Role Of Point-of-care Ultrasound Research Articles

An [illustrative] update on pediatric emergency medicine ultrasound: part 1 – trauma and thoracic applications

Point-of-care ultrasound (POCUS) plays an essential role in emergency medicine, providing a range of diagnostic and procedural modalities. It does not involve any ionizing radiation and can improve procedural accuracy and safety. The role of POCUS in the care of pediatric patients differs somewhat from that of adult patients, as there are a range of conditions specific to infants and children. The technical background of pediatric POCUS and its current applications for trauma and thoracic scanning are reviewed and illustrated in this first article of this series.

Role of POCUS in Assessing an Acute Aortic Thrombus

A 67-year-old female patient presented with abdominal pain with a recent diagnosis of paroxysmal atrial fibrillation. Computed tomography (CT) of the abdomen demonstrated a filling defect concerning for an aortic thrombus. Point of care ultrasound (POCUS) confirmed a mobile thrombus in the proximal abdominal aorta in close proximity to several major arterial branches, leading to urgent surgical consultation due to a concern for mesenteric and end-organ ischemia. POCUS played a role in determining patient management in this novel case, and the patient was anticoagulated and ultimately discharged from the hospital.

Point-of-care ultrasound (POCUS) in acute hospitalized older patients focused on hydration.

Acutely ill older patients frequently suffer not only from their acute disease, but also polymorbidity and frailty. Dehydration is another typical symptom, usually occurring in its both forms: low-intake dehydration and volume depletion. POCUS is goal-directed bedside ultrasound examination and several studies refer to its positive impact on hydration assessment. The aim of our study was to determine whether POCUS might influence (de)hydration diagnostics and/or treatments in older patients with acute illness. We randomized 120 acutely ill patients, aged ≥65 years, into POCUS and non-POCUS groups. All participants underwent routine laboratory tests, including haematocrit, serum and urine osmolality, blood urea nitrogen (BUN), creatinine, BUN/creatinine ratio, and C-reactive protein (CRP). POCUS was performed twice during the first two days to determine chest and abdominal status, with inferior vena cava (IVC) measurements. Length of hospital stay (HL) and consumption of infused fluids (CIF) was evaluated too. Data were analysed with exploratory methods and appropriate statistics. Among all participants, the serum osmolality significantly correlated with age, BUN, creatinine and CIF. HL correlated with CRP and CIF. No significant correlations between IVC and other followed parameters were found. The POCUS group consumed significantly less infused fluids than the non-POCUS group, what could be influenced by POCUS examination of defined body compartments. Dehydration is a common feature in older individuals and its diagnostics is rather complicated. The role of POCUS in assessing hydration status remains unclear. However, our study showed, that ultrasound assessment provides next important information for comprehensive understanding of clinical status in older patients and can be beneficial for optimizing the treatment strategy, including fluid management decisions.

