Clinician Performed Ultrasound Research Articles

Lung ultrasound for the sick child: less harm and more information than a radiograph.

In the realm of emergency medicine, the swift adoption of lung ultrasound (LU) has extended from the adult population to encompass pediatric and neonatal intensivists. LU stands out as a bedside, replicable, and cost-effective modality, distinct in its avoidance of ionizing radiations, a departure from conventional chest radiography. Recent years have witnessed a seamless adaptation of experiences gained in the adult setting to the neonatal and pediatric contexts, underscoring the versatility of bedside Point of care ultrasound (POCUS). This adaptability has proven reliable in diagnosing common pathologies and executing therapeutic interventions, including chest drainage, and central and peripheral vascular cannulation. The surge in POCUS utilization among neonatologists and pediatric intensivists is notable, spanning economically advanced Western nations with sophisticated, high-cost intensive care facilities and extending to low-income countries. Within the neonatal and pediatric population, POCUS has become integral for diagnosing and monitoring respiratory infections and chronic and acute lung pathologies. This, in turn, contributes to a reduction in radiation exposure during critical periods of growth, thereby mitigating oncological risks. Collaboration among various national and international societies has led to the formulation of guidelines addressing both the clinical application and regulatory aspects of operator training. Nevertheless, unified guidelines specific to the pediatric and neonatal population remain lacking, in contrast to the well-established protocols for adults. The initial application of POCUS in neonatal and pediatric settings centered on goal-directed echocardiography. Pivotal developments include expert statements in 2011, the UK consensus statement on echocardiography by neonatologists, and European training recommendations. The Australian Clinician Performed Ultrasound (CPU) program has played a crucial role, providing a robust academic curriculum tailored for training neonatologists in cerebral and cardiac assessment. Notably, the European Society for Paediatric and Neonatal Intensive Care (ESPNIC) recently disseminated evidence-based guidelines through an international panel, delineating the use and applications of POCUS in the pediatric setting. These guidelines are pertinent to any professional tending to critically ill children in routine or emergency scenarios. In light of the burgeoning literature, this paper will succinctly elucidate the methodology of performing an LU scan and underscore its primary indications in the neonatal and pediatric patient cohort. The focal points of this review comprise as follows: (1) methodology for conducting a lung ultrasound scan, (2) key ultrasonographic features characterizing a healthy lung, and (3) the functional approach: Lung Ultrasound Score in the child and the neonate. Conclusion:the aim of this review is to discuss the following key points: 1. How to perform a lung ultrasound scan 2. Main ultrasonographic features of the healthy lung 3. The functional approach: Lung Ultrasound Score in the child and the neonate What is Known: • Lung Ultrasound (LUS) is applied in pediatric and neonatal age for the diagnosis of pneumothorax, consolidation, and pleural effusion. • Recently, LUS has been introduced into clinical practice as a bedside diagnostic method for monitoring surfactant use in NARDS and lung recruitment in PARDS. What is New: • Lung Ultrasound (LUS) has proven to be useful in confirming diagnoses of pneumothorax, consolidation, and pleural effusion. • Furthermore, it has demonstrated effectiveness in monitoring the response to surfactant therapy in neonates, in staging the severity of bronchiolitis, and in PARDS.

Nephrology Fellowship Clinician-Performed Ultrasound Curriculum.

Fluid overload (FO) contributes significantly to the development of cardiovascular disease among patients with end-stage kidney disease (ESKD) on hemodialysis (HD), yet remains underappreciated due to limitations of the physical exam [1]. Lung ultrasound (US) is an established tool for quantification of FO [2]. Previous validation of quantitative lung US among nephrology attendings using a remote web-based lung ultrasound training has been demonstrated [3]. Interest in ultrasound education among nephrology fellows is high [4]. Clinician-performed ultrasound curricula for nephrology fellows have been described previously, however fellows’ competency in quantitative lung US has not been described [5]. In the present study we aimed to assess the current level of knowledge among nephrology fellows as well as the efficacy of a brief training course in quantitative lung US.

