Structured Reporting of Whole-Body Trauma CT Scans Using Checklists: Diagnostic Accuracy of Reporting Radiologists Depending on Their Level of Experience. / Strukturierte Befundung von Polytrauma-CTs mit Checklisten: Diagnostische Genauigkeit in Abhängigkeit von der Erfahrung des Radiologen.

PURPOSE: Evaluation of the diagnostic accuracy of a checklist-style structured reporting template in the setting of whole-body multislice computed tomography in major trauma patients depending on the level of experience of the reporting radiologist. MATERIALS AND METHODS: A total of 140 major trauma scans with the same protocol were included in this retrospective study. In a purely trial-intended reading, the trauma scans were analyzed by three radiologists with different levels of experience (resident, radiologist with 3 years of experience after board certification, and radiologist with 7 years of experience after board certification). The aim was to fill in the checklist 1 template within one minute to immediately diagnose management-altering findings. Checklist 2 was intended for the analysis of important trauma-related findings within 10 minutes. Reading times were documented. The final radiology report and the documented injuries in the patient's medical record were used as gold standard. RESULTS: The evaluation of checklist 1 showed a range of false-negative reports between 5.0 % and 11.4 % with the resident showing the highest accuracy. Checklist 2 showed overall high diagnostic inaccuracy (19.3-35.0 %). The resident's diagnostic accuracy was statistically significantly higher compared to the radiologist with 3 years of experience after board certification (p = 0.0197) and with 7 years of experience after board certification (p = 0.0046). Shorter average reporting time resulted in higher diagnostic inaccuracy. Most of the missed diagnoses were fractures of the spine and ribs. CONCLUSION: By using a structured reporting template in the setting of major trauma computed tomography, less experienced radiologists reach a higher diagnostic accuracy compared to experienced readers. KEY POINTS: · In the setting of a pure trial reading, the diagnostic inaccuracy of template-based reporting of major trauma CT examinations is high.. · Fractures in general and especially of the vertebral bodies and ribs were the most commonly missed diagnoses.. · In a study setting, less experienced radiologists seem to reach a higher diagnostic accuracy when using a structured reporting approach.. CITATION FORMAT: · Dendl LM, Pausch AM, Hoffstetter P et al. Structured Reporting of Whole-Body Trauma CT Scans Using Checklists: Diagnostic Accuracy of Reporting Radiologists Depending on Their Level of Experience. Fortschr Röntgenstr 2021; 193: 1451 - 1460.

A systematic database-derived approach to improve indexation of transpulmonary thermodilution-derived global end-diastolic volume.

Global end-diastolic volume (GEDV) has been indexed to body surface area (BSA). However, data validating this indexation of GEDV are scarce. Furthermore, it has been suggested to index GEDV to "predicted BSA" based on predicted body weight. Therefore, we aimed to identify biometric parameters independently associated with GEDV. We analyzed a database including 3812 TPTD measurements in 234 patients treated in the ICU of a German university hospital. GEDVI indexed to actual BSA was significantly lower than GEDVI indexed to predicted BSA (748 ± 179 vs. 804 ± 190 mL/m2; p < 0.001). GEDV was independently associated with older age, male sex, height, and actual body weight. In a regression model for the estimation of GEDV, age and height were the most important parameters: Each year in age and each cm in height increased GEDV by 9 and 15 mL, respectively. In addition to height and weight also age and sex should be considered for indexation of GEDV.

Femoral indicator injection for transpulmonary thermodilution using the EV1000/VolumeView(®): do the same criteria apply as for the PiCCO(®)?