CLOT IN TRANSIT: THE ROLE OF POINT-OF-CARE ULTRASOUND IN EARLY DIAGNOSIS AND IMPROVED OUTCOMES

SESSION TITLE: Thrombosis Jamboree: Rare and Unique CasesSESSION TYPE: Rapid Fire Case ReportsPRESENTED ON: 10/19/2022 12:45 pm - 1:45 pmINTRODUCTION: A clot in transit is a rare clinical manifestation of venous thromboembolism (VTE), with an incidence of 3-18% in patients with acute pulmonary embolism (PE). It is defined as a mobile echogenic mass usually visualized in the right atrium or right ventricle using point of care ultrasound (POCUS). A clot in transit is associated with high morbidity and mortality and is deemed a medical emergency. This case report focuses on clot in transit and the role of POCUS in facilitating early intervention in submassive pulmonary embolism.CASE PRESENTATION: The patient is a 78-year-old male admitted to the acute inpatient rehabilitation unit after having an ischemic cerebrovascular accident two weeks prior. On Day 3 of admission, the patient suddenly developed altered mental status, hypotension that improved with fluids, intermittent supraventricular tachycardia , and new-onset hypoxia requiring transfer to the intensive care unit. POCUS revealed a mobile linear echogenic mass in the right atrium traversing the tricuspid valve into the right ventricle, consistent with a clot in transit. Evidence of right heart strain, suspicious for PE was seen. Labs were consistent with a submassive PE with elevated D-dimer, BNP, and troponin. Computed tomography of the chest with angiography (CTA) with PE protocol was not done due to a concomitant acute kidney injury. Therapeutic anticoagulation with heparin was initiated. After a review of the case by the multidisciplinary PE Response Team, the patient underwent percutaneous thrombectomy, with the extraction of emboli from both the right and left pulmonary arteries. After the procedure, there was an improvement in hemodynamics with an increased cardiac index (1.5 to 1.8) and decreased mean pulmonary artery pressure (36 mmHg to 23 mmHg). The patient significantly improved and was discharged on apixaban.DISCUSSION: A clot in transit is a rare finding in acute pulmonary embolism and is associated with increased mortality, as high as 45%, compared to PE alone. Although there are no established treatment guidelines due to the lack of prospective studies, a recent study showed that mortality was higher in patients treated with anticoagulation alone (36.4%) compared to thrombolysis (18.2%) or surgical embolectomy (18%). POCUS is an effective clinical modality that can be used to diagnose a clot in transit and promptly identify certain pathologies associated with acute PE, such as right heart strain. In this patient who could not undergo CTA, the gold standard to diagnose pulmonary embolism, POCUS was the sole diagnostic modality used to diagnose the VTE.CONCLUSIONS: The increasing use of POCUS as an initial screening tool to evaluate for causes of hemodynamic and respiratory compromise can lead to early identification of clot in transit in patients with pulmonary embolism and facilitate early intervention, ultimately leading to improved outcomes and decreased mortality.Reference #1: Garvey S, Dudzinski DM, Giordano N, Torrey J, Zheng H, Kabrhel C. Pulmonary embolism with clot in transit: An analysis of risk factors and outcomes. Thromb Res. 2020 Mar;187:139-147.Reference #2: Burgos LM, Costabel JP, Brito VG, Sigal A, Maymo D, Iribarren A, Trivi M. Floating right heart thrombi: A pooled analysis of cases reported over the past 10 years. Am J Emerg Med. 2018 Jun; 36(6): 911-915.Reference #3: Shah DP, Min JK, Raman J, Lodato JA, Van Kley D, Lang RM, Ward RP. Thrombus-in-transit: two cases and a review of diagnosis and management. J Am Soc Echocardiogr. 2007 Oct;20(10):1219.e6-8.DISCLOSURES: Consultant relationship with Boehringer Ingelheim Please note: 8/10/2021 Added 03/31/2022 by Julia Budde, value=Consulting feeNo relevant relationships by Yasmin LeighNo relevant relationships by Racine Elaine ReinosoNo relevant relationships by James Thomas Salmon SESSION TITLE: Thrombosis Jamboree: Rare and Unique Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: A clot in transit is a rare clinical manifestation of venous thromboembolism (VTE), with an incidence of 3-18% in patients with acute pulmonary embolism (PE). It is defined as a mobile echogenic mass usually visualized in the right atrium or right ventricle using point of care ultrasound (POCUS). A clot in transit is associated with high morbidity and mortality and is deemed a medical emergency. This case report focuses on clot in transit and the role of POCUS in facilitating early intervention in submassive pulmonary embolism. CASE PRESENTATION: The patient is a 78-year-old male admitted to the acute inpatient rehabilitation unit after having an ischemic cerebrovascular accident two weeks prior. On Day 3 of admission, the patient suddenly developed altered mental status, hypotension that improved with fluids, intermittent supraventricular tachycardia , and new-onset hypoxia requiring transfer to the intensive care unit. POCUS revealed a mobile linear echogenic mass in the right atrium traversing the tricuspid valve into the right ventricle, consistent with a clot in transit. Evidence of right heart strain, suspicious for PE was seen. Labs were consistent with a submassive PE with elevated D-dimer, BNP, and troponin. Computed tomography of the chest with angiography (CTA) with PE protocol was not done due to a concomitant acute kidney injury. Therapeutic anticoagulation with heparin was initiated. After a review of the case by the multidisciplinary PE Response Team, the patient underwent percutaneous thrombectomy, with the extraction of emboli from both the right and left pulmonary arteries. After the procedure, there was an improvement in hemodynamics with an increased cardiac index (1.5 to 1.8) and decreased mean pulmonary artery pressure (36 mmHg to 23 mmHg). The patient significantly improved and was discharged on apixaban. DISCUSSION: A clot in transit is a rare finding in acute pulmonary embolism and is associated with increased mortality, as high as 45%, compared to PE alone. Although there are no established treatment guidelines due to the lack of prospective studies, a recent study showed that mortality was higher in patients treated with anticoagulation alone (36.4%) compared to thrombolysis (18.2%) or surgical embolectomy (18%). POCUS is an effective clinical modality that can be used to diagnose a clot in transit and promptly identify certain pathologies associated with acute PE, such as right heart strain. In this patient who could not undergo CTA, the gold standard to diagnose pulmonary embolism, POCUS was the sole diagnostic modality used to diagnose the VTE. CONCLUSIONS: The increasing use of POCUS as an initial screening tool to evaluate for causes of hemodynamic and respiratory compromise can lead to early identification of clot in transit in patients with pulmonary embolism and facilitate early intervention, ultimately leading to improved outcomes and decreased mortality. Reference #1: Garvey S, Dudzinski DM, Giordano N, Torrey J, Zheng H, Kabrhel C. Pulmonary embolism with clot in transit: An analysis of risk factors and outcomes. Thromb Res. 2020 Mar;187:139-147. Reference #2: Burgos LM, Costabel JP, Brito VG, Sigal A, Maymo D, Iribarren A, Trivi M. Floating right heart thrombi: A pooled analysis of cases reported over the past 10 years. Am J Emerg Med. 2018 Jun; 36(6): 911-915. Reference #3: Shah DP, Min JK, Raman J, Lodato JA, Van Kley D, Lang RM, Ward RP. Thrombus-in-transit: two cases and a review of diagnosis and management. J Am Soc Echocardiogr. 2007 Oct;20(10):1219.e6-8. DISCLOSURES: Consultant relationship with Boehringer Ingelheim Please note: 8/10/2021 Added 03/31/2022 by Julia Budde, value=Consulting fee No relevant relationships by Yasmin Leigh No relevant relationships by Racine Elaine Reinoso No relevant relationships by James Thomas Salmon

