment, quality assurance, and device maintenance. Our study demonstrates a significant absence of adequate documentation leading to potential revenue loss for an emergency ultrasound program.

Utilization of Point-of-care Ultrasound (POCUS) in Outpatient and Home Settings / 日本プライマリ・ケア連合学会誌

Point-of-care ultrasound (POCUS) as a physical examination was performed using a pocket-sized ultrasound device (pocket echo) for internal medicine outpatients at general hospitals and home care patients. The combination of lectures and hands-on learning was required for technical understanding. Securing time during the consultation was not difficult by determining the protocol and examining for abnormal findings at the specified sites. Cost reduction is desired in order for one pocket echo device to be available for each practitioner.

Non-Invasive Intracranial Pressure Evaluation in an Emergency Room ­ Point-of-Care Ultrasonography

Point-of-care ultrasound ismodifying conducts in emergency care. The variousmedical specialties, in addition to traditional indications in cases of multiple trauma, are using this technique for rapid diagnosis at the bedside without patient mobilization and without radiation. Point-of-care ultrasound in neurocritical patients, through its transorbital window, can estimate the intracranial pressure by a non-invasive method. Through the measurement of the diameter of the optic nerve sheath 3mmposterior to the retina, the intracranial pressure is estimated if the value of the diameter is >5mm, as it has been verified in other studies. The present article describes the most current data on this topic, and it also highlights the need formoremulticentric and randomized trials to determine the correct cut-off points that represent the high sensibility and specificity of the method.

Can emergency physicians perform extended compression ultrasound for the diagnosis of lower extremity deep vein thrombosis? / 世界急诊医学杂志（英文）

BACKGROUND@# Current point-of-care ultrasound protocols in the evaluation of lower extremity deep vein thrombosis (DVT) can miss isolated femoral vein clots. Extended compression ultrasound (ECUS) includes evaluation of the femoral vein from the femoral vein/deep femoral vein bifurcation to the adductor canal. Our objective is to determine if emergency physicians (EPs) can learn ECUS for lower extremity DVT evaluation after a focused training session.@*METHODS@# Prospective study at an urban academic center. Participants with varied ultrasound experience received instruction in ECUS prior to evaluation. Two live models with varied levels of difficult sonographic anatomy were intentionally chosen for the evaluation. Each participant scanned both models. Pre- and post-study surveys were completed.@*RESULTS@# A total of 96 ultrasound examinations were performed by 48 participants (11 attendings and 37 residents). Participants’ assessment scores averaged 95.8% (95% CI 93.3%–98.3%) on the easier anatomy live model and averaged 92.3% (95% CI 88.4%–96.2%) on the difficult anatomy model. There were no statistically significant differences between attendings and residents. On the model with easier anatomy, all but 1 participant identified and compressed the proximal femoral vein successfully, and all participants identified and compressed the mid and distal femoral vein. With the difficult anatomy, 97.9% (95% CI 93.8%–102%) identified and compressed the proximal femoral vein, whereas 93.8% (95% CI 86.9%–100.6%) identified and compressed the mid femoral vein, and 91.7% (95% CI 83.9%–99.5%) identified and compressed the distal femoral vein.@*CONCLUSION@# EPs at our institution were able to perform ECUS with good reproducibility after a focused training session.

Can an 8th grade student learn point of care ultrasound? / 世界急诊医学杂志（英文）

BACKGROUND@# Point-of-care ultrasound has gained widespread use in developing countries due to decreased cost and improved telemedicine capabilities. Ultrasound training, specifically image acquisition skills, is occurring with more frequency in non-medical personnel with varying educational levels in these underdeveloped areas. This study evaluates if students without a high school education can be trained to acquire useful FAST images, and to determine if an 8th grade student can teach peers these skills.@*METHODS@# The 8th grade students at a small middle school were divided into two groups. One group received training by a certified medical sonographer, while the other group received training by a peer 8th grade student trainer who had previously received training by the sonographer. After training, each student was independently tested by scanning the four FAST locations. A blinded ultrasound expert evaluated these images and deemed each image adequate or inadequate for clinical use.@*RESULTS@# Eighty video image clips were obtained. The overall image adequacy rate was 74%. The splenorenal window had the highest rate at 95%, followed by retrovesical at 90%, hepatorenal at 75%, and subxiphoid cardiac at 35%. The adequacy rate of the sonographer-trained group was 78%, while the adequacy rate of the student-trained group was 70%. The difference in image adequacy rate between the two groups was not significant (P-value 0.459).@*CONCLUSION@# The majority of 8th graders obtained clinically adequate FAST images after minimal training. Additionally, the student-trained group performed as well as the sonographer-trained group.