OBJECTIVE: Comparison of global end-diastolic volume index (GEDVI) obtained by femoral and jugular transpulmonary thermodilution (TPTD) indicator injections using the EV1000/VolumnView(®) device (Edwards Lifesciences, Irvine, USA). METHODS: In an 87-year-old woman with hypovolemic shock and equipped with both jugular and femoral vein access and monitored with the EV1000/VolumeView(®) device, we recorded 10 datasets, each comprising duplicate TPTD via femoral access and duplicate TPTD (20 ml cold saline) via jugular access. RESULTS: Mean femoral GEDVI ((674.6±52.3) ml/m(2)) was significantly higher than jugular GEDVI ((552.3±69.7) ml/m(2)), with P=0.003. Bland-Altman analysis demonstrated a bias of (+122±61) ml/m(2), limits of agreement of -16 and +260 ml/m(2), and a percentage error of 22%. Use of the correction-formula recently suggested for the PiCCO(®) device significantly reduced bias and percentage error. Similarly, mean values of parameters derived from GEDVI such as pulmonary vascular permeability index (PVPI; 1.244±0.101 vs. 1.522±0.139; P<0.001) and global ejection fraction (GEF; (24.7±1.6)% vs. (28.1±1.8)%; P<0.001) were significantly different in the case of femoral compared to jugular indicator injection. Furthermore, the mean cardiac index derived from femoral indicator injection ((4.50±0.36) L/(min·m²)) was significantly higher (P=0.02) than that derived from jugular indicator injection ((4.12±0.44) L/(min·m²)), resulting in a bias of (+0.38±0.37) L/(min·m²) and a percentage error of 19.4%. CONCLUSIONS: Femoral access for indicator injection results in markedly altered values provided by the EV1000/VolumeView(®), particularly for GEDVI, PVPI, and GEF.

Indexation of cardiac output to biometric parameters in critically ill patients: A systematic analysis of a transpulmonary thermodilution-derived database.

PURPOSE: Cardiac output (CO) (liters per minute) is usually normalized (ie, indexed) to the patient's body surface area (BSA) resulting in the hemodynamic variable cardiac index (CI) (liters per minute per square meter). We aimed (1) to evaluate the impact of different body weight-based CO indexations on the resulting CI values and (2) to identify biometric parameters independently associated with CO in critically ill patients. MATERIALS AND METHODS: The study is an analysis of a database containing transpulmonary thermodilution-derived hemodynamic variables of 234 medical intensive care unit patients. RESULTS: Cardiac index indexed to actual BSA was statistically significantly lower compared with CI indexed to predicted BSA in the totality of patients and in the subgroups of patients with body mass index greater than or equal to 25 kg/m(2) but less than 30 kg/m(2) and body mass index greater than or equal to 30 kg/m(2) (with a statistically significant difference in the proportion of low and high CI measurements). Multivariate analysis of the first CO measurement of each patient demonstrated that CO was independently associated with age (P < .001), height (P = .001), and actual body weight (BWact) (P = .030). Multivariate analysis of the mean of the patients' CO measurements confirmed age (P < .001), height (P = .001), and BWact (P < .001) as biometric factors independently associated with CO. Age was identified as the most important factor with each year of age decreasing CO by 66 mL/min (95% confidence interval, 47-86 mL/min). CONCLUSIONS: The indexation of CO to BSA is highly dependent on the body weight estimation formula used to calculate BSA. Cardiac output is independently associated with the biometric factors age, height, and BWact. These factors might be considered for indexation of CO.

Association between different indexations of extravascular lung water (EVLW) and PaO2/FiO2: a two-center study in 231 patients.