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.(2) 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. (3) In this review, we will discuss neonatal & pediatric point of care ultrasound (POCUS) as a novel standard practice & its clinical application for assessment of the head, heart, lung, gut, 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.

Credentialing of emergency medicine trainees in point-of-care ultrasound: An effective, efficient and enjoyable model.

The Australasian College for Emergency Medicine Curriculum Framework contains numerous mentions of point-of-care ultrasound (PoCUS). However, obtaining formal PoCUS credentials is often problematic. The Fiona Stanley Hospital ED PoCUS training programme was devised to assist emergency medicine trainees to meet the credentialing requirements of the Australasian College for Emergency Medicine and the Australasian Society for Ultrasound in Medicine. Six emergency medicine registrars are selected for each 6-month semester. Successful applicants nominate two modules of Australasian Society for Ultrasound in Medicine's Certificate in Clinician Performed Ultrasound and receive dedicated non-clinical time. For 3 h a week, an emergency physician holding formal PoCUS credentials supervises a pair of trainees while they perform scans on ED patients. During these sessions, trainee logbooks can be reviewed and assessments occur as required by the module. Over an 18-month period, 18 emergency registrars were involved, averaging eight 3-h sessions each. All selected the Extended Focused Abdominal Scan for Trauma module, 14 chose Abdominal Aortic Aneurysm and eight chose Basic Echo in Life Support. Overall, 30 (75%) of 40 modules were completed within the trainees' 6-month semester. Just under half of logged scans were obtained during the supervised sessions. Overall, the average number of scans performed exceeded each module's logbook requirements. Trainees perceived that involvement in the programme benefited their ability to manage patients. There was overwhelming support for the structure of the programme. The Fiona Stanley Hospital ED model is effective in assisting emergency medicine trainees to gain formal PoCUS credentials. As it requires relatively little organisation, time and staffing, it could be adopted in many EDs around Australia and New Zealand.

Use of clinician-performed ultrasound in the assessment of safe umbilical venous catheter tip placement.

Safe tip placement of umbilical venous catheters (UVCs) in sick neonates is critical in minimising risk. We aimed to demonstrate the utility of clinician-performed ultrasound (CPU) in identifying UVCs that are placed within small intrahepatic portal vessels or within the heart despite the appearance of being well placed on X-ray. This was a retrospective observational study of preterm and term neonates who had a UVC placed and the position assessed by X-ray and/or CPU according to the Royal Prince Alfred Hospital level 3 neonatal intensive care unit (NICU) guideline. Cases were identified by exporting the records of all admissions between 1 April 2015 and 30 June 2016 from the NICU's data collection database. Paper-based medical records, NICU's data collection database records and the ultrasound reporting system were reviewed to determine X-ray and CPU findings. A total of 157 neonates had 169 UVCs placed. CPU was performed in 77% (111). In 15 cases (14%), UVC placement on X-ray appeared appropriate based on estimated vertebral level; however, CPU demonstrated the line to be in an unsafe position (small intrahepatic portal vessel (3); right atrium (9); left atrium (3)). Assessment of safe UVC placement by estimations according to vertebral level on X-ray alone is inadequate. CPU offers confident localisation of the UVC tip and enables corrective manipulation of intracardiac or intrahepatic UVCs in real time. We recommend CPU as an adjunct to X-ray to ensure safe UVC placement.

Point of care ultrasound in the neonatal unit: Applications, training and accreditation

Point-of-care, or clinician-performed ultrasound (CPU), is increasingly utilised within neonatology as a valuable adjunct to clinical examination. The ability to perform and interpret rapid, real-time, serial assessment of patient physiology at the bedside has seen the potential uses of CPU expand, with an evolving list of clinical and research applications. Benefits of functional assessment of neonatal haemodynamics in particular have been described across a range of gestational ages and disease states. Devising suitable curricula for trainees and ensuring robust processes for the training and credentialing of clinicians performing CPU is essential. Challenges to universal implementation of CPU in the neonatal intensive care setting exist, and regional differences in training and accreditation are well described. Appropriate integration into clinical decision-making and ensuring competency-based locally appropriate training programs, which build on an expanding evidence base, are key priorities in ensuring newborns receive optimal benefit from the modality.

