International Evidence-Based Recommendations for Focused Cardiac Ultrasound
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
01 Jul 2014-Journal of The American Society of Echocardiography (J Am Soc Echocardiogr)-Vol. 27, Iss: 7, pp 683
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.
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TL;DR: There was strong agreement among a large cohort of international experts regarding several recommendations for the use of ultrasound in the ICU and equivalent care sites for diagnostic and therapeutic purposes for organs of the chest, abdomen, pelvis, neck, and extremities.
Abstract: Objective:To establish evidence-based guidelines for the use of bedside cardiac ultrasound, echocardiography, in the ICU and equivalent care sites.Methods:Grading of Recommendations, Assessment, Development and Evaluation system was used to rank the “levels” of quality of evidence into high (A), mod
362 citations
Helsinki University Central Hospital1, University of Hasselt2, Hannover Medical School3, Carol Davila University of Medicine and Pharmacy4, Vanderbilt University5, Humboldt University of Berlin6, National and Kapodistrian University of Athens7, University of Zurich8, University of Hamburg9, University of Ljubljana10, University of Paris11, Chartered Institute of Management Accountants12, University of Basel13, University of Debrecen14, Harvard University15, University of Belgrade16, American University of Beirut17, Cumhuriyet University18
TL;DR: The prevention and correction of organ dysfunction represent a therapeutic target of interest in AHF and should be evaluated in clinical trials to determine if such interventions impact mortality, morbidity and patient‐centred outcomes.
Abstract: Organ injury and impairment are commonly observed in patients with acute heart failure (AHF), and congestion is an essential pathophysiological mechanism of impaired organ function Congestion is the predominant clinical profile in most patients with AHF; a smaller proportion presents with peripheral hypoperfusion or cardiogenic shock Hypoperfusion further deteriorates organ function The injury and dysfunction of target organs (ie heart, lungs, kidneys, liver, intestine, brain) in the setting of AHF are associated with increased risk for mortality Improvement in organ function after decongestive therapies has been associated with a lower risk for post-discharge mortality Thus, the prevention and correction of organ dysfunction represent a therapeutic target of interest in AHF and should be evaluated in clinical trials Treatment strategies that specifically prevent, reduce or reverse organ dysfunction remain to be identified and evaluated to determine if such interventions impact mortality, morbidity and patient-centred outcomes This paper reflects current understanding among experts of the presentation and management of organ impairment in AHF and suggests priorities for future research to advance the field
241 citations
TL;DR: It is highlighted that there is an urgent need to increase awareness of AAS worldwide, including dedicated education/prevention programmes, and to improve diagnostic and therapeutic strategies, outcomes, and lifelong surveillance.
Abstract: Acute aortic syndromes (AAS) encompass a constellation of life-threatening medical conditions including classic acute aortic dissection (AAD), intramural haematoma, and penetrating atherosclerotic aortic ulcer. Given the non-specific symptoms and physical signs, a high clinical index of suspicion is necessary to detect the disease before irreversible lethal complications occur. In order to reduce the diagnostic time delay, a comprehensive flowchart for decision-making based on pre-test sensitivity of AAS has been designed by the European Society of Cardiology guidelines on aortic diseases and should be thus applied in the emergency scenario. When the definitive diagnosis is made, prompt and appropriate therapeutic interventions should be undertaken if indicated by a highly specialized aortic team. Urgent surgery for AAD involving the ascending aorta (Type A) and medical therapy alone for AAD not involving the ascending aorta (Type B) are typically recommended. In complicated Type B AAD, thoracic endovascular aortic repair (TEVAR) is generally indicated. On the other hand, in uncomplicated Type B AAD, pre-emptive TEVAR rather than medical therapy alone to prevent late complications, while intuitive, requires further study in randomized cohorts. Finally, it should be highlighted that there is an urgent need to increase awareness of AAS worldwide, including dedicated education/prevention programmes, and to improve diagnostic and therapeutic strategies, outcomes, and lifelong surveillance.
208 citations
01 Dec 2016
TL;DR: 2 common patient scenarios (heart failure and sepsis) are described to highlight the impact of POCUS performed by internists on efficiency, diagnostic accuracy, resource utilization, and radiation exposure.
Abstract: Point-of-care ultrasonography (POCUS) is a safe and rapidly evolving diagnostic modality that is now utilized by health care professionals from nearly all specialties. Technological advances have improved the portability of equipment, enabling ultrasound imaging to be executed at the bedside and thereby allowing internists to make timely diagnoses and perform ultrasound-guided procedures. We reviewed the literature on the POCUS applications most relevant to the practice of internal medicine. The use of POCUS can immediately narrow differential diagnoses by building on the clinical information revealed by the traditional physical examination and refining clinical decision making for further management. We describe 2 common patient scenarios (heart failure and sepsis) to highlight the impact of POCUS performed by internists on efficiency, diagnostic accuracy, resource utilization, and radiation exposure. Using POCUS to guide procedures has been found to reduce procedure-related complications, along with costs and lengths of stay associated with these complications. Despite several undisputed advantages of POCUS, barriers to implementation must be considered. Most importantly, the utility of POCUS depends on the experience and skills of the operator, which are affected by the availability of training and the cost of ultrasound devices. Additional system barriers include availability of templates for documentation, electronic storage for image archiving, and policies and procedures for quality assurance and billing. Integration of POCUS into the practice of internal medicine is an inevitable change that will empower internists to improve the care of their patients at the bedside.
