Introduction
In the emergency setting, focused cardiac ultrasound has become a fundamental tool for diagnostic, initial emergency treatment and triage decisions. A new ultra-miniaturized pocket ultrasound device (PUD) may be suited to this specific setting. Therefore, we aimed to compare the diagnostic ability of an ultra-miniaturized ultrasound device (Vscan™, GE Healthcare, Wauwatosa, WI) and of a conventional high-quality echocardiography system (Vivid S5™, GE Healthcare) for a cardiac focused ultrasonography in patients admitted to the emergency department.

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Assessment of left ventricular ejection fraction using an ultrasonic stethoscope in critically ill patients

Evaluation of a new pocket echoscopic device for focused cardiac ultrasonography in an emergency setting.

Introduction: Assessment of cardiac function is key in the management of intensive care unit (ICU) patients and frequently relies on the use of standard transthoracic echocardiography (TTE). A commercially available new generation ultrasound system with two-dimensional imaging capability, which has roughly the size of a mobile phone, is adequately suited to extend the physical examination. The primary endpoint of this study was to evaluate the additional value of this new miniaturized device used as an ultrasonic stethoscope (US) for the determination of left ventricular (LV) systolic function, when compared to conventional clinical assessment by experienced intensivists. The secondary endpoint was to validate the US against TTE for the semi-quantitative assessment of left ventricular ejection fraction (LVEF) in ICU patients. Methods: In this single-center prospective descriptive study, LVEF was independently assessed clinically by the attending physician and echocardiographically by two experienced intensivists trained in critical care echocardiography who used the US (size: 135 × 73 × 28 mm; weight: 390 g) and TTE. LVEF was visually estimated semi-quantitatively and classified in one of the following categories: increased (LVEF > 75%), normal (LVEF: 50 to 75%), moderately reduced (LVEF: 30 to 49%), or severely reduced (LVEF < 30%). Biplane LVEF measured using the Simpson’s rule on TTE loops by an independent investigator was used as reference. Results: A total of 94 consecutive patients were studied (age: 60 ± 17 years; simplified acute physiologic score 2: 41 ± 15), 63 being mechanically ventilated and 36 receiving vasopressors and/or inotropes. Diagnostic concordance between the clinically estimated LVEF and biplane LVEF was poor (Kappa: 0.33; 95% CI: 0.16 to 0.49) and only slightly improved by the knowledge of a previously determined LVEF value (Kappa: 0.44; 95% CI: 0.22 to 0.66). In contrast, the diagnostic agreement was good between visually assessed LVEF using the US and TTE (Kappa: 0.75; CI 95%: 0.63 to 0.87) and between LVEF assessed on-line and biplane LVEF, regardless of the system used (Kappa: 0.75; CI 95%: 0.64 to 0.87 and Kappa: 0.70; CI 95%: 0.59 to 0.82, respectively).

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Transthoracic echocardiography (TTE), usually performed by cardiologists, is increasingly used by physicians at the patient‟s bedside. Focused TTE is an abbreviated study used as part of clinical assessment to improve diagnostic accuracy and aid clinical decision-making in real-time. Cardiac disease is a leading cause of perioperative mortality, which may be contributed to by poor preoperative cardiac assessment. The hypothesis is that focused TTE influences cardiovascular diagnosis and management by anaesthetists.
An audit of focused TTE revealed changes to anaesthetist‟s management plans in 53% of 87 patients undergoing emergency surgery (75%), elective surgery (56%) and preoperative assessment clinic assessment (22%). TTE helped guide preoperative cardiology referral, anaesthetic technique, invasive monitoring and postoperative disposition. TTE was possible in 10 out of 24 patients with intraoperative haemodynamic instability, avoiding need for transoesophageal echocardiography and associated risk of oesophageal injury.
I conducted prospective observational studies of 100 patients attending the preoperative assessment clinic for elective surgery; and 99 patients requiring emergency surgery. In patients with clinically suspected cardiac disease or age ≥65 years, the anaesthetist‟s management plan was compared before and after TTE performed by an independent anaesthetist.
In elective surgery, the TTE findings triaged patients to those with significant cardiac pathology leading to a step-up in care (20%), and those without, leading to a step-down in care (34%). Management was also altered in asymptomatic patients aged over 65 years (step-up in 10%, step-down in 15%). An overall reduction in hospital resource use (cardiology referral, invasive monitoring and intensive care) and improved efficiency (less delays and hospital visits) resulted.
In emergency surgery, TTE revealed significant cardiac pathology in 75%, altering preoperative assessment in 67% leading to a higher step-up (36%) than step-down (8%) in treatment. Haemodynamic treatment changes (such as fluids and invasive monitoring) were more common (30%) than changes to surgical workflow and postoperative intensive care (14%).
In a retrospective cohort sub-analysis, the mortality of 64 hip fracture patients who received preoperative TTE was compared to a randomised retrospective control group with similar risk factors. Mortality was lower in the TTE group over the 30 days (4.7% v 15.2%, p=0.047) and 12 months after surgery (17.1% versus 33.3%, p=0.031). Hazard of death over 12 months was reduced after adjustment for known risk factors (hazard ratio 0.41, 95% CI 0.2 to 0.85, p=0.016).
In surgical patients at increased risk of cardiac disease, preoperative focused TTE by anaesthetists frequently changed management decisions and may reduce mortality.

/pdf/the-impact-of-focused-transthoracic-echocardiography-in-non-rno9i11nh3.pdf

Assessment of left ventricular ejection fraction using an ultrasonic stethoscope in critically ill patients

Citations

Evaluation of a new pocket echoscopic device for focused cardiac ultrasonography in an emergency setting.

Assessment of left ventricular ejection fraction using an ultrasonic stethoscope in critically ill patients

The impact of focused transthoracic echocardiography in non-cardiac anaesthesia and surgery

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