Bedside Availability Research Articles

Renal and Genitourinary Ultrasound Evaluation in Emergency and Critical Care: An Overview.

Renal and genitourinary ultrasound are fundamental resources employed by emergency and critical care healthcare providers to make prompt diagnoses and perform ultrasound-guided procedures. At the bedside, ultrasound can aid in the diagnosis of relevant pathologies, such as post-renal obstruction or kidney stones, and life-threatening conditions such as aortic dissection or hemoperitoneum. A narrative overview was performed, providing an updated review of renal and genitourinary ultrasound for emergency and critical care healthcare providers, emphasizing its advantages and the latest advances in the field. A thorough summary that can be utilized as a guide for emergency and critical care healthcare providers is presented. The daily hemodynamic management of critically ill patients involves the implementation of new protocols, such as VexUS or the evaluation of the renal resistance index. The role of ultrasound in managing acute nephropathy and genitourinary issues is increasingly crucial given its bedside availability, thus this imaging modality not only facilitates the initiation of therapeutic interventions but also provides swift prognostic insights that are vital to provide tailored patient care. As further advances in ultrasound will arise, it is important for healthcare providers to foster the use of these technologies capable of improving patient outcomes.

Expert consensus on the application of critical care ultrasonography in invasive procedures

The evolution of critical care medicine is inextricably linked to the development of critical care procedures. These procedures not only facilitate diagnosis and treatment of critically ill patients, but also provide valuable insights into disease pathophysiology. While critical care interventions offer undeniable benefits, the potential for iatrogenic complications necessitates careful consideration. The recent surge in critical care ultrasound (US) utilization is a testament to its unique advantages: non-invasiveness, real-time bedside availability, direct visualization of internal structures, elimination of ionizing radiation exposure, repeatability, and relative ease of learning. Recognizing the need to optimize procedures and minimize complications, critical care utrasound study group of Beijing critical care ultrasound research assocition convened a panel of critical care experts to generate this consensus statement. This document serves as a guide for healthcare providers, aiming to ensure patient safety and best practices in critical care.

DIAGNOSTIC ACCURACY OF FOCUSED ASSESSMENT WITH SONOGRAPHY IN TRAUMA FOR VISCERAL INJURIES IN BLUNT ABDOMINAL TRAUMA PATIENTS KEEPING CT AS GOLD STANDARD

Background: Blunt abdominal trauma is common and is associated with intra-abdominal injury. Focused assessment with sonography in trauma (FAST) is extremely sensitive and specific test for the diagnosis of visceral injury in such patients with added benefit of quick scan and bedside availability. This study was conducted with an aim to establish the diagnostic accuracy of FAST for diagnosing visceral injuries in blunt abdominal trauma patients. Methods: This study involved 247 patients of both genders aged 18–60 years, referred to Department of Diagnostic Radiology with history of blunt abdominal trauma. All these 247 patients underwent FAST and CT abdomen. The results of CT scan were taken as gold standard and those of FAST were judged accordingly as true/false positive/negative. Results: Visceral injury was diagnosed in 167 (67.6%) patients on FAST while CT scan confirmed visceral injury in 165 (66.8%) patients. There were 155 true positive, 12 false positive, 10 false negative and 70 true negative cases which yielded 93.94% sensitivity, 85.37% specificity, 91.09% accuracy, 92.81% positive predictive value and 87.50% negative predictive value for FAST in detecting visceral injury. Conclusion: FAST is fairly sensitive, specific, and accurate in diagnosing visceral injury among blunt abdominal trauma. Its non-invasive, radiation-free nature, and widespread bedside availability advocate its preferred use in place of CT in diagnosis of visceral injury in blunt abdominal trauma cases. Pak J Physiol 2022;18(3):7?10

