MDedge



Soni NJ, Schnobrich D, Mathews B, et al. Point-of-care Ultrasound for Hospitalists: a Position Statement of the Society of Hospital Medicine. Selected evidence for clinical applicationsAppendix 1: Cardiac UltrasoundAppendix 2: Lung & Pleural UltrasoundAppendix 3: Abdominal UltrasoundAppendix 4: Vascular UltrasoundAppendix 5: Musculoskeletal UltrasoundAppendix 6: Hypotension, Pulseless Electric Activity, and ResuscitationAppendix 7: Acute Respiratory Failure and DyspneaAppendix 8: Acute Kidney InjuryAppendix 9: BillingTable 1. Frequently used CPT codes for point-of-care ultrasound billingAppendix 10: References for AppendicesAppendix 1: Cardiac UltrasoundPoint-of-care ultrasound can improve the hospitalists’ ability to diagnose many important cardiac abnormalities. These abnormalities include the qualitative assessment of left ventricular systolic function (LVSF); the estimation of right atrial pressure (RAP); and the detection of pericardial effusions, right ventricular dysfunction, chamber hypertrophy, chamber enlargement, and some gross valvular abnormalities. The use of cardiac POCUS has repeatedly been shown to influence management decisions, ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"jj5U44O3","properties":{"formattedCitation":"\\super 1\\uc0\\u8211{}3\\nosupersub{}","plainCitation":"1–3","noteIndex":0},"citationItems":[{"id":4852,"uris":[""],"uri":[""],"itemData":{"id":4852,"type":"article-journal","title":"Feasibility and potential clinical utility of goal-directed transthoracic echocardiography performed by noncardiologist intensivists using a small hand-carried device (SonoHeart) in critically ill patients","container-title":"Journal of Cardiothoracic and Vascular Anesthesia","page":"155-9","volume":"19","issue":"2","abstract":"OBJECTIVE: This study was designed to assess the clinical applicability of a small, handheld, portable transthoracic echocardiography device by noncardiologist intensivists. DESIGN: Prospective, observational study. After 10 one-hour tutorials, intensivists performed a limited transthoracic echocardiography (TTE) (2-4 views, without Doppler or M-mode) examination with the 5.6-lb SonoHeart Echo System (SonoSite, Bethell, WA) on critically ill patients admitted to the surgical intensive care unit. After initial cardiac clinical assessment in 90 patients, a limited TTE was performed by an intensivist to assess left ventricular (LV) function and LV volume status. Each study was immediately reviewed and repeated by an echocardiographer to determine the technical quality of the TTE and the accuracy of the intensivist's interpretation. Data were analyzed and presented in proportions using descriptive statistics. SETTING: Surgical intensive care unit of an academic medical center. PARTICIPANTS: Ninety critically ill adult patients. INTERVENTIONS: After initial cardiac clinical assessment, a limited TTE was performed by an intensivist to assess LV size and function, to rule out significant pericardial effusions, and to estimate circulatory volume. RESULTS: Intensivists successfully performed a diagnostic limited TTE in 94% of patients and interpreted their studies correctly in 84%. Limited TTE provided new cardiac information and changed management in 37% of patients. TTE added useful information in an additional 47% of patients but did not alter immediate management. The mean \"goal-directed TTE\" acquisition time was 10.5 +/- 4.2 minutes. CONCLUSION: After a brief formal training in using this handheld echocardiographic system in intensive care unit patients, surgical intensivists successfully performed and correctly interpreted a limited TTE in critically ill patients. Limited TTE provided new information and altered management in a significant number of patients. This study supports incorporating bedside goal-directed, limited TTE into intensivists' training programs.","ISSN":"1053-0770 (Print) 1053-0770","journalAbbreviation":"J. Cardiothorac. Vasc. Anesth.","language":"eng","author":[{"family":"Manasia","given":"A. R."},{"family":"Nagaraj","given":"H. M."},{"family":"Kodali","given":"R. B."},{"family":"Croft","given":"L. B."},{"family":"Oropello","given":"J. M."},{"family":"Kohli-Seth","given":"R."},{"family":"Leibowitz","given":"A. B."},{"family":"DelGiudice","given":"R."},{"family":"Hufanda","given":"J. F."},{"family":"Benjamin","given":"E."},{"family":"Goldman","given":"M. E."}],"issued":{"date-parts":[["2005",4]]}}},{"id":3925,"uris":[""],"uri":[""],"itemData":{"id":3925,"type":"article-journal","title":"Diagnostic accuracy and therapeutic impact of transthoracic and transesophageal echocardiography in mechanically ventilated patients in the ICU","container-title":"Chest","page":"1829-34","volume":"106","issue":"6","abstract":"STUDY OBJECTIVES: To assess the respective diagnostic accuracy of transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) and their therapeutic implications in mechanically ventilated patients, in the intensive care unit (ICU). DESIGN: A prospective study. SETTINGS: Intensive care units of two tertiary referral teaching hospitals. PATIENTS: One hundred eleven ICU patients (81 men and 30 women; mean age 57 +/- 16 years). Fifty-seven percent were hospitalized for medical illnesses, 16.5 percent after thoracic surgery, 10.5 percent after other surgery, and 16.0 percent for multiple trauma. Their Simplified Acute Physiologic Score was 16 +/- 5. INTERVENTIONS: The echocardiograms were performed in order to solve well-defined clinical problems. TTE was the first step of the procedure and TEE was performed only when (1) TTE did not solve the clinical problems, and (2) TTE yielded unsuspected findings requiring TEE. During each echocardiographic study, the following were noted: ventilatory mode, clinical problems, imaging quality, results, consequence on acute care, duration of the procedure, and potential complications of TEE. Diagnostic accuracy was defined as the proportion of solved problems, and therapeutic impact was defined as changes on acute care that resulted directly from the procedure. MEASUREMENTS AND RESULTS: One hundred twenty-eight consecutive TTE and 96 TEE were performed. TTE solved 60 of 158 clinical problems (38 percent), whether positive end-expiratory pressure (> 4 cm H2O) was present or not (28 of 74 vs 32 of 84: p > 0.50). TTE allowed evaluation of left ventricular function in 77 percent of cases and pericardial effusion in every case, but it did not solve most of the other clinical problems. Indeed, the diagnostic accuracy of TEE was markedly superior (95/98 vs 60/158: p < 0.001), but TEE required a physician's presence longer (43 +/- 17 min vs 27 +/- 12 min: p < 0.001). When TTE and TEE were scheduled (n = 96), TEE yielded an additional diagnosis or excluded with more certitude a suspected diagnosis, except in two cases. TEE had a therapeutic impact more frequently than TTE (35/96 vs 20/128: p < 0.001). Cardiovascular surgery was prompted by echocardiographic findings in ten patients. TEE was well tolerated in all patients; there were no complications. CONCLUSIONS: TEE is a valuable well-tolerated imaging technique in mechanically ventilated patients. For the assessment of left ventricular systolic function and pericardial effusion; however, TTE continues to be an excellent diagnostic tool, even when positive end-expiratory pressure is present. Both TTE and TEE have a therapeutic impact in approximately 25 percent of cases.","ISSN":"0012-3692 (Print) 0012-3692","journalAbbreviation":"Chest","language":"eng","author":[{"family":"Vignon","given":"P."},{"family":"Mentec","given":"H."},{"family":"Terre","given":"S."},{"family":"Gastinne","given":"H."},{"family":"Gueret","given":"P."},{"family":"Lemaire","given":"F."}],"issued":{"date-parts":[["1994",12]]}}},{"id":4625,"uris":[""],"uri":[""],"itemData":{"id":4625,"type":"article-journal","title":"Transthoracic echocardiography for cardiopulmonary monitoring in intensive care","container-title":"European Journal of Anaesthesiology","page":"700-7","volume":"21","issue":"9","abstract":"BACKGROUND AND OBJECTIVE: To evaluate the feasibility of an abbreviated focus assessed transthoracic echocardiographic protocol, consisting of four standardized acoustic views for cardiopulmonary screening and monitoring. METHODS: The protocol was applied in 210 patients in a 20-bed multidisciplinary intensive care unit in a university hospital. When inconclusive, an additional transoesophageal echocardiographic examination was performed. Diagnosis, indication, acoustic window, position and value were recorded. Significant pathology, load, dimensions and contractility were assessed. RESULTS: Two-hundred-and-thirty-three transthoracic and four transoesophageal echoes were performed. The protocol provided usable images of the heart in 97% of the patients, 58% subcostal, 80% apical and 69% parasternal. Images through one window were obtainable in 23%, through two windows in 41% and through three windows in 34%. In 227 patients (97.4%) the focus assessed echo protocol contributed positively. In 24.5% of cases the information was decisive, in 37.3% supplemental and in 35.6% supportive. CONCLUSIONS: By means of an abbreviated, focus assessed transthoracic echo protocol it is feasible to visualize the haemodynamic determinants for assessment and optimization. One or more useful images are obtainable in 97% of critically ill patients.","ISSN":"0265-0215 (Print) 0265-0215","journalAbbreviation":"Eur. J. Anaesthesiol.","language":"eng","author":[{"family":"Jensen","given":"M. B."},{"family":"Sloth","given":"E."},{"family":"Larsen","given":"K. M."},{"family":"Schmidt","given":"M. B."}],"issued":{"date-parts":[["2004",9]]}}}],"schema":""} 1–3 including a hospital medicine study in which it changed management in 37% of patients. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"boTJg0LQ","properties":{"formattedCitation":"\\super 4\\nosupersub{}","plainCitation":"4","noteIndex":0},"citationItems":[{"id":6600,"uris":[""],"uri":[""],"itemData":{"id":6600,"type":"article-journal","title":"Hand-carried echocardiography by hospitalists: a randomized trial","container-title":"American Journal of Medicine","page":"766-74","volume":"124","issue":"8","abstract":"BACKGROUND: Hospitalists can use hand-carried echocardiography for accurate point-of-care information, but patient outcome data for its application are sparse. METHODS: We performed an unblinded, parallel-group randomized trial between July 2008 and March 2009 at one teaching hospital in Chicago, Illinois. We randomly assigned adult general medicine inpatients referred for standard echocardiography with indications investigatable by hand-carried echocardiography to care guided by hand-carried echocardiography or usual care. The main outcome measure was length of stay on the referring hospitalist's service. Secondary outcomes included a before-after analysis of reported changes in management due to hand-carried echocardiography and the diagnostic accuracy of hand-carried echocardiography. RESULTS: The difference in length of stay between 226 participants randomized to care guided by hand-carried echocardiography (geometric mean 46.1 hours, interquartile range 29.0-70.9 hours) and 227 participants randomized to usual care (46.9 hours, interquartile range 34.1-68.3 hours) corresponded to a 1.7% reduction in length of stay that was not statistically significant (95% confidence interval, -12.1 to 9.8%). In post hoc subgroup analyses, care guided by hand-carried echocardiography reduced length of stay in participants who were referred for heart failure (P=.0008). Among participants who underwent both hand-carried and standard echocardiography, hospitalists changed management due to hand-carried echocardiography in 37%. Despite the favorable diagnostic accuracy of hand-carried echocardiography, most changes to the timing of hospital discharge occurred after standard echocardiography. CONCLUSION: Hospitalist care guided by hand-carried echocardiography for unselected general medicine patients does not meaningfully affect length of stay. Whether or not it affects care quality remains unstudied.","DOI":"10.1016/j.amjmed.2011.03.029","ISSN":"1555-7162 (Electronic) 0002-9343 (Linking)","journalAbbreviation":"Am. J. Med.","language":"eng","author":[{"family":"Lucas","given":"B. P."},{"family":"Candotti","given":"C."},{"family":"Margeta","given":"B."},{"family":"Mba","given":"B."},{"family":"Kumapley","given":"R."},{"family":"Asmar","given":"A."},{"family":"Franco-Sadud","given":"R."},{"family":"Baru","given":"J."},{"family":"Acob","given":"C."},{"family":"Borkowsky","given":"S."},{"family":"Evans","given":"A. T."}],"issued":{"date-parts":[["2011",8]]}}}],"schema":""} 4Qualitative assessment of LVSF: Hospitalists can qualitatively assess LVSF accurately. In one randomized study of hospitalists, POCUS had an LR+ of 5.7, a LR- of 0.2. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Yzu4RIgM","properties":{"formattedCitation":"\\super 4\\nosupersub{}","plainCitation":"4","noteIndex":0},"citationItems":[{"id":6600,"uris":[""],"uri":[""],"itemData":{"id":6600,"type":"article-journal","title":"Hand-carried echocardiography by hospitalists: a randomized trial","container-title":"American Journal of Medicine","page":"766-74","volume":"124","issue":"8","abstract":"BACKGROUND: Hospitalists can use hand-carried echocardiography for accurate point-of-care information, but patient outcome data for its application are sparse. METHODS: We performed an unblinded, parallel-group randomized trial between July 2008 and March 2009 at one teaching hospital in Chicago, Illinois. We randomly assigned adult general medicine inpatients referred for standard echocardiography with indications investigatable by hand-carried echocardiography to care guided by hand-carried echocardiography or usual care. The main outcome measure was length of stay on the referring hospitalist's service. Secondary outcomes included a before-after analysis of reported changes in management due to hand-carried echocardiography and the diagnostic accuracy of hand-carried echocardiography. RESULTS: The difference in length of stay between 226 participants randomized to care guided by hand-carried echocardiography (geometric mean 46.1 hours, interquartile range 29.0-70.9 hours) and 227 participants randomized to usual care (46.9 hours, interquartile range 34.1-68.3 hours) corresponded to a 1.7% reduction in length of stay that was not statistically significant (95% confidence interval, -12.1 to 9.8%). In post hoc subgroup analyses, care guided by hand-carried echocardiography reduced length of stay in participants who were referred for heart failure (P=.0008). Among participants who underwent both hand-carried and standard echocardiography, hospitalists changed management due to hand-carried echocardiography in 37%. Despite the favorable diagnostic accuracy of hand-carried echocardiography, most changes to the timing of hospital discharge occurred after standard echocardiography. CONCLUSION: Hospitalist care guided by hand-carried echocardiography for unselected general medicine patients does not meaningfully affect length of stay. Whether or not it affects care quality remains unstudied.","DOI":"10.1016/j.amjmed.2011.03.029","ISSN":"1555-7162 (Electronic) 0002-9343 (Linking)","journalAbbreviation":"Am. J. Med.","language":"eng","author":[{"family":"Lucas","given":"B. P."},{"family":"Candotti","given":"C."},{"family":"Margeta","given":"B."},{"family":"Mba","given":"B."},{"family":"Kumapley","given":"R."},{"family":"Asmar","given":"A."},{"family":"Franco-Sadud","given":"R."},{"family":"Baru","given":"J."},{"family":"Acob","given":"C."},{"family":"Borkowsky","given":"S."},{"family":"Evans","given":"A. T."}],"issued":{"date-parts":[["2011",8]]}}}],"schema":""} 4 In two studies by Martin, POCUS improved hospitalists’ detection of left ventricular dysfunction compared to traditional physical examination, and approached but did not match the acquisition and interpretation scores of formal echocardiography. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"cqjibMti","properties":{"formattedCitation":"\\super 5,6\\nosupersub{}","plainCitation":"5,6","noteIndex":0},"citationItems":[{"id":5300,"uris":[""],"uri":[""],"itemData":{"id":5300,"type":"article-journal","title":"Hospitalist performance of cardiac hand-carried ultrasound after focused training","container-title":"American Journal of Medicine","page":"1000-4","volume":"120","issue":"11","abstract":"PURPOSE: Because the training that noncardiologists require to perform cardiac hand-carried ultrasound has not been defined, we studied how well hospitalists perform hand-carried echocardiography after limited training. METHODS: Ten hospitalists completed a focused training program that included performing an average of 35 hand-carried echocardiograms. Hospitalists' echocardiograms were compared with gold-standard conventional echocardiograms, and hospitalists were compared with 5 certified echocardiography technicians in their ability to acquire, measure, and interpret hand-carried ultrasound images and with 6 senior cardiology fellows in their ability to interpret echocardiograms. RESULTS: Echocardiography technicians had significantly higher performance scores for image acquisition, measurement, and interpretation than hospitalists. Senior cardiology fellows outperformed hospitalists in most aspects of image interpretation. For hospitalists, learning image acquisition was more difficult than image interpretation. CONCLUSIONS: Hospitalists can learn aspects of hand-carried echocardiography, but after 35 training echocardiograms cannot replicate the quality of conventional echocardiography. Whether the lower performance skills are important will depend on the clinical context of hand-carried echocardiography performed by hospitalists.","DOI":"10.1016/j.amjmed.2007.07.029","ISSN":"1555-7162 (Electronic) 0002-9343 (Linking)","journalAbbreviation":"Am. J. Med.","language":"eng","author":[{"family":"Martin","given":"L. D."},{"family":"Howell","given":"E. E."},{"family":"Ziegelstein","given":"R. C."},{"family":"Martire","given":"C."},{"family":"Shapiro","given":"E. P."},{"family":"Hellmann","given":"D. B."}],"issued":{"date-parts":[["2007",11]]}}},{"id":5853,"uris":[""],"uri":[""],"itemData":{"id":5853,"type":"article-journal","title":"Hand-carried ultrasound performed by hospitalists: does it improve the cardiac physical examination?","container-title":"American Journal of Medicine","page":"35-41","volume":"122","issue":"1","abstract":"OBJECTIVE: The traditional physical examination of the heart is relatively inaccurate. There is little information regarding whether cardiac hand-carried ultrasound performed by noncardiologists adds to the accuracy of physical examinations. The purpose of this study was to determine whether hand-carried ultrasound can add to the accuracy of hospitalists' cardiac physical examinations. METHODS: During a focused training program in hand-carried echocardiography, 10 hospitalists performed cardiac examinations of 354 general medical inpatients first by physical examination and then by hand-carried ultrasound. Eligible inpatients included those for whom a conventional hospital echocardiogram was ordered. We measured how frequently the hospitalists' cardiac examination with or without hand-carried ultrasound matched or came within 1 scale level of an expert cardiologist's interpretation of the hospital echocardiogram. RESULTS: Adding hand-carried ultrasound to the physical examination improved hospitalists' assessment of left ventricular function, cardiomegaly, and pericardial effusion. For left ventricular function, using hand-carried ultrasound increased the percentage of exact matches with the expert cardiologist's assessment from 46% to 59% (P=.005) and improved the percentage of within 1-level matches from 67% to 88% (P=.0001). The addition of hand-carried ultrasound failed to improve the assessments of aortic stenosis, aortic regurgitation, and mitral regurgitation. CONCLUSION: Adding hand-carried ultrasound to physical examination increases the accuracy of hospitalists' assessment of left ventricular dysfunction, cardiomegaly, and pericardial effusion, and fails to improve assessment of valvular heart disease. The clinical benefit achieved by improved immediacy of this information has not been determined. An important limitation is that the study assessed only 1 level of training in hand-carried ultrasound.","DOI":"10.1016/j.amjmed.2008.07.022","ISSN":"1555-7162 (Electronic) 0002-9343 (Linking)","journalAbbreviation":"Am. J. Med.","language":"eng","author":[{"family":"Martin","given":"L. D."},{"family":"Howell","given":"E. E."},{"family":"Ziegelstein","given":"R. C."},{"family":"Martire","given":"C."},{"family":"Whiting-O'Keefe","given":"Q. E."},{"family":"Shapiro","given":"E. P."},{"family":"Hellmann","given":"D. B."}],"issued":{"date-parts":[["2009",1]]}}}],"schema":""} 5,6 Numerous studies of other acute care physicians corroborate the ability of physicians with focused training to assess LVSF. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"OtqwJTGs","properties":{"formattedCitation":"\\super 7\\uc0\\u8211{}12\\nosupersub{}","plainCitation":"7–12","noteIndex":0},"citationItems":[{"id":4435,"uris":[""],"uri":[""],"itemData":{"id":4435,"type":"article-journal","title":"The use of small personal ultrasound devices by internists without formal training in echocardiography","container-title":"European Journal of Echocardiography","page":"141-7","volume":"4","issue":"2","abstract":"AIMS: Hand-held ultrasound devices will probably be used for bedside cardiac diagnoses by internists without formal training in echocardiography. We compared the accuracy of hand-held ultrasound devices studies performed by expert echocardiographers vs internal medicine residents with brief training in echocardiography. METHODS AND RESULTS: Three internal medicine residents participated in an organized training program in echocardiographic principles, image acquisition, and interpretation. Subsequently, these residents and three echocardiographers imaged 300 patients with a hand-held ultrasound device. Sensitivity, specificity, positive and negative predictive values for internist- and echocardiographer-performed studies for the detection of cardiac abnormalities were compared using a full-featured exam as the gold standard. Resident- and echocardiographer-performed scans had similar overall sensitivity and specificity. There was a higher positive predictive value for the echocardiographer-performed scans. For clinically important findings (likely to affect patient care), sensitivity was slightly but significantly higher for the echocardiographer-performed scans. Clinically important findings most often missed by residents included regional wall motion abnormalities, intra-cardiac thrombus, right ventricular dysfunction and non-trivial pericardial effusions. CONCLUSION: Hand-held ultrasound devices provide useful screening tools for cardiac disease but should not replace a standard platform study. Training guidelines and competency evaluation are needed if these devices are to be used by non-echocardiographers for clinical decision-making.","ISSN":"1525-2167 (Print) 1532-2114 (Linking)","journalAbbreviation":"Eur. J. Echocardiogr.","language":"eng","author":[{"family":"DeCara","given":"J. M."},{"family":"Lang","given":"R. M."},{"family":"Koch","given":"R."},{"family":"Bala","given":"R."},{"family":"Penzotti","given":"J."},{"family":"Spencer","given":"K. T."}],"issued":{"date-parts":[["2003",6]]}}},{"id":5487,"uris":[""],"uri":[""],"itemData":{"id":5487,"type":"article-journal","title":"Hand carried echocardiography screening for LV systolic dysfunction in a pulmonary function laboratory","container-title":"European Journal of Echocardiography","page":"381-3","volume":"9","issue":"3","abstract":"AIMS: Dyspnea is a common indication for pulmonary evaluation but also a common symptom in heart failure. Identification of dyspneic patients with significant LV systolic dysfunction is critical because of high morbidity of untreated heart failure. We sought to determine whether screening patients referred for pulmonary function testing (PFT) using a hand carried ultrasound (HCU) device could identify LV systolic dysfunction. METHODS: Forty-nine subjects were recruited from a pulmonary function lab to undergo a brief echocardiographic examination by an internist using a HCU device. All subjects also received an examination with a full-featured echocardiogram machine as a gold standard. RESULTS: All subjects with normal PFT had normal LV systolic function. Among subjects with abnormal PFT, 6 (15%) had LV systolic dysfunction and the remainder had normal LV systolic function. No subjects with LV systolic dysfunction by full-featured echocardiograms were missed by the HCU (sensitivity 100%, specificity 95%, negative predictive value 100%, positive predictive value 75%). CONCLUSIONS: LV systolic dysfunction is prevalent among patients with pulmonary disease and can be accurately screened for by a physician using a hand carried ultrasound device with subsequent confirmation with complete echocardiography.","DOI":"10.1016/j.euje.2007.06.013","ISSN":"1532-2114 (Electronic) 1532-2114 (Linking)","journalAbbreviation":"Eur. J. Echocardiogr.","language":"eng","author":[{"family":"Kirkpatrick","given":"J. N."