The Hartnett Model: An effective low-resource training program that facilitates formal point-of-care ultrasound credentialing of emergency medicine trainees

Introduction Training in point-of-care ultrasound (POCUS) is embedded within the curriculum framework of the Australasian College for Emergency Medicine (ACEM). However, formal credentialing in POCUS is often problematic due to lack of supervision and feedback. Within a supportive learning environment, it is expected that trainees would be more likely to satisfy the requirements of formal credentialing, such as the Australasian Society for Ultrasound in Medicine's Certificate in Clinician Performed Ultrasound (CCPU). Methods The Fiona Stanley Hospital (FSH) emergency department's Hartnett Model training program was devised to address traditional deficiencies in supervision and feedback during POCUS credentialing. The primary aim of this novel program is to assist ACEM trainees to acquire CCPU modules. Six emergency medicine registrars are selected for each six-month semester of the program through a formal selection process. Successful applicants nominate two CCPU modules for completion during the term and receive dedicated non-clinical time. For three hours once a week, an emergency physician holding formal POCUS credentials supervises a pair of trainees while they perform bedside scans on patients within the FSH emergency department. During these sessions, there are also opportunities for trainees' logbook scans to be reviewed. Formative and summative assessments occur as required by the CCPU module. Results The Hartnett Model has proven to be a successful method of assisting emergency medicine trainees in obtaining CCPU credentials. Over an 18-month period starting in 2017, eighteen registrars and four instructors were involved. All participants selected the E-FAST module; 13 chose Abdominal Aortic Aneurysm and 5 Basic Echo in Life Support. During their six-months in the training program, most trainees satisfied the requirements of both CCPU modules that they enrolled in (28/36 modules completed). Overall, the average number of scans in each module exceeded the requirements for the CCPU logbook. Approximately 40% of the scans were obtained by participants during the supervised sessions. Following their involvement in the program, trainees' perceived that undergoing POCUS training had significantly benefited their ability to manage patients. There was overwhelming support for the structure of the program. Conclusions The FSH emergency department's Hartnett Model is effective in assisting emergency medicine trainees to gain formal POCUS credentials. As it requires relatively little organisation, time and staffing, it could be adopted in many emergency departments around Australia.

The utility of Point-Of-Care Ultrasound (POCUS) in emergency department; an observational study

Objective An observational study on the current diagnostic and procedural utility and impact of point of care ultrasound (POCUS) in Emergency Departments. Background POCUS has been recognised as a readily available, non-invasive imaging tool; providing prompt clinical information at the bedside, as well as a useful guiding tool during procedural interventions. However, its current use and clinical impact in ED remain unknown. Methods In October 2016, a 31-day prospective observational study was performed in three Monash Health Emergency Departments in Melbourne, Australia. Data regarding patients’ presenting complaints, frequency, operators’ qualifications and POCUS module were archived and analysed. Factors associated with diagnostic impacts were identified. Results A total of 390 (2.82%) POCUS examinations were performed among 18,355 (13,822 adults) presentationsin the three Monash Health EDs during the 31-day study period. 292 (74.9%) cases were retrieved from electronic medical records (Symphony), recorded as Clinician-Performed Ultrasound (CPU);and 98 (25.1%) cases from written records which were collected by research assistants. The POCUS was performed as a diagnostic tool in 344 (88.2%) and procedural in 46 (11.8%) cases. eFAST/AAA and BELS were the two most frequently utilised diagnostic modalities. Overall, the majority of diagnostic POCUS cases were in patients presented with abdominal pain (35.3%), chest pain (14.0%) and trauma mainly motor vehicle accidents (5.8%). Procedural POCUS was most commonly used for vascular access (71.7%), where dyspnoea (21.6%) was the most common presenting complaint. Most of the cases were performed by Senior Medical Staffs (66.4%). DiagnosticPOCUS overall sensitivity and specificity were 94.1% (95% CI 85.6 - 98.4%) and 99.6% (97.5 - 100%); positive and negative predictive values were 98.5% (95% CI 90.1 – 99.8%) and 98.2% (95% CI 95.6 – 99.3%), respectively. Conclusions Despite known diagnostic and procedural pros, the prevalence of POCUS in our EDs was found to be lower than what is expected and potentially beneficial in our population. In our study, POCUS mostly served for diagnostic purposes and demonstrated satisfactory diagnostic values. However, the true diagnostic and therapeutic impacts could not be elicited given the few numbers of cases. Prevalence is shown to be proportional to the level of clinical expertise among the operators. Training and utility of POCUS among physicians ought to be further advocated and supported.