THE ROLE OF TRANSCRANIAL ULTRASOUND IN THE EVALUATION OF HYPOXIC ISCHEMIC ENCEPHALOPATHY

Introduction: Hypoxic ischemic encephalopathy is a clinical term used to describe an abnormal neurobehavioral state that consists of a decreased level of consciousness with abnormalities in neuromotor tone. Any neonate, regardless of birth weight, size, or gestational age, who has a greater than average chance of morbidity or mortality, due to fetal, maternal or placental anomalies or an otherwise compromised pregnancy especially within the first 28 days of life is categorized as high-risk neonate. Cranial ultrasonography plays an important role in the diagnosis of significant lesions in infants presenting with hypoxic ischemic encephalopathy (HIE) and seizures and assessing severity, neurodevelopment outcome and neurological prognosis of these high-risk infants. In the neonate, many sutures and fontanelles are still open and these can be used as acoustic windows to look into the brain. Methodology: This was a hospital based descriptive observational study of 100 preterm and term babies with suspected brain injuries who were referred for cranial USG examination to the Radiodiagnosis Department of R.N.T. Medical College, Udaipur with hypoxic ischemic encephalopathy over a period of 18 months from June 2020 to November 2021. Results:The most common affected age group was 32-37weeks (51%). The abnormalities found on neurosonogram were germinal matrix hemorrhage, periventricular leucomalacia, cystic PVL, cerebral edema and ventriculomegaly. The most common abnormality was germinal matrix hemorrhage (17%) and subependymal hemorrhage (41%) was most common type. Isolated ventriculomegaly (53.8%) was more common than ventriculomegaly with hemorrhage (46.2%). Conclusion: Neurosonogram remains the accurate, rapid imaging modality of choice for detecting brain injuries in preterm infant. This technique is both sensitive and specific for detecting germinal matrix hemorrhage and periventricular leucomalacia. It is a useful modality to perform frequent follow-up scans. The advantages of neurosonogram are that it is easy to operate, non invasive, accurate, has lack of ionizing radiation, bed side availability for unstable infants, rapid diagnosis, wide availability, cost effectiveness and repeatability.

Implementing use of sucrose analgesia (non-pharmacological management of neonatal pain) in a standalone private facility level 3 neonatal care unit using point of care quality improvement methodology

BackgroundNeonatal pain not only has negative impact on the acute physiological parameters of the neonate but also has got the potential to cause long-term neurodevelopmental disabilities. However, neonatal pain especially...

Ultrasound of the chest and mediastinum in children, interventions and artefacts. WFUMB review paper (part 3).

Ultrasound (US) is an ideal diagnostic tool for paediatric patients owning to its high spatial and temporal resolution, realtime imaging, and lack of ionizing radiation and bedside availability. The lack of superficial adipose tissue and favourable acoustic windows in children makes US the first line of investigation for evaluation of pleural and chest wall abnormalities.In the first part of the topic the technical requirements were explained and the use of ultrasound in the lung and pleura in paediatric patients were discussed. In the second part lung parenchymal diseases with their subpleural consolidations are reflected. In the third part, the use of ultrasound for chest wall, mediastinum, diaphragmatic diseases, trachea, interventions and artifacts in paediatric patients are summarized.

Lung Ultrasound B-lines as a Surrogate Marker for High Left Ventricular Diastolic Pressures; a bed-side Diagnostic tool

Background: We studied the diagnostic accuracy of B-lines (comet-tail sign) on bedside lung US, NT-proBNP, E/e` on ECHO in differentiation of the causes of acute dyspnea in the emergency setting. Major advantages include bedside availability, no radiation, high feasibility and reproducibility, and cost efficiency. Methods: Our prospective study was performed at the alazhar university hospital, Cairo, Egypt, between July 2019 and March 2020. All patients underwent lung ultrasound examinations, along with TTE, laboratory testing, including rapid NT-proBNP testing. Results: The median E/e’ levels in patients with B-profile were 18, compared with a median of 7.4 in the subjects with A-profile (P =< 0.0001 CI = -9.649 to -7.044). It was found that the sensitivity and the specificity of detecting B-profile on ultrasound is high when E/e’ > 15.5 (95.0% and 83.0% consecutively), which concluded the high correlation between finding B profile on U/S chest and elevated left ventricle filling pressure in a patient presenting with picture of suggestive of heart failure Conclusion: Chest ultrasound can be used as screening test for the evaluation of patients with suspicion of heart failure with excellent sensitivity and good specificity.

Lung ultrasound in children, WFUMB review paper (part 2).