},{"family":"Ghani","given":"S. N."},{"family":"Spencer","given":"K. T."}],"issued":{"date-parts":[["2008",5]]}}},{"id":4557,"uris":[""],"uri":[""],"itemData":{"id":4557,"type":"article-journal","title":"Feasibility of point-of-care echocardiography by internal medicine house staff","container-title":"American Heart Journal","page":"476-81","volume":"147","issue":"3","abstract":"OBJECTIVE: To determine whether internal medicine house staff with limited training in echocardiography can use point-of-care echocardiography to make simple, clinically important diagnoses. BACKGROUND: Availability of small, portable ultrasound devices could make point-of-care echocardiography widely available. The training required to perform point-of-care echocardiography has not been established. METHODS: Medical house staff participated in a 3-hour point-of-care echocardiography training program. Patients scheduled for standard echocardiography as part of clinical care underwent point-of-care echocardiography within 24 hours to assess four common clinically important diagnoses. Each standard echocardiogram was interpreted twice. Agreement (kappa) was calculated between point-of-care and standard echocardiography by using standard echocardiography as the gold standard and between the two interpretations of standard echocardiography. RESULTS: Agreement (kappa) between point-of-care echocardiography and standard echocardiography was 75% (0.51) for left ventricular dysfunction (ejection fraction <55%), 79% (0.31) for moderate or severe mitral regurgitation, 92% (0.32) for aortic valve thickening or immobility, and 98% (0.51) for moderate or large pericardial effusion. Agreement between the two interpretations of standard echocardiography was 83% (0.63) for left ventricular dysfunction, 92% (0.68) for moderate or severe mitral regurgitation, 95% (0.62) for aortic valve thickening or immobility, and 97% (0.53) for moderate or large pericardial effusion. CONCLUSIONS: Medical house staff with limited training in echocardiography can use point-of-care echocardiography to assess left ventricular function and pericardial effusion with moderate accuracy that is lower than that of standard echocardiography. Assessment of valvular disease and other diagnoses likely requires more training and/or experience in echocardiography.","DOI":"10.1016/j.ahj.2003.10.010","ISSN":"1097-6744 (Electronic) 0002-8703 (Linking)","journalAbbreviation":"Am. Heart J.","language":"eng","author":[{"family":"Alexander","given":"J. H."},{"family":"Peterson","given":"E. D."},{"family":"Chen","given":"A. Y."},{"family":"Harding","given":"T. M."},{"family":"Adams","given":"D. B."},{"family":"Kisslo","given":"J. A."}],"issued":{"date-parts":[["2004",3]]}}},{"id":6363,"uris":[""],"uri":[""],"itemData":{"id":6363,"type":"article-journal","title":"Feasibility and reliability of point-of-care pocket-sized echocardiography","container-title":"European Journal of Echocardiography","page":"665-70","volume":"12","issue":"9","abstract":"AIMS: To study the reliability and feasibility of point-of-care pocket-sized echocardiography (POCKET) at the bedside in patients admitted to a medical department at a non-university hospital. METHODS AND RESULTS: One hundred and eight patients were randomized to bedside POCKET examination shortly after admission and later high-end echocardiography (HIGH) in the echo-lab. The POCKET examinations were done by cardiologists on their ward rounds. Assessments of global and regional left ventricular (LV) function, right ventricular (RV) function, valvular function, left atrial (LA) size, the pericardium and pleura were done with respect to effusion and measurements of inferior vena cava (IVC) and abdominal aorta (AA) were performed. Correlations between POCKET and HIGH/appropriate radiological technique for LV function, AA size and presence of pericardial effusion were almost perfect, with r >/= 0.92. Strong correlation (r >/= 0.81) was shown for RV and valvular function, except for grading of aortic stenosis (r = 0.62). The correlations were substantial for IVC and LA dimensions. Median time used for bedside screening with POCKET was 4.2 min (range: 2.3-13.0). There was excellent feasibility for cardiac structures and pleura, which was assessed to satisfaction in >/= 94% of patients. Lower feasibility (71-79%) was seen for the abdominal great vessels. CONCLUSION: Point-of-care semi-quantitative evaluation of cardiac anatomy and function showed high feasibility and correlation with the reference method for most indices. Pocket-sized echocardiographic examinations of approximately 4 min length, performed at the bedside by experts, offers reliable assessment of cardiac structures, the pleural space and the large abdominal vessels. Clinical trial registration: ; unique ID: NCT01081210.","DOI":"10.1093/ejechocard/jer108","ISSN":"1532-2114 (Electronic) 1532-2114 (Linking)","note":"PMCID: PMC3171198","journalAbbreviation":"Eur. J. Echocardiogr.","language":"eng","author":[{"family":"Andersen","given":"G. N."},{"family":"Haugen","given":"B. O."},{"family":"Graven","given":"T."},{"family":"Salvesen","given":"O."},{"family":"Mjolstad","given":"O. C."},{"family":"Dalen","given":"H."}],"issued":{"date-parts":[["2011",9]]}}},{"id":9164,"uris":[""],"uri":[""],"itemData":{"id":9164,"type":"article-journal","title":"Internal medicine point-of-care ultrasound assessment of left ventricular function correlates with formal echocardiography","container-title":"Journal of Clinical Ultrasound","page":"92-9","volume":"44","issue":"2","abstract":"PURPOSE: Although focused cardiac ultrasonographic (FoCUS) examination has been evaluated in emergency departments and intensive care units with good correlation to formal echocardiography, accuracy for the assessment of left ventricular systolic function (LVSF) when performed by internal medicine physicians still needs independent evaluation. METHODS: This prospective observational study in a 640-bed, academic, quaternary care center, included 178 inpatients examined by 10 internal medicine physicians who had completed our internal medicine bedside ultrasound training program. The ability to estimate LVSF with FoCUS as \"normal,\" \"mild to moderately decreased,\" or \"severely decreased\" was compared with left ventricular ejection fraction (>50%, 31-49%, and <31%, respectively) from formal echocardiography interpreted by a cardiologist. RESULTS: Sensitivity and specificity of FoCUS for any degree of LVSF impairment were 0.91 (95% confidence interval [CI] 0.80, 0.97) and 0.88 (95% CI 0.81, 0.93), respectively. The interrater agreement between internal medicine physician-performed FoCUS and formal echocardiography for any LVSF impairment was \"good/substantial\" with kappa = 0.77 (p < 0.001), 95% CI (0.67, 0.87). Formal echocardiography was classified as \"technically limited due to patient factors\" in 20% of patients; however, echogenicity was sufficient in 100% of FoCUS exams to classify LVSF. CONCLUSIONS: Internal medicine physicians using FoCUS identify normal versus decreased LVSF with high sensitivity, specificity, and \"good/substantial\" interrater agreement when compared with formal echocardiography. These results support the role of cardiac FoCUS by properly trained internal medicine physicians for discriminating normal from reduced LVSF.","DOI":"10.1002/jcu.22272","ISSN":"0091-2751","journalAbbreviation":"J. Clin. Ultrasound","language":"eng","author":[{"family":"Johnson","given":"B. K."},{"family":"Tierney","given":"D. M."},{"family":"Rosborough","given":"T. K."},{"family":"Harris","given":"K. M."},{"family":"Newell","given":"M. C."}],"issued":{"date-parts":[["2016",2]]}}},{"id":6688,"uris":[""],"uri":[""],"itemData":{"id":6688,"type":"article-journal","title":"Bedside hand-carried ultrasound by internal medicine residents versus traditional clinical assessment for the identification of systolic dysfunction in patients admitted with decompensated heart failure","container-title":"Journal of the American Society of Echocardiography","page":"1319-24","volume":"24","issue":"12","abstract":"BACKGROUND: The rapid detection of left ventricular systolic dysfunction (LVSD) is an important step in the clinical management of patients admitted with acute decompensated heart failure, because it allows the initiation of treatment specific to LVSD and avoidance of contraindicated therapies. The aim of this study was to determine whether internal medicine residents with limited ultrasound training could use hand-carried ultrasound (HCU) to identify LVSD. METHODS: Fifty patients admitted with acute decompensated heart failure were imaged from the parasternal window at the bedside with an HCU device by residents blinded to all clinical data, who had undergone limited cardiac ultrasound training (20 practice studies). Ejection fraction (EF) on HCU was graded as >40% or <40%. HCU EF and a number of physical exam findings and electrocardiographic and laboratory variables were compared for their ability to predict to formal echocardiographic left ventricular EF. RESULTS: The average formal EF was 32 +/- 16% (range, 7%-70%), with 66% of patients having EFs < 40%. The residents' ability to detect an EF < 40% with HCU was excellent (sensitivity, 94%; specificity, 94%; negative predictive value, 88%; positive predictive value, 97%). Binary logistic regression demonstrated that HCU EF was the most powerful predictor of EF < 40%, with minimal additional value from clinical, exam, lab, and electrocardiographic variables. The time interval between clinical assessment and availability of formal echocardiographic results was 22 +/- 17 hours. CONCLUSIONS: Residents with limited training in cardiac ultrasound were able to identify LVSD in patients with acute decompensated heart failure with superior accuracy compared with clinical, physical exam, lab, and electrocardiographic findings and an average of 22 hours before the results of formal echocardiography were available.","DOI":"10.1016/j.echo.2011.07.013","ISSN":"1097-6795 (Electronic) 0894-7317 (Linking)","journalAbbreviation":"J. Am. Soc. Echocardiogr.","language":"eng","author":[{"family":"Razi","given":"R."},{"family":"Estrada","given":"J. R."},{"family":"Doll","given":"J."},{"family":"Spencer","given":"K. T."}],"issued":{"date-parts":[["2011",12]]}}}],"schema":""} 7–12Pericardial effusion: Hospitalists accurately detected moderate or larger pericardial effusions with a LR+ of 7.7, LR- of 0 in one study, ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"g18HiOAI","properties":{"formattedCitation":"\\super 4\\nosupersub{}","plainCitation":"4","noteIndex":0},"citationItems":[{"id":6600,"uris":[""],"uri":[""],"itemData":{"id":6600,"type":"article-journal","title":"Hand-carried echocardiography by hospitalists: a randomized trial","container-title":"American Journal of Medicine","page":"766-74","volume":"124","issue":"8","abstract":"BACKGROUND: Hospitalists can use hand-carried echocardiography for accurate point-of-care information, but patient outcome data for its application are sparse. METHODS: We performed an unblinded, parallel-group randomized trial between July 2008 and March 2009 at one teaching hospital in Chicago, Illinois. We randomly assigned adult general medicine inpatients referred for standard echocardiography with indications investigatable by hand-carried echocardiography to care guided by hand-carried echocardiography or usual care. The main outcome measure was length of stay on the referring hospitalist's service. Secondary outcomes included a before-after analysis of reported changes in management due to hand-carried echocardiography and the diagnostic accuracy of hand-carried echocardiography. RESULTS: The difference in length of stay between 226 participants randomized to care guided by hand-carried echocardiography (geometric mean 46.1 hours, interquartile range 29.0-70.9 hours) and 227 participants randomized to usual care (46.9 hours, interquartile range 34.1-68.3 hours) corresponded to a 1.7% reduction in length of stay that was not statistically significant (95% confidence interval, -12.1 to 9.8%). In post hoc subgroup analyses, care guided by hand-carried echocardiography reduced length of stay in participants who were referred for heart failure (P=.0008). Among participants who underwent both hand-carried and standard echocardiography, hospitalists changed management due to hand-carried echocardiography in 37%. Despite the favorable diagnostic accuracy of hand-carried echocardiography, most changes to the timing of hospital discharge occurred after standard echocardiography. CONCLUSION: Hospitalist care guided by hand-carried echocardiography for unselected general medicine patients does not meaningfully affect length of stay. Whether or not it affects care quality remains unstudied.","DOI":"10.1016/j.amjmed.2011.03.029","ISSN":"1555-7162 (Electronic) 0002-9343 (Linking)","journalAbbreviation":"Am. J. Med.","language":"eng","author":[{"family":"Lucas","given":"B. P."},{"family":"Candotti","given":"C."},{"family":"Margeta","given":"B."},{"family":"Mba","given":"B."},{"family":"Kumapley","given":"R."},{"family":"Asmar","given":"A."},{"family":"Franco-Sadud","given":"R."},{"family":"Baru","given":"J."},{"family":"Acob","given":"C."},{"family":"Borkowsky","given":"S."},{"family":"Evans","given":"A. T."}],"issued":{"date-parts":[["2011",8]]}}}],"schema":""} 4 detected effusions at rates similar to a cardiology fellow in another, ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"yDV3t1yk","properties":{"formattedCitation":"\\super 5\\nosupersub{}","plainCitation":"5","noteIndex":0},"citationItems":[{"id":5300,"uris":[""],"uri":[""],"itemData":{"id":5300,"type":"article-journal","title":"Hospitalist performance of cardiac hand-carried ultrasound after focused training","container-title":"American Journal of Medicine","page":"1000-4","volume":"120","issue":"11","abstract":"PURPOSE: Because the training that noncardiologists require to perform cardiac hand-carried ultrasound has not been defined, we studied how well hospitalists perform hand-carried echocardiography after limited training. METHODS: Ten hospitalists completed a focused training program that included performing an average of 35 hand-carried echocardiograms. Hospitalists' echocardiograms were compared with gold-standard conventional echocardiograms, and hospitalists were compared with 5 certified echocardiography technicians in their ability to acquire, measure, and interpret hand-carried ultrasound images and with 6 senior cardiology fellows in their ability to interpret echocardiograms. RESULTS: Echocardiography technicians had significantly higher performance scores for image acquisition, measurement, and interpretation than hospitalists. Senior cardiology fellows outperformed hospitalists in most aspects of image interpretation. For hospitalists, learning image acquisition was more difficult than image interpretation. CONCLUSIONS: Hospitalists can learn aspects of hand-carried echocardiography, but after 35 training echocardiograms cannot replicate the quality of conventional echocardiography. Whether the lower performance skills are important will depend on the clinical context of hand-carried echocardiography performed by hospitalists.","DOI":"10.1016/j.amjmed.2007.07.029","ISSN":"1555-7162 (Electronic) 0002-9343 (Linking)","journalAbbreviation":"Am. J. Med.","language":"eng","author":[{"family":"Martin","given":"L. D."},{"family":"Howell","given":"E. E."},{"family":"Ziegelstein","given":"R. C."},{"family":"Martire","given":"C."},{"family":"Shapiro","given":"E. P."},{"family":"Hellmann","given":"D. B."}],"issued":{"date-parts":[["2007",11]]}}}],"schema":""} 5 and vastly exceeded their detection compared to physical examination in a third. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"iamTMpr4","properties":{"formattedCitation":"\\super 6\\nosupersub{}","plainCitation":"6","noteIndex":0},"citationItems":[{"id":5853,"uris":[""],"uri":[""],"itemData":{"id":5853,"type":"article-journal","title":"Hand-carried ultrasound performed by hospitalists: does it improve the cardiac physical examination?","container-title":"American Journal of Medicine","page":"35-41","volume":"122","issue":"1","abstract":"OBJECTIVE: The traditional physical examination of the heart is relatively inaccurate. There is little information regarding whether cardiac hand-carried ultrasound performed by noncardiologists adds to the accuracy of physical examinations. The purpose of this study was to determine whether hand-carried ultrasound can add to the accuracy of hospitalists' cardiac physical examinations. METHODS: During a focused training program in hand-carried echocardiography, 10 hospitalists performed cardiac examinations of 354 general medical inpatients first by physical examination and then by hand-carried ultrasound. Eligible inpatients included those for whom a conventional hospital echocardiogram was ordered. We measured how frequently the hospitalists' cardiac examination with or without hand-carried ultrasound matched or came within 1 scale level of an expert cardiologist's interpretation of the hospital echocardiogram. RESULTS: Adding hand-carried ultrasound to the physical examination improved hospitalists' assessment of left ventricular function, cardiomegaly, and pericardial effusion. For left ventricular function, using hand-carried ultrasound increased the percentage of exact matches with the expert cardiologist's assessment from 46% to 59% (P=.005) and improved the percentage of within 1-level matches from 67% to 88% (P=.0001). The addition of hand-carried ultrasound failed to improve the assessments of aortic stenosis, aortic regurgitation, and mitral regurgitation. CONCLUSION: Adding hand-carried ultrasound to physical examination increases the accuracy of hospitalists' assessment of left ventricular dysfunction, cardiomegaly, and pericardial effusion, and fails to improve assessment of valvular heart disease. The clinical benefit achieved by improved immediacy of this information has not been determined. An important limitation is that the study assessed only 1 level of training in hand-carried ultrasound.","DOI":"10.1016/j.amjmed.2008.07.022","ISSN":"1555-7162 (Electronic) 0002-9343 (Linking)","journalAbbreviation":"Am. J. Med.","language":"eng","author":[{"family":"Martin","given":"L. D."},{"family":"Howell","given":"E. E."},{"family":"Ziegelstein","given":"R. C."},{"family":"Martire","given":"C."},{"family":"Whiting-O'Keefe","given":"Q. E."},{"family":"Shapiro","given":"E. P."},{"family":"Hellmann","given":"D. B."}],"issued":{"date-parts":[["2009",1]]}}}],"schema":""} 6 Numerous other studies of acute care physicians have shown similar results. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"79N3bowX","properties":{"formattedCitation":"\\super 7,9,10,13\\nosupersub{}","plainCitation":"7,9,10,13","noteIndex":0},"citationItems":[{"id":4435,"uris":[""],"uri":[""],"itemData":{"id":4435,"type":"article-journal","title":"The use of small personal ultrasound devices by internists without formal training in echocardiography","container-title":"European Journal of Echocardiography","page":"141-7","volume":"4","issue":"2","abstract":"AIMS: Hand-held ultrasound devices will probably be used for bedside cardiac diagnoses by internists without formal training in echocardiography. We compared the accuracy of hand-held ultrasound devices studies performed by expert echocardiographers vs internal medicine residents with brief training in echocardiography. METHODS AND RESULTS: Three internal medicine residents participated in an organized training program in echocardiographic principles, image acquisition, and interpretation. Subsequently, these residents and three echocardiographers imaged 300 patients with a hand-held ultrasound device. Sensitivity, specificity, positive and negative predictive values for internist- and echocardiographer-performed studies for the detection of cardiac abnormalities were compared using a full-featured exam as the gold standard. Resident- and echocardiographer-performed scans had similar overall sensitivity and specificity. There was a higher positive predictive value for the echocardiographer-performed scans. For clinically important findings (likely to affect patient care), sensitivity was slightly but significantly higher for the echocardiographer-performed scans. Clinically important findings most often missed by residents included regional wall motion abnormalities, intra-cardiac thrombus, right ventricular dysfunction and non-trivial pericardial effusions. CONCLUSION: Hand-held ultrasound devices provide useful screening tools for cardiac disease but should not replace a standard platform study. Training guidelines and competency evaluation are needed if these devices are to be used by non-echocardiographers for clinical decision-making.","ISSN":"1525-2167 (Print) 1532-2114 (Linking)","journalAbbreviation":"Eur. J. Echocardiogr.","language":"eng","author":[{"family":"DeCara","given":"J. M."},{"family":"Lang","given":"R. M."},{"family":"Koch","given":"R."},{"family":"Bala","given":"R."},{"family":"Penzotti","given":"J."},{"family":"Spencer","given":"K. T."}],"issued":{"date-parts":[["2003",6]]}}},{"id":4557,"uris":[""],"uri":[""],"itemData":{"id":4557,"type":"article-journal","title":"Feasibility of point-of-care echocardiography by internal medicine house staff","container-title":"American Heart Journal","page":"476-81","volume":"147","issue":"3","abstract":"OBJECTIVE: To determine whether internal medicine house staff with limited training in echocardiography can use point-of-care echocardiography to make simple, clinically important diagnoses. BACKGROUND: Availability of small, portable ultrasound devices could make point-of-care echocardiography widely available. The training required to perform point-of-care echocardiography has not been established. METHODS: Medical house staff participated in a 3-hour point-of-care echocardiography training program. Patients scheduled for standard echocardiography as part of clinical care underwent point-of-care echocardiography within 24 hours to assess four common clinically important diagnoses. Each standard echocardiogram was interpreted twice. Agreement (kappa) was calculated between point-of-care and standard echocardiography by using standard echocardiography as the gold standard and between the two interpretations of standard echocardiography. RESULTS: Agreement (kappa) between point-of-care echocardiography and standard echocardiography was 75% (0.51) for left ventricular dysfunction (ejection fraction <55%), 79% (0.31) for moderate or severe mitral regurgitation, 92% (0.32) for aortic valve thickening or immobility, and 98% (0.51) for moderate or large pericardial effusion. Agreement between the two interpretations of standard echocardiography was 83% (0.63) for left ventricular dysfunction, 92% (0.68) for moderate or severe mitral regurgitation, 95% (0.62) for aortic valve thickening or immobility, and 97% (0.53) for moderate or large pericardial effusion. CONCLUSIONS: Medical house staff with limited training in echocardiography can use point-of-care echocardiography to assess left ventricular function and pericardial effusion with moderate accuracy that is lower than that of standard echocardiography. Assessment of valvular disease and other diagnoses likely requires more training and/or experience in echocardiography.","DOI":"10.1016/j.ahj.2003.10.010","ISSN":"1097-6744 (Electronic) 0002-8703 (Linking)","journalAbbreviation":"Am. Heart J.","language":"eng","author":[{"family":"Alexander","given":"J. H."},{"family":"Peterson","given":"E. D."},{"family":"Chen","given":"A. Y."},{"family":"Harding","given":"T. M."},{"family":"Adams","given":"D. B."},{"family":"Kisslo","given":"J. A."