Simplified point-of-care ultrasound protocol to confirm central venous catheter placement: A prospective study.

BACKGROUND: The current standard for confirmation of correct supra-diaphragmatic central venous catheter (CVC) placement is with plain film chest radiography (CXR). We hypothesized that a simple point-of-care ultrasound (POCUS) protocol could effectively confirm placement and reduce time to confirmation. METHODS: We prospectively enrolled a convenience sample of patients in the emergency department and intensive care unit who required CVC placement. Correct positioning was considered if turbulent flow was visualized in the right atrium on sub-xiphoid, parasternal or apical cardiac ultrasound after injecting 5 cc of sterile, non-agitated, normal saline through the CVC. RESULTS: Seventy-eight patients were enrolled. POCUS had a sensitivity of 86.8% (95%CI 77.1%-93.5%) and specificity of 100% (95%CI 15.8%-100.0%) for identifying correct central venous catheter placement. Median POCUS and CXR completion were 16 minutes (IQR 10-29) and 32 minutes (IQR 19-45), respectively. CONCLUSION: Ultrasound may be an effective tool to confirm central venous catheter placement in instances where there is a delay in obtaining a confirmatory CXR.

Implementation of a 4-Year Point-of-Care Ultrasound Curriculum in a Liaison Committee on Medical Education-Accredited US Medical School.

OBJECTIVES: The established benefits of point-of-care ultrasound have given rise to multiple new and innovative curriculums to incorporate ultrasound teaching into medical education. This study sought to measure the educational success of a comprehensive and integrated 4-year point-of-care ultrasound curriculum. METHODS: We integrated a curriculum consisting of traditional didactics combined with asynchronous learning modules and hands-on practice on live models with skilled sonographers into all 4 years of education at a Liaison Committee on Medical Education-accredited US Medical School. Each graduating student was administered an exit examination with 48 questions that corresponded to ultrasound milestones. RESULTS: Ninety-five percent (n = 84) of fourth-year medical students completed the exit examination. The mean score was 79.5% (SD, 10.2%), with mean scores on the ultrasound physics and anatomy subsections being 77.1% (SD, 11.0%) and 85.9% (SD, 21.0%), respectively. CONCLUSIONS: A comprehensive 4-year point-of-care ultrasound curriculum integrated into medical school may successfully equip graduating medical students with a fundamental understanding of ultrasound physics, anatomy, and disease recognition.

Simplified point-of-care ultrasound protocol to confirm central venous catheter placement:A prospective study / 世界急诊医学杂志（英文）

@#BACKGROUND: The current standard for confirmation of correct supra-diaphragmatic central venous catheter (CVC) placement is with plain film chest radiography (CXR). We hypothesized that a simple point-of-care ultrasound (POCUS) protocol could effectively confirm placement and reduce time to confirmation. METHODS: We prospectively enrolled a convenience sample of patients in the emergency department and intensive care unit who required CVC placement. Correct positioning was considered if turbulent flow was visualized in the right atrium on sub-xiphoid, parasternal or apical cardiac ultrasound after injecting 5 cc of sterile, non-agitated, normal saline through the CVC. RESULTS: Seventy-eight patients were enrolled. POCUS had a sensitivity of 86.8% (95%CI 77.1%–93.5%) and specificity of 100% (95%CI 15.8%–100.0%) for identifying correct central venous catheter placement. Median POCUS and CXR completion were 16 minutes (IQR 10–29) and 32 minutes (IQR 19–45), respectively. CONCLUSION: Ultrasound may be an effective tool to confirm central venous catheter placement in instances where there is a delay in obtaining a confirmatory CXR.

Prospective evaluation of point-of-care ultrasound for pre-procedure identification of landmarks versus traditional palpation for lumbar puncture.

BACKGROUND: The objective of this study is to determine if point-of-care ultrasound (POCUS) pre-procedure identification of landmarks can decrease failure rate, reduce procedural time, and decrease the number of needle redirections and reinsertions when performing a lumbar puncture (LP). METHODS: This was a prospective, randomized controlled trial comparing POCUS pre-procedure identification of landmarks versus traditional palpation for LP in a cohort of patients in the emergency department and intensive care unit. RESULTS: A total of 158 patients were enrolled. No significant difference was found in time to completion, needle re-direction, or needle re-insertion when using POCUS when compared to the traditional method of palpation. CONCLUSION: Consistent with findings of previous studies, our data indicate that there was no observed benefit of using POCUS to identify pre-procedure landmarks when performing an LP.

Point-of-care ultrasound versus radiology department pelvic ultrasound on emergency department length of stay.