Ultrasound (US) is an ideal diagnostic tool for paediatric patients owning to its high spatial and temporal resolution, real-time imaging, and lack of ionizing radiation and bedside availability. In the current World Federation of Societies for Ultra-sound in Medicine and Biology (WFUMB) paper series so far (part I) the topic has been introduced and the technical require-ments explained. In the present paper the use of US in the lung in paediatric patients is analysed. Lung diseases including the interstitial syndrome, bacterial pneumonia and viral infections, CoViD findings, atelectasis, lung consolidation, bronchiolitis and congenital diseases of the respiratory system including congenital pulmonary airway malformation (CPAM) and sequester but also pneumothorax are discussed.

Lung ultrasound for detection of pneumonic changes in patients with COVID-19 infection

Background and Aim Given the pandemic crisis of COVID-19 pneumonia, the computed tomography (CT) chest is widely used for initial management of patients with suspected COVID-19 because of its well-known high sensitivity for detection of COVID-19 pneumonia, but its cost, which decreases its availability for certain populations, risk of radiation, need for transportation of the patient, the burden of proper disinfection of the CT room and its unsuitability for some patients like pregnant and lactating women certainly lead to the necessity for a more advantageous tool like lung ultrasound that could solve many of the previous obstacles encountered while deciding to perform the CT chest. This study aims to determine the suitability of lung ultrasound as an alternative to CT chest to aid in the initial management of these patients. The aim was to determine the value of lung ultrasound in the diagnosis of lung parenchymal affection in patients with COVID-19. Patients and methods A prospective including 150 patients was carried out in the Chest, Interventional Radiology and Clinical Pathology Departments in Bab-El-Sha'aria and Al-Hussin Hospitals, Al-Azhar University, during the period from May 2020 to September 2020. Lung ultrasound was performed in 150 patients with COVID-19 pneumonia diagnosed based on the integrated clinical, laboratory, and CT chest radiological data. Results Among 150 patients, there were 86 males and 64 males, ranging in age from 30 to 75 years and a mean age of 55.8±12.1 years. Bilateral lung infiltrates in the CT scan were present in 146 patients (97.3%), CXR infiltrates were present in 63 patients (42%), sonographic evidence of pleuropulmonary involvement was present in 139 patients (92.7%), B lines and pleural line thickening were present in all patients with ultrasound findings (100%), subpleural consolidation associated with B lines was present only in 33 patients (23.7%) and pleural effusion was absent in all cases; crackles were only present in 53 (35.3%) patients. Conclusion Because of its simplicity in interpretation, bedside availability, lack of risk of radiation and good sensitivity in the detection of lung parenchymal affection, the chest ultrasound is a useful tool in the management of patients with symptoms suspicious of COVID-19 infection and seems to be a suitable substitute for the CT chest in such circumstances.

The Diagnostic Role of Lung Ultrasound in Critically Ill Patients In Comparison With Chest X-Ray

Abstract Purpose To compare between lung ultrasound and chest X-ray in diagnosis of different lung pathologies in critically ill patients using lung CT as a gold standard. Methods Comparative prospective randomized single group observational study was conducted in the Critical Care unit (medical and surgical ICU). The study was conducted upon fifty patients (28 females &22 males) with a mean age of 58 years (SD ± 15.55; (19 - 82) presented to Kom Hamadah Hospital during a period of one year starting from July 2018 to July 2019, with acute dyspnea as the primary complaint or developed acute dyspnea and or tachypnea during their ICU stay were evaluated for the presence of pleural effusion, pneumothorax, alveolar-Interstitial Pathology and consolidation by LUS and CXR for detecting the sensitivity and specificity of each modality with CT chest done as a reference in cases of doubt. Results The comparison between Sensitivity and Specificity of US finding was (86.8% for parenchymal disease, 100.0% for pleural diseases) and (100.0% for parenchymal diseases, 94.7% for pleural diseases) respectively while CXR finding was (65.8% for parenchymal diseases, 75.0% for pleural diseases) and (58.3% for parenchymal diseases), (92.1% for pleural diseases) respectively among studied patients. Conclusion Transthoracic ultrasound is valuable for the evaluation of a wide variety of chest diseases, particularly mechanically ventilated patient. The advantages of low cost, bedside availability and no radiation exposure have made ultrasound an indispensable diagnostic tool in ICU. Lung ultrasound is more sensitive than chest x-ray in diagnosis and follow up chest diseases) PNX, alveolar-interstitial syndromes, parenchymal consolidations, and pleural effusion (LUS is an interesting medical method that is complementary to bedside CXR and reduces the need to use a CT scan.