How to assess, detect, and manage joint involvement in the era of transformational therapies: Role of point-of-care ultrasound.

Patients with haemophilia experience recurring hemarthroses, mainly involving knees, elbows and ankles, which lead to haemophilic arthropathy, the major chronic complication of haemophilia. With new approaches to haemophilia treatment leading to fewer joint bleeds and, in some cases, no bleeding events, assessing whether current outcome assessment tools provide adequate sensitivity and specificity for management and care of patients with haemophilia is needed. An overview of current imaging tools for monitoring joint health, novel osteochondral damage and synovial proliferation biomarkers, and the relationship between assessments for functionality and imaging modalities is provided. Usefulness and sensitivity of point-of-care ultrasound (POCUS) to complement other assessments and use of ultrasound to monitor haemophilic arthropathy are also examined. This review provides rationale for haemophilia teams to move beyond traditional outcomes in joint imaging, as well as guidance and evidence on assessment of joint health for potential new treatment modalities, such as gene therapy. The role of POCUS in the existing paradigm for haemophilia care and management along with the use of ultrasound as a complement to other outcome assessment tools are also discussed. Finally, the clinical effects of subclinical bleeding on joint function are described, to motivate screening for synovial proliferation. POCUS can facilitate the early detection of joint damage and can monitor disease progression while providing insights into the efficacy of treatment regimens, and should be considered as an essential assessment tool for managing the care of patients with haemophilia.

Diagnostic Utility of Point-of-Care Ultrasound in the Pediatric Cardiac Intensive Care Unit.

Purpose of ReviewThis review summarizes the diverse uses of point-of-care ultrasound (POCUS) in critically ill children with congenital and acquired heart disease. Diagnostic utility and practicality of POCUS is reviewed. Importantly, the role of POCUS in the medical management of children in the cardiac intensive care unit is highlighted.Recent FindingsThe use of POCUS in critically ill pediatric patients has emerged as an essential diagnostic tool that enhances the physical examination and influences delivery of care. Assessment of a wide range of body systems and pathologies has been impacted by the use of POCUS. Recent studies have demonstrated the use of POCUS for evaluation of cardiac tamponade, pneumonia, vocal cord function, and loss of muscle mass in critically ill children (Hamilton et al. Pediatr Crit Care Med 22(10):e532-e539, 2021; Hoffmann et al. Pediatr Crit Care Med 22(10):889-897, 2021; Najgrodzka et al. Ultrasound Q 35(2):157 163, 2019; Alerhand et al. Pediatr Ann 50(10):e424-e431, 2021).SummaryPOCUS is a non-invasive, low-risk, imaging modality that can be used to diagnose and help guide management of critically ill children in the cardiac intensive care unit. POCUS can be performed by an intensivist at the patient’s bedside with real-time interpretation, leading to rapid clinical decision-making and the hope of improving patient outcomes.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40746-022-00250-1.