}],"issued":{"date-parts":[["2004",3]]}}},{"id":6363,"uris":[""],"uri":[""],"itemData":{"id":6363,"type":"article-journal","title":"Feasibility and reliability of point-of-care pocket-sized echocardiography","container-title":"European Journal of Echocardiography","page":"665-70","volume":"12","issue":"9","abstract":"AIMS: To study the reliability and feasibility of point-of-care pocket-sized echocardiography (POCKET) at the bedside in patients admitted to a medical department at a non-university hospital. METHODS AND RESULTS: One hundred and eight patients were randomized to bedside POCKET examination shortly after admission and later high-end echocardiography (HIGH) in the echo-lab. The POCKET examinations were done by cardiologists on their ward rounds. Assessments of global and regional left ventricular (LV) function, right ventricular (RV) function, valvular function, left atrial (LA) size, the pericardium and pleura were done with respect to effusion and measurements of inferior vena cava (IVC) and abdominal aorta (AA) were performed. Correlations between POCKET and HIGH/appropriate radiological technique for LV function, AA size and presence of pericardial effusion were almost perfect, with r >/= 0.92. Strong correlation (r >/= 0.81) was shown for RV and valvular function, except for grading of aortic stenosis (r = 0.62). The correlations were substantial for IVC and LA dimensions. Median time used for bedside screening with POCKET was 4.2 min (range: 2.3-13.0). There was excellent feasibility for cardiac structures and pleura, which was assessed to satisfaction in >/= 94% of patients. Lower feasibility (71-79%) was seen for the abdominal great vessels. CONCLUSION: Point-of-care semi-quantitative evaluation of cardiac anatomy and function showed high feasibility and correlation with the reference method for most indices. Pocket-sized echocardiographic examinations of approximately 4 min length, performed at the bedside by experts, offers reliable assessment of cardiac structures, the pleural space and the large abdominal vessels. Clinical trial registration: ; unique ID: NCT01081210.","DOI":"10.1093/ejechocard/jer108","ISSN":"1532-2114 (Electronic) 1532-2114 (Linking)","note":"PMCID: PMC3171198","journalAbbreviation":"Eur. J. Echocardiogr.","language":"eng","author":[{"family":"Andersen","given":"G. N."},{"family":"Haugen","given":"B. O."},{"family":"Graven","given":"T."},{"family":"Salvesen","given":"O."},{"family":"Mjolstad","given":"O. C."},{"family":"Dalen","given":"H."}],"issued":{"date-parts":[["2011",9]]}}},{"id":5366,"uris":[""],"uri":[""],"itemData":{"id":5366,"type":"article-journal","title":"Focused training for goal-oriented hand-held echocardiography performed by noncardiologist residents in the intensive care unit","container-title":"Intensive Care Medicine","page":"1795-9","volume":"33","issue":"10","abstract":"OBJECTIVE: We sought to evaluate the efficacy of a limited training dedicated to residents without knowledge in ultrasound for performing goal-oriented echocardiography in ICU patients. DESIGN: Prospective pilot observational study. SETTING: Medical-surgical ICU of a teaching hospital. PATIENTS: 61 consecutive adult ICU patients (SAPS II score: 38 +/- 17; 46 ventilated patients) requiring a transthoracic echocardiography were studied. INTERVENTIONS: After a curriculum including a 3-h training course and 5 h of hands-on training, one of four noncardiologist residents and an intensivist experienced in ultrasound subsequently performed hand-held echocardiography (HHE), independently and in random order. Assessable \"rule in, rule out\" clinical questions were purposely limited to easily identifiable conditions by the sole use of two-dimensional imaging. MEASUREMENTS AND RESULTS: When compared with residents, the experienced intensivist performed shorter examinations (4 +/- 1 vs. 11 +/- 4 min: p < 0.0001) and had significantly less unsolved clinical questions [3 (0.8%) vs. 27 (7.4%) of 366 clinical questions: p < 0.0001]. When addressed, clinical questions were adequately appraised by residents: left ventricular systolic dysfunction [Kappa: 0.76 +/- 0.09 (95% CI: 0.59-0.93)], left ventricular dilatation [Kappa: 0.66 +/- 0.12 (95% CI: 0.43-0.90)], right ventricular dilatation [Kappa: 0.71 +/- 0.12 (95% CI: 0.46-0.95)], pericardial effusion [Kappa: 0.68 +/- 0.18 (95 CI: 0.33-1.03)], and pleural effusion [Kappa: 0.71 +/- 0.09 (95% CI: 0.53-0.88)]. The only case of tamponade was accurately diagnosed by the resident. CONCLUSIONS: Limited training of noncardiologist ICU residents without previous knowledge in ultrasound appears feasible and efficient to address simple clinical questions using point-of-care echography. Influence of the learning curve on diagnostic accuracy and potential therapeutic impact remain to be determined.","DOI":"10.1007/s00134-007-0742-8","ISSN":"0342-4642 (Print) 0342-4642 (Linking)","journalAbbreviation":"Intensive Care Med.","language":"eng","author":[{"family":"Vignon","given":"P."},{"family":"Dugard","given":"A."},{"family":"Abraham","given":"J."},{"family":"Belcour","given":"D."},{"family":"Gondran","given":"G."},{"family":"Pepino","given":"F."},{"family":"Marin","given":"B."},{"family":"Francois","given":"B."},{"family":"Gastinne","given":"H."}],"issued":{"date-parts":[["2007",10]]}}}],"schema":""} 7,9,10,13Chamber hypertrophy and enlargement: POCUS allows detection of chamber hypertrophy and enlargement. Left ventricular hypertrophy (LVH) and left atrial enlargement (LAE) are two such examples which are useful to detect in hospitalized patients and which may be detected with POCUS. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"yjrCAfNU","properties":{"formattedCitation":"\\super 14\\uc0\\u8211{}16\\nosupersub{}","plainCitation":"14–16","noteIndex":0},"citationItems":[{"id":7700,"uris":[""],"uri":[""],"itemData":{"id":7700,"type":"article-journal","title":"Focused cardiac ultrasound: recommendations from the American Society of Echocardiography","container-title":"Journal of the American Society of Echocardiography","page":"567-81","volume":"26","issue":"6","DOI":"10.1016/j.echo.2013.04.001","ISSN":"1097-6795 (Electronic) 0894-7317 (Linking)","journalAbbreviation":"J. Am. Soc. Echocardiogr.","language":"eng","author":[{"family":"Spencer","given":"K. T."},{"family":"Kimura","given":"B. J."},{"family":"Korcarz","given":"C. E."},{"family":"Pellikka","given":"P. A."},{"family":"Rahko","given":"P. S."},{"family":"Siegel","given":"R. J."}],"issued":{"date-parts":[["2013",6]]}}},{"id":4833,"uris":[""],"uri":[""],"itemData":{"id":4833,"type":"article-journal","title":"Detection of left atrial enlargement using hand-carried ultrasound devices to screen for cardiac abnormalities","container-title":"American Journal of Medicine","page":"912-6","volume":"118","issue":"8","DOI":"10.1016/j.amjmed.2005.03.036","ISSN":"0002-9343 (Print) 0002-9343","journalAbbreviation":"Am. J. Med.","language":"eng","author":[{"family":"Kimura","given":"B. J."},{"family":"Fowler","given":"S. J."},{"family":"Fergus","given":"T. S."},{"family":"Minuto","given":"J. J."},{"family":"Amundson","given":"S. A."},{"family":"Gilpin","given":"E. A."},{"family":"DeMaria","given":"A. N."}],"issued":{"date-parts":[["2005",8]]}}},{"id":7041,"uris":[""],"uri":[""],"itemData":{"id":7041,"type":"article-journal","title":"Routinely adding ultrasound examinations by pocket-sized ultrasound devices improves inpatient diagnostics in a medical department","container-title":"European Journal of Internal Medicine","page":"185-91","volume":"23","issue":"2","abstract":"BACKGROUND: We aimed to investigate the potential benefit of adding a routine cardiac and abdominal diagnostic examination by pocket-sized ultrasound device in patients admitted to a medical department. METHODS: A random sample of 196 patients admitted to the medical department at a non-university hospital in Norway between March and September 2010 was studied. The patients underwent cardiac and abdominal screening with a pocket-sized ultrasound device with B-mode and color flow imaging after a principal diagnosis was set. Three internists/cardiologists experienced in ultrasonography performed the examinations. Diagnostic corrections were made and findings were confirmed by high-end echocardiography and examinations at the radiologic department. RESULTS: 196 patients were included (male=56.6%, mean+/-SD; 68.1+/-15.0 years old). The time spent doing the ultrasound screening was mean+/-SD 4.3+/-1.6 min for the cardiac screening and 2.5+/-1.1 min for the abdominal screening. In 36 (18.4%) patients this examination resulted in a major change in the primary diagnosis. In 38 (19.4%) patients the diagnosis was verified and in 18 (9.2%) patients an important additional diagnosis was made. CONCLUSION: By adding a pocket-sized ultrasound examination of <10 min to usual care, we corrected the diagnosis in almost 1 of 5 patients admitted to a medical department, resulting in a completely different treatment strategy without delay in many of the patients. Routinely adding a cardiac and abdominal ultrasound screening has the potential to rearrange inpatients workflow and diagnosis.","DOI":"10.1016/j.ejim.2011.10.009","ISSN":"0953-6205","journalAbbreviation":"Eur. J. Intern. Med.","language":"eng","author":[{"family":"Mjolstad","given":"O. C."},{"family":"Dalen","given":"H."},{"family":"Graven","given":"T."},{"family":"Kleinau","given":"J. O."},{"family":"Salvesen","given":"O."},{"family":"Haugen","given":"B. O."}],"issued":{"date-parts":[["2012",3]]}}}],"schema":""} 14–16 In one study of hospitalists, LVH was detected with LR+ of 1.6 and LR- of 0.7, while LAE had LR+ of 2.4, LR- of 0.4. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"EzVAIeM6","properties":{"formattedCitation":"\\super 4\\nosupersub{}","plainCitation":"4","noteIndex":0},"citationItems":[{"id":6600,"uris":[""],"uri":[""],"itemData":{"id":6600,"type":"article-journal","title":"Hand-carried echocardiography by hospitalists: a randomized trial","container-title":"American Journal of Medicine","page":"766-74","volume":"124","issue":"8","abstract":"BACKGROUND: Hospitalists can use hand-carried echocardiography for accurate point-of-care information, but patient outcome data for its application are sparse. METHODS: We performed an unblinded, parallel-group randomized trial between July 2008 and March 2009 at one teaching hospital in Chicago, Illinois. We randomly assigned adult general medicine inpatients referred for standard echocardiography with indications investigatable by hand-carried echocardiography to care guided by hand-carried echocardiography or usual care. The main outcome measure was length of stay on the referring hospitalist's service. Secondary outcomes included a before-after analysis of reported changes in management due to hand-carried echocardiography and the diagnostic accuracy of hand-carried echocardiography. RESULTS: The difference in length of stay between 226 participants randomized to care guided by hand-carried echocardiography (geometric mean 46.1 hours, interquartile range 29.0-70.9 hours) and 227 participants randomized to usual care (46.9 hours, interquartile range 34.1-68.3 hours) corresponded to a 1.7% reduction in length of stay that was not statistically significant (95% confidence interval, -12.1 to 9.8%). In post hoc subgroup analyses, care guided by hand-carried echocardiography reduced length of stay in participants who were referred for heart failure (P=.0008). Among participants who underwent both hand-carried and standard echocardiography, hospitalists changed management due to hand-carried echocardiography in 37%. Despite the favorable diagnostic accuracy of hand-carried echocardiography, most changes to the timing of hospital discharge occurred after standard echocardiography. CONCLUSION: Hospitalist care guided by hand-carried echocardiography for unselected general medicine patients does not meaningfully affect length of stay. Whether or not it affects care quality remains unstudied.","DOI":"10.1016/j.amjmed.2011.03.029","ISSN":"1555-7162 (Electronic) 0002-9343 (Linking)","journalAbbreviation":"Am. J. Med.","language":"eng","author":[{"family":"Lucas","given":"B. P."},{"family":"Candotti","given":"C."},{"family":"Margeta","given":"B."},{"family":"Mba","given":"B."},{"family":"Kumapley","given":"R."},{"family":"Asmar","given":"A."},{"family":"Franco-Sadud","given":"R."},{"family":"Baru","given":"J."},{"family":"Acob","given":"C."},{"family":"Borkowsky","given":"S."},{"family":"Evans","given":"A. T."}],"issued":{"date-parts":[["2011",8]]}}}],"schema":""} 4Right ventricular function: POCUS may be useful in the detection of right ventricular dysfunction in severe cases of acute pulmonary embolism, particularly in combination with lower extremity venous ultrasound. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"qJI7at1S","properties":{"formattedCitation":"\\super 17,18\\nosupersub{}","plainCitation":"17,18","noteIndex":0},"citationItems":[{"id":4056,"uris":[""],"uri":[""],"itemData":{"id":4056,"type":"article-journal","title":"Utility of an integrated clinical, echocardiographic, and venous ultrasonographic approach for triage of patients with suspected pulmonary embolism","container-title":"American Journal of Cardiology","page":"1230-5","volume":"82","issue":"10","abstract":"The potential role of ultrasound techniques in diagnosing acute pulmonary embolism (PE) has been investigated in severe cases with hemodynamic compromise, but is still unclear for the whole clinical spectrum of patients with suspected PE. The aim of this study was to assess the utility of an integrated bedside evaluation for PE based on the combination of a clinical score, 2-dimensional echocardiography, and color venous duplex scanning. A group of 117 consecutive patients with suspected PE was assessed using a clinical likelihood score, echocardiography, and venous duplex scanning in order to obtain a preliminary diagnosis of PE, which was subsequently compared with the final diagnosis obtained by lung perfusion scintigraphy and angiography. A preliminary diagnosis of PE was made in 70 patients; a final diagnosis of PE was made in 63 patients, of which 56 had and 7 did not have a preliminary diagnosis of PE. The preliminary diagnosis therefore showed 89% sensitivity and 74% specificity, with a total accuracy of 82%. In patients with massive PE, sensitivity and negative predictive values of the preliminary diagnosis were 97% and 98%, respectively. Echocardiography was poorly sensitive (51%) but highly specific (87%) for PE. Thus, the integration of clinical likelihood, echocardiography, and venous duplex scanning provides a practical approach to patients with suspected PE, allows the rapid implementation of appropriate management strategies, and may reduce or postpone the need for further instrumental evaluation of more limited access.","ISSN":"0002-9149 (Print) 0002-9149","journalAbbreviation":"Am. J. Cardiol.","language":"eng","author":[{"family":"Grifoni","given":"S."},{"family":"Olivotto","given":"I."},{"family":"Cecchini","given":"P."},{"family":"Pieralli","given":"F."},{"family":"Camaiti","given":"A."},{"family":"Santoro","given":"G."},{"family":"Pieri","given":"A."},{"family":"Toccafondi","given":"S."},{"family":"Magazzini","given":"S."},{"family":"Berni","given":"G."},{"family":"Agnelli","given":"G."}],"issued":{"date-parts":[["1998",11,15]]}}},{"id":5529,"uris":[""],"uri":[""],"itemData":{"id":5529,"type":"article-journal","title":"Triage patients with suspected pulmonary embolism in the emergency department using a portable ultrasound device","container-title":"Echocardiography","page":"451-6","volume":"25","issue":"5","abstract":"The diagnosis of pulmonary embolism (PE) is difficult, despite validated diagnostic models. We sought to determine the value of a portable ultrasound device for triage of patients with suspected PE referred to the emergency department, using simplified echo criteria. We prospectively studied 103 consecutive patients with suspected PE, referred to our emergency department. After D-dimer screening, 76 patients were prospectively enrolled in this ultrasound study and underwent helical chest tomography, transthoracic echocardiography, and venous ultrasonography. Among patients with PE (n = 31), a right ventricular dilation was detected in 17 patients (55%), a direct visualization of clot in the lower limbs was present in 18 patients (58%), and 8 patients (26%) had both right ventricular dilation and deep venous thrombosis. The sensitivity and specificity of a combined ultrasound strategy using echocardiography and venous ultrasonography were respectively 87% (95% confidence interval 74% to 96%), and 69% (95% confidence interval 53% to 82%). The sensitivity of this combined strategy was significantly improved as compared to venous ultrasonography alone (P = 0.01) or echocardiography alone (P = 0.005). In patients with dyspnea or with high clinical probability of PE, this combined strategy was particularly relevant with high sensitivities (respectively 94% and 100%). Echocardiography combined with venous ultrasonography using a portable ultrasound device is a reliable method for screening patients with suspected PE referred to an emergency department, especially in patients with dyspnea or with high clinical probability.","DOI":"10.1111/j.1540-8175.2007.00623.x","ISSN":"0742-2822 (Print) 0742-2822","journalAbbreviation":"Echocardiography","language":"eng","author":[{"family":"Mansencal","given":"N."},{"family":"Vieillard-Baron","given":"A."},{"family":"Beauchet","given":"A."},{"family":"Farcot","given":"J. C."},{"family":"El Hajjam","given":"M."},{"family":"Dufaitre","given":"G."},{"family":"Brun-Ney","given":"D."},{"family":"Lacombe","given":"P."},{"family":"Jardin","given":"F."},{"family":"Dubourg","given":"O."}],"issued":{"date-parts":[["2008",5]]}}}],"schema":""} 17,18Right atrial pressure (RAP) estimation: Ultrasound measurements of the inferior vena cava (IVC) may be useful in the assessment of right atrial pressure, ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ENg6qWv6","properties":{"formattedCitation":"\\super 19,20\\nosupersub{}","plainCitation":"19,20","noteIndex":0},"citationItems":[{"id":5954,"uris":[""],"uri":[""],"itemData":{"id":5954,"type":"article-journal","title":"Intensivist use of hand-carried ultrasonography to measure IVC collapsibility in estimating intravascular volume status: correlations with CVP","container-title":"Journal of the American College of Surgeons","page":"55-61","volume":"209","issue":"1","abstract":"BACKGROUND: Volume status assessment is an important aspect of patient management in the surgical intensive care unit (SICU). Echocardiologist-performed measurement of IVC collapsibility index (IVC-CI) provides useful information about filling pressures, but is limited by its portability, cost, and availability. Intensivist-performed bedside ultrasonography (INBU) examinations have the potential to overcome these impediments. We used INBU to evaluate hemodynamic status of SICU patients, focusing on correlations between IVC-CI and CVP. STUDY DESIGN: Prospective evaluation of hemodynamic status was conducted on a convenience sample of SICU patients with a brief (3 to 10 minutes) INBU examination. INBU examinations were performed by noncardiologists after 3 hours of didactics in interpreting and acquiring two-dimensional and M-mode images, and > or =25 proctored examinations. IVC-CI measurements were compared with invasive CVP values. RESULTS: Of 124 enrolled patients, 101 had CVP catheters (55 men, mean age 58.3 years, 44.6% intubated). Of these, 18 patients had uninterpretable INBU examinations, leaving 83 patients with both CVP monitoring devices and INBU IVC evaluations. Patients in three IVC-CI ranges (<0.20, 0.20 to 0.60, and >0.60) demonstrated significant decrease in mean CVP as IVC-CI increased (p = 0.023). Although <5% of patients with IVC-CI <0.20 had CVP <7 mmHg, >40% of this group had a CVP >12 mmHg. Conversely, >60% of patients with IVC-CI >0.6 had CVP <7 mmHg. CONCLUSIONS: Measurements of IVC-CI by INBU can provide a useful guide to noninvasive volume status assessment in SICU patients. IVC-CI appears to correlate best with CVP in the setting of low (<0.20) and high (>0.60) collapsibility ranges. Additional studies are needed to confirm and expand on findings of this study.","DOI":"10.1016/j.jamcollsurg.2009.02.062","ISSN":"1879-1190 (Electronic) 1072-7515 (Linking)","journalAbbreviation":"J. Am. Coll. Surg.","language":"eng","author":[{"family":"Stawicki","given":"S. P."},{"family":"Braslow","given":"B. M."},{"family":"Panebianco","given":"N. L."},{"family":"Kirkpatrick","given":"J. N."},{"family":"Gracias","given":"V. H."},{"family":"Hayden","given":"G. E."},{"family":"Dean","given":"A. J."}],"issued":{"date-parts":[["2009",7]]}}},{"id":8903,"uris":[""],"uri":[""],"itemData":{"id":8903,"type":"article-journal","title":"Guidelines for the use of echocardiography as a monitor for therapeutic intervention in adults: a report from the American Society of Echocardiography","container-title":"Journal of the American Society of Echocardiography","page":"40-56","volume":"28","issue":"1","DOI":"10.1016/j.echo.2014.09.009","ISSN":"1097-6795 (Electronic) 0894-7317 (Linking)","journalAbbreviation":"J. Am. Soc. Echocardiogr.","language":"eng","author":[{"family":"Porter","given":"T. R."},{"family":"Shillcutt","given":"S. K."},{"family":"Adams","given":"M. S."},{"family":"Desjardins","given":"G."},{"family":"Glas","given":"K. E."},{"family":"Olson","given":"J. J."},{"family":"Troughton","given":"R. W."}],"issued":{"date-parts":[["2015",1]]}}}],"schema":""} 19,20 may be used in combination with other findings to diagnose heart failure exacerbations, ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"y6RvN3I9","properties":{"formattedCitation":"\\super 21,22\\nosupersub{}","plainCitation":"21,22","noteIndex":0},"citationItems":[{"id":5696,"uris":[""],"uri":[""],"itemData":{"id":5696,"type":"article-journal","title":"Identification of congestive heart failure via respiratory variation of inferior vena cava diameter","container-title":"American Journal of Emergency Medicine","page":"71-5","volume":"27","issue":"1","abstract":"INTRODUCTION: Rapid diagnosis of volume overload in patients with suspected congestive heart failure (CHF) is necessary for the timely administration of therapeutic agents. We sought to use the measurement of respiratory variation of inferior vena cava (IVC) diameter as a diagnostic tool for identification of CHF in patients presenting with acute dyspnea. METHODS: The IVC was measured sonographically during a complete respiratory cycle of 46 patients meeting study criteria. Percentage of respiratory variation of IVC diameter was compared to the diagnosis of CHF or alternative diagnosis. RESULTS: Respiratory variation of IVC was smaller in patients with CHF (9.6%) than without CHF (46%) and showed good diagnostic accuracy with area under the receiver operating characteristic curve of 0.96. Receiver operating characteristic curve analysis showed optimum cutoff of 15% variation or less of IVC diameter with 92% sensitivity and 84% specificity for the diagnosis of CHF. CONCLUSION: Inferior vena cava ultrasound is a rapid, reliable means for identification of CHF in the acutely dyspneic patient.","DOI":"10.1016/j.ajem.2008.01.002","ISSN":"1532-8171 (Electronic) 0735-6757 (Linking)","journalAbbreviation":"Am. J. Emerg. Med.","language":"eng","author":[{"family":"Blehar","given":"D. J."},{"family":"Dickman","given":"E."},{"family":"Gaspari","given":"R."}],"issued":{"date-parts":[["2009",1]]}}},{"id":7033,"uris":[""],"uri":[""],"itemData":{"id":7033,"type":"article-journal","title":"Inferior vena cava assessment in the bedside diagnosis of acute heart failure","container-title":"American Journal of Emergency Medicine","page":"778-83","volume":"30","issue":"5","abstract":"OBJECTIVES: The objective of this study was to determine the test characteristics of the caval index and caval-aortic ratio in predicting the diagnosis of acute heart failure in patients with undifferentiated dyspnea in the emergency department (ED). METHODS: This prospective observational study was performed at an urban ED that enrolled patients, 50 years or older, with acute dyspnea. A sonographic caval index was calculated as the percentage decrease in the inferior vena cava (IVC) diameter during respiration. A caval-aortic ratio was defined by the maximum IVC diameter divided by the aortic diameter. The sensitivity, specificity, and likelihood ratios of these measurements associated with heart failure were estimated. RESULTS: Eighty-nine patients were enrolled in the study with a mean age of 68 years. A caval index of less than 33% had 80% sensitivity (95% confidence interval [CI], 63%-91%) and 81% specificity (95% CI, 68%-90%) in diagnosing acute heart failure, whereas an index of less than 15% had a 37% sensitivity (95% CI, 22%-55%) and 96% specificity (95% CI, 86%-99%). The sensitivity of a caval-aortic ratio of more than 1.2 was 33% (95% CI, 18%-52%) and the specificity was 96% (95% CI, 86%-99%). Positive likelihood ratios were 10 for a caval index of less than 15%, 4.3 for an index of less than 33%, and 8.3 for a caval-aortic ratio of more than 1.2. CONCLUSION: Bedside assessments of the caval index or caval-aortic ratio may be useful clinical adjuncts in establishing the diagnosis of acute heart failure in patients with undifferentiated dyspnea.","DOI":"10.1016/j.ajem.2011.04.008","ISSN":"1532-8171 (Electronic) 0735-6757 (Linking)","journalAbbreviation":"Am. J. Emerg. Med.","language":"eng","author":[{"family":"Miller","given":"J. B."