BACKGROUND: Variability of body weight (BW) and height calls for indexation of volumetric hemodynamic parameters. Extravascular lung water (EVLW) has formerly been indexed to actual BW (BW(act)) termed EVLW-index (EVLWI). In overweight patients indexation to BW(act) might inappropriately lower indexed EVLWI(act). Several studies suggest indexation of EVLWI to predicted BW (EVLWI(pred)). However, data regarding association of EVLWI(act) and EVLW(pred) to mortality and PaO2/FiO2 are inconsistent. Two recent studies based on biometric database-analyses suggest indexation of EVLWI to height (EVLWI(height)). Therefore, our study compared the association of un-indexed EVLW, EVLWI(height), EVLW(pred) and EVLWI(act) to PaO2/FiO2 and Oxygenation index (OI = mean airway pressure*FiO2*/PaO2). METHODS: A total of 2119 triplicate transpulmonary thermodilutions (TPTDs; PiCCO; Pulsion Medical-Systems, Germany) were performed in 50 patients from the evaluation, and 181 patients from the validation groups. Correlations of EVLW and EVLWI to PaO2/FiO2, OI and ROC-AUC-analyses regarding PaO2/FiO2<200 mmHg (primary endpoint) and OI>10 were performed. RESULTS: In the evaluation group, un-indexed EVLW (AUC 0.758; 95%-CI: 0.637-0.880) and EVLWI(height) (AUC 0.746; 95%-CI: 0.622-0.869) provided the largest ROC-AUCs regarding PaO2/FiO2<200 mmHg. The AUC for EVLWI(pred) was smaller (0.713). EVLWI(act) provided the smallest AUC (0.685). This was confirmed in the validation group: EVLWI(height) provided the largest AUC (0.735), EVLWI(act) (0.710) the smallest. In the merged data-pool, AUC was significantly greater for EVLWI(height) (0.729; 95%-CI: 0.674-0.784) compared to all other indexations including EVLWI(act) (ROC-AUC 0.683, p = 0.007) and EVLWI(pred) (ROC-AUC 0.707, p = 0.015). The association of EVLW(I) was even stronger to OI compared to PaO2/FiO2. In the merged data-pool, EVLWI(height) provided the largest AUC regarding "OI>10" (0.778; 95%-CI: 0.713-0.842) compared to 0.739 (95%-CI: 0.669-0.810) for EVLWI(act) and 0.756 (95%-CI: 0.688-0.824) for EVLWI(pred). CONCLUSIONS: Indexation of EVLW to height (EVLWI(height)) improves the association of EVLW(I) to PaO2/FiO2 and OI compared to all other indexations including EVLWI(pred) and EVLWI(act). Also considering two recent biometric database analyses, EVLWI should be indexed to height.

Advanced hemodynamic monitoring before and after transjugular intrahepatic portosystemic shunt: implications for selection of patients--a prospective study.

PURPOSE: To investigate immediate and short-term effects of transjugular intrahepatic portosystemic shunt (TIPS) on cardiocirculatory, hepatic, and renal function and characterize predictors for TIPS outcome in terms of organ function after TIPS. MATERIALS AND METHODS: This prospective study was approved by the ethics committee at a university hospital and was conducted in a medical intensive care unit. Informed consent was obtained. Twenty patients with indication for TIPS were enrolled. Monitoring of hemodynamic and hepatic function (transpulmonary thermodilution, indocyanine green plasma disappearance rate [ICG-PDR]) was performed. Biochemical markers of organ function were obtained. Statistical analysis (Wilcoxon test, Spearman correlation, multivariate linear regression analysis, receiver operating characteristic [ROC] analysis) was performed. RESULTS: After TIPS, central venous pressure (median, 11 vs 15 cm H(2)O; P < .001), cardiac index (3.4 vs 3.8 L/min/m(2); P = .001), and global end-diastolic volume index (GEDVI) (726 vs 775 mL/m(2); P = .003) increased significantly. Portosystemic pressure gradient (28 vs 11 cm H(2)O; P < .001) and systemic vascular resistance index (1610 vs 1384 dyn · sec · cm(-5) · m(2); P = .015) decreased significantly. Creatinine (1.1 vs 1.1 mg/dL; P = .008) and blood urea nitrogen (BUN) (27 vs 21 mg/dL; P = .006) decreased significantly. Bilirubin (1.8 vs 2.2 mg/dL; P = .032) and international normalized ratio (1.4 vs 1.5; P = .022) increased significantly. ICG-PDR significantly deteriorated after TIPS (P = .006). Higher baseline creatinine was independently associated with a decrease in creatinine after TIPS (R = 0.816, P < .001). ROC analysis identified baseline BUN (P = .026, area under ROC curve [AUC] = 0.818), cystatin C (P = .033, AUC = 0.805), and creatinine (P = .052, AUC = 0.779) as predictors of a decrease in creatinine of 0.5 mg/dL or greater and/or 25% or greater. An increase in bilirubin of 1 mg/dL or greater 1 week after TIPS was significantly associated with high baseline BUN (P = .007, AUC = 0.893) and high central venous pressure (P = .040, AUC = 0.800). Lower baseline alanine aminotransferase (P = .002, AUC = 1.000) and cardiac power index · GEDVI (P = .005, AUC = 0.960) predicted favorable TIPS outcome (creatinine decrease of ≥ 0.2 mg/dL without model for end-stage liver disease score increase of more than one point). CONCLUSION: Patients with renal insufficiency, compensated hepatocellular function, decreased cardiac preload, and decreased cardiac performance benefit most from TIPS.