ASNC/AHA/ASE/EANM/HFSA/ISA/SCMR/SNMMI Expert Consensus Recommendations for Multimodality Imaging in Cardiac Amyloidosis: Part 1 of 2-Evidence Base and Standardized Methods of Imaging.

ASNC/AHA/ASE/EANM/HFSA/ISA/SCMR/SNMMI Expert Consensus Recommendations for Multimodality Imaging in Cardiac Amyloidosis: Part 1 of 2-Evidence Base and Standardized Methods of Imaging.

Ultrasound of the pleura in children, WFUMB review paper.

Ultrasound (US) is an ideal diagnostic tool for paediatric patients owning to its high spatial and temporal resolution, real-time imaging, and lack of ionizing radiation and bedside availability. The lack of superficial adipose tissue and favorable acoustic windows in children makes US the first line of investigation for the evaluation of pleural and chest wall abnormali-ties. Lung parenchyma was previously thought to be inaccessible to ultrasound due to the presence of the air and bony thorax. The change in attitude and growing awareness of the diagnostic possibilities has led to lung ultrasound (LUS) being accepted as a valuable point of care method. In addition, the application of LUS has widened with improvements in technology such as higher resolution transducers, harmonic imaging and contrast-enhanced ultrasound. In the current World Federation of Societies for Ultrasound in Medicine and Biology (WFUMB) paper series the topic will be introduced, the technical requirements explained and the use of ultrasound in the lung and pleura in pediatric patients are discussed.

Diagnostic accuracy of bedside ultrasonography in COVID-19 suspected patients admitted to the emergency department

Introduction: Due to the risk of cross contamination and radiation exposure of computed tomography (CT) and low sensitivity rate of X-Ray, point of care ultrasound (POCUS) lung can be used as a diagnostic tool of COVID-19 pneumonia. The current study aimed to evaluate the potential of POCUS for detection of lung pathologies caused by COVID-19. Methods: This prospective observational study was conducted with 84 patients admitted to the emergency department with suspected COVID-19. CT and POCUS lung were performed for all participants. CCT was taken as the reference diagnostic method and the presence of B-lines or consolidation or pleural irregularity-thickening (>3 mm) in the lung in POCUS lung, were evaluated in favor of COVID-19 pneumonia. Results: Of the 84 patients included, lesions of COVID-19 pneumonia were detected 53.5%. COVID-19 pneumonia findings were shown by POCUS lung in 51.2% of participants. The left lower lobe in 48.8% and the right lower lobe in 47.6% of the patients were the most commonly affected regions. In POCUS lung, COVID-19 pneumonia lesions located in 2nd area for 44.0%, in 7th area for 35.7%, in 8th area for 34.5%. Sensitivity of POCUS lung was found to be 88.9%, specificity pointed for 92.3%, positive predictive value was 93.0% and negative predictive value was 87.8%. Conclusion: POCUS lung, has a high sensitivity and specificity in the diagnosis of COVID-19 pneumonia, especially in severe lung involvement. Therefore, POCUS lung should be the method of choice as its practical use, bedside availability and avoidance of radiation exposure for COVID-19 associated lung lesions.