Integrating Point of Care Ultrasound into Nephrology Fellowship Training: Insights from a Pilot Program.

In nephrology, point-of-care ultrasound (POCUS) has multiple applications including the rapid evaluation of acute kidney injury, enhancing the initial evaluation of chronic kidney disease, direct evaluation of vascular access, and improved fluid balance management in acute and chronic settings [1, 2]. Recently, the role of POCUS has been formally acknowledged by the American College of Physicians and curricula specific to nephrology have been proposed [3, 4]. However, the integration of a novel clinical skill into a field comes with its unique set of challenges. Above all, most nephrologists in leadership roles within fellowship training programs lack POCUS experience, which represent a significant barrier for adequate exposure and teaching. Although educational curriculum centered on nephrology have been proposed, the optimal model to ensure adequate POCUS exposure considering the scarcity of expertise among educators is not known. 

American Society of Regional Anesthesia and Pain Medicine expert panel recommendations on point-of-care ultrasound education and training for regional anesthesiologists and pain physicians—part I: clinical indications

Point-of-care ultrasound (POCUS) is a critical skill for all regional anesthesiologists and pain physicians to help diagnose relevant complications related to routine practice and guide perioperative management. In an effort...

Application of Point-of-Care Ultrasound(POCUS) in Children with End-Stage KidneyDisease

The use of point-of-care ultrasound is becoming increasingly common among non-radiologist clinicians. There has also been increased interest in the bedside assessment of fluid status in hemodialytic patients. Lung ultrasound and inferior vena cava collapsibility index measurement methods may assist the detection of fluid overload. Current information on the role of POCUS in regard of the assessment of predialytic fluid overload in hemodialytic children is scarce. In this article, we aim to review and emphasize the importance of a non-invasive bedside method of assessing the predialytic volume overload of children based on the published literature. Well-designed studies with larger samples are needed to prove the reliability of the use of lung ultrasound and inferior vena cava collapsibility index in the assessment of predialysis fluid overload in children.

Point-of-care echocardiography for the evaluation of right-to-left cardiopulmonary shunts: a narrative review.

Right-to-left pulmonary and cardiac shunts (RLS) are important causes of refractory hypoxia in the critically-ill perioperative patient. Using a point-of-care ultrasound (POCUS) agitated saline bubble study for an early diagnosis allows patients with clinically significant RLSs to receive expedited therapy. This narrative review discusses the principles of agitated saline ultrasonography as well as the role of POCUS in detecting the most common RLS types seen in the intensive care unit, including patent foramen ovale, atrial septal defects, and pulmonary arterio-venous malformations. An illustrated discussion of the procedure, as well as shunt-enhancing maneuvers (Valsalva or lung recruitment maneuver with subsequent rapid release) is provided. With the wide dissemination of bedside ultrasound within the perioperative and critical care arena, POCUS practitioners should be knowledgeable of the potential pitfalls leading to both false-positive and false-negative studies. False-positive studies may be due to congenital abnormalities, mischaracterization of intrapulmonary shunts as intracardiac shunts (and vice versa), or evidence of the Valsalva effect. False negatives are typically due to respiratory-phasic variation, performing an inadequate shunt-enhancing maneuver, inadequate injection of agitated saline, or pathophysiologic states of elevated left atrial pressure. Finally, alternative POCUS methods for determining presence of an RLS in patients with poor echocardiographic windows are discussed, with a focus on pulsed-wave Doppler interrogation of arterial signals.