},{"family":"Sen","given":"A."},{"family":"Strote","given":"S. R."},{"family":"Hegg","given":"A. J."},{"family":"Farris","given":"S."},{"family":"Brackney","given":"A."},{"family":"Amponsah","given":"D."},{"family":"Mossallam","given":"U."}],"issued":{"date-parts":[["2012",6]]}}}],"schema":""} 21,22 and may distinguish etiologies of shock. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"r66rnlYM","properties":{"formattedCitation":"\\super 23,24\\nosupersub{}","plainCitation":"23,24","noteIndex":0},"citationItems":[{"id":5658,"uris":[""],"uri":[""],"itemData":{"id":5658,"type":"article-journal","title":"Abdominal and Cardiac Evaluation with Sonography in Shock (ACES): an approach by emergency physicians for the use of ultrasound in patients with undifferentiated hypotension","container-title":"Emergency Medicine Journal","page":"87-91","volume":"26","issue":"2","abstract":"BACKGROUND: Non-traumatic undifferentiated hypotension is a common critical presentation in the emergency department. In this group of patients, early diagnosis and goal-directed therapy is essential for an optimal outcome. The usefulness of focused bedside ultrasound is reviewed and a protocol for Abdominal and Cardiac Evaluation with Sonography in Shock (ACES) is proposed. METHODS: The protocol consists of six windows including cardiac, peritoneal, pleural, inferior vena cava and aortic views, and aims to shorten the time period taken to establish a diagnosis and hence to deliver the most appropriate goal-directed therapy. Its use in seven case examples is described. RESULTS: In all cases the ACES protocol helped in guiding the initial management while further information was obtained. CONCLUSION: The six-view ACES protocol is a useful adjunct to clinical examination in patients with undifferentiated hypotension in the emergency department. A prospective randomised trial or multicentre database/registry is needed to investigate the validity and impact of this protocol on the early diagnosis and management of hypotensive patients.","DOI":"10.1136/emj.2007.056242","ISSN":"1472-0205","journalAbbreviation":"Emerg. Med. J.","language":"eng","author":[{"family":"Atkinson","given":"P. R."},{"family":"McAuley","given":"D. J."},{"family":"Kendall","given":"R. J."},{"family":"Abeyakoon","given":"O."},{"family":"Reid","given":"C. G."},{"family":"Connolly","given":"J."},{"family":"Lewis","given":"D."}],"issued":{"date-parts":[["2009",2]]}}},{"id":6236,"uris":[""],"uri":[""],"itemData":{"id":6236,"type":"article-journal","title":"The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically lll","container-title":"Emergency Medicine Clinics of North America","page":"29-56, vii","volume":"28","issue":"1","abstract":"The RUSH exam (Rapid Ultrasound in SHock examination), presented in this article, represents a comprehensive algorithm for the integration of bedside ultrasound into the care of the patient in shock. By focusing on a stepwise evaluation of the shock patient defined here as \"Pump, Tank, and Pipes,\" clinicians will gain crucial anatomic and physiologic data to better care for these patients.","DOI":"10.1016/j.emc.2009.09.010","ISSN":"1558-0539 (Electronic) 0733-8627 (Linking)","journalAbbreviation":"Emerg. Med. Clin. North Am.","language":"eng","author":[{"family":"Perera","given":"P."},{"family":"Mailhot","given":"T."},{"family":"Riley","given":"D."},{"family":"Mandavia","given":"D."}],"issued":{"date-parts":[["2010",2]]}}}],"schema":""} 23,24, ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"hF4es7ZI","properties":{"formattedCitation":"\\super 25\\nosupersub{}","plainCitation":"25","noteIndex":0},"citationItems":[{"id":4600,"uris":[""],"uri":[""],"itemData":{"id":4600,"type":"article-journal","title":"The respiratory variation in inferior vena cava diameter as a guide to fluid therapy","container-title":"Intensive Care Medicine","page":"1834-7","volume":"30","issue":"9","abstract":"OBJECTIVE: To investigate whether the respiratory variation in inferior vena cava diameter (DeltaD(IVC)) could be related to fluid responsiveness in mechanically ventilated patients. DESIGN: Prospective clinical study. SETTING: Medical ICU of a non-university hospital. PATIENTS: Mechanically ventilated patients with septic shock (n=39). INTERVENTIONS: Volume loading with 8 mL/kg of 6% hydroxyethylstarch over 20 min. MEASUREMENTS AND RESULTS: Cardiac output and DeltaD(IVC) were assessed by echography before and immediately after the standardized volume load. Volume loading induced an increase in cardiac output from 5.7+/-2.0 to 6.4+/-1.9 L/min (P<0.001) and a decrease in DeltaD(IVC) from 13.8+/-13.6 vs 5.2+/-5.8% (P<0.001). Sixteen patients responded to volume loading by an increase in cardiac output > or =15% (responders). Before volume loading, the DeltaD(IVC) was greater in responders than in non-responders (25+/-15 vs 6+/-4%, P<0.001), closely correlated with the increase in cardiac output (r=0.82, P<0.001), and a 12% DeltaD(IVC) cut-off value allowed identification of responders with positive and negative predictive values of 93% and 92%, respectively. CONCLUSION: Analysis of DeltaD(IVC) is a simple and non-invasive method to detect fluid responsiveness in mechanically ventilated patients with septic shock.","DOI":"10.1007/s00134-004-2233-5","ISSN":"0342-4642 (Print) 0342-4642 (Linking)","journalAbbreviation":"Intensive Care Med.","language":"eng","author":[{"family":"Feissel","given":"M."},{"family":"Michard","given":"F."},{"family":"Faller","given":"J. P."},{"family":"Teboul","given":"J. L."}],"issued":{"date-parts":[["2004",9]]}}}],"schema":""} 25 Internal jugular veins may also be used. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"3uKtpsnl","properties":{"formattedCitation":"\\super 26,27\\nosupersub{}","plainCitation":"26,27","noteIndex":0},"citationItems":[{"id":7141,"uris":[""],"uri":[""],"itemData":{"id":7141,"type":"article-journal","title":"The sensitivity and specificity of ultrasound estimation of central venous pressure using the internal jugular vein","container-title":"Journal of Critical Care","page":"315.e7-11","volume":"27","issue":"3","abstract":"PURPOSE: The fluid volume status of a patient is difficult to assess clinically. The aim of this study was to compare the ultrasound estimation of the height of the right internal jugular vein (CVP(IJV)) with direct estimation of central venous pressure (CVP) (CVP(CVC)). MATERIALS AND METHODS: A portable ultrasound machine defined the \"top\" of the right internal jugular vein in 44 patients from a single tertiary hospital. The vertical height from this point to the sternal angle was used to estimate CVP(IJV). A central venous catheter was then inserted and direct measurement of CVP was made with a pressure transducer. A normal CVP was defined as 3 to 6 mm Hg. RESULTS: For overloaded patients, CVP(IJV) correlated well with CVP(CVC), P = .004, sensitivity of 64.3%, specificity of 81.3%, and positive predictive value of 85.7%. The area under the curve for the receiver operating characteristic curve was 0.73 (95% confidence interval, 0.59-0.86). For undervolumed patients, the correlation remained statistically significant, P < .001, sensitivity of 88.9%, specificity of 77.1%, and negative predictive value of 96.4%. The area under the curve was 0.83 (95% confidence interval, 0.70-0.96). CONCLUSION: Ultrasound estimation of CVP using a portable ultrasound machine and the internal jugular vein is simple, noninvasive, and accurate.","DOI":"10.1016/j.jcrc.2011.09.008","ISSN":"0883-9441","journalAbbreviation":"J. Crit. Care","language":"eng","author":[{"family":"Siva","given":"B."},{"family":"Hunt","given":"A."},{"family":"Boudville","given":"N."}],"issued":{"date-parts":[["2012",6]]}}},{"id":8062,"uris":[""],"uri":[""],"itemData":{"id":8062,"type":"article-journal","title":"Jugular vein distensibility predicts fluid responsiveness in septic patients","container-title":"Critical Care (London, England)","page":"647","volume":"18","issue":"6","abstract":"INTRODUCTION: The purpose of the study was to verify the efficacy of using internal jugular vein (IJV) size and distensibility as a reliable index of fluid responsiveness in mechanically ventilated patients with sepsis. METHODS: Hemodynamic data of mechanically ventilated patients with sepsis were collected through a radial arterial indwelling catheter connected to continuous hemodynamic monitoring system (Most Care(R), Vytech Health, Padova, Italy), including cardiac index (CI) (L/min/M(2)), heart rate (beats/min), mean arterial pressure (MAP) (mmHg), central venous pressure (CVP) (mmHg) and arterial pulse pressure variation (PPV), coupled with ultrasound evaluation of IJV distensibility (%), defined as a ratio of the difference between IJV maximal antero-posterior diameter during inspiration and minimum expiratory diameter to minimum expiratory diameter x100. Patients were retrospectively divided into two groups; fluid responders (R), if CI increase of more than or equal to 15% after a 7 ml/kg crystalloid infusion, and non-responders (NR) if CI increased more than 15%. We compared differences in measured variables between R and NR groups and calculated receiver-operator-characteristic (ROC) curves of optimal IJV distensibility and PPV sensitivity and specificity to predicting R. We also calculated a combined inferior vena cava distensibility-PPV ROC curve to predict R. RESULTS: We enrolled 50 patients, of these, 30 were R. Responders presented higher IJV distensibility and PPV before fluid challenge than NR (P <0.05). An IJV distensibility more than 18% prior to volume challenge had an 80% sensitivity and 85% specificity to predict R. Pairwise comparison between IJV distensibility and PPV ROC curves revealed similar ROC area under the curve results. Interestingly, combining IJV distensibility more than 9.7% and PPV more than 12% predicted fluid responsiveness with a sensitivity of 100% and specificity of 95%. CONCLUSION: IJV distensibility is an accurate, easily acquired non-invasive parameter of fluid responsiveness in mechanically ventilated septic patients with performance similar to PPV. The combined use of IJV distensibility with left-sided indexes of fluid responsiveness improves their predictive value.","DOI":"10.1186/s13054-014-0647-1","ISSN":"1364-8535","note":"PMCID: PMC4301660","journalAbbreviation":"Crit. Care","language":"eng","author":[{"family":"Guarracino","given":"F."},{"family":"Ferro","given":"B."},{"family":"Forfori","given":"F."},{"family":"Bertini","given":"P."},{"family":"Magliacano","given":"L."},{"family":"Pinsky","given":"M. R."}],"issued":{"date-parts":[["2014",12,5]]}}}],"schema":""} 26,27Severe valvular disease: POCUS may help hospitalists and similarly trained physicians detect some types of valvular disease, such as severe mitral regurgitation ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Xy8VdvQZ","properties":{"formattedCitation":"\\super 4\\nosupersub{}","plainCitation":"4","noteIndex":0},"citationItems":[{"id":6600,"uris":[""],"uri":[""],"itemData":{"id":6600,"type":"article-journal","title":"Hand-carried echocardiography by hospitalists: a randomized trial","container-title":"American Journal of Medicine","page":"766-74","volume":"124","issue":"8","abstract":"BACKGROUND: Hospitalists can use hand-carried echocardiography for accurate point-of-care information, but patient outcome data for its application are sparse. METHODS: We performed an unblinded, parallel-group randomized trial between July 2008 and March 2009 at one teaching hospital in Chicago, Illinois. We randomly assigned adult general medicine inpatients referred for standard echocardiography with indications investigatable by hand-carried echocardiography to care guided by hand-carried echocardiography or usual care. The main outcome measure was length of stay on the referring hospitalist's service. Secondary outcomes included a before-after analysis of reported changes in management due to hand-carried echocardiography and the diagnostic accuracy of hand-carried echocardiography. RESULTS: The difference in length of stay between 226 participants randomized to care guided by hand-carried echocardiography (geometric mean 46.1 hours, interquartile range 29.0-70.9 hours) and 227 participants randomized to usual care (46.9 hours, interquartile range 34.1-68.3 hours) corresponded to a 1.7% reduction in length of stay that was not statistically significant (95% confidence interval, -12.1 to 9.8%). In post hoc subgroup analyses, care guided by hand-carried echocardiography reduced length of stay in participants who were referred for heart failure (P=.0008). Among participants who underwent both hand-carried and standard echocardiography, hospitalists changed management due to hand-carried echocardiography in 37%. Despite the favorable diagnostic accuracy of hand-carried echocardiography, most changes to the timing of hospital discharge occurred after standard echocardiography. CONCLUSION: Hospitalist care guided by hand-carried echocardiography for unselected general medicine patients does not meaningfully affect length of stay. Whether or not it affects care quality remains unstudied.","DOI":"10.1016/j.amjmed.2011.03.029","ISSN":"1555-7162 (Electronic) 0002-9343 (Linking)","journalAbbreviation":"Am. J. Med.","language":"eng","author":[{"family":"Lucas","given":"B. P."},{"family":"Candotti","given":"C."},{"family":"Margeta","given":"B."},{"family":"Mba","given":"B."},{"family":"Kumapley","given":"R."},{"family":"Asmar","given":"A."},{"family":"Franco-Sadud","given":"R."},{"family":"Baru","given":"J."},{"family":"Acob","given":"C."},{"family":"Borkowsky","given":"S."},{"family":"Evans","given":"A. T."}],"issued":{"date-parts":[["2011",8]]}}}],"schema":""} 4 and severe aortic stenosis ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"HSFqUfPK","properties":{"formattedCitation":"\\super 28\\nosupersub{}","plainCitation":"28","noteIndex":0},"citationItems":[{"id":8515,"uris":[""],"uri":[""],"itemData":{"id":8515,"type":"article-journal","title":"Can severe aortic stenosis be identified by emergency physicians when interpreting a simplified two-view echocardiogram obtained by trained echocardiographers?","container-title":"Crit Ultrasound J","page":"5","volume":"7","abstract":"BACKGROUND: Aortic stenosis (AS) is a common valve problem that causes significant morbidity and mortality. The goal of this study was to determine whether an emergency physician (EP) could determine severe AS by reviewing only two B-mode echocardiographic views (parasternal long axis (PSLA) and parasternal short axis (PSSA)) obtained by trained echocardiographers. METHODS: A convenience sample of 60 patients with no AS, mild/moderate AS or severe AS was selected for health record and echocardiogram review. The echocardiograms were performed in an accredited echocardiography laboratory. An EP blinded to the cardiologist's final report reviewed the PSLA and PSSA views after the cases were randomly sorted. Severe AS was defined as no cusp movement seen by the EP reviewers. A second EP independently reviewed 25% of randomly selected patients for inter-rater reliability. Collected data included patient demographics, EP interpretation and details of each echo view (quality, the number of cusps visualized, presence of calcification) and compared to final cardiology reports. Analyses included descriptive statistics, test characteristics for severe AS and kappa for agreement. RESULTS: The mean age was 75.3 years (range 18 to 90) with 36.7% females. The cardiologist's diagnosis was as follows: 38.3% severe AS, 28.3% mild/moderate AS and 33.3% no AS. The PSSA view was poorer in quality compared with the PSLA (33.3% vs. 13.3%, p = 0.02), but the PSSA view was better than PSLA to visualize all three cusps (83.3% vs. 0%, p = 0.001). There was no difference in the presence of calcification between the mild/moderate and severe AS groups (94.1% vs. 100.0%, p = 0.46). The sensitivity and specificity for EP diagnosis of severe AS was 75.0% (95% CI 56.7% to 85.4%) and 92.5% (83.3% to 97.7%). The kappa for severe AS was 0.69 (0.41 to 0.85), and there was no significant difference between observers in the quality of the view, presence of aortic calcification and the number of cusps visible. CONCLUSIONS: PSLA and PSSA views obtained by trained echocardiographers can be interpreted by an EP with appropriate training to identify severe AS with good specificity. Further larger prospective studies are required before widespread use by EPs.","DOI":"10.1186/s13089-015-0022-8","ISSN":"2036-3176 (Print) 2036-3176","note":"PMCID: PMC4409610","journalAbbreviation":"Critical ultrasound journal","language":"eng","author":[{"family":"Alzahrani","given":"H."},{"family":"Woo","given":"M. Y."},{"family":"Johnson","given":"C."},{"family":"Pageau","given":"P."},{"family":"Millington","given":"S."},{"family":"Thiruganasambandamoorthy","given":"V."}],"issued":{"date-parts":[["2015"]]}}}],"schema":""} 28. However, for many valvular abnormalities formal echocardiography will be necessary. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"SfhyOGeR","properties":{"formattedCitation":"\\super 5\\nosupersub{}","plainCitation":"5","noteIndex":0},"citationItems":[{"id":5300,"uris":[""],"uri":[""],"itemData":{"id":5300,"type":"article-journal","title":"Hospitalist performance of cardiac hand-carried ultrasound after focused training","container-title":"American Journal of Medicine","page":"1000-4","volume":"120","issue":"11","abstract":"PURPOSE: Because the training that noncardiologists require to perform cardiac hand-carried ultrasound has not been defined, we studied how well hospitalists perform hand-carried echocardiography after limited training. METHODS: Ten hospitalists completed a focused training program that included performing an average of 35 hand-carried echocardiograms. Hospitalists' echocardiograms were compared with gold-standard conventional echocardiograms, and hospitalists were compared with 5 certified echocardiography technicians in their ability to acquire, measure, and interpret hand-carried ultrasound images and with 6 senior cardiology fellows in their ability to interpret echocardiograms. RESULTS: Echocardiography technicians had significantly higher performance scores for image acquisition, measurement, and interpretation than hospitalists. Senior cardiology fellows outperformed hospitalists in most aspects of image interpretation. For hospitalists, learning image acquisition was more difficult than image interpretation. CONCLUSIONS: Hospitalists can learn aspects of hand-carried echocardiography, but after 35 training echocardiograms cannot replicate the quality of conventional echocardiography. Whether the lower performance skills are important will depend on the clinical context of hand-carried echocardiography performed by hospitalists.","DOI":"10.1016/j.amjmed.2007.07.029","ISSN":"1555-7162 (Electronic) 0002-9343 (Linking)","journalAbbreviation":"Am. J. Med.","language":"eng","author":[{"family":"Martin","given":"L. D."},{"family":"Howell","given":"E. E."},{"family":"Ziegelstein","given":"R. C."},{"family":"Martire","given":"C."},{"family":"Shapiro","given":"E. P."},{"family":"Hellmann","given":"D. B."}],"issued":{"date-parts":[["2007",11]]}}}],"schema":""} 5Limitations: More sophisticated and quantitative assessments, such as evaluation of pericardial constriction, pulmonary hypertension, and quantified severity of valvular stenotic or regurgitation are beyond the scope of most hospitalists, but may be performed when a hospitalist has had sufficient training.Appendix 2: Lung and Pleural UltrasoundPulmonary ultrasound is highly useful in detecting lung pathology. The most common uses include the detection and characterization of pleural effusions; interstitial syndromes, most commonly pulmonary edema; alveolar syndromes, such as pneumonias; and pneumothoraces. Ultrasound is also an important tool in improving the safety of thoracentesis.Pleural effusion: POCUS detects pleural effusions with high accuracy. A 2010 meta-analysis of four primary studies showed that ultrasound detected effusions with a 93% sensitivity and 96% specificity. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"mUf6zMK5","properties":{"formattedCitation":"\\super 29\\nosupersub{}","plainCitation":"29","noteIndex":0},"citationItems":[{"id":6121,"uris":[""],"uri":[""],"itemData":{"id":6121,"type":"article-journal","title":"Diagnostic accuracy of sonography for pleural effusion: systematic review","container-title":"Sao Paulo Medical Journal","page":"90-5","volume":"128","issue":"2","abstract":"CONTEXT AND OBJECTIVE: The initial method for evaluating the presence of pleural effusion was chest radiography. Isolated studies have shown that sonography has greater accuracy than radiography for this diagnosis; however, no systematic reviews on this matter are available in the literature. Thus, the aim of this study was to evaluate the accuracy of sonography in detecting pleural effusion, by means of a systematic review of the literature. DESIGN AND SETTING: This was a systematic review with meta-analysis on accuracy studies. This study was conducted in the Department of Diagnostic Imaging and in the Brazilian Cochrane Center, Discipline of Emergency Medicine and Evidence-Based Medicine, Department of Medicine, Universidade Federal de Sao Paulo (Unifesp), Sao Paulo, Brazil. METHOD: The following databases were searched: Cochrane Library, Medline, Web of Science, Embase and Literatura Latino-Americana e do Caribe em Ciencias da Saude (Lilacs). The references of relevant studies were also screened for additional citations of interest. Studies in which the accuracy of sonography for detecting pleural effusion was tested, with an acceptable reference standard (computed tomography or thoracic drainage), were included. RESULTS: Four studies were included. All of them showed that sonography had high sensitivity, specificity and accuracy for detecting pleural effusions. The mean sensitivity was 93% (95% confidence interval, CI: 89% to 96%), and specificity was 96% (95% CI: 95% to 98%). CONCLUSIONS: In different populations and clinical settings, sonography showed consistently high sensitivity, specificity and accuracy for detecting fluid in the pleural space.","ISSN":"1806-9460 (Electronic) 1516-3180 (Linking)","journalAbbreviation":"Sao Paulo Med. J.","language":"eng","author":[{"family":"Grimberg","given":"A."},{"family":"Shigueoka","given":"D. C."},{"family":"Atallah","given":"A. N."},{"family":"Ajzen","given":"S."},{"family":"Iared","given":"W."}],"issued":{"date-parts":[["2010"]]}}}],"schema":""} 29 POCUS outperformed anterior-posterior chest radiography in two studies. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"uHOdXgz1","properties":{"formattedCitation":"\\super 30,31\\nosupersub{}","plainCitation":"30,31","noteIndex":0},"citationItems":[{"id":4657,"uris":[""],"uri":[""],"itemData":{"id":4657,"type":"article-journal","title":"Comparative diagnostic performances of auscultation, chest radiography, and lung ultrasonography in acute respiratory distress syndrome","container-title":"Anesthesiology","page":"9-15","volume":"100","issue":"1","abstract":"BACKGROUND: Lung auscultation and bedside chest radiography are routinely used to assess the respiratory condition of ventilated patients with acute respiratory distress syndrome (ARDS). Clinical experience suggests that the diagnostic accuracy of these procedures is poor. METHODS: This prospective study of 32 patients with ARDS and 10 healthy volunteers was performed to compare the diagnostic accuracy of auscultation, bedside chest radiography, and lung ultrasonography with that of thoracic computed tomography. Three pathologic entities were evaluated in 384 lung regions (12 per patient): pleural effusion, alveolar consolidation, and alveolar-interstitial syndrome. RESULTS: Auscultation had a diagnostic accuracy of 61% for pleural effusion, 36% for alveolar consolidation, and 55% for alveolar-interstitial syndrome. Bedside chest radiography had a diagnostic accuracy of 47% for pleural effusion, 75% for alveolar consolidation, and 72% for alveolar-interstitial syndrome. Lung ultrasonography had a diagnostic accuracy of 93% for pleural effusion, 97% for alveolar consolidation, and 95% for alveolar-interstitial syndrome. Lung ultrasonography, in contrast to auscultation and chest radiography, could quantify the extent of lung injury. Interobserver agreement for the ultrasound findings as assessed by the kappa statistic was satisfactory: 0.74, 0.77, and 0.73 for detection of alveolar-interstitial syndrome, alveolar consolidation, and pleural effusion, respectively. CONCLUSIONS: At the bedside, lung ultrasonography is highly sensitive, specific, and reproducible for diagnosing the main lung pathologic entities in patients with ARDS and can be considered an attractive alternative to bedside chest radiography and thoracic computed tomography.","ISSN":"0003-3022 (Print) 0003-3022 (Linking)","journalAbbreviation":"Anesthesiology","language":"eng","author":[{"family":"Lichtenstein","given":"D."