The History of Ultrasound and Its Use at Point of Care: Neonatal Ultrasound in Transport

Purpose of review The purposes of this review are to explore the history of the diagnostic ultrasound and its use in medical care and to report on the latest findings on the utility of ultrasound during the transport of patients. Recent findings The Neonatal Ultrasound in Transport (NUiT) study demonstrated the feasibility and utility of ultrasound assessment prior to the retrieval of critically ill newborns to a higher level of care. It is feasible to carry a laptop ultrasound with the transport team without hindering flight or retrieval processes. The NUiT study demonstrated that many term babies had evidence of clinically unsuspected haemodynamic compromise. Other babies had clinically unsuspected abnormal heart structure allowing for redirection of transport toward paediatric cardiology centres. The preterm cohort revealed many babies with clinically unsuspected low systemic blood flow and stable head ultrasound findings pre- and post transport. This has implications for therapeutic targeting of treatment and for counselling parents. Summary Clinician-performed ultrasound (CPU) during the retrieval of neonates confirms a high incidence of haemodynamic pathology. Ultrasound in retrieval is feasible, allows the accurate triage of babies to cardiac centres and may allow more accurate and earlier targeting of fluid and inotropic support.

Feasibility and utility of portable ultrasound during retrieval of sick term and late preterm infants.

To determine the role of clinician performed ultrasound (CPU) during the retrieval and transport of critically ill term and near term newborns. A neonatologist with portable ultrasound accompanied a sample of newborn retrievals to perform cardiac and cerebral ultrasound before and after transportation. A total of fifty-five babies were studied. Median birthweight: 3350g (2220-5030g). CPU led to a change in the planned receiving hospital in ten babies. Eleven babies were suspected congenital heart disease (CHD) prior to retrieval: eight confirmed CHD by CPU and three normal structure. One transported to a children's hospital for cardiology review was confirmed as having normal structure; one to a perinatal hospital where normal structure was confirmed and one baby died at the referring hospital and postmortem confirmed normal structure. In five babies with clinical pulmonary hypertension, CPU revealed unsuspected CHD. The destination was changed to a paediatric cardiology centre, avoiding a second retrieval. Eleven babies had evidence of haemodynamic compromise allowing targeting of inotropes. This is the first study of CPU during retrieval of high-risk infants. Ultrasound in retrieval is feasible, allows accurate triage of babies to cardiac centres and may allow more accurate targeting of fluid and inotrope support.

IS-025 Functional Echocardiography: Core Competency For The Neonatologist?

Point of care ultrasound: a core competency for the neonatologist? Nick Evans: Newborn Care, RPA Hospital and University of Sydney, Sydney, Australia. Introduction Protagonists of point of care clinician performed ultrasound (CPU) point to the value of 24/7 immediate diagnosis, antagonists point to limited formal accreditation and risk of misdiagnosis. Implementation of CPU should embrace the benefits while minimising the risk of harms. Cardiac ultrasound Permits a window on haemodynamic pathophysiology where there are few alternatives. There is a range of acute care indication and with systematic use of ultrasound, the extent to which clinical and vital signs have misled us has become apparent. Other organ ultrasound Beyond the heart, NPU extends to acute head ultrasound to exclude cerebral haemorrhage. Abdominal and thoracic ultrasound to diagnose abnormal fluid. Bladder ultrasound to confirm urine prior to supra-pubic aspiration. Screening of the entry points of the IVC and SVC into the heart can exclude an intra-cardiac tip position. Ultrasound allows real time localisation of UVC tip position during insertion. There is evolving use of lung ultrasound to diagnose a range of pulmonary conditions and gut ultrasound for NEC. Training and accreditation It’s hard to see that ultrasound skills are not going to become a core competency for neonatologists. There is a need for formal training and accreditation structures. We have such a structure in Australasia in the form of the Certificate of Clinician Performed Ultrasound (CCPU). The training needs in neonatology should be determined by neonatologists, not by other specialties.

