Veno-venous extracorporeal membrane oxygenation (VV ECMO) cannula malposition identified with point-of-care ultrasound.

BACKGROUND: Point-of-care ultrasound (POCUS) has become a mainstay in the evaluation of critically ill patients in the intensive care unit (ICU). ECMO patients are susceptible to complications during prolonged ICU stay, including cannula malposition, which has deleterious consequences. Although the literature surrounding utility of ultrasound on ECMO patients is expansive, direct comparison between radiographic imaging versus ultrasound for identification of cannula malposition is lacking. CASE PRESENTATION: The authors identified four patients with cannula malposition discovered through POCUS that was missed on routine radiographic imaging. Identification and correction of malposition changed their ECMO course. CONCLUSION: This case series is the first in literature demonstrating that ultrasound may be superior to radiographic images for ECMO cannula malposition. Further investigation into this subject is warranted.

Implementing a 3 year, longitudinal point of care ultrasound curriculum in an internal medicine residency program.

PURPOSE: Point-of-care ultrasound (POCUS) is highly utilized in the critical care setting. There is also growing evidence supporting use of POCUS by internal medicine (IM) physicians as an extension of traditional physical diagnostic skills. As part of the newly formed curriculum at our residency program, we performed pre and post curriculum assessment of the residents' ability to acquire focused cardiac, lung, pleural, abdominal and vascular images. METHODS: The POCUS instruction was delivered as a combination of pre-workshop self-study learning materials (monthly textbook chapters, online modules etc.), with short didactic sessions, and hands-on-scanning of healthy, male volunteers at 10-week intervals. RESULTS: A total of 62 residents (23 Post-Graduate Year 1 (PGY), 24 PGY2, 15 PGY3) participated in the year-long curriculum. When pretest and post test data were analyzed at the end of the curriculum, we calculated the odds ratio for acquiring the correct image (score of 1) vs partial/incorrect acquisition (scores of 2 and 3). Significant differences were found in acquisition of most views including para-sternal short (OR 7.7, 95% CI 2.86-20.74, p < 0.001), Inferior vena cava (IVC) (OR 5.05, 95% CI 1.91-13.35, p = 0.001) and bladder (OR 5.06, 95% CI 1.76-14.55, p = 0.003). Non-significant differences were found in acquisition of apical 4 chamber, pl (A-Line) and internal jugular vein (IJV). CONCLUSION: We found that the implementation of a longitudinal POCUS curriculum resulted in significant improvement in image acquisition for many common bedside ultrasound views. Future directions include advancing our bedside echocardiography curriculum for upper-level residents to include quantitative left ventricular and right ventricular function analysis, and including more case based pathologic image review.

A Prospective Analysis of Motor and Cognitive Skill Retention in Novice Learners of Point of Care Ultrasound.

OBJECTIVES: To identify the time at which point of care ultrasound static image recognition and image acquisition skills decay in novice learners. SETTING: The University of Iowa Hospitals and Clinics. SUBJECTS: Twenty-four subjects (23 first-year medical students and one first-year physician assistant student). DESIGN: The subjects completed an initial didactic and hands-on session with immediate testing of learned image acquisition and static image identification skills. INTERVENTIONS: Retesting occurred at 1, 4, and 8 weeks after the initial training session with no retraining in between. Image acquisition skills were obtained on the same healthy male volunteers, and the students were given no immediate feedback on their performance. The image identification skills were assessed with a 10 question test at each follow-up session. MEASUREMENTS AND MAIN RESULTS: For pleural ultrasound by 4 weeks, there was a significant decline of the ability to identify A-lines (p = 0.0065). For pleural image acquisition, there was no significant decline in the ability to demonstrate lung sliding. Conversely, cardiac image recognition did not significantly decline throughout the study, while the ability to demonstrate cardiac images at 4 weeks (parasternal short axis view) did (p = 0.0008). CONCLUSIONS: Motor and cognitive skills decay at different times for pleural and cardiac images. Future ultrasound curricula should retrain skills at a maximum of 8 weeks from initial training. They should focus more on didactic sessions related to image identification for pleural images, and more hands-on image acquisition training for cardiac images, which represents a novel finding.

Looking for light in the din: An examination of the circadian-disrupting properties of a medical intensive care unit.

OBJECTIVE: Critically ill patients exhibit profound disturbances of circadian rhythmicity, most commonly in the form of a phase delay. We investigated the specific zeitgeber properties of a medical intensive care unit to develop a model that explained these abnormalities. RESEARCH METHODOLOGY: Prospective, observational study conducted during 2013-2014. Twenty-four-hour ambient light (lux, 672 hours) and sound pressure levels (dBA, 504 hours) were measured in patient rooms. Patients and families were surveyed regarding their perceptions of the environment. SETTING: University-based adult medical intensive care unit. MAIN OUTCOME MEASURES: The timing and intensity of the ambient light-dark cycle and sound environment and the relationship of these measurements to patient/family perceptions. RESULTS: Twenty-four-hour light-dark cycles were extremely weak and phase delayed relative to the solar cycle. Morning light averaged 12.1 (4.8, 37.2) lux, when only 24.9% ±â€¯10.9% of available light was utilised; yet patients and families did not identify low daytime light levels as problematic. Median noise levels were invariably excessive (nighttime 47.9 [45.0, 51.3] dBA) with minimal variation, consistent with the absence of a defined rest period. CONCLUSION: The intensive care unit functions as a near-constant routine protocol disconnected from solar time. Behavioural interventions to promote entrainment should be supported by objective measurements of light and sound.