},{"family":"Goldstein","given":"I."},{"family":"Mourgeon","given":"E."},{"family":"Cluzel","given":"P."},{"family":"Grenier","given":"P."},{"family":"Rouby","given":"J. J."}],"issued":{"date-parts":[["2004",1]]}}},{"id":9764,"uris":[""],"uri":[""],"itemData":{"id":9764,"type":"article-journal","title":"Lung ultrasound in critically ill patients: comparison with bedside chest radiography","container-title":"Intensive Care Medicine","page":"1488-1493","volume":"37","issue":"9","source":"PubMed","abstract":"PURPOSE: To compare the diagnostic performance of lung ultrasound and bedside chest radiography (CXR) for the detection of various pathologic abnormalities in unselected critically ill patients, using thoracic computed tomography (CT) as a gold standard.\nMETHODS: Forty-two mechanically ventilated patients scheduled for CT were prospectively studied with a modified lung ultrasound protocol. Four pathologic entities were evaluated: consolidation, interstitial syndrome, pneumothorax, and pleural effusion. Each hemithorax was evaluated for the presence or absence of each abnormality.\nRESULTS: Eighty-four hemithoraces were evaluated by the three imaging techniques. The sensitivity, specificity, and diagnostic accuracy of CXR were 38, 89, and 49% for consolidation, 46, 80, and 58% for interstitial syndrome, 0, 99, and 89% for pneumothorax, and 65, 81, and 69% for pleural effusion, respectively. The corresponding values for lung ultrasound were 100, 78, and 95% for consolidation, 94, 93, and 94% for interstitial syndrome, 75, 93, and 92% for pneumothorax, and 100, 100, and 100% for pleural effusion, respectively. The relatively low sensitivity of lung ultrasound for pneumothorax could be due to small number of cases (n = 8) and/or suboptimal methodology.\nCONCLUSIONS: In our unselected general ICU population lung ultrasound has a considerably better diagnostic performance than CXR for the diagnosis of common pathologic conditions and may be used as an alternative to thoracic CT.","DOI":"10.1007/s00134-011-2317-y","ISSN":"1432-1238","note":"PMID: 21809107","shortTitle":"Lung ultrasound in critically ill patients","journalAbbreviation":"Intensive Care Med","language":"eng","author":[{"family":"Xirouchaki","given":"Nektaria"},{"family":"Magkanas","given":"Eleftherios"},{"family":"Vaporidi","given":"Katerina"},{"family":"Kondili","given":"Eumorfia"},{"family":"Plataki","given":"Maria"},{"family":"Patrianakos","given":"Alexandros"},{"family":"Akoumianaki","given":"Evaggelia"},{"family":"Georgopoulos","given":"Dimitrios"}],"issued":{"date-parts":[["2011",9]]}}}],"schema":""} 30,31 Ultrasound may also be used to estimate pleural effusion volume. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"kcK91LIu","properties":{"formattedCitation":"\\super 32\\nosupersub{}","plainCitation":"32","noteIndex":0},"citationItems":[{"id":6248,"uris":[""],"uri":[""],"itemData":{"id":6248,"type":"article-journal","title":"Multiplane ultrasound approach to quantify pleural effusion at the bedside","container-title":"Intensive Care Medicine","page":"656-64","volume":"36","issue":"4","abstract":"OBJECTIVE: To assess the accuracy of a multiplane ultrasound approach to measure pleural effusion volume (PEV), considering pleural effusion (PE) extension along the cephalocaudal axis and PE area. METHODS: Prospective study performed on 58 critically ill patients with 102 PEs. Thoracic drainage was performed in 46 patients (59 PEs) and lung computed tomography (CT) in 24 patients (43 PEs). PE was assessed using bedside lung ultrasound. Adjacent paravertebral intercostal spaces were examined, and ultrasound PEV was calculated by multiplying the paravertebral PE length by its area, measured at half the distance between the apical and caudal limits of the PE. RESULTS: Ultrasound PEV was compared to either the volume of the drained PE (59 PE) or PEV assessed on lung CT (43 PE). In patients with lung CT, the accuracy of this new method was compared to the accuracy of previous methods proposed for PEV measurement. Ultrasound PEV was tightly correlated with drained PEV (r = 0.84, p < 0.001) and with CT PEV (r = 0.90, p < 0.001). The mean biases between ultrasound and actual volumes of PE were -33 ml when compared to drainage (limits of agreement -292 to +227 ml) and -53 ml when compared to CT (limits of agreement -303 to +198 ml). This new method was more accurate than previous methods to measure PEV. CONCLUSION: Using a multiplane approach increases the accuracy of lung ultrasound to measure the volume of large to small pleural effusions in critically ill patients.","DOI":"10.1007/s00134-010-1769-9","ISSN":"0342-4642","journalAbbreviation":"Intensive Care Med.","language":"eng","author":[{"family":"Remerand","given":"F."},{"family":"Dellamonica","given":"J."},{"family":"Mao","given":"Z."},{"family":"Ferrari","given":"F."},{"family":"Bouhemad","given":"B."},{"family":"Jianxin","given":"Y."},{"family":"Arbelot","given":"C."},{"family":"Lu","given":"Q."},{"family":"Ichai","given":"C."},{"family":"Rouby","given":"J. J."}],"issued":{"date-parts":[["2010",4]]}}}],"schema":""} 32 Ultrasound can detect complex features that may suggest exudative effusion, ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"02G5IKhI","properties":{"formattedCitation":"\\super 33\\nosupersub{}","plainCitation":"33","noteIndex":0},"citationItems":[{"id":3889,"uris":[""],"uri":[""],"itemData":{"id":3889,"type":"article-journal","title":"Value of sonography in determining the nature of pleural effusion: analysis of 320 cases","container-title":"AJR: American Journal of Roentgenology","page":"29-33","volume":"159","issue":"1","abstract":"To assess the value of sonography in determining the nature of pleural effusions, we prospectively analyzed the sonographic findings in 320 patients with pleural effusion of various causes (224 with exudates and 96 with transudates). The nature of the effusions was established on the basis of chemical, bacteriologic, and cytologic examination of pleural fluid; pleural biopsy; and clinical follow-up. All patients had high-frequency, real-time sonography performed by one of three sonographers who had no clinical information concerning the patients. The sonographer evaluated the images for internal echogenicity of the effusion, thickness of the pleura, and associated parenchymal lesions of the lung. The images were also printed out and interpreted a second time by the other two sonographers to reach a consensus. Our results showed that the two types of effusions could be distinguished on the basis of sonographic findings. Transudates were anechoic, whereas an anechoic effusion could be either a transudate or an exudate. Pleural effusions with complex septated, complex nonseptated, or homogeneously echogenic patterns were always exudates (p less than .01). Sonographic findings of thickened pleura and associated parenchymal lesions in the lung also were indicative of an exudate (p less than .01). Homogenous echogenic effusions were due to hemorrhagic effusion or empyema. Sonographic evidence of a pleural nodule was a specific finding in patients with a malignant effusion. We conclude that sonography is useful in determining the nature of pleural effusion.","DOI":"10.2214/ajr.159.1.1609716","ISSN":"0361-803X (Print) 0361-803x","journalAbbreviation":"AJR Am. J. Roentgenol.","language":"eng","author":[{"family":"Yang","given":"P. C."},{"family":"Luh","given":"K. T."},{"family":"Chang","given":"D. B."},{"family":"Wu","given":"H. D."},{"family":"Yu","given":"C. J."},{"family":"Kuo","given":"S. H."}],"issued":{"date-parts":[["1992",7]]}}}],"schema":""} 33 or malignancy. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"6buTTN5u","properties":{"formattedCitation":"\\super 34\\nosupersub{}","plainCitation":"34","noteIndex":0},"citationItems":[{"id":4592,"uris":[""],"uri":[""],"itemData":{"id":4592,"type":"article-journal","title":"Echogenic swirling pattern as a predictor of malignant pleural effusions in patients with malignancies","container-title":"Chest","page":"129-34","volume":"126","issue":"1","abstract":"OBJECTIVES: Chest ultrasonography is a useful diagnostic tool for the detection of pleural effusions of different etiologies. Our purpose was to determine whether the echogenic swirling pattern identifiable on real-time chest ultrasonographic images is a predictor of malignant pleural effusions in patients with malignancies. DESIGN: Medical records of patients undergoing chest ultrasonography in the Tri-Service General Hospital (Taiwan) between January 2000 and December 2002 were reviewed retrospectively. Patients with an echogenic swirling pattern in the pleural effusion, or with malignant diseases associated with pleural effusions, whose pleural fluids had been examined cytologically or whose pleural tissues had been examined pathologically, were enrolled in this study (n = 140). Malignant pleural effusions were defined by the presence of malignant cells in the pleural fluid identified by thoracentesis or by pleural biopsy. The echogenic swirling pattern was defined as numerous echogenic floating particles within the pleural effusion, which swirled in response to respiratory movement or heartbeat. Correlation between malignant pleural effusions and the echogenic swirling pattern was compared in patients with an underlying malignant disease. RESULTS: In patients with underlying malignancies, malignant pleural effusions were diagnosed in 81.8% of patients with a positive echogenic swirling pattern and in 48% of those with no echogenic swirling pattern. The presence of echogenic swirling was significantly more predictive of malignant pleural effusions than was the absence of echogenic swirling (p < 0.01). CONCLUSIONS: The echogenic swirling pattern is a useful predictor of possible malignant pleural effusions, and may be a good marker for malignant pleural effusions in patients with underlying malignancies.","DOI":"10.1378/chest.126.1.129","ISSN":"0012-3692 (Print) 0012-3692","journalAbbreviation":"Chest","language":"eng","author":[{"family":"Chian","given":"C. F."},{"family":"Su","given":"W. L."},{"family":"Soh","given":"L. H."},{"family":"Yan","given":"H. C."},{"family":"Perng","given":"W. C."},{"family":"Wu","given":"C. P."}],"issued":{"date-parts":[["2004",7]]}}}],"schema":""} 34Interstitial syndromes: Pulmonary ultrasound is superior to chest radiography in both ruling in and ruling out interstitial syndromes, such as cardiogenic and non-cardiogenic pulmonary edema, and pulmonary fibrosis. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"n0zaqDPM","properties":{"formattedCitation":"\\super 35,36\\nosupersub{}","plainCitation":"35,36","noteIndex":0},"citationItems":[{"id":7180,"uris":[""],"uri":[""],"itemData":{"id":7180,"type":"article-journal","title":"International evidence-based recommendations for point-of-care lung ultrasound","container-title":"Intensive Care Medicine","page":"577-91","volume":"38","issue":"4","abstract":"BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.","DOI":"10.1007/s00134-012-2513-4","ISSN":"0342-4642","journalAbbreviation":"Intensive Care Med.","language":"eng","author":[{"family":"Volpicelli","given":"G."},{"family":"Elbarbary","given":"M."},{"family":"Blaivas","given":"M."},{"family":"Lichtenstein","given":"D. A."},{"family":"Mathis","given":"G."},{"family":"Kirkpatrick","given":"A. W."},{"family":"Melniker","given":"L."},{"family":"Gargani","given":"L."},{"family":"Noble","given":"V. E."},{"family":"Via","given":"G."},{"family":"Dean","given":"A."},{"family":"Tsung","given":"J. W."},{"family":"Soldati","given":"G."},{"family":"Copetti","given":"R."},{"family":"Bouhemad","given":"B."},{"family":"Reissig","given":"A."},{"family":"Agricola","given":"E."},{"family":"Rouby","given":"J. J."},{"family":"Arbelot","given":"C."},{"family":"Liteplo","given":"A."},{"family":"Sargsyan","given":"A."},{"family":"Silva","given":"F."},{"family":"Hoppmann","given":"R."},{"family":"Breitkreutz","given":"R."},{"family":"Seibel","given":"A."},{"family":"Neri","given":"L."},{"family":"Storti","given":"E."},{"family":"Petrovic","given":"T."}],"issued":{"date-parts":[["2012",4]]}}},{"id":5418,"uris":[""],"uri":[""],"itemData":{"id":5418,"type":"article-journal","title":"Chest sonography: a useful tool to differentiate acute cardiogenic pulmonary edema from acute respiratory distress syndrome","container-title":"Cardiovascular Ultrasound","page":"16","volume":"6","abstract":"BACKGROUND: Differential diagnosis between acute cardiogenic pulmonary edema (APE) and acute lung injury/acute respiratory distress syndrome (ALI/ARDS) may often be difficult. We evaluated the ability of chest sonography in the identification of characteristic pleuropulmonary signs useful in the diagnosis of ALI/ARDS and APE. METHODS: Chest sonography was performed on admission to the intensive care unit in 58 consecutive patients affected by ALI/ARDS or by acute pulmonary edema (APE). RESULTS: Ultrasound examination was focalised on finding in the two groups the presence of: 1) alveolar-interstitial syndrome (AIS) 2) pleural lines abnormalities 3) absence or reduction of \"gliding\" sign 4) \"spared areas\" 5) consolidations 6) pleural effusion 7) \"lung pulse\".AIS was found in 100% of patients with ALI/ARDS and in 100% of patients with APE (p = ns). Pleural line abnormalities were observed in 100% of patients with ALI/ARDS and in 25% of patients with APE (p < 0.0001). Absence or reduction of the 'gliding sign' was observed in 100% of patients with ALI/ARDS and in 0% of patients with APE. 'Spared areas' were observed in 100% of patients with ALI/ARDS and in 0% of patients with APE (p < 0.0001). Consolidations were present in 83.3% of patients with ALI/ARDS in 0% of patients with APE (p < 0.0001). A pleural effusion was present in 66.6% of patients with ALI/ARDS and in 95% of patients with APE (p < 0.004). 'Lung pulse' was observed in 50% of patients with ALI/ARDS and in 0% of patients with APE (p < 0.0001). All signs, except the presence of AIS, presented a statistically significant difference in presentation between the two syndromes resulting specific for the ultrasonographic characterization of ALI/ARDS. CONCLUSION: Pleuroparenchimal patterns in ALI/ARDS do find a characterization through ultrasonographic lung scan. In the critically ill the ultrasound demonstration of a dyshomogeneous AIS with spared areas, pleural line modifications and lung consolidations is strongly predictive, in an early phase, of non-cardiogenic pulmonary edema.","DOI":"10.1186/1476-7120-6-16","ISSN":"1476-7120 (Electronic) 1476-7120 (Linking)","note":"PMCID: PMC2386861","journalAbbreviation":"Cardiovasc. Ultrasound","language":"eng","author":[{"family":"Copetti","given":"R."},{"family":"Soldati","given":"G."},{"family":"Copetti","given":"P."}],"issued":{"date-parts":[["2008"]]}}}],"schema":""} 35,36 In a 2014 systematic review of seven studies, B-lines were found to have a sensitivity of 94% and specificity of 92% for acute cardiogenic pulmonary edema. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"HS36mwhR","properties":{"formattedCitation":"\\super 37\\nosupersub{}","plainCitation":"37","noteIndex":0},"citationItems":[{"id":7861,"uris":[""],"uri":[""],"itemData":{"id":7861,"type":"article-journal","title":"Point-of-care ultrasonography for the diagnosis of acute cardiogenic pulmonary edema in patients presenting with acute dyspnea: a systematic review and meta-analysis","container-title":"Academic Emergency Medicine","page":"843-52","volume":"21","issue":"8","abstract":"OBJECTIVES: Acute dyspnea is a common presenting complaint to the emergency department (ED), and point-of-care (POC) lung ultrasound (US) has shown promise as a diagnostic tool in this setting. The primary objective of this systematic review was to determine the sensitivity and specificity of US using B-lines in diagnosing acute cardiogenic pulmonary edema (ACPE) in patients presenting to the ED with acute dyspnea. METHODS: A systematic review protocol adhering to Cochrane Handbook guidelines was created to guide the search and analysis, and we searched the following databases: PubMed, EMBASE, Ovid MEDLINE, Ovid MEDLINE In-Process & Other Non-Indexed Citations, and the Cochrane Database of Systematic Reviews. References of reviewed articles were hand-searched, and electronic searches of conference abstracts from major emergency medicine, cardiology, and critical care conferences were conducted. The authors included prospective cohort and prospective case-control studies that recruited patients presenting to hospital with symptomatic, acute dyspnea, or where there was a clinical suspicion of congestive heart failure, and reported the sensitivity and specificity of B-lines in diagnosing ACPE. Studies of asymptomatic individuals or in patients where there was no suspicion of ACPE were excluded. The outcome of interest was a diagnosis of ACPE using US B-lines. A final diagnosis from clinical follow-up was accepted as the reference standard. Two reviewers independently reviewed all citations to assess for inclusion, abstracted data, and assessed included studies for methodologic quality using the QUADAS-2 tool. Contingency tables were used to calculate sensitivity and specificity. Three subgroup analyses were planned a priori to examine the effects of the type of study, patient population, and lung US protocol employed. RESULTS: Seven articles (n = 1,075) were identified that met inclusion criteria (two studies completed in the ED, two in the intensive care unit [ICU], two on inpatient wards, and one in the prehospital setting). The seven studies were rated as average to excellent methodologic quality. The sensitivity of US using B-lines to diagnosis ACPE is 94.1% (95% confidence interval [CI] = 81.3% to 98.3%) and the specificity is 92.4% (95% CI = 84.2% to 96.4%). Preplanned subgroup analyses did not reveal statistically significant changes in the overall summary estimates, nor did exclusion of three potential outlier studies. CONCLUSIONS: This study suggests that in patients with a moderate to high pretest probability for ACPE, an US study showing B-lines can be used to strengthen an emergency physician's working diagnosis of ACPE. In patients with a low pretest probability for ACPE, a negative US study can almost exclude the possibility of ACPE. Further studies including large numbers of ED patients presenting with undifferentiated dyspnea are required to gain more valid and reliable estimates of test accuracy in ED patients.","DOI":"10.1111/acem.12435","ISSN":"1069-6563","journalAbbreviation":"Acad. Emerg. Med.","language":"eng","author":[{"family":"Al Deeb","given":"M."},{"family":"Barbic","given":"S."},{"family":"Featherstone","given":"R."},{"family":"Dankoff","given":"J."},{"family":"Barbic","given":"D."}],"issued":{"date-parts":[["2014",8]]}}}],"schema":""} 37 Other studies have demonstrated that increasing numbers of B-lines correlate with several different measures of increasing extravascular lung water, ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"IuBg6Bkl","properties":{"formattedCitation":"\\super 38\\uc0\\u8211{}40\\nosupersub{}","plainCitation":"38–40","noteIndex":0},"citationItems":[{"id":9292,"uris":[""],"uri":[""],"itemData":{"id":9292,"type":"article-journal","title":"Detection and prognostic value of pulmonary congestion by lung ultrasound in ambulatory heart failure patients","container-title":"European Heart Journal","page":"1244-51","volume":"37","issue":"15","abstract":"AIMS: Pulmonary congestion is a common and important finding in heart failure (HF). While clinical examination and chest radiography are insensitive, lung ultrasound (LUS) is a novel technique that may detect and quantify subclinical pulmonary congestion. We sought to independently relate LUS and clinical findings to 6-month HF hospitalizations and all-cause mortality (composite primary outcome). METHODS: We used LUS to examine 195 NYHA class II-IV HF patients (median age 66, 61% men, 74% white, ejection fraction 34%) during routine cardiology outpatient visits. Lung ultrasound was performed in eight chest zones with a pocket ultrasound device (median exam duration 2 min) and analysed offline. RESULTS: In 185 patients with adequate LUS images in all zones, the sum of B-lines (vertical lines on LUS) ranged from 0 to 13. B-lines, analysed by tertiles, were associated with clinical and laboratory markers of congestion. Thirty-two per cent of patients demonstrated >/=3 B-lines on LUS, yet 81% of these patients had no findings on auscultation. During the follow-up period, 50 patients (27%) were hospitalized for HF or died. Patients in the third tertile (>/=3 B-lines) had a four-fold higher risk of the primary outcome (adjusted HR 4.08, 95% confidence interval, CI 1.95, 8.54; P < 0.001) compared with those in the first tertile and spent a significantly lower number of days alive and out of the hospital (125 days vs. 165 days; adjusted P < 0.001). CONCLUSIONS: Pulmonary congestion assessed by ultrasound is prevalent in ambulatory patients with chronic HF, is associated with other features of clinical congestion, and identifies those who have worse prognosis.","DOI":"10.1093/eurheartj/ehv745","ISSN":"0195-668x","journalAbbreviation":"Eur. Heart J.","language":"eng","author":[{"family":"Platz","given":"E."},{"family":"Lewis","given":"E. F."},{"family":"Uno","given":"H."},{"family":"Peck","given":"J."},{"family":"Pivetta","given":"E."},{"family":"Merz","given":"A. A."},{"family":"Hempel","given":"D."},{"family":"Wilson","given":"C."},{"family":"Frasure","given":"S. E."},{"family":"Jhund","given":"P. S."},{"family":"Cheng","given":"S."},{"family":"Solomon","given":"S. D."}],"issued":{"date-parts":[["2016",4,14]]}}},{"id":5091,"uris":[""],"uri":[""],"itemData":{"id":5091,"type":"article-journal","title":"Ultrasound lung comets: a clinically useful sign of extravascular lung water","container-title":"Journal of the American Society of Echocardiography","page":"356-63","volume":"19","issue":"3","abstract":"Assessment of extravascular lung water is a challenging task for the clinical cardiologist and an elusive target for the echocardiographer. Today chest x-ray is considered the best way to assess extravascular lung water objectively, but this requires radiology facilities and specific reading expertise, uses ionizing energy, and poses a significant logistic burden. Recently, a new method was developed using echocardiography (with cardiac probes) of the lung. An increase in extravascular lung water-as assessed independently by chest computed tomography, chest x-ray, and thermodilution techniques-is mirrored by appearance of ultrasound lung comets (ULCs). ULCs consist of multiple comet tails originating from water-thickened interlobular septa and fanning out from the lung surface. The technique requires ultrasound scanning of the anterior right and left chest, from the second to the fifth intercostal space. It is simple (with a learning curve of < 10 examinations) and fast to perform (requiring < 3 minutes). ULC assessment is independent of the cardiac acoustic window, because the lung on the anterior chest is scanned. It requires very basic 2-D technology imaging, even without a second harmonic or Doppler. ULCs probably represent an ultrasonic equivalent of radiologic Kerley B-lines. On still-frame assessment, cardiogenic watery comets can be difficult to distinguish from pneumogenic fibrotic comets, although the latter are usually more localized and are not dissolved by an acute diuretic challenge. Functionally, ULCs are a sign of distress of the alveolar-capillary membrane, often associated with reduced ejection fraction and increased pulmonary wedge pressure. The ULC sign is quantitative, reproducible, and ideally suited to complement conventional echocardiography in the evaluation of heart failure patients in the emergency department (for the differential diagnosis of dyspnea), in-hospital evaluation (for tailoring diuretic therapy), home care (with portable ultrasound), and stress echocardiography lab (as a sign of acute pulmonary congestion during stress). In conclusion, ULCs represent a useful, practical, and appealingly simple way to image directly extravascular lung water.","DOI":"10.1016/j.echo.2005.05.019","ISSN":"1097-6795 (Electronic) 0894-7317 (Linking)","journalAbbreviation":"J. Am. Soc. Echocardiogr.","language":"eng","author":[{"family":"Picano","given":"E."},{"family":"Frassi","given":"F."},{"family":"Agricola","given":"E."},{"family":"Gligorova","given":"S."},{"family":"Gargani","given":"L."},{"family":"Mottola","given":"G."