Clinician-Performed Ultrasound in Identifying Osteomyelitis of the Hand

Clinician-Performed Ultrasound in Identifying Osteomyelitis of the Hand

Clinician‐performed ultrasound in assessing potentially malignant thyroid nodules

Ultrasound (US) is used in the workup of thyroid nodules. Ultrasonographic characteristics, such as an ill-defined margin, hypoechoicity or fine calcifications, are known to be associated with malignant thyroid lesions. The association between these characteristics and the risk of malignancy has been reported predominantly from series published where US is performed in radiology departments. Clinician-performed ultrasound (CPU) is increasingly being used as a modality, although there is little published literature validating this practice. A prospectively collected database of known ultrasonographic characteristics of malignancy as determined by CPU on thyroid nodules is reported and correlated against adequate cytology or operative histopathology. In total, 157 thyroid nodules (28 malignant, 129 benign) were included and characteristics of poorly defined capsule (sensitivity 46%, specificity 91%), absence of halo (sensitivity 54%, specificity 80%), hypoechoicity (sensitivity 79%, specificity 54%), heterogeneity (sensitivity 64%, specificity 68%), fine calcifications (sensitivity 36%, specificity 95%) and central blood supply (sensitivity 71%, specificity 69%) were found to be associated with malignant thyroid nodules. Negative-predictive values (NPVs) for these characteristics were consistently high (89%, 89%, 92%, 90%, 87% and 94%, respectively). These results are consistent with the previously published datasets of ultrasonographic characteristics of malignancy and validate the use of CPU. The consistently high NPV suggests that the absence of ultrasonographic characteristics of malignancy correlates well with benign lesions. CPU is a reliable and useful tool in the hands of surgeons assessing and following potentially malignancy thyroid nodules.

Neonatal Ultrasound in Transport

Current practices for monitoring the haemodynamics of critically ill newborns whilst in transport to tertiary care are poorly validated. These include arterial blood pressure monitoring, capillary return and urine output. Clinician performed ultrasound (CPU) has been validated in the NICU and is currently being trialled in transport. This case based discussion describes the retrieval of four newborn infants utilising CPU assessment of the newborn systemic blood flow and investigation of intracranial blood flow and pathology. Case one describes a baby with subgaleal haemorrhage who was pre arrest where the CPU (cardiac) allowed the treating team to effectively change the inotropes and alter the clinical course. Case two is a baby with the classical diagnostic dilemma of persistent pulmonary hypertension of the newborn (PPHN) versus cyanotic congenital heart disease (CCHD) – the screening CPU (cardiac) was able to define CCHD and the transport was re-directed to tertiary paediatric cardiac services. The CPU (cardiac) in case three, a baby born at 25 weeks, also assisted in the choice of therapeutic options for the treating team. Both case three and four were born at 25 week gestation and the CPU (cranial) provided information prior to transport that aided in the counselling of the parents.

Effectiveness of a Training Program in Clinician Performed Ultrasound in the Diagnosis of Pneumothorax in Trauma

Effectiveness of a Training Program in Clinician Performed Ultrasound in the Diagnosis of Pneumothorax in Trauma

Effectiveness of a Training Program in Clinician-performed Ultrasound in the Diagnosis of Pneumothorax in Trauma

Effectiveness of a Training Program in Clinician-performed Ultrasound in the Diagnosis of Pneumothorax in Trauma