Role of Ultrasonography in Diagnosis of Pleuropulmonary Diseases in Adults

Introduction: The advantage of transthoracic ultrasound (TUS) includes the absence of ionizing radiation, easy performance, rapid, accurate, safe, short time of examination, lower cost, bedside availability and high sensitivity in detecting pleural and pulmonary diseases. Aim of this study: Aim of the current study was to assess of the role of transthoracic ultrasound in pleuropulmonary diseases in adults. Patients and methods: The present study included 50 patients who fulfilled the selection criteria and formed the study population. The present study was conducted in Radiology Department, Aswan University Hospital in the period from December 2016 to November 2017. All patients were subjected basically to full history taking, full clinical examination, chest x-ray, chest ultrasonography, CT chest and histopathological correlation for some cases. Results: In this study, patients were classified into 2 groups based on the final diagnosis. The first group included 28 cases with pleural diseases that the US reported sensitivity of 96.43%, specificity of 81.8%. The second group included 22 patients with pulmonary diseases that the US reported sensitivity of 95.45%, specificity of 78.57%. Recommendations: TUS has a valuable role at diagnosis of pleuropulmonary diseases

Availability of Internationally Controlled Essential Medicines in the COVID-19 Pandemic

Section 2 of the 2019 World Health Organization Model List of Essential Medicines includes opioid analgesics formulations commonly used for the control of pain and respiratory distress, as well as sedative and anxiolytic substances such as midazolam and diazepam. These medicines, essential to palliative care, are regulated under the international drug control conventions overseen by United Nations specialized agencies and treaty bodies and under national drug control laws. Those national laws and regulations directly affect bedside availability of Internationally Controlled Essential Medicines (ICEMs). The complex interaction between national regulatory systems and global supply chains (now impacted by COVID-19 pandemic) directly affects bedside availability of ICEMs and patient care. Despite decades of global civil society advocacy in the United Nations system, ICEMs have remained chronically unavailable, inaccessible, and unaffordable in low- and-middle-income countries, and there are recent reports of shortages in high-income countries as well. The most prevalent symptoms in COVID-19 are breathlessness, cough, drowsiness, anxiety, agitation, and delirium. Frequently used medicines include opioids such as morphine or fentanyl and midazolam, all of them listed as ICEMs. This paper describes the issues related to the lack of availability and limited access to ICEMs during the COVID-19 pandemic in both intensive and palliative care patients in countries of all income levels and makes recommendations for improving access.

Near real-time bedside detection of spinal cord ischaemia during aortic repair by microdialysis of the cerebrospinal fluid.

Spinal cord ischaemia (SCI) remains the most devastating complication after thoraco-abdominal aortic aneurysm (TAAA) repair. Its early detection is crucial if therapeutic interventions are to be successful. Cerebrospinal fluid (CSF) is readily available and accessible to microdialysis (MD) capable of detecting metabolites involved in SCI [i.e. lactate, pyruvate, the lactate/pyruvate ratio (LPR), glucose and glycerol] in real time. Our aim was to evaluate the feasibility of CSF MD for the real-time detection of SCI metabolites. In a combined experimental and translational approach, CSF MD was evaluated (i) in an established experimental large animal model of SCI with 2 arms: (a) after aortic cross-clamping (AXC, N = 4), simulating open TAAA repair and (b) after total segmental artery sacrifice (Th4-L5, N = 8) simulating thoracic endovascular aortic repair. The CSF was analysed utilizing MD every 15 min. Additionally, CSF was collected hourly from 6 patients undergoing open TAAA repair in a high-volume aortic reference centre and analysed using CSF MD. In the experimental AXC group, CSF lactate increased 3-fold after 10 min and 10-fold after 60 min of SCI. Analogously, the LPR increased 5-fold by the end of the main AXC period. Average glucose levels demonstrated a 1.5-fold increase at the end of the first (preconditioning) AXC period (0.60±0.14 vs 0.97±0.32 mmol/l); however, they decreased below (to 1/3 of) baseline levels (0.60±0.14 vs 0.19±0.13 mmol/l) by the end of the experiment (after simulated distal arrest). In the experimental segmental artery sacrifice group, lactate levels doubled and the LPR increased 3.3-fold within 30 min and continued to increase steadily almost 5-fold 180 min after total segmental artery sacrifice (P < 0.05). In patients undergoing TAAA repair, lactate similarly increased 5-fold during ischaemia, reaching a maximum at 6 h postoperatively. In 2 patients with intraoperative SCI, indicated by a decrease in the motor evoked potential of >50%, the LPR increased by 200%. CSF is widely available during and after TAAA repair, and CSF MD is feasible for detection of early anaerobic metabolites of SCI. CSF MD is a promising new tool combining bedside availability and real-time capacity to potentially enable rapid detection of imminent SCI, thereby maximizing chances to prevent permanent paraplegia in patients with TAAA.