BACKGROUND: The study aimed to compare the time to overall length of stay (LOS) for patients who underwent point-of-care ultrasound (POCUS) versus radiology department ultrasound (RDUS). METHODS: This was a prospective study on a convenience sample of patients who required pelvic ultrasound imaging as part of their emergency department (ED) assessment. RESULTS: We enrolled a total of 194 patients who were on average 32 years-old. Ninety-eight (51%) patients were pregnant (<20 weeks). Time to completion of RDUS was 66 minutes longer than POCUS (95%CI 60-73, P<0.01). Patients randomized to the RDUS arm experienced a 120 minute longer ED length of stay (LOS) (95%CI 66-173, P<0.01). CONCLUSION: In patients who require pelvic ultrasound as part of their diagnostic evaluation, POCUS resulted in a significant decrease in time to ultrasound and ED LOS.

Thrombosis of Inferior Vena Cava Diagnosed Using Point-of-Care Ultrasound After Pediatric Near-Syncope.

BACKGROUND: Venous thromboembolism (VTE) is extremely rare but under recognized in the pediatric population. Although the literature on the use of ultrasound to detect VTEs in adults is plentiful, little has been documented on its use in the pediatric population. CASE REPORT: We present a case of a healthy 16-year-old female who presented to our emergency department with 3 months of dyspnea on exertion and one episode of near-syncope. Point-of-care cardiac ultrasound identified an inferior vena cava thrombosis. Subsequent computed tomography angiography diagnosed concurrent bilateral pulmonary emboli (PE). The patient's identical twin sister presented with similar symptoms shortly thereafter and was also diagnosed with VTE and bilateral PE. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case demonstrates an instance of VTE and pulmonary embolism in twin adolescent girls. Physical examination findings, electrocardiogram, chest x-ray study, and several previous evaluations did not reveal the diagnosis. Point of care ultrasound was used to correctly diagnosis VTE and for heightened concern for a pulmonary embolism.

Ultrasound-guided central venous access: which probe is preferred for viewing the subclavian vein using a supraclavicular approach?

BACKGROUND: Point-of-care ultrasound guidance using a linear probe is well established as a tool to increase safety when performing a supradiaphragmatic cannulation of the internal jugular central vein. However, little data exist on which probe is best for performing a supradiaphragmatic cannulation of the subclavian vein. METHODS: This was a prospective, observational study at a single-site emergency department, where 5 different physician sonologists evaluate individual practice preference for visualization of the subclavian vein using a supraclavicular approach with 2 different linear probes and 1 endocavitary probe. RESULTS: Of 155 patients enrolled, there was no clear preference any of the probes (P= .03). After pooling linear probe preference, there was a preference for either linear probe over the alternative endocavitary probe (76.8% vs 23.1%, P< .05). CONCLUSION: We observed a preference for a linear probe over an endocavitary probe. Further investigation is necessary to determine which probe is optimal for this application.

Pilot Study to Determine Accuracy of Posterior Approach Ultrasound for Shoulder Dislocation by Novice Sonographers.

INTRODUCTION: The goal of this study was to investigate the efficacy of diagnosing shoulder dislocation using a single-view, posterior approach point-of-care ultrasound (POCUS) performed by undergraduate research students, and to establish the range of measured distance that discriminates dislocated shoulder from normal. METHODS: We enrolled a prospective, convenience sample of adult patients presenting to the emergency department with acute shoulder pain following injury. Patients underwent ultrasonographic evaluation of possible shoulder dislocation comprising a single transverse view of the posterior shoulder and assessment of the relative positioning of the glenoid fossa and the humeral head. The sonographic measurement of the distance between these two anatomic structures was termed the Glenohumeral Separation Distance (GhSD). A positive GhSD represented a posterior position of the glenoid rim relative to the humeral head and a negative GhSD value represented an anterior position of the glenoid rim relative to the humeral head. We compared ultrasound (US) findings to conventional radiography to determine the optimum GhSD cutoff for the diagnosis of shoulder dislocation. Sensitivity, specificity, positive predictive value, and negative predictive value of the derived US method were calculated. RESULTS: A total of 84 patients were enrolled and 19 (22.6%) demonstrated shoulder dislocation on conventional radiography, all of which were anterior. All confirmed dislocations had a negative measurement of the GhSD, while all patients with normal anatomic position had GhSD>0. This value represents an optimum GhSD cutoff of 0 for the diagnosis of (anterior) shoulder dislocation. This method demonstrated a sensitivity of 100% (95% CI [82.4-100]), specificity of 100% (95% CI [94.5-100]), positive predictive value of 100% (95% CI [82.4-100]), and negative predictive value of 100% (95% CI [94.5-100]). CONCLUSION: Our study suggests that a single, posterior-approach POCUS can diagnose anterior shoulder dislocation, and that this method can be employed by novice ultrasonographers, such as non-medical trainees, after a brief educational session. Further validation studies are necessary to confirm these findings.

