Evaluation of a new pocket echoscopic device for focused cardiac ultrasonography in an emergency setting.
TL;DR: In an emergency setting, this new ultraportable echoscope (PUD) was reliable for the real-time detection of focused cardiac abnormalities.
Abstract: 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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King Abdulaziz Medical City1, University of the Witwatersrand2, University of Minnesota3, King Saud University4, Harvard University5, Icahn School of Medicine at Mount Sinai6, University of Belgrade7, Beth Israel Deaconess Medical Center8, Aarhus University Hospital9, University of South Florida10, Scripps Mercy Hospital11, University Hospital of Wales12, Sydney Adventist Hospital13, Peking Union Medical College Hospital14, Apollo Hospitals15, University of South Carolina16, Cornell University17
TL;DR: For the first time, evidence-based clinical recommendations comprehensively address this branch of point-of-care ultrasound, providing a framework for FoCUS to standardize its application in different clinical settings around the world.
Abstract: Background Focused cardiac ultrasound (FoCUS) is a simplified, clinician-performed application of echocardiography that is rapidly expanding in use, especially in emergency and critical care medicine. Performed by appropriately trained clinicians, typically not cardiologists, FoCUS ascertains the essential information needed in critical scenarios for time-sensitive clinical decision making. A need exists for quality evidence-based review and clinical recommendations on its use. Methods The World Interactive Network Focused on Critical UltraSound conducted an international, multispecialty, evidence-based, methodologically rigorous consensus process on FoCUS. Thirty-three experts from 16 countries were involved. A systematic multiple-database, double-track literature search (January 1980 to September 2013) was performed. The Grading of Recommendation, Assessment, Development and Evaluation method was used to determine the quality of available evidence and subsequent development of the recommendations. Evidence-based panel judgment and consensus was collected and analyzed by means of the RAND appropriateness method. Results During four conferences (in New Delhi, Milan, Boston, and Barcelona), 108 statements were elaborated and discussed. Face-to-face debates were held in two rounds using the modified Delphi technique. Disagreement occurred for 10 statements. Weak or conditional recommendations were made for two statements and strong or very strong recommendations for 96. These recommendations delineate the nature, applications, technique, potential benefits, clinical integration, education, and certification principles for FoCUS, both for adults and pediatric patients. Conclusions This document presents the results of the first International Conference on FoCUS. For the first time, evidence-based clinical recommendations comprehensively address this branch of point-of-care ultrasound, providing a framework for FoCUS to standardize its application in different clinical settings around the world.
397 citations
TL;DR: In this article, the anterior and posterior axillary lines are used as anatomical landmarks to locate the diaphragm and the lungs, and three areas per hemithorax (anterior, lateral, and posterior) are iden-tified.
Abstract: LUS is normally performed in supine patients. Operator should firstly locate the diaphragm and the lungs. Lung consolidation or pleural effusion is found predominantly in dependent and dorsal lung regions and can be easily distinguished from liver or spleen once the diaphragm has been identified. By using the anterior and posterior axillary lines as anatomical landmarks, three areas per hemithorax (anterior, lateral, and posterior) can be iden-tified. Each area is divided in two, superior and inferior. In a given region of interest, lung surface of all adjacent inter-costal spaces must be explored by moving the probe trans-versally.
211 citations
TL;DR: The advantages and limits of using continuous, real-time, minimally or totally non-invasive hemodynamic monitoring techniques with an emphasis on their respective place in the hemodynamic management of critically ill patients with hemodynamic instability are discussed.
Abstract: Over the last decade, the way to monitor hemodynamics at the bedside has evolved considerably in the intensive care unit as well as in the operating room. The most important evolution has been the declining use of the pulmonary artery catheter along with the growing use of echocardiography and of continuous, real-time, minimally or totally non-invasive hemodynamic monitoring techniques. This article, which is the result of an agreement between authors belonging to the Cardiovascular Dynamics Section of the European Society of Intensive Care Medicine, discusses the advantages and limits of using such techniques with an emphasis on their respective place in the hemodynamic management of critically ill patients with hemodynamic instability.
205 citations
Cites background from "Evaluation of a new pocket echoscop..."
..., by electrical impedance tomography, will also increase the amount of information available at the bedside [75, 76]....
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TL;DR: The feasibility of performing sonographer-driven focused echocardiographic studies with long-distance Web-based assessments of recorded images for identifying the burden of structural heart disease in a community is demonstrated.