Abstract: Identifying Drivers of Plastic Surgeons’ Online Ratings in Abdominoplasty

BACKGROUND: Patients increasingly utilize the internet for decision-making regarding cosmetic procedures, and online reviews have become both a signifier of patient preferences and a valuable source of data. We endeavored to perform a comprehensive and quantitative review of abdominoplasty reviews. METHODS: Reviews were systematically obtained from Yelp (www.yelp.com), Google (www.google.com), and RealSelf (www.realself.com) via search terms “plastic surgery”, “tummy tuck”, and “abdominoplasty” for the top 30 surgeons in the top 5 metro areas by population (New York, Chicago, Los Angeles, Houston, Philadelphia) and Miami. Each review was assessed against a panel of 35 concepts that were developed via a modified Grounding Theory approach. Other data of interest included star rating of the physician, word count, and metropolitan area. Only positive (4 and 5 star, or “Worth It”) and negative (1 or 2 star, or “Not Worth It”) reviews were included. Due to the overwhelming number of positive reviews on RealSelf, a random 10% sample of positive reviews were included to provide 90% power. RESULTS: Of 794 reviews meeting inclusion criteria, 402 were obtained from RealSelf, 319 from Google, and 73 from Yelp. Between all sources, 683 (86.0%) reviews were positive and 111 (14.0%) were negative. Average Yelp and Google ratings varied by metropolitan area (p=0.4 by ANOVA) with Philadelphia, PA having the highest average rating (5.0) and Miami, FL the lowest (4.4). Overall rating was not associated with the word length of the reviews or cost of procedure. Aesthetic outcome was a major driver of patient satisfaction or dissatisfaction– all 316 reviews mentioning a good aesthetic outcome were positive, and 50 of the 52 two reviews mentioning a poor aesthetic outcome were negative. Notably, only 368 (46.3%) of all reviews mentioned aesthetic outcome at all. Other themes cited were Bedside Manner (364, 45.8%), Surgeon as a Resource (318, 40.1%) and Interactions with Staff (264, 33.2%). Post-Operative Care was the 5th most common theme in reviews overall (185, 23.3%), but second only to Aesthetic Outcome in mentions in negative reviews. Cost of surgery did not appear to be an independent driver of review rating and was almost always perceived in the context of the patient’s outcome. Thirteen reviews from Yelp (3) and Google (10) by patients who had a consult for abdominoplasty but had not undergone surgery were not included in our analysis. Of these, 10/13 (77%) reviews were negative. CONCLUSION: We present the first comprehensive and quantitative analysis of online reviews of abdominoplasty. While aesthetic outcome was the most common determinant of patient satisfaction, it was only noted in half of reviews. Surgeon characteristics such as bedside manner and availability to answer questions were weighted almost as heavily. Negative reviews cited post operative care as a critical factor and cost did not seem to play a significant role in either positive or negative reviews. As surgeons gain greater clarity on drivers of online patient satisfaction, they will be able to utilize this information to provide more responsive and patient-centric care.

Ultrasonography in Trauma: Physics, Practice, and Training.

* Ultrasonography has gained a unique role in assisting emergency medicine physicians in the trauma setting. Its major advantages include safety, bedside availability, repeatability, and portability. In addition, it does not have to interrupt resuscitation, it does not require sedation, it takes images in real time using multiplanar and nonstandard imaging, and it provides interventional guidance.* Advances in technology have enabled portable ultrasonography devices to offer excellent imaging quality and a quick-start function. In trauma, it can be used in the pre-hospital setting, in disaster situations, during patient retrieval, and in the hospital setting from the emergency department to the operating room, intensive care units, and the wards. It can be used by pre-hospital medical staff, emergency physicians, trauma surgeons, anesthesiologists, radiologists, and sonographers after adequate training.* The limitations of ultrasonography in trauma include the skill of the operators, the need for training and experience, and image artifacts and display.