}],"issued":{"date-parts":[["2006",3]]}}},{"id":8673,"uris":[""],"uri":[""],"itemData":{"id":8673,"type":"article-journal","title":"Simplified lung ultrasound protocol shows excellent prediction of extravascular lung water in ventilated intensive care patients","container-title":"Critical Care (London, England)","page":"36","volume":"19","abstract":"INTRODUCTION: Ultrasound of the lung and quantification of B lines was recently introduced as a novel tool to detect overhydration. In the present study, we aimed to evaluate a four-region protocol of lung ultrasound to determine the pulmonary fluid status in ventilated patients in the intensive care unit. METHODS: Fifty patients underwent both lung ultrasound and transpulmonary thermodilution measurement with the PiCCO system. An ultrasound score based on number of single and confluent B lines per intercostal space was used to quantify pulmonary overhydration. To check for reproducibility, two different intensivists who were blinded as to the ultrasound pictures reassessed and classified them using the same scoring system. The results were compared with those obtained using other methods of evaluating hydration status, including extravascular lung water index (EVLWI) and intrathoracic blood volume index calculated with data from transpulmonary thermodilution measurements. Moreover, chest radiographs were assessed regarding signs of pulmonary overhydration and categorized based on a numeric rating scale. RESULTS: Lung water assessment by ultrasound using a simplified protocol showed excellent correlation with EVLWI over a broad range of lung hydration grades and ventilator settings. Correlation of chest radiography and EVLWI was less accurate. No correlation whatsoever was found with central venous pressure measurement. CONCLUSION: Lung ultrasound is a useful, non-invasive tool in predicting hydration status in mechanically ventilated patients. The four-region protocol that we used is time-saving, correlates well with transpulmonary thermodilution measurements and performs markedly better than chest radiography.","DOI":"10.1186/s13054-015-0756-5","ISSN":"1364-8535","note":"PMCID: PMC4335373","journalAbbreviation":"Crit. Care","language":"eng","author":[{"family":"Enghard","given":"P."},{"family":"Rademacher","given":"S."},{"family":"Nee","given":"J."},{"family":"Hasper","given":"D."},{"family":"Engert","given":"U."},{"family":"Jorres","given":"A."},{"family":"Kruse","given":"J. M."}],"issued":{"date-parts":[["2015",2,6]]}}}],"schema":""} 38–40 that B-lines decrease in number as volume is removed, ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"2kFyFbzW","properties":{"formattedCitation":"\\super 41\\uc0\\u8211{}43\\nosupersub{}","plainCitation":"41–43","noteIndex":0},"citationItems":[{"id":9732,"uris":[""],"uri":[""],"itemData":{"id":9732,"type":"article-journal","title":"Serial Sonographic Assessment of Pulmonary Edema in Patients With Hypertensive Acute Heart Failure","container-title":"Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine","page":"337-345","volume":"37","issue":"2","abstract":"OBJECTIVES: Objective measures of clinical improvement in patients with acute heart failure (AHF) are lacking. The aim of this study was to determine whether repeated lung sonography could semiquantitatively capture changes in pulmonary edema (B-lines) in patients with hypertensive AHF early in the course of treatment. METHODS: We conducted a feasibility study in a cohort of adults with acute onset of dyspnea, severe hypertension in the field or at triage (systolic blood pressure >/= 180 mm Hg), and a presumptive diagnosis of AHF. Patients underwent repeated dyspnea and lung sonographic assessments using a 10-cm visual analog scale (VAS) and an 8-zone scanning protocol. Lung sonographic assessments were performed at the time of triage, initial VAS improvement, and disposition from the emergency department. Sonographic pulmonary edema was independently scored offline in a randomized and blinded fashion by using a scoring method that accounted for both the sum of discrete B-lines and degree of B-line fusion. RESULTS: Sonographic pulmonary edema scores decreased significantly from initial to final sonographic assessments (P < .001). The median percentage decrease among the 20 included patient encounters was 81% (interquartile range, 55%-91%). Although sonographic pulmonary edema scores correlated with VAS scores (rho = 0.64; P < .001), the magnitude of the change in these scores did not correlate with each other (rho = -0.04; P = .89). CONCLUSIONS: Changes in sonographic pulmonary edema can be semiquantitatively measured by serial 8-zone lung sonography using a scoring method that accounts for B-line fusion. Sonographic pulmonary edema improves in patients with hypertensive AHF during the initial hours of treatment.","DOI":"10.1002/jum.14336","ISSN":"0278-4297","note":"PMCID: PMC5798430","journalAbbreviation":"J. Ultrasound Med.","language":"eng","author":[{"family":"Martindale","given":"J. L."},{"family":"Secko","given":"M."},{"family":"Kilpatrick","given":"J. F."},{"family":"deSouza","given":"I. S."},{"family":"Paladino","given":"L."},{"family":"Aherne","given":"A."},{"family":"Mehta","given":"N."},{"family":"Conigiliaro","given":"A."},{"family":"Sinert","given":"R."}],"issued":{"date-parts":[["2018",2]]}}},{"id":5896,"uris":[""],"uri":[""],"itemData":{"id":5896,"type":"article-journal","title":"Ultrasound assessment for extravascular lung water in patients undergoing hemodialysis. Time course for resolution","container-title":"Chest","page":"1433-1439","volume":"135","issue":"6","abstract":"BACKGROUND: Sonographic B-lines, also known as lung comets, have been shown to correlate with the presence of extravascular lung water (EVLW). Absent in normal lungs, these sonographic findings become prominent as interstitia and alveoli fill with fluid. Characterization of the dynamics of B-lines, specifically their rate of disappearance as volume is removed, has not been previously described. In this study, we describe the dynamics of B-line resolution in patients undergoing hemodialysis. METHODS: Patients undergoing hemodialysis underwent three chest ultrasound examinations: before, at the midpoint, and after dialysis. We followed a previously described chest ultrasound protocol that counts the number of B-lines visualized in 28 lung zones. Baseline demographics, assessment of ejection fraction, time elapsed, net volume of fluid removed, and subjective degree of shortness of breath were recorded for each patient. RESULTS: Forty of 45 patients completed full dialysis runs and had all three lung scans performed; 6 of 40 patients had zero or one B-line predialysis, and none of these 6 patients gained B-lines during dialysis. Thirty-four of 40 patients had statistically significant reductions in the number of B-lines from predialysis to the midpoint scan and from predialysis to postdialysis with a p value < 0.001. There was no association between subjective dyspnea scores and number of B-lines removed. CONCLUSIONS: B-line resolution appears to occur real-time as fluid is removed from the body, and this change was statistically significant. These data support thoracic ultrasound as a useful method for evaluating real-time changes in EVLW and in assessing a patient's physiologic response to the removal of fluid. TRIAL REGISTRATION: Massachusetts General Hospital trial registration protocol No. 2007P 002226.","DOI":"10.1378/chest.08-1811","ISSN":"0012-3692","journalAbbreviation":"Chest","language":"eng","author":[{"family":"Noble","given":"V. E."},{"family":"Murray","given":"A. F."},{"family":"Capp","given":"R."},{"family":"Sylvia-Reardon","given":"M. H."},{"family":"Steele","given":"D. J. R."},{"family":"Liteplo","given":"A."}],"issued":{"date-parts":[["2009",6]]}}},{"id":8703,"uris":[""],"uri":[""],"itemData":{"id":8703,"type":"article-journal","title":"Persistent pulmonary congestion before discharge predicts rehospitalization in heart failure: a lung ultrasound study","container-title":"Cardiovascular Ultrasound","page":"40","volume":"13","abstract":"BACKGROUND: B-lines evaluated by lung ultrasound (LUS) are the sonographic sign of pulmonary congestion, a major predictor of morbidity and mortality in patients with heart failure (HF). Our aim was to assess the prognostic value of B-lines at discharge to predict rehospitalization at 6 months in patients with acute HF (AHF). METHODS: A prospective cohort of 100 patients admitted to a Cardiology Department for dyspnea and/or clinical suspicion of AHF were enrolled (mean age 70 +/- 11 years). B-lines were evaluated at admission and before discharge. Subjects were followed-up for 6-months after discharge. RESULTS: Mean B-lines at admission was 48 +/- 48 with a statistically significant reduction before discharge (20 +/- 23, p < .0001). During follow-up, 14 patients were rehospitalized for decompensated HF. The 6-month event-free survival was highest in patients with less B-lines (</= 15) and lowest in patients with more B-lines (> 15) (log rank chi(2) 20.5, p < .0001). On multivariable analysis, B-lines > 15 before discharge (hazard ratio [HR] 11.74; 95 % confidence interval [CI] 1.30-106.16) was an independent predictor of events at 6 months. CONCLUSIONS: Persistent pulmonary congestion before discharge evaluated by ultrasound strongly predicts rehospitalization for HF at 6-months. Absence or a mild degree of B-lines identify a subgroup at extremely low risk to be readmitted for HF decompensation.","DOI":"10.1186/s12947-015-0033-4","ISSN":"1476-7120","note":"PMCID: PMC4558829","journalAbbreviation":"Cardiovasc. Ultrasound","language":"eng","author":[{"family":"Gargani","given":"L."},{"family":"Pang","given":"P. S."},{"family":"Frassi","given":"F."},{"family":"Miglioranza","given":"M. H."},{"family":"Dini","given":"F. L."},{"family":"Landi","given":"P."},{"family":"Picano","given":"E."}],"issued":{"date-parts":[["2015"]]}}}],"schema":""} 41–43 and that they may be useful in predicting mortality, ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"xc8mUS9n","properties":{"formattedCitation":"\\super 44\\nosupersub{}","plainCitation":"44","noteIndex":0},"citationItems":[{"id":8615,"uris":[""],"uri":[""],"itemData":{"id":8615,"type":"article-journal","title":"Prognostic value of residual pulmonary congestion at discharge assessed by lung ultrasound imaging in heart failure","container-title":"European Journal of Heart Failure","abstract":"AIMS: Residual pulmonary congestion at discharge is associated with poor prognosis in heart failure (HF), but its quantification through physical examination is challenging. Ultrasound imaging of lung comets (B-lines) could improve congestion evaluation. The aim of this study was to assess the short-term prognostic value of B-lines after discharge from HF hospitalisation compared with other indices of haemodynamic congestion (BNP, E/e', and inferior vena cava diameter) or clinical status (NYHA class). METHODS AND RESULTS: Sixty consecutive HF inpatients underwent clinical examination, echocardiography, and lung ultrasound at discharge, independently of, and in addition to routine management by the attending physicians. The median B-line count was 8.5 (5-34). Three-month event-free survival for the primary endpoint (all-cause death or HF hospitalisation) was 27 +/- 10% in patients with >/=30 B-lines and 88 +/- 5% in those with <30 B-lines (P < 0.0001). In a multivariable model, >/=30 B-lines significantly predicted the combined endpoint (hazard ratio 5.66, 95% confidence interval 1.74-18.39, P = 0.04), along with NYHA >/=III and inferior vena cava diameter, while other indirect measures of congestion (BNP and E/e' >/=15) were not retained in the model; furthermore >/=30 B-lines independently also predicted the secondary outcomes (HF hospitalisation and death). Importantly, B-line addition to NYHA class and BNP was associated with improved risk classification (integrated discrimination improvement 15%, P = 0.02; continuous net reclassification improvement 65%, P = 0.03). CONCLUSION: Residual pulmonary congestion at discharge, as assessed by a B-line count >/=30, is a strong predictor of outcome. Lung ultrasonography may represent a useful tool to identify and monitor congestion and optimize therapy during and/or after hospitalisation for HF, which should be further validated in multicentre studies.","DOI":"10.1002/ejhf.344","ISSN":"1388-9842","journalAbbreviation":"Eur. J. Heart Fail.","language":"Eng","author":[{"family":"Coiro","given":"S."},{"family":"Rossignol","given":"P."},{"family":"Ambrosio","given":"G."},{"family":"Carluccio","given":"E."},{"family":"Alunni","given":"G."},{"family":"Murrone","given":"A."},{"family":"Tritto","given":"I."},{"family":"Zannad","given":"F."},{"family":"Girerd","given":"N."}],"issued":{"date-parts":[["2015",9,29]]}}}],"schema":""} 44 readmission, ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"1zcsaMil","properties":{"formattedCitation":"\\super 43\\nosupersub{}","plainCitation":"43","noteIndex":0},"citationItems":[{"id":8703,"uris":[""],"uri":[""],"itemData":{"id":8703,"type":"article-journal","title":"Persistent pulmonary congestion before discharge predicts rehospitalization in heart failure: a lung ultrasound study","container-title":"Cardiovascular Ultrasound","page":"40","volume":"13","abstract":"BACKGROUND: B-lines evaluated by lung ultrasound (LUS) are the sonographic sign of pulmonary congestion, a major predictor of morbidity and mortality in patients with heart failure (HF). Our aim was to assess the prognostic value of B-lines at discharge to predict rehospitalization at 6 months in patients with acute HF (AHF). METHODS: A prospective cohort of 100 patients admitted to a Cardiology Department for dyspnea and/or clinical suspicion of AHF were enrolled (mean age 70 +/- 11 years). B-lines were evaluated at admission and before discharge. Subjects were followed-up for 6-months after discharge. RESULTS: Mean B-lines at admission was 48 +/- 48 with a statistically significant reduction before discharge (20 +/- 23, p < .0001). During follow-up, 14 patients were rehospitalized for decompensated HF. The 6-month event-free survival was highest in patients with less B-lines (</= 15) and lowest in patients with more B-lines (> 15) (log rank chi(2) 20.5, p < .0001). On multivariable analysis, B-lines > 15 before discharge (hazard ratio [HR] 11.74; 95 % confidence interval [CI] 1.30-106.16) was an independent predictor of events at 6 months. CONCLUSIONS: Persistent pulmonary congestion before discharge evaluated by ultrasound strongly predicts rehospitalization for HF at 6-months. Absence or a mild degree of B-lines identify a subgroup at extremely low risk to be readmitted for HF decompensation.","DOI":"10.1186/s12947-015-0033-4","ISSN":"1476-7120","note":"PMCID: PMC4558829","journalAbbreviation":"Cardiovasc. Ultrasound","language":"eng","author":[{"family":"Gargani","given":"L."},{"family":"Pang","given":"P. S."},{"family":"Frassi","given":"F."},{"family":"Miglioranza","given":"M. H."},{"family":"Dini","given":"F. L."},{"family":"Landi","given":"P."},{"family":"Picano","given":"E."}],"issued":{"date-parts":[["2015"]]}}}],"schema":""} 43 and other important metrics. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"04lCnogP","properties":{"formattedCitation":"\\super 45\\nosupersub{}","plainCitation":"45","noteIndex":0},"citationItems":[{"id":9749,"uris":[""],"uri":[""],"itemData":{"id":9749,"type":"article-journal","title":"Pulmonary ultrasound scoring system for intubated critically ill patients and its association with clinical metrics and mortality: A prospective cohort study","container-title":"Journal of Clinical Ultrasound","page":"14-22","volume":"46","issue":"1","abstract":"PURPOSE: Pulmonary ultrasound (PU) examination at the point-of-care can rapidly identify the etiology of acute respiratory failure (ARF) and assess treatment response. The often-subjective classification of PU abnormalities makes it difficult to document change over time and communicate findings across providers. The study goal was to develop a simple, PU scoring system that would allow for standardized documentation, have high interprovider agreement, and correlate with clinical metrics. METHODS: In this prospective study of 250 adults intubated for ARF, a PU examination was performed at intubation, 48-hours later, and at extubation. A total lung score (TLS) was calculated. Clinical metrics and final diagnosis were extracted from the medical record. RESULTS: TLS correlated positively with mortality (P = .03), ventilator hours (P = .003), intensive care unit, and hospital length of stay (P = .003, P = .008), and decreasing PaO2 /FiO2 (P < .001). Agreement of PU findings was very good (kappa = 0.83). Baseline TLS and subscores differed significantly between ARF categories (nonpulmonary, obstructive, and parenchymal disease). CONCLUSIONS: A quick, scored, PU examination was associated with clinical metrics, including mortality among a diverse population of patients intubated for ARF. In addition to diagnostic and prognostic information at the bedside, a standardized and quantifiable approach to PU provides objectivity in serial assessment and may enhance communication of findings between providers.","DOI":"10.1002/jcu.22526","ISSN":"0091-2751","journalAbbreviation":"J. Clin. Ultrasound","language":"eng","author":[{"family":"Tierney","given":"D. M."},{"family":"Boland","given":"L. L."},{"family":"Overgaard","given":"J. D."},{"family":"Huelster","given":"J. S."},{"family":"Jorgenson","given":"A."},{"family":"Normington","given":"J. P."},{"family":"Melamed","given":"R. R."}],"issued":{"date-parts":[["2018",1]]}}}],"schema":""} 45Alveolar syndromes: Lung ultrasound is highly useful in the detection of ultrasonic alveolar syndromes, such as bacteria pneumonia. In a 2017 meta-analysis of 20 primary studies, pooled sensitivity was found to be 0.85 and specificity 0.93. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"IXURLcZy","properties":{"formattedCitation":"\\super 46\\nosupersub{}","plainCitation":"46","noteIndex":0},"citationItems":[{"id":9417,"uris":[""],"uri":[""],"itemData":{"id":9417,"type":"article-journal","title":"Systematic review and meta-analysis for the use of ultrasound versus radiology in diagnosing of pneumonia","container-title":"Crit Ultrasound J","page":"6","volume":"9","issue":"1","abstract":"BACKGROUND: Physicians are increasingly using point of care lung ultrasound (LUS) for diagnosing pneumonia, especially in critical situations as it represents relatively easy and immediately available tool. They also used it in many associated pathological conditions such as consolidation, pleural effusion, and interstitial syndrome with some reports of more accuracy than chest X-ray. This systematic review and meta-analysis are aimed to estimate the pooled diagnostic accuracy of ultrasound for the diagnosis of pneumonia versus the standard chest radiological imaging. METHODS AND MAIN RESULTS: A systematic literature search was conducted for all published studies comparing the diagnostic accuracy of LUS against a reference Chest radiological exam (C X-ray or Chest computed Tomography CT scan), combined with clinical criteria for pneumonia in all age groups. Eligible studies were required to have a Chest X-ray and/or CT scan at the time of clinical evaluation. The authors extracted qualitative and quantitative information from eligible studies, and calculated pooled sensitivity and specificity and pooled positive/negative likelihood ratios (LR). Twenty studies containing 2513 subjects were included in this meta-analysis. The pooled estimates for lung ultrasound in the diagnosis of pneumonia were, respectively, as follows: Overall pooled sensitivity and specificity for diagnosis of pneumonia by lung ultrasound were 0.85 (0.84-0.87) and 0.93 (0.92-0.95), respectively. Overall pooled positive and negative LRs were 11.05 (3.76-32.50) and 0.08 (0.04-0.15), pooled diagnostic Odds ratio was 173.64 (38.79-777.35), and area under the pooled ROC (AUC for SROC) was 0.978. CONCLUSION: Point of care lung ultrasound is an accurate tool for the diagnosis of pneumonia. Considering being easy, readily availability, low cost, and free from radiological hazards, it can be considered as important diagnostic strategy in this condition.","DOI":"10.1186/s13089-017-0059-y","ISSN":"2036-3176 (Print) 2036-3176","note":"PMCID: PMC5328906","journalAbbreviation":"Critical ultrasound journal","language":"eng","author":[{"family":"Alzahrani","given":"S. A."},{"family":"Al-Salamah","given":"M. A."},{"family":"Al-Madani","given":"W. H."},{"family":"Elbarbary","given":"M. A."}],"issued":{"date-parts":[["2017",12]]}}}],"schema":""} 46Pneumothorax: In a 2013 meta-analysis of 13 studies, ultrasound had a higher sensitivity than chest radiography (78.6% vs 39.8%) with similar specificity (98.4% vs 99.3%). ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Lxodjiwj","properties":{"formattedCitation":"\\super 47\\nosupersub{}","plainCitation":"47","noteIndex":0},"citationItems":[{"id":7214,"uris":[""],"uri":[""],"itemData":{"id":7214,"type":"article-journal","title":"Pleural ultrasonography versus chest radiography for the diagnosis of pneumothorax: review of the literature and meta-analysis","container-title":"Critical Care (London, England)","page":"R208","volume":"17","issue":"5","abstract":"INTRODUCTION: Ultrasonography is being increasingly utilized in acute care settings with expanding applications. Pneumothorax evaluation by ultrasonography is a fast, safe, easy and inexpensive alternative to chest radiographs. In this review, we provide a comprehensive analysis of the current literature comparing ultrasonography and chest radiography for the diagnosis of pneumothorax. METHODS: We searched English-language articles in MEDLINE, EMBASE and Cochrane Library dealing with both ultrasonography and chest radiography for diagnosis of pneumothorax. In eligible studies that met strict inclusion criteria, we conducted a meta-analysis to evaluate the diagnostic accuracy of pleural ultrasonography in comparison with chest radiography for the diagnosis of pneumothorax. RESULTS: We reviewed 601 articles and selected 25 original research articles for detailed review. Only 13 articles met all of our inclusion criteria and were included in the final analysis. One study used lung sliding sign alone, 12 studies used lung sliding and comet tail signs, and 6 studies searched for lung point in addition to the other two signs. Ultrasonography had a pooled sensitivity of 78.6% (95% CI, 68.1 to 98.1) and a specificity of 98.4% (95% CI, 97.3 to 99.5). Chest radiography had a pooled sensitivity of 39.8% (95% CI, 29.4 to 50.3) and a specificity of 99.3% (95% CI, 98.4 to 100). Our meta-regression and subgroup analyses indicate that consecutive sampling of patients compared to convenience sampling provided higher sensitivity results for both ultrasonography and chest radiography. Consecutive versus nonconsecutive sampling and trauma versus nontrauma settings were significant sources of heterogeneity. In addition, subgroup analysis showed significant variations related to operator and type of probe used. CONCLUSIONS: Our study indicates that ultrasonography is more accurate than chest radiography for detection of pneumothorax. The results support the previous investigations in this field, add new valuable information obtained from subgroup analysis, and provide accurate estimates for the performance parameters of both bedside ultrasonography and chest radiography for pneumothorax evaluation.","DOI":"10.1186/cc13016","ISSN":"1466-609X (Electronic) 1364-8535 (Linking)","journalAbbreviation":"Crit. Care","language":"Eng","author":[{"family":"Alrajab","given":"S."},{"family":"Youssef","given":"A. M."},{"family":"Akkus","given":"N. I."},{"family":"Caldito","given":"G."}],"issued":{"date-parts":[["2013",9,23]]}}}],"schema":""} 47Thoracentesis: Ultrasound can be used to identify pleural effusions amenable to bedside thoracentesis, guide site selection, and evaluate for post-procedure complications. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"l3b8F6rC","properties":{"formattedCitation":"\\super 33,48\\uc0\\u8211{}51\\nosupersub{}","plainCitation":"33,48–51","noteIndex":0},"citationItems":[{"id":3889,"uris":[""],"uri":[""],"itemData":{"id":3889,"type":"article-journal","title":"Value of sonography in determining the nature of pleural effusion: analysis of 320 cases","container-title":"AJR: American Journal of Roentgenology","page":"29-33","volume":"159","issue":"1","abstract":"To assess the value of sonography in determining the nature of pleural effusions, we prospectively analyzed the sonographic findings in 320 patients with pleural effusion of various causes (224 with exudates and 96 with transudates). The nature of the effusions was established on the basis of chemical, bacteriologic, and cytologic examination of pleural fluid; pleural biopsy; and clinical follow-up. All patients had high-frequency, real-time sonography performed by one of three sonographers who had no clinical information concerning the patients. The sonographer evaluated the images for internal echogenicity of the effusion, thickness of the pleura, and associated parenchymal lesions of the lung. The images were also printed out and interpreted a second time by the other two sonographers to reach a consensus. Our results showed that the two types of effusions could be distinguished on the basis of sonographic findings. Transudates were anechoic, whereas an anechoic effusion could be either a transudate or an exudate. Pleural effusions with complex septated, complex nonseptated, or homogeneously echogenic patterns were always exudates (p less than .01). Sonographic findings of thickened pleura and associated parenchymal lesions in the lung also were indicative of an exudate (p less than .01). Homogenous echogenic effusions were due to hemorrhagic effusion or empyema. Sonographic evidence of a pleural nodule was a specific finding in patients with a malignant effusion. We conclude that sonography is useful in determining the nature of pleural effusion.","DOI":"10.2214/ajr.159.1.1609716","ISSN":"0361-803X (Print) 0361-803x","journalAbbreviation":"AJR Am. J. Roentgenol.","language":"eng","author":[{"family":"Yang","given":"P. C."},{"family":"Luh","given":"K. T."},{"family":"Chang","given":"D. B."},{"family":"Wu","given":"H. D."},{"family":"Yu","given":"C. J."},{"family":"Kuo","given":"S. H."}],"issued":{"date-parts":[["1992",7]]}}},{"id":4443,"uris":[""],"uri":[""],"itemData":{"id":4443,"type":"article-journal","title":"Accuracy of pleural puncture sites: a prospective comparison of clinical examination with ultrasound","container-title":"Chest","page":"436-41","volume":"123","issue":"2","abstract":"STUDY OBJECTIVE: To assess the value of chest ultrasonography vs clinical examination for planning of diagnostic pleurocentesis (DPC). DESIGN: Prospective comparative study. SETTING: Pulmonary unit of a tertiary teaching hospital. PATIENTS AND PARTICIPANTS: Sixty-seven consecutive patients referred to 30 physicians of varying degrees of experience for DPC. INTERVENTIONS: Based on clinical data and examination, physicians determined whether and where a DPC should be performed. Selected puncture sites were evaluated with ultrasound and considered accurate when > or = 10 mm fluid perpendicular to the skin were present. MEASUREMENTS AND RESULTS: In 172 of 255 cases (67%), a puncture site was proposed. Twenty-five sites (15%) were found to be inaccurate on ultrasound examination, and a different, accurate site was established in 20 of these cases. Physicians were unable to locate a puncture site in 83 cases (33%). Among these, ultrasound demonstrated an accurate site in 45 cases (54%), while a safe tap was truly impossible in 38 cases (46%). Overall, ultrasound prevented possible accidental organ puncture in 10% of all cases and increased the rate of accurate sites by 26%. The sensitivity and specificity for identifying a proper puncture site with clinical examination compared to ultrasound as the \"gold standard\" were 76.6% and 60.3% (positive and negative predictive values, 85.5% and 45.8%, respectively). Risk factors associated with inaccurate clinical site selection were as follows: small effusion (p < 0.001), evidence of fluid loculation on chest radiography (p = 0.01; relative risk, 7.8; 95% confidence interval, 1.9 to 32.9), and sharp costodiaphragmatic angle on chest radiography (p < 0.001; relative risk, 7.0; 95% confidence interval, 2.3 to 15.2). Experienced physicians did not perform better than physicians in training. CONCLUSIONS: Puncture site selection with bedside ultrasonography increases the yield of and potentially reduces complication rate in DPC. Physician experience does not predict the accuracy of selected puncture sites.","ISSN":"0012-3692 (Print) 0012-3692","journalAbbreviation":"Chest","language":"eng","author":[{"family":"Diacon","given":"A. H."},{"family":"Brutsche","given":"M. H."},{"family":"Soler","given":"M."}],"issued":{"date-parts":[["2003",2]]}}},{"id":3928,"uris":[""],"uri":[""],"itemData":{"id":3928,"type":"article-journal","title":"Ultrasound findings following failed, clinically directed thoracenteses","container-title":"Journal of Clinical Ultrasound","page":"419-26","volume":"22","issue":"7","abstract":"We prospectively examined 26 patients who were referred for ultrasound-guided thoracentesis, following at least one unsuccessful, clinically guided attempt. Sonographically guided thoracentesis was successful in obtaining fluid in 88% of patients. In addition, ultrasonography proved useful in suggesting or defining the cause for the initial unsuccessful attempt. Patients who have undergone an unsuccessful clinically guided thoracentesis and are referred for sonographic assistance represent a selected group who may have complicating factors not typically present during routine thoracentesis. Awareness of these potential complicating factors may facilitate the performance of ultrasound-guided thoracenteses.","ISSN":"0091-2751 (Print) 0091-2751","journalAbbreviation":"J. Clin. Ultrasound","language":"eng","author":[{"family":"Weingardt","given":"J. P."},{"family":"Guico","given":"R. R."},{"family":"Nemcek","given":"A. A."},{"family":"Li","given":"Y. P."},{"family":"Chiu","given":"S. T."}],"issued":{"date-parts":[["1994",9]]}}},{"id":7685,"uris":[""],"uri":[""],"itemData":{"id":7685,"type":"article-journal","title":"Bedside sonography for detection of postprocedure pneumothorax","container-title":"Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine","page":"1003-9","volume":"32","issue":"6","abstract":"OBJECTIVES: Bedside sonography for diagnosis of pneumothorax has been well described in emergency and trauma medicine literature. Its role in detection of iatrogenic pneumothorax has not been well studied. We describe the performance of bedside sonography for detection of procedure-related pneumothorax and highlight some limitations. METHODS: A total of 185 patients underwent thoracentesis (n = 60), transbronchial biopsy (n = 48), and computed tomography-guided needle lung biopsy (n = 77). Bedside preprocedure and postprocedure transthoracic sonography and postprocedure chest radiograph were performed in all patients. Patients in whom the pleural surface was not well imaged with sonography were said to have a limited examination. Chest radiography was the standard for diagnosing pneumothorax. RESULTS: Chest radiography showed pneumothorax in 8 of 185 patients (4.0%). These patients had undergone computed tomography-guided needle lung biopsy (n = 7) and transbronchial needle lung biopsy (n = 1). Sonography showed pneumothorax in 7 of these patients. The sensitivity, specificity, and diagnostic accuracy were 88%, 97%, and 97%, respectively. Limited-quality sonographic examinations due to preexisting lung disease were seen in 43 of 185 patients. The positive and negative likelihood ratios for patients with adequate scans were 55 and 0.17, respectively. The likelihood ratio for patients with limited-quality scans was 1.08. CONCLUSIONS: When a good-quality scan is achieved, bedside chest sonography is a valuable tool for evaluation of postprocedure pneumothorax. Patients with preexisting lung disease, in whom the quality of the sonographic examination is limited, should be studied with chest radiography.","DOI":"10.7863/ultra.32.6.1003","ISSN":"1550-9613 (Electronic) 0278-4297 (Linking)","journalAbbreviation":"J. Ultrasound Med.","language":"eng","author":[{"family":"Shostak","given":"E."},{"family":"Brylka","given":"D."},{"family":"Krepp","given":"J."},{"family":"Pua","given":"B."},{"family":"Sanders","given":"A."}],"issued":{"date-parts":[["2013",6]]}}},{"id":5712,"uris":[""],"uri":[""],"itemData":{"id":5712,"type":"article-journal","title":"Transthoracic ultrasonography in predicting the outcome of small-bore catheter drainage in empyemas or complicated parapneumonic effusions","container-title":"Ultrasound in Medicine and Biology","page":"1468-74","volume":"35","issue":"9","abstract":"Thoracic sonography has been advocated as being complementary to small-bore catheter drainage in pleural effusions. However, it is not known whether the initial sonographic appearances of empyemas or complicated parapneumonic effusions (CPPEs) can predict the outcomes of small-bore catheter drainage for these pleural insults. This retrospective study investigated the outcomes of patients who had been diagnosed with empyema and CPPE and had received ultrasound-guided small-bore catheter (size from 12F to 16F) drainage in a tertiary university hospital from September 2005 to August 2007. Patients were excluded when empyemas or CPPEs were traumatic, they were less than 18 years old or their charts were incomplete. We evaluated 141 small-bore catheters in 70 patients with empyemas and 71 patients with CPPEs over a two-year period. The mean age was 58+/-15 y and the male gender was more frequent (112 men, 79%). The overall successful rate of small-bore catheter drainage in empyemas or CPPEs was 63% (89/141). The sonographic appearances of these empyemas or CPPEs exhibited a complex septated pattern in 57% (81/141) of patients and a complex nonseptated pattern in 43% (60/141) of patients. The success rate in a complex nonseptated sonographic pattern was significantly higher than in a complex septated sonographic pattern (48/60, 80% vs. 41/81, 51%, respectively; p=0.001). Moreover, patients with complex septated sonographic patterns also had higher intensive care unit admission rates compared with nonseptated sonographic patterns (22/81, 27%, vs. 8/60, 13%, respectively; p=0.0047), as well as infection-related mortality rates (17/81, 21% vs. 4/60, 7%, respectively; p=0.018). The appearance of sonographic septation is a useful sign to help predict the outcome of small-bore catheter drainage in cases of empyemas or CPPEs. Patients with a complex septated sonographic pattern have a poorer prognosis for a successful outcome, higher ICU admission rate and a higher mortality rate.","DOI":"10.1016/j.ultrasmedbio.2009.04.021","ISSN":"0301-5629","journalAbbreviation":"Ultrasound Med. Biol.","language":"eng","author":[{"family":"Chen","given":"C. H."},{"family":"Chen","given":"W."},{"family":"Chen","given":"H. J."},{"family":"Yu","given":"Y. H."},{"family":"Lin","given":"Y. C."},{"family":"Tu","given":"C. Y."},{"family":"Hsu","given":"W. H."}],"issued":{"date-parts":[["2009",9]]}}}],"schema":""} 33,48–51 Importantly, use of ultrasound has been shown to decrease the odds of pneumothorax, the most common complication of thoracentesis. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"izZoDbti","properties":{"formattedCitation":"\\super 52\\uc0\\u8211{}55\\nosupersub{}","plainCitation":"52–55","noteIndex":0},"citationItems":[{"id":3492,"uris":[""],"uri":[""],"itemData":{"id":3492,"type":"article-journal","title":"Pneumothorax following thoracentesis: a systematic review and meta-analysis","container-title":"Archives of Internal Medicine","page":"332-339","volume":"170","issue":"4","source":"PubMed","abstract":"BACKGROUND: Little is known about the factors related to the development of pneumothorax following thoracentesis. We aimed to determine the mean pneumothorax rate following thoracentesis and to identify risk factors for pneumothorax through a systematic review and meta-analysis.\nMETHODS: We reviewed MEDLINE-indexed studies from January 1, 1966, through April 1, 2009, and included studies of any design with at least 10 patients that reported the pneumothorax rate following thoracentesis. Two investigators independently extracted data on the pneumothorax rate, risk factors for pneumothorax, and study methodological quality.\nRESULTS: Twenty-four studies reported pneumothorax rates following 6605 thoracenteses. The overall pneumothorax rate was 6.0% (95% confidence interval [CI], 4.6%-7.8%), and 34.1% of pneumothoraces required chest tube insertion. Ultrasonography use was associated with significantly lower risk of pneumothorax (odds ratio [OR], 0.3; 95% CI, 0.2-0.7). Lower pneumothorax rates were observed with experienced operators (3.9% vs 8.5%, P = .04), but this was nonsignificant within studies directly comparing this factor (OR, 0.7; 95% CI, 0.2-2.3). Pneumothorax was more likely following therapeutic thoracentesis (OR, 2.6; 95% CI, 1.8-3.8), in conjunction with periprocedural symptoms (OR, 26.6; 95% CI, 2.7-262.5), and in association with, although nonsignificantly, mechanical ventilation (OR, 4.0; 95% CI, 0.95-16.8). Two or more needle passes conferred a nonsignificant increased risk of pneumothorax (OR, 2.5; 95% CI, 0.3-20.1).\nCONCLUSIONS: Iatrogenic pneumothorax is a common complication of thoracentesis and frequently requires chest tube insertion. Real-time ultrasonography use is a modifiable factor that reduces the pneumothorax rate. Performance of thoracentesis for therapeutic purposes and in patients undergoing mechanical ventilation confers a higher likelihood of pneumothorax. Experienced operators may have lower pneumothorax rates. Patient safety may be improved by changes in clinical practice in accord with these findings.","DOI":"10.1001/archinternmed.2009.548","ISSN":"1538-3679","note":"PMID: 20177035","shortTitle":"Pneumothorax following thoracentesis","journalAbbreviation":"Arch. Intern. Med.","language":"eng","author":[{"family":"Gordon","given":"Craig E."},{"family":"Feller-Kopman","given":"David"},{"family":"Balk","given":"Ethan M."},{"family":"Smetana","given":"Gerald W."}],"issued":{"date-parts":[["2010",2,22]]}}},{"id":3494,"uris":[""],"uri":[""],"itemData":{"id":3494,"type":"article-journal","title":"Ultrasound guidance decreases complications and improves the cost of care among patients undergoing thoracentesis and paracentesis","container-title":"Chest","page":"532-538","volume":"143","issue":"2","source":"PubMed","abstract":"Ultrasound guidance enables visualization of the needle insertion site for thoracentesis and paracentesis. The improved accuracy of needle placement using ultrasound may reduce risk of complications and their costs associated with these procedures. Using claims data from the Premier Perspective hospital database from January 1, 2007, through December 31, 2008, we conducted an observational cohort study examining the effect of ultrasound guidance on risk of pneumothorax among patients undergoing thoracentesis and on risk of bleeding complications after paracentesis. Patients at elevated risk of these outcomes for reasons beyond the procedure of interest were excluded. Adjusted risk of events was assessed using multivariate logistic regression controlling for patient and hospitalization characteristics. Hospitalization cost and length of stay (LOS) were estimated using multivariate ordinary least squares regression of log-transformed values. We analyzed 61,261 thoracentesis and 69,859 paracentesis patient records. Approximately 45% of these procedures were ultrasound guided. Pneumothorax occurred in 2.7% (n = 1,670) of patients undergoing thoracentesis. Of patients undergoing paracentesis, 0.8% (n = 565) experienced bleeding complications. After adjustment, ultrasound guidance reduced the risk of pneumothorax after thoracentesis by 19% (OR, 0.81; 95% CI, 0.74-0.90) and by 68% for bleeding complications after paracentesis (OR, 0.32; 95% CI, 0.25-0.41). Pneumothorax increased the total cost of hospitalization by $2,801 (P &lt; .001) and LOS by 1.5 days (P &lt; .001). Bleeding complications increased cost by $19,066 (P &lt; .0001) and LOS by 4.3 days (P &lt; .0001). The data indicate that ultrasound guidance is associated with decreased risk of pneumothorax with thoracentesis and of bleeding complications with paracentesis. These complications resulted in measurable increases in hospitalization costs and LOS.","DOI":"10.1378/chest.12-0447","ISSN":"1931-3543","note":"PMID: 23381318","journalAbbreviation":"Chest","language":"eng","author":[{"family":"Mercaldi","given":"Catherine J."},{"family":"Lanes","given":"Stephan F."}],"issued":{"date-parts":[["2013",2,1]]}}},{"id":7074,"uris":[""],"uri":[""],"itemData":{"id":7074,"type":"article-journal","title":"Ultrasonography guidance reduces complications and costs associated with thoracentesis procedures","container-title":"Journal of Clinical Ultrasound","page":"135-41","volume":"40","issue":"3","abstract":"PURPOSE.: We performed an analysis of hospitalizations involving thoracentesis procedures to determine whether the use of ultrasonographic (US) guidance is associated with differences in complications or hospital costs as compared with not using US guidance. METHODS.: We used the Premier hospital database to identify patients with ICD-9 coded thoracentesis in 2008. Use of US guidance was identified using CPT-4 codes. We performed univariate and multivariable analyses of cost data and adjusted for patient demographics, hospital characteristics, patient morbidity severity, and mortality. Logistic regression models were developed for pneumothorax and hemorrhage adverse events, controlling for patient demographics, morbidity severity, mortality, and hospital size. RESULTS.: Of 19,339 thoracentesis procedures, 46% were performed with US guidance. Mean total hospitalization costs were $11,786 (+/-$10,535) and $12,408 (+/-$13,157) for patients with and without US guidance, respectively (p < 0.001). Unadjusted risk of pneumothorax or hemorrhage was lower with US guidance (p = 0.019 and 0.078, respectively). Logistic regression analyses demonstrate that US is associated with a 16.3% reduction likelihood of pneumothorax (adjusted odds ratio 0.837, 95% CI: 0.73-0.96; p= 0.014), and 38.7% reduction in likelihood of hemorrhage (adjusted odds ratio 0.613, 95% CI: 0.36-1.04; p = 0.071). CONCLUSIONS.: US-guided thoracentesis is associated with lower total hospital stay costs and lower incidence of pneumothorax and hemorrhage. (c) 2011 Wiley Periodicals, Inc. J Clin Ultrasound, 2011.","DOI":"10.1002/jcu.20884","ISSN":"1097-0096 (Electronic) 0091-2751 (Linking)","journalAbbreviation":"J. Clin. Ultrasound","language":"eng","author":[{"family":"Patel","given":"P. A."},{"family":"Ernst","given":"F. R."},{"family":"Gunnarsson","given":"C. L."}],"issued":{"date-parts":[["2012",4]]}}},{"id":3864,"uris":[""],"uri":[""],"itemData":{"id":3864,"type":"article-journal","title":"Factors affecting the development of pneumothorax associated with thoracentesis","container-title":"AJR: American Journal of Roentgenology","page":"917-20","volume":"156","issue":"5","abstract":"This study is a retrospective survey of the variables that may influence the development of pneumothorax after thoracentesis. In a 30-month period, a computer search of hospital records identified 342 thoracenteses, of which 154 were done with conventional techniques by the clinical services, and 188 were done with sonographic guidance. Other factors surveyed included the patients' age, sex, underlying pulmonary disease, and overall clinical condition; the size of the effusion; the type of tap (diagnostic or therapeutic); the amount and type (exudate or transudate) of fluid acquired; and the size of the needles used. The technique used was the most significant single risk factor affecting the development of pneumothorax (18% for clinical vs 3% for sonography-guided thoracenteses). The incidence of pneumothorax decreased when a smaller amount of pleural fluid was aspirated (mean, 246 ml aspirated from patients who did not vs 472 ml from those who did develop pneumothorax) and when thin needles were used (4% pneumothorax with 20-gauge or smaller and 18% with larger than 20-gauge needles). The other factors surveyed did not influence the development of pneumothorax. Our results show that sonography-guided thoracentesis is complicated by pneumothorax significantly less often than is thoracentesis done with conventional techniques. Use of the smallest possible needle and aspiration of the smallest possible amount of fluid will also result in fewer cases of pneumothorax.","DOI":"10.2214/ajr.156.5.2017951","ISSN":"0361-803X (Print) 0361-803x","journalAbbreviation":"AJR Am. J. Roentgenol.","language":"eng","author":[{"family":"Raptopoulos","given":"V."},{"family":"Davis","given":"L. M."},{"family":"Lee","given":"G."},{"family":"Umali","given":"C."},{"family":"Lew","given":"R."},{"family":"Irwin","given":"R. S."}],"issued":{"date-parts":[["1991",5]]}}}],"schema":""} 52–55 The success rate of this procedure also increases with ultrasound guidance. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"yig6tVzJ","properties":{"formattedCitation":"\\super 48,49,56,57\\nosupersub{}","plainCitation":"48,49,56,57","noteIndex":0},"citationItems":[{"id":4443,"uris":[""],"uri":[""],"itemData":{"id":4443,"type":"article-journal","title":"Accuracy of pleural puncture sites: a prospective comparison of clinical examination with ultrasound","container-title":"Chest","page":"436-41","volume":"123","issue":"2","abstract":"STUDY OBJECTIVE: To assess the value of chest ultrasonography vs clinical examination for planning of diagnostic pleurocentesis (DPC). DESIGN: Prospective comparative study. SETTING: Pulmonary unit of a tertiary teaching hospital. PATIENTS AND PARTICIPANTS: Sixty-seven consecutive patients referred to 30 physicians of varying degrees of experience for DPC. INTERVENTIONS: Based on clinical data and examination, physicians determined whether and where a DPC should be performed. Selected puncture sites were evaluated with ultrasound and considered accurate when > or = 10 mm fluid perpendicular to the skin were present. MEASUREMENTS AND RESULTS: In 172 of 255 cases (67%), a puncture site was proposed. Twenty-five sites (15%) were found to be inaccurate on ultrasound examination, and a different, accurate site was established in 20 of these cases. Physicians were unable to locate a puncture site in 83 cases (33%). Among these, ultrasound demonstrated an accurate site in 45 cases (54%), while a safe tap was truly impossible in 38 cases (46%). Overall, ultrasound prevented possible accidental organ puncture in 10% of all cases and increased the rate of accurate sites by 26%. The sensitivity and specificity for identifying a proper puncture site with clinical examination compared to ultrasound as the \"gold standard\" were 76.6% and 60.3% (positive and negative predictive values, 85.5% and 45.8%, respectively). Risk factors associated with inaccurate clinical site selection were as follows: small effusion (p < 0.001), evidence of fluid loculation on chest radiography (p = 0.01; relative risk, 7.8; 95% confidence interval, 1.9 to 32.9), and sharp costodiaphragmatic angle on chest radiography (p < 0.001; relative risk, 7.0; 95% confidence interval, 2.3 to 15.2). Experienced physicians did not perform better than physicians in training. CONCLUSIONS: Puncture site selection with bedside ultrasonography increases the yield of and potentially reduces complication rate in DPC. Physician experience does not predict the accuracy of selected puncture sites.","ISSN":"0012-3692 (Print) 0012-3692","journalAbbreviation":"Chest","language":"eng","author":[{"family":"Diacon","given":"A. H."},{"family":"Brutsche","given":"M. H."},{"family":"Soler","given":"M."}],"issued":{"date-parts":[["2003",2]]}}},{"id":3928,"uris":[""],"uri":[""],"itemData":{"id":3928,"type":"article-journal","title":"Ultrasound findings following failed, clinically directed thoracenteses","container-title":"Journal of Clinical Ultrasound","page":"419-26","volume":"22","issue":"7","abstract":"We prospectively examined 26 patients who were referred for ultrasound-guided thoracentesis, following at least one unsuccessful, clinically guided attempt. Sonographically guided thoracentesis was successful in obtaining fluid in 88% of patients. In addition, ultrasonography proved useful in suggesting or defining the cause for the initial unsuccessful attempt. Patients who have undergone an unsuccessful clinically guided thoracentesis and are referred for sonographic assistance represent a selected group who may have complicating factors not typically present during routine thoracentesis. Awareness of these potential complicating factors may facilitate the performance of ultrasound-guided thoracenteses.","ISSN":"0091-2751 (Print) 0091-2751","journalAbbreviation":"J. Clin. Ultrasound","language":"eng","author":[{"family":"Weingardt","given":"J. P."},{"family":"Guico","given":"R. R."},{"family":"Nemcek","given":"A. A."},{"family":"Li","given":"Y. P."},{"family":"Chiu","given":"S. T."