Abstract: Background Developing countries face the dual burden of high rates of cardiovascular disease and barriers in accessing diagnostic and referral programs. The aim of this study was to test the feasibility of performing focused echocardiographic studies with long-distance Web-based assessments of recorded images for facilitating care of patients with cardiovascular disease. Methods Subjects were recruited using newspaper advertisements and were prescreened by paramedical workers during a community event in rural north India. Focused echocardiographic studies were performed by nine sonographers using pocket-sized or handheld devices; the scans were uploaded on a Web-based viewing system for remote worldwide interpretation by 75 physicians. Results A total of 1,023 studies were interpreted at a median time of 11:44 hours. Of the 1,021 interpretable scans, 207 (20.3%) had minor and 170 (16.7%) had major abnormalities. Left ventricular systolic dysfunction was the most frequent major abnormality (45.9%), followed by valvular (32.9%) and congenital (13.5%) defects. There was excellent agreement in assessing valvular lesions (κ = 0.85), whereas the on-site readings were frequently modified by expert reviewers for left ventricular function and hypertrophy (κ = 0.40 and 0.29, respectively). Six-month telephone follow-up in 71 subjects (41%) with major abnormalities revealed that 57 (80.3%) had improvement in symptoms, 11 (15.5%) experienced worsening symptoms, and three died. Conclusions This study demonstrates the feasibility of performing sonographer-driven focused echocardiographic studies for identifying the burden of structural heart disease in a community. Remote assessment of echocardiograms using a cloud-computing environment may be helpful in expediting care in remote areas.
98 citations
Cites methods from "Evaluation of a new pocket echoscop..."
...However, numerous previous studies have clearly demonstrated that when used by experienced echocardiographers, excellent diagnostic accuracy can be achieved with these pocket-sized devices, comparable with traditional stationary equipment.(27,30,32-34) In addition, we used a visual, qualitative approach for the diagnosis and grading of various echocardiographic abnormalities, which added subjectivity to the interpretations and may have influenced the agreement between the on-site sonographers and the remote expert readers....
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TL;DR: This document provides updated recommendations for the use of HUD, including nomenclature, appropriateness, indications, operators, clinical environments, data management and storage, educational needs, and training of potential users.
Abstract: Recent technological advances in echocardiography, with progressive miniaturization of ultrasound machines, have led to the development of handheld ultrasound devices (HUD). These devices, no larger than some mobile phones, can be used to perform partial, focused exams as an extension to the physical examination. The European Association of Cardiovascular Imaging (EACVI) acknowledges that the dissemination of appropriate HUD use is inevitable and desirable, because of its potential impact on patient management. However, as a scientific society of cardiac imaging, our role is to provide guidance in order to optimize patient benefit and minimize drawbacks from inappropriate use of this technology. This document provides updated recommendations for the use of HUD, including nomenclature, appropriateness, indications, operators, clinical environments, data management and storage, educational needs, and training of potential users. It also addresses gaps in evidence, controversial issues, and future technological developments.
81 citations
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3 citations
TL;DR: Establishing direct access echo services where general practitioners can refer patients presenting with possible heart failure or other cardiac abnormalities for definitive echocardiographic diagnosis without cardiology referral is proposed.
Abstract: Heart failure is a common chronic disorder with high associated morbidity, mortality and cost [1]. Although therapeutic intervention markedly improves prognosis [2], heart failure may be difficult to diagnose in primary care where facilities are limited due to the non-specificity of the clinical symptoms and the non-sensitivity of the clinical signs [3]. Echocardiography has been recognised as the best and most convenient non-invasive assessment of left ventricular function, also providing information on valvular structure and function, left ventricular hypertrophy and congenital heart defects. Accordingly, authors have proposed establishing direct access echo services where general practitioners can refer patients presenting with possible heart failure or other cardiac abnormalities for definitive echocardiographic diagnosis without cardiology referral [4, 5]. Although many such services are already well established in the United Kingdom, the study by Baur et al. presents the results of such a service in Holland over a 19 month period where general practitioners could refer patients for echocardiography if they had any of dyspnoea, a cardiac murmur or peripheral oedema of unknown origin [6]. Of the 77 patients referred with dyspnoea, 12% had significant left ventricular systolic dysfunction; 49% had evidence of left ventricular diastolic dysfunction and 14% had significant mitral valve disease. Similarly, of the 61 patients referred with cardiac murmur, 17% had significant aortic valve disease, 13% had important mitral valve disease and 3% had significant pulmonary valve disease. Similar results have been seen elsewhere. In one direct access echo study, Francis et al. found that among referred patients already on heart failure medications, only 36% of men and 18% of women had definite left ventricular systolic dysfunction, with the echo result leading to a change in treatment in 70% of those on diuretics [4]. A number of important caveats must be borne in mind when establishing direct access echocardiography, namely guidelines governing whom to refer; the interpretation of results to minimise incorrect conclusions by the general practitioners, and established mechanisms to guarantee maintenance of a high echocardiographic standard. Furthermore, echocardiography may sometimes be difficult to interpret without a fuller individual assessment. Certainly, one difficulty alluded to by Baur et al. is that many symptomatic patients will have no evidence of left ventricular systolic dysfunction but may have evidence of ‘diastolic dysfunction’. Unfortunately, diastolic dysfunction is currently difficult to diagnose, with no accepted diagnostic criteria and no simple diagnostic tests [7], and thus whether such apparent diastolic dysfunction on echocardiography is the cause of the patient’s symptoms or not may require a further cardiological opinion.
2 citations
"Evaluation of a new pocket echoscop..." refers background in this paper
...By increasing the number of clinical diagnoses, PUD could prove costeffective by decreasing the number of medical errors, providing a more efficient real-time diagnosis, and reducing the use of unnecessary routine US examinations [17,30]....
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