157 citations
Boston Children's Hospital1, Children's National Medical Center2, Maimonides Medical Center3, New York Methodist Hospital4, Hospital for Sick Children5, The Queen's Medical Center6, University of California, Davis7, Morgan Stanley Children's Hospital8, University of California, San Diego9, Boston Medical Center10, Harvard University11, Columbia University Medical Center12, Mount Sinai St. Luke's and Mount Sinai Roosevelt13, Montefiore Medical Center14, Newark Beth Israel Medical Center15, Mount Sinai Hospital16, Cornell University17, University of Colorado Boulder18
TL;DR: This document serves as an initial step in the detailed “how to” and description of individual point-of-care ultrasound examinations for pediatric emergency medicine providers.
Abstract: The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers. To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed “how to” and description of individual point-of-care ultrasound examinations. Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.
146 citations
References
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TL;DR: The advantages of the GRADE system are explored, which is increasingly being adopted by organisations worldwide and which is often praised for its high level of consistency.
Abstract: Guidelines are inconsistent in how they rate the quality of evidence and the strength of recommendations. This article explores the advantages of the GRADE system, which is increasingly being adopted by organisations worldwide
13,324 citations
TL;DR: A strategy was needed to differentiate among guidelines and ensure that those guidelines that vary widely in quality are distinguished.
Abstract: Clinical practice guidelines, which are systematically developed statements aimed at helping people make clinical, policy-related and system-related decisions,[1][1],[2][2] frequently vary widely in quality.[3][3],[4][4] A strategy was needed to differentiate among guidelines and ensure that those
2,616 citations
TL;DR: In this article, the authors used a continuous wave Doppler (Doppler) to detect aortic regurgitation, MS mitral stenosis, MVA mitral valve area, DP pressure gradient, RV right ventricle, RVOT right ventricular outflow tract, SV stroke volume.
Abstract: Abbreviations: AR aortic regurgitation, AS aortic stenosis, AVA aortic valve area, CSA cross sectional area, CWD continuous wave Doppler, D diameter, HOCM hypertrophic obstructive cardiomyopathy, LV left ventricle, LVOT left ventricular outflow tract, MR mitral regurgitation, MS mitral stenosis, MVA mitral valve area, DP pressure gradient, RV right ventricle, RVOT right ventricular outflow tract, SV stroke volume, TEE transesophageal echocardiography, T1/2 pressure half-time, TR tricuspid regurgitation, TS tricuspid stenosis, V velocity, VSD ventricular septal defect, VTI velocity time integral
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Gonzaga University1, King Saud University2, Northside Hospital3, Praxis4, Foothills Medical Centre5, Cornell University6, National Research Council7, Harvard University8, University of Pennsylvania9, Icahn School of Medicine at Mount Sinai10, University of Jena11, Pierre-and-Marie-Curie University12, University of California, Davis13, University of South Carolina14
TL;DR: This document reflects the overall results of the first consensus conference on “point-of-care” lung ultrasound and utilizes the RAND appropriateness method for panel judgment and decisions/consensus.
Abstract: The purpose of this study is to provide evidence-based and expert consensus recommendations for lung ultrasound with focus on emergency and critical care settings. A multidisciplinary panel of 28 experts from eight countries was involved. Literature was reviewed from January 1966 to June 2011. Consensus members searched multiple databases including Pubmed, Medline, OVID, Embase, and others. The process used to develop these evidence-based recommendations involved two phases: determining the level of quality of evidence and developing the recommendation. The quality of evidence is assessed by the grading of recommendation, assessment, development, and evaluation (GRADE) method. However, the GRADE system does not enforce a specific method on how the panel should reach decisions during the consensus process. Our methodology committee decided to utilize the RAND appropriateness method for panel judgment and decisions/consensus. Seventy-three proposed statements were examined and discussed in three conferences held in Bologna, Pisa, and Rome. Each conference included two rounds of face-to-face modified Delphi technique. Anonymous panel voting followed each round. The panel did not reach an agreement and therefore did not adopt any recommendations for six statements. Weak/conditional recommendations were made for 2 statements, and strong recommendations were made for the remaining 65 statements. The statements were then recategorized and grouped to their current format. Internal and external peer-review processes took place before submission of the recommendations. Updates will occur at least every 4 years or whenever significant major changes in evidence appear. This document reflects the overall results of the first consensus conference on “point-of-care” lung ultrasound. Statements were discussed and elaborated by experts who published the vast majority of papers on clinical use of lung ultrasound in the last 20 years. Recommendations were produced to guide implementation, development, and standardization of lung ultrasound in all relevant settings.
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TL;DR: The goal of therapy for bradycardia or tachycardia is to rapidly identify and treat patients who are hemodynamically unstable or symptomatic due to the arrhythmia.
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1,999 citations
"International Evidence-Based Recomm..." refers background in this paper
...In both traumatic and atraumatic pericardial effusion, with concern for the deleterious consequence of cardiac tamponade, both agreement and consensus were high for diagnostic, therapeutic, and clinical effectiveness.(32,102,135,165,172,178,183,184,186,187,193) The notion that the additional costs of a new technology such as FoCUS may outweigh its benefit over conventional management has been a justifiable concern....
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