Point-of-care ultrasound versus radiology department pelvic ultrasound on emergency department length of stay / 世界急诊医学杂志（英文）

@#BACKGROUND: The study aimed to compare the time to overall length of stay (LOS) for patients who underwent point-of-care ultrasound (POCUS) versus radiology department ultrasound (RDUS).METHODS: This was a prospective study on a convenience sample of patients who required pelvic ultrasound imaging as part of their emergency department (ED) assessment.RESULTS: We enrolled a total of 194 patients who were on average 32 years-old. Ninety-eight (51％) patients were pregnant (<20 weeks). Time to completion of RDUS was 66 minutes longer than POCUS (95％CI 60–73,P<0.01). Patients randomized to the RDUS arm experienced a 120 minute longer ED length of stay (LOS) (95％CI 66–173,P<0.01)CONCLUSION: In patients who require pelvic ultrasound as part of their diagnostic evaluation, POCUS resulted in a signifi cant decrease in time to ultrasound and ED LOS.

Prospective evaluation of point-of-care ultrasound for pre-procedure identification of landmarks versus traditional palpation for lumbar puncture / 世界急诊医学杂志（英文）

@#BACKGROUND: The objective of this study is to determine if point-of-care ultrasound (POCUS) pre-procedure identification of landmarks can decrease failure rate, reduce procedural time, and decrease the number of needle redirections and reinsertions when performing a lumbar puncture (LP).METHODS: This was a prospective, randomized controlled trial comparing POCUS pre-procedure identifi cation of landmarks versus traditional palpation for LP in a cohort of patients in the emergency department and intensive care unit.RESULTS: A total of 158 patients were enrolled. No signifi cant difference was found in time to completion, needle re-direction, or needle re-insertion when using POCUS when compared to the traditional method of palpation.CONCLUSION: Consistent with fi ndings of previous studies, our data indicate that there was no observed benefi t of using POCUS to identify pre-procedure landmarks when performing an LP.

Nosocomial infection reduction in VLBW infants with a statewide quality-improvement model.

OBJECTIVE: To evaluate the effectiveness of the California Perinatal Quality Care Collaborative quality-improvement model using a toolkit supplemented by workshops and Web casts in decreasing nosocomial infections in very low birth weight infants. DESIGN: This was a retrospective cohort study of continuous California Perinatal Quality Care Collaborative members' data during the years 2002-2006. The primary dependent variable was nosocomial infection, defined as a late bacterial or coagulase-negative staphylococcal infection diagnosed after the age of 3 days by positive blood/cerebro-spinal fluid culture(s) and clinical criteria. The primary independent variable of interest was voluntary attendance at the toolkit's introductory event, a direct indicator that at least 1 member of an NICU team had been personally exposed to the toolkit's features rather than being only notified of its availability. The intervention's effects were assessed using a multivariable logistic regression model that risk adjusted for selected demographic and clinical factors. RESULTS: During the study period, 7733 eligible very low birth weight infants were born in 27 quality-improvement participant hospitals and 4512 very low birth weight infants were born in 27 non-quality-improvement participant hospitals. For the entire cohort, the rate of nosocomial infection decreased from 16.9% in 2002 to 14.5% in 2006. For infants admitted to NICUs participating in at least 1 quality-improvement event, there was an associated decreased risk of nosocomial infection (odds ratio: 0.81 [95% confidence interval: 0.68-0.96]) compared with those admitted to nonparticipating hospitals. CONCLUSIONS: The structured intervention approach to quality improvement in the NICU setting, using a toolkit along with attendance at a workshop and/or Web cast, is an effective means by which to improve care outcomes.

Low Apgar score and mortality in extremely preterm neonates born in the United States.

AIM: To investigate the relationship between low Apgar score and neonatal mortality in preterm neonates. METHODS: Infant birth and death certificate data from the US National Center for Health Statistics for 2001-2002 were analysed. Primary outcome was 28-day mortality for 690, 933 neonates at gestational ages 24-36 weeks. Mortality rates were calculated for each combination of gestational age and 5-min Apgar score. Relative risks of mortality, by high vs. low Apgar score, were calculated for each age. RESULTS: Distribution of Apgar scores depended on gestational age, the youngest gestational ages having higher proportions of low Apgar scores. Median Apgar score ranged from 6 at 24 weeks, to 9 at 30-36 weeks gestation. The relative risk of death was significantly higher at Apgar scores 0-3 vs. 7-10, including at the youngest gestational ages, ranging from 3.1 (95% confidence interval 2.9, 3.4) at 24 weeks to 18.5 (95% confidence interval 15.7, 21.8) at 28 weeks. CONCLUSION: Low Apgar score was associated with increased mortality in premature neonates, including those at 24-28 weeks gestational age, and may be a useful tool for clinicians in assessing prognosis and for researchers as a risk prediction variable.