Ultrasound of the knee in rheumatology

The knee joint, surrounding ligaments, and extensor mechanism (quadriceps and patellar tendon), given their superficial nature, are easily accessible and accurately assessed with high-resolution musculoskeletal (MSK) ultrasound. Its bedside availability, lower cost than magnetic resonance imaging (MRI), and its high sensitivity in the detection of a small effusion, synovitis, and Baker's cyst, together with its ability to be used for needle guidance in invasive procedures, make ultrasound a highly desired diagnostic tool. In this article, we will focus on common rheumatologic indications of MSK ultrasound in the knee and discuss scanning technique and sonographic findings. Transducer positioning and essential sonographic bony landmarks will be reviewed and scanning in two orthogonal planes (both long and short axis of the structure) will be emphasized. With advances in technology, cost reduction, and easy availability, it is expected that more and more clinicians will be utilizing ultrasound in their clinics in management and treatment of rheumatologic diseases. The diagnostic ability of MSK ultrasound is based on an operator's training and experience, the patient's habitus and aptly chosen clinical indications. A good grasp of anatomy, sound ultrasound technique, and knowledge of limitations of ultrasound modality is essential for a safe ultrasound practice. It is also important to keep in mind that ultrasound provides limited information about internal structures such as meniscus and cruciate ligament pathologies and it has a complementary role with MRI.

Anticoagulation on extracorporeal membrane oxygenation (ECMO)

Introduction: Extracorporeal circulation has been around for more than half a century, but many questions remain regarding how to best achieve anticoagulation in a patient on extracorporeal membrane oxygenation (ECMO). Although unfractionated heparin is the predominant agent used for cardiopulmonary bypass, the amount required and how best to monitor its effects are still unresolved. Extracorporeal circulation is associated with the activation of clotting cascade upon contact with a foreign surface of the ECMO circuit; therefore, heparin or a heparin-bonded circuit is used for anticoagulation. Objectives: To describe commonly used tests to monitor anticoagulation status and ways to maintain a clot-free circuit with least damage to circulating platelets. Methods: A literature search was conducted on PubMed for articles published in peer-reviewed medical journals in English in the past 10 years. Results: Various evidence-based facts emerged. Upon initiation of ECMO flow, there is a strong inflammatory response almost similar to systemic inflammatory response syndrome (SIRS) with the release of various cytokine mediators such as interleukins and tumor necrosis factor as well as a trigger to arachidonic acid metabolism with the release of prostaglandins and destruction of platelets.1 Monitoring of anticoagulation status requires close monitoring of activated clotting times (ACTs), a close watch of platelet count, looking for evidence of heparin-induced thrombocytopenia (HIT), and finally, greater use of thromboelastogram (TEG) for precise analysis of coagulation status (Figs. 1 and 2). The ECMO circuit needs to be physically monitored (lines, pump head, oxygenator) for any clots as well as the values of the pre- and post-membrane pressures to detect clots in the membrane oxygenator. In view of a higher duration of ECMO run when compared with cardiopulmonary bypass, it is particularly challenging to achieve an optimal anticoagulation keeping in mind inflammation, disseminated intravascular coagulation, as well as side effects such as HIT.2 Treatment of bleeding/clotting emergencies involves early detection and use of anticoagulation reversal agents with or without transfusion of blood or blood products with full round-the-clock support by blood bank. Although heparin-coated circuits have been safely used for extracorporeal lung assist with little or no systemic anticoagulation,3 prospective studies are clearly needed to determine whether this approach is advantageous, and it would seem appropriate to develop heparin coating for silicone-based membrane oxygenators.Figure 1. TEG report on clot characteristics (http://marylandccproject.org/core-content/utility-teg-blood-component-therapy/). Figure 2. Interpretation of thromboelastogram.4 Conclusion: Various tests are available to monitor the anticoagulation status of a patient on ECMO with bedside availability. It is important to perform physical inspection of the ECMO circuit as well as to monitor pre- and post-membrane pressures frequently, in order to detect clots in the circuit, and to further regulate heparin therapy. Activated clotting time (ACT) by far remains the most commonly used monitoring tool at most ECMO centers.