POCUS in Acute Medicine

In this edition of Acute Medicine, Knight et al. demonstrate from SAMBA data that access to ultrasound machines and supervision is geographically heterogeneous.1 They raise concerns that this may lead to inequity of provision of Point of Care Ultrasound (POCUS) and the benefits it can provide for patients. This point is well made: Since the development of the Focused Acute Medicine Ultrasound (FAMUS) competencies in 20162 there has been a steady increase in the provision of supervisors to 803 and the number of individuals completing training has increased to 56. Whilst this is to be applauded, our experience concurs with this paper that much of the ultrasound training is concentrated in pockets of expertise in particular hospitals. As part of the AIM curriculum rewrite for 2022, the Special Advisory Group has proposed to the GMC that POCUS competencies become mandatory for all trainees in AIM. This will be supported by half a day of clinical time for training. This is a laudable aim but it is questionable whether, given the number of supervisors and their idiosyncratic distribution, the specialty of Acute Medicine would be able to support accreditation for all trainees. It is estimated that it takes 22 hours of supervision per supervised trainee.1 This is a significant commitment for jobbing consultants, especially with no supporting professional activity time in a job plan. The COVID19 pandemic has shown the value of POCUS lung ultrasound but has also highlighted further these training issues. A joint statement by the FAMUS and Focused Ultrasound in Intensive Care (FUSIC) committees has for the time being suggested that attendance at a course should no longer be a requirement for accreditation.4 This is an understandable attempt to try to keep training going but may have unintended consequences: It is often on courses that people are able to network and find solutions to mentoring and supervision in their areas and hospitals. The welcome support of the Royal College of Radiologists in their newsletter from Autumn 2019 may go some way to helping to fill the gap.5 The support of radiology and sonography departments will certainly lead to a greater number of training opportunities however there are concerns that many radiology departments remain sceptical about the role of POCUS and at an individual hospital level engagement is likely to be variable. As a solution to some of these problems at the Royal Berkshire hospital we have set up the AIM POCUS Academy with the goal of further embedding POCUS within the Acute Medicine department and the wider hospital.6 We are doing this by developing a multi-professional, multidisciplinary approach to POCUS through weekly teaching ‘Ultrarounds’. Links to the Sonography department, Cardiology, Respiratory Medicine, Emergency Medicine, Intensive Care, Vascular Access, Critical Care Outreach and Primary Care has led to a culture in which POCUS is considered a standard of care within the hospital and very much driven by the Acute Medicine department. This provides tremendous opportunities in all areas of the hospital for training and supervision but also the opportunities for different specialties to learn from each other. Individual Physiotherapists, Nurses and the Advanced Critical Care Practitioners in the hospital are either trained or are training up in lung ultrasound, ultrasound for vascular access or focused echocardiography and provide an excellent long term solution to the challenges of mentoring and supervision as they are more permanent members of staff. Where the sonography department and echocardiography department also provide mentorship for FAMUS and FUSIC, the exchange is both ways: Acute Medicine trainees have provided teaching around interpreting liver function testing which has led to rationalisation of inpatient abdominal ultrasounds and have taught sonographers how to interpret lung ultrasound; the echocardiography department are auditing the use of focused scans in specific conditions rather than a complete British Society of Echocardiography (BSE) full data sheet (so for instance in the context of an acute PE the echocardiographer will focus of right heart measures). This has helped to reduce waiting times within these departments. Technology has also helped to embed best practice and facilitate easier mentoring and supervision. Using the Butterfly IQ devices and a triple encrypted ‘cloud’ allows easy archiving of images and the possibility of remote reviewing which can even be in real time. This was invaluable during the COVID pandemic when GPs in our local ‘hot hub’ were trained up to use ultrasound to rule in and rule out COVID pneumonia allowing them to refer onto the ambulatory COVID pathway.6 They were able to share images via the cloud for review by experts in the hospital ensuring an extra degree of governance and oversight. We are trialing a similar system with our ‘Hospital at Home’ team with the hope it may save patients unnecessary visits to hospital for CXR and other imaging. If the specialty of Acute Medicine wants to take ownership of POCUS then we need to up our game and get serious about the supervision and mentoring of our trainees. Whilst the model of the AIM POCUS Academy may not be achievable everywhere, we believe initiatives like ours can act as the model for effective teaching and these centres could potentially provide a regional solution for POCUS training.

A Case of Thrombus in Transit: Role of POCUS in Early Diagnosis of Pulmonary Thromboembolism.

Pulmonary embolism is a cause of significant morbidity and mortality. Thrombus in transit is defined on ultrasound as mobile echogenic material, temporarily located in the right heart chambers making its way to the pulmonary vasculature, which is highly diagnostic of pulmonary embolism. Point-of-care ultrasound (POCUS) places significant role in early diagnosis of thrombus in transit. Point-of-care ultrasound also avoids the need for subsequent computed tomography angiogram for diagnosis of pulmonary embolism. We present the case of 53-year-old male who presented with shortness of breath and was noted to have sinus tachycardia; thrombus in transit was diagnosed by point-of-care ultrasound and was subsequently confirmed through computer tomography angiogram of the pulmonary artery.