}],"issued":{"date-parts":[["1994",9]]}}},{"id":3719,"uris":[""],"uri":[""],"itemData":{"id":3719,"type":"article-journal","title":"Thoracocentesis of loculated pleural effusions using grey scale ultrasonic guidance","container-title":"Chest","page":"666-8","volume":"71","issue":"5","abstract":"Six patients with either malignant pleural effusion or empyema, in whom multiple conventional attempts at thoracocentesis were unsuccessful, were evaluated by ultrasound. In each case, a subsequent thoracocentesis guided by ultrasound produced sufficient fluid to enable a diagnosis to be established. In no case was pneumothorax produced.","ISSN":"0012-3692 (Print) 0012-3692","journalAbbreviation":"Chest","language":"eng","author":[{"family":"Ravin","given":"C. E."}],"issued":{"date-parts":[["1977",5]]}}},{"id":8319,"uris":[""],"uri":[""],"itemData":{"id":8319,"type":"article-journal","title":"Can ultrasound guidance reduce the risk of pneumothorax following thoracentesis?","container-title":"Jornal Brasileiro de Pneumologia : Publicacao Oficial da Sociedade Brasileira de Pneumologia e Tisilogia","page":"6-12","volume":"40","issue":"1","abstract":"OBJECTIVE: Thoracentesis is one of the bedside procedures most commonly associated with iatrogenic complications, particularly pneumothorax. Various risk factors for complications associated with thoracentesis have recently been identified, including an inexperienced operator; an inadequate or inexperienced support team; the lack of a standardized protocol; and the lack of ultrasound guidance. We sought to determine whether ultrasound-guided thoracentesis can reduce the risk of pneumothorax and improve outcomes (fewer procedures without fluid removal and greater volumes of fluid removed during the procedures). In our comparison of thoracentesis with and without ultrasound guidance, all procedures were performed by a team of expert pulmonologists, using the same standardized protocol in both conditions. METHODS: A total of 160 participants were randomly allocated to undergo thoracentesis with or without ultrasound guidance (n = 80 per group). The primary outcome was pneumothorax following thoracentesis. Secondary outcomes included the number of procedures without fluid removal and the volume of fluid drained during the procedure. RESULTS: Pneumothorax occurred in 1 of the 80 patients who underwent ultrasound-guided thoracentesis and in 10 of the 80 patients who underwent thoracentesis without ultrasound guidance, the difference being statistically significant (p = 0.009). Fluid was removed in 79 of the 80 procedures performed with ultrasound guidance and in 72 of the 80 procedures performed without it. The mean volume of fluid drained was larger during the former than during the latter (960 +/- 500 mL vs. 770 +/- 480 mL), the difference being statistically significant (p = 0.03). CONCLUSIONS: Ultrasound guidance increases the yield of thoracentesis and reduces the risk of post-procedure pneumothorax. (Chinese Clinical Trial Registry identifier: ChiCTR-TRC-12002174 []).","DOI":"10.1590/s1806-37132014000100002","ISSN":"1806-3713","note":"PMCID: PMC4075913","journalAbbreviation":"J. Bras. Pneumol.","language":"eng por","author":[{"family":"Perazzo","given":"A."},{"family":"Gatto","given":"P."},{"family":"Barlascini","given":"C."},{"family":"Ferrari-Bravo","given":"M."},{"family":"Nicolini","given":"A."}],"issued":{"date-parts":[["2014",2]]}}}],"schema":""} 48,49,56,57 A large retrospective cohort study suggested that ultrasound guidance may decrease the risk of hemorrhage, although this finding failed to reach statistical significance. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"IGYtHT66","properties":{"formattedCitation":"\\super 54\\nosupersub{}","plainCitation":"54","noteIndex":0},"citationItems":[{"id":7074,"uris":[""],"uri":[""],"itemData":{"id":7074,"type":"article-journal","title":"Ultrasonography guidance reduces complications and costs associated with thoracentesis procedures","container-title":"Journal of Clinical Ultrasound","page":"135-41","volume":"40","issue":"3","abstract":"PURPOSE.: We performed an analysis of hospitalizations involving thoracentesis procedures to determine whether the use of ultrasonographic (US) guidance is associated with differences in complications or hospital costs as compared with not using US guidance. METHODS.: We used the Premier hospital database to identify patients with ICD-9 coded thoracentesis in 2008. Use of US guidance was identified using CPT-4 codes. We performed univariate and multivariable analyses of cost data and adjusted for patient demographics, hospital characteristics, patient morbidity severity, and mortality. Logistic regression models were developed for pneumothorax and hemorrhage adverse events, controlling for patient demographics, morbidity severity, mortality, and hospital size. RESULTS.: Of 19,339 thoracentesis procedures, 46% were performed with US guidance. Mean total hospitalization costs were $11,786 (+/-$10,535) and $12,408 (+/-$13,157) for patients with and without US guidance, respectively (p < 0.001). Unadjusted risk of pneumothorax or hemorrhage was lower with US guidance (p = 0.019 and 0.078, respectively). Logistic regression analyses demonstrate that US is associated with a 16.3% reduction likelihood of pneumothorax (adjusted odds ratio 0.837, 95% CI: 0.73-0.96; p= 0.014), and 38.7% reduction in likelihood of hemorrhage (adjusted odds ratio 0.613, 95% CI: 0.36-1.04; p = 0.071). CONCLUSIONS.: US-guided thoracentesis is associated with lower total hospital stay costs and lower incidence of pneumothorax and hemorrhage. (c) 2011 Wiley Periodicals, Inc. J Clin Ultrasound, 2011.","DOI":"10.1002/jcu.20884","ISSN":"1097-0096 (Electronic) 0091-2751 (Linking)","journalAbbreviation":"J. Clin. Ultrasound","language":"eng","author":[{"family":"Patel","given":"P. A."},{"family":"Ernst","given":"F. R."},{"family":"Gunnarsson","given":"C. L."}],"issued":{"date-parts":[["2012",4]]}}}],"schema":""} 54 Finally, ultrasound can be used immediately after thoracentesis to evaluate for pneumothorax with better sensitivity than supine or upright chest radiography. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"S0eVETnc","properties":{"formattedCitation":"\\super 47,50,58,59\\nosupersub{}","plainCitation":"47,50,58,59","noteIndex":0},"citationItems":[{"id":7214,"uris":[""],"uri":[""],"itemData":{"id":7214,"type":"article-journal","title":"Pleural ultrasonography versus chest radiography for the diagnosis of pneumothorax: review of the literature and meta-analysis","container-title":"Critical Care (London, England)","page":"R208","volume":"17","issue":"5","abstract":"INTRODUCTION: Ultrasonography is being increasingly utilized in acute care settings with expanding applications. Pneumothorax evaluation by ultrasonography is a fast, safe, easy and inexpensive alternative to chest radiographs. In this review, we provide a comprehensive analysis of the current literature comparing ultrasonography and chest radiography for the diagnosis of pneumothorax. METHODS: We searched English-language articles in MEDLINE, EMBASE and Cochrane Library dealing with both ultrasonography and chest radiography for diagnosis of pneumothorax. In eligible studies that met strict inclusion criteria, we conducted a meta-analysis to evaluate the diagnostic accuracy of pleural ultrasonography in comparison with chest radiography for the diagnosis of pneumothorax. RESULTS: We reviewed 601 articles and selected 25 original research articles for detailed review. Only 13 articles met all of our inclusion criteria and were included in the final analysis. One study used lung sliding sign alone, 12 studies used lung sliding and comet tail signs, and 6 studies searched for lung point in addition to the other two signs. Ultrasonography had a pooled sensitivity of 78.6% (95% CI, 68.1 to 98.1) and a specificity of 98.4% (95% CI, 97.3 to 99.5). Chest radiography had a pooled sensitivity of 39.8% (95% CI, 29.4 to 50.3) and a specificity of 99.3% (95% CI, 98.4 to 100). Our meta-regression and subgroup analyses indicate that consecutive sampling of patients compared to convenience sampling provided higher sensitivity results for both ultrasonography and chest radiography. Consecutive versus nonconsecutive sampling and trauma versus nontrauma settings were significant sources of heterogeneity. In addition, subgroup analysis showed significant variations related to operator and type of probe used. CONCLUSIONS: Our study indicates that ultrasonography is more accurate than chest radiography for detection of pneumothorax. The results support the previous investigations in this field, add new valuable information obtained from subgroup analysis, and provide accurate estimates for the performance parameters of both bedside ultrasonography and chest radiography for pneumothorax evaluation.","DOI":"10.1186/cc13016","ISSN":"1466-609X (Electronic) 1364-8535 (Linking)","journalAbbreviation":"Crit. Care","language":"Eng","author":[{"family":"Alrajab","given":"S."},{"family":"Youssef","given":"A. M."},{"family":"Akkus","given":"N. I."},{"family":"Caldito","given":"G."}],"issued":{"date-parts":[["2013",9,23]]}}},{"id":7685,"uris":[""],"uri":[""],"itemData":{"id":7685,"type":"article-journal","title":"Bedside sonography for detection of postprocedure pneumothorax","container-title":"Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine","page":"1003-9","volume":"32","issue":"6","abstract":"OBJECTIVES: Bedside sonography for diagnosis of pneumothorax has been well described in emergency and trauma medicine literature. Its role in detection of iatrogenic pneumothorax has not been well studied. We describe the performance of bedside sonography for detection of procedure-related pneumothorax and highlight some limitations. METHODS: A total of 185 patients underwent thoracentesis (n = 60), transbronchial biopsy (n = 48), and computed tomography-guided needle lung biopsy (n = 77). Bedside preprocedure and postprocedure transthoracic sonography and postprocedure chest radiograph were performed in all patients. Patients in whom the pleural surface was not well imaged with sonography were said to have a limited examination. Chest radiography was the standard for diagnosing pneumothorax. RESULTS: Chest radiography showed pneumothorax in 8 of 185 patients (4.0%). These patients had undergone computed tomography-guided needle lung biopsy (n = 7) and transbronchial needle lung biopsy (n = 1). Sonography showed pneumothorax in 7 of these patients. The sensitivity, specificity, and diagnostic accuracy were 88%, 97%, and 97%, respectively. Limited-quality sonographic examinations due to preexisting lung disease were seen in 43 of 185 patients. The positive and negative likelihood ratios for patients with adequate scans were 55 and 0.17, respectively. The likelihood ratio for patients with limited-quality scans was 1.08. CONCLUSIONS: When a good-quality scan is achieved, bedside chest sonography is a valuable tool for evaluation of postprocedure pneumothorax. Patients with preexisting lung disease, in whom the quality of the sonographic examination is limited, should be studied with chest radiography.","DOI":"10.7863/ultra.32.6.1003","ISSN":"1550-9613 (Electronic) 0278-4297 (Linking)","journalAbbreviation":"J. Ultrasound Med.","language":"eng","author":[{"family":"Shostak","given":"E."},{"family":"Brylka","given":"D."},{"family":"Krepp","given":"J."},{"family":"Pua","given":"B."},{"family":"Sanders","given":"A."}],"issued":{"date-parts":[["2013",6]]}}},{"id":6469,"uris":[""],"uri":[""],"itemData":{"id":6469,"type":"article-journal","title":"Diagnosis of pneumothorax by radiography and ultrasonography: a meta-analysis","container-title":"Chest","page":"859-66","volume":"140","issue":"4","abstract":"OBJECTIVE: This study compares, by meta-analysis, the use of anterior-posterior chest radiography (CR) with transthoracic ultrasonography for the diagnosis of pneumothorax. METHODS: English-language articles on the performance of CR and ultrasonography in the diagnosis of a pneumothorax were selected. In eligible studies, data were recalculated, and the forest plots and summary receiver operating characteristic (sROC) curves were analyzed. RESULTS: Pooled sensitivity and specificity were 0.88 and 0.99, respectively, for ultrasonography, and 0.52 and 1.00, respectively, for CR. For ultrasonography performed by clinicians other than radiologists, pooled sensitivity and specificity were 0.89 and 0.99, respectively. The sROC areas under the curve were compared, and no significant differences between ultrasonography and CR were found. Meta-regression analysis implied that the operator is strongly associated with accuracy (relative diagnostic OR, 0.21; 95% CI, 0.05-0.96; P = .0455). CONCLUSIONS: The meta-analysis indicated that bedside ultrasonography performed by clinicians had higher sensitivity and similar specificity compared with CR in the diagnosis of pneumothorax, but the accuracy of ultrasonography in the diagnosis of pneumothorax depended on the skill of the operators.","DOI":"10.1378/chest.10-2946","ISSN":"1931-3543 (Electronic) 0012-3692 (Linking)","journalAbbreviation":"Chest","language":"eng","author":[{"family":"Ding","given":"W."},{"family":"Shen","given":"Y."},{"family":"Yang","given":"J."},{"family":"He","given":"X."},{"family":"Zhang","given":"M."}],"issued":{"date-parts":[["2011",10]]}}},{"id":6784,"uris":[""],"uri":[""],"itemData":{"id":6784,"type":"article-journal","title":"Test characteristics of ultrasonography for the detection of pneumothorax: a systematic review and meta-analysis","container-title":"Chest","page":"703-8","volume":"141","issue":"3","abstract":"BACKGROUND: A pneumothorax is a potentially life-threatening condition. Although CT scan is the reference standard for diagnosis, chest radiographs are commonly used to rule out the diagnosis. We compared the test characteristics of ultrasonography and supine chest radiography in adult patients clinically suspected of having a pneumothorax, using CT scan or release of air on chest tube placement as reference standard. METHODS: We searched for English literature in MEDLINE and EMBASE and performed hand searches. Two independent investigators used standardized forms to review articles for inclusion, quality (QUADAS tool), and data extraction. We calculated kappa agreement for study selection and evaluated clinical and quality homogeneity before meta-analysis. RESULTS: We reviewed 570 articles and selected 21 for full review (kappa, 0.89); eight articles (total of 1,048 patients) met all inclusion criteria (kappa, 0.81). All studies but one used the ultrasonographic signs of lung sliding and comet tail to rule out pneumothorax. Chest radiography data were available for 864 of 1,048 patients evaluated with ultrasonography. Ultrasonography was 90.9% sensitive (95% CI, 86.5-93.9) and 98.2% specific (95% CI, 97.0-99.0) for the detection of pneumothorax. Chest radiography was 50.2% sensitive (95% CI, 43.5-57.0) and 99.4% specific (95% CI, 98.3-99.8). CONCLUSIONS: Performance of ultrasonography for the detection of pneumothorax is excellent and is superior to supine chest radiography. Considering the rapid access to bedside ultrasonography and the excellent performance of this simple test, this study supports the routine use of ultrasonography for the detection of pneumothorax.","DOI":"10.1378/chest.11-0131","ISSN":"1931-3543 (Electronic) 0012-3692 (Linking)","journalAbbreviation":"Chest","language":"eng","author":[{"family":"Alrajhi","given":"K."},{"family":"Woo","given":"M. Y."},{"family":"Vaillancourt","given":"C."}],"issued":{"date-parts":[["2012",3]]}}}],"schema":""} 47,50,58,59Appendix 3: Abdominal UltrasoundNumerous abdominal POCUS applications may be of high utility to the hospitalist, including detection of intraperitoneal free fluid, hydronephrosis, splenomegaly, hepatomegaly, acute cholecystitis, and abdominal aortic aneurysms, as well as estimation of kidney size and bladder volume. Use of ultrasound guidance for paracentesis improves selection of optimal needle insertion site.Intraperitoneal free fluid: POCUS outperforms traditional physical exam maneuvers and has evolved to become the standard test for detection of intraperitoneal fluid with the ability to detect as little as 100-300ml of fluid. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"PobJYPXz","properties":{"formattedCitation":"\\super 60\\uc0\\u8211{}62\\nosupersub{}","plainCitation":"60–62","noteIndex":0},"citationItems":[{"id":3709,"uris":[""],"uri":[""],"itemData":{"id":3709,"type":"article-journal","title":"Ultrasonic evaluation of intraperitoneal fluid","container-title":"JAMA","page":"2427-30","volume":"235","issue":"22","ISSN":"0098-7484 (Print) 0098-7484","journalAbbreviation":"JAMA","language":"eng","author":[{"family":"Goldberg","given":"B. B."}],"issued":{"date-parts":[["1976",5,31]]}}},{"id":4041,"uris":[""],"uri":[""],"itemData":{"id":4041,"type":"article-journal","title":"Accuracy of clinical manoeuvres in detection of minimal ascites","container-title":"Indian Journal of Medical Sciences","page":"514-20","volume":"52","issue":"11","abstract":"A study was conducted to assess the clinical accuracy of various clinical manoeuvres and signs used routinely for detection of ascites. Sixty-six patients admitted in medical ward of a teaching hospital after initial screening by a consultant were selected. Exclusion criteria were; cases with previous history of ascites, who had undergone paracentesis in the recent past or with evidence of ascites from history. Another clinician blind to history and clinical details assessed the presence of ascites by the selected methods a sonographer blind of clinical and historical details assessed the cases for presence of ascitic fluid. The clinical findings were compared using ultrasonographic (USG) findings as gold standard. Ascites was detected in 35 patients by USG. the mean weight and abdominal girth of study subjects with or without ascites were comparable (p > 0.05). Sensitivity of auscultatory percussion was highest (65.7%) followed by flank dullness (57.1%) and least for fluid wave sign (20.0%). Fluid wave sign had the highest specificity (100%). We found that none of the manoeuvres studied for detection of ascites was both highly sensitive and specific. However, auscultatory percussion could be useful for initial screening of patients to detect ascites.","ISSN":"0019-5359 (Print) 0019-5359","journalAbbreviation":"Indian J. Med. Sci.","language":"eng","author":[{"family":"Chongtham","given":"D. S."},{"family":"Singh","given":"M. M."},{"family":"Kalantri","given":"S. P."},{"family":"Pathak","given":"S."},{"family":"Jain","given":"A. P."}],"issued":{"date-parts":[["1998",11]]}}},{"id":9172,"uris":[""],"uri":[""],"itemData":{"id":9172,"type":"article-journal","title":"Pocket ultrasound device as a complement to physical examination for ascites evaluation and guided paracentesis","container-title":"Internal and Emergency Medicine","page":"461-6","volume":"11","issue":"3","abstract":"The pocket ultrasound device (PUD) is a new tool that may be of use in the early detection of ascites. Abdominal ultrasound-guided paracentesis has been reported to decrease the rate of complications due to the procedure, but must be performed in a healthcare setting; this new tool may be a useful on an ambulatory basis. The aim of this study was to determine the diagnostic usefulness of the PUD in the diagnosis of ascites and the safety of guided paracentesis. We conducted a retrospective study that included adult patients suspected of having ascites and in whom an evaluation was performed with the PUD to identify it. Concordance with abdominal ultrasound (AUS) was determined with the Kappa coefficient. Sensitivity (Se), specificity (Sp) and likelihood ratios (LR) were determined and compared with physical examination, AUS, computed tomography and procurement of fluid by paracentesis. Complications resulting from the guided paracentesis were analyzed. 89 participants were included and 40 underwent a paracentesis. The PUD for ascites detection had 95.8 % Se, 81.8 % Sp, 5.27 +LR and 0.05 -LR. It had a concordance with AUS of 0.781 (p < 0.001). Technical problems during the guided paracentesis were present in only two participants (5 %) and three patients (7.5 %) developed minor complications that required no further intervention. There were no severe complications or deaths. This study suggests that the PUD is a reliable tool for ascites detection as a complement to physical examination and appears to be a safe method to perform guided paracentesis.","DOI":"10.1007/s11739-016-1406-x","ISSN":"1828-0447","journalAbbreviation":"Intern. Emerg. Med.","language":"eng","author":[{"family":"Keil-Rios","given":"D."},{"family":"Terrazas-Solis","given":"H."},{"family":"Gonzalez-Garay","given":"A."},{"family":"Sanchez-Avila","given":"J. F."},{"family":"Garcia-Juarez","given":"I."}],"issued":{"date-parts":[["2016",4]]}}}],"schema":""} 60–62Hydronephrosis: POCUS allows the clinician to detect or exclude hydronephrosis. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"FSILCsx8","properties":{"formattedCitation":"\\super 63\\nosupersub{}","plainCitation":"63","noteIndex":0},"citationItems":[{"id":4680,"uris":[""],"uri":[""],"itemData":{"id":4680,"type":"article-journal","title":"Renal ultrasound","container-title":"Emergency Medicine Clinics of North America","page":"641-59","volume":"22","issue":"3","abstract":"Renal US is one of several imaging modalities available to the EP in the evaluation of patients with acute urologic disorders. It offers excellent anatomic detail without exposure to radiation or contrast agents but is limited in its assessment of renal function. It is an important alternative to helical CT scanning for evaluating renal colic, especially in children and pregnant women. It has an important role in excluding bilateral renal obstruction as the cause of acute renal failure. It is likely that Doppler renal US also will take on a prominent role in the evaluation of renal vascular disorders. It already has become the standard of care in the management of renal transplant patients. Bedside emergency renal US performed and interpreted by EPs with limited training and experience is increasing in use and gaining acceptance. At present, the primary role of renal US is to identify hydronephrosis in patients with renal colic or acute renal failure but, in the future, its role likely will expand as technology advances and its use increases. In many patients, bedside renal US may obviate the need for further diagnostic workup and speed the diagnosis and treatment of an emergency patient.","DOI":"10.1016/j.emc.2004.04.014","ISSN":"0733-8627 (Print) 0733-8627","journalAbbreviation":"Emerg. Med. Clin. North Am.","language":"eng","author":[{"family":"Noble","given":"V. E."},{"family":"Brown","given":"D. F."}],"issued":{"date-parts":[["2004",8]]}}}],"schema":""} 63 The overall reported sensitivity of ultrasound for detection of moderate or greater hydronephrosis ranges from 72%-87% when compared to CT. Sensitivity increases with increased ultrasound experience of the provider, as well as increased size of an underlying nephrolith. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"qmmSJmsP","properties":{"formattedCitation":"\\super 64\\uc0\\u8211{}66\\nosupersub{}","plainCitation":"64–66","noteIndex":0},"citationItems":[{"id":9538,"uris":[""],"uri":[""],"itemData":{"id":9538,"type":"article-journal","title":"Ultrasound vs. Computed Tomography for Severity of Hydronephrosis and Its Importance in Renal Colic","container-title":"Western Journal of Emergency Medicine","page":"559-568","volume":"18","issue":"4","abstract":"INTRODUCTION: Supporting an \"ultrasound-first\" approach to evaluating renal colic in the emergency department (ED) remains important for improving patient care and decreasing healthcare costs. Our primary objective was to compare emergency physician (EP) ultrasound to computed tomography (CT) detection of hydronephrosis severity in patients with suspected renal colic. We calculated test characteristics of hydronephrosis on EP-performed ultrasound for detecting ureteral stones or ureteral stone size >5mm. We then analyzed the association of hydronephrosis on EP-performed ultrasound, stone size >5mm, and proximal stone location with 30-day events. METHODS: This was a prospective observational study of ED patients with suspected renal colic undergoing CT. Subjects had an EP-performed ultrasound evaluating for the severity of hydronephrosis. A chart review and follow-up phone call was performed. RESULTS: We enrolled 302 subjects who had an EP-performed ultrasound. CT and EP ultrasound results were comparable in detecting severity of hydronephrosis (x(2)=51.7, p<0.001). Hydronephrosis on EP-performed ultrasound was predictive of a ureteral stone on CT (PPV 88%; LR+ 2.91), but lack of hydronephrosis did not rule it out (NPV 65%). Lack of hydronephrosis on EP-performed ultrasound makes larger stone size >5mm less likely (NPV 89%; LR- 0.39). Larger stone size > 5mm was associated with 30-day events (OR 2.30, p=0.03). CONCLUSION: Using an ultrasound-first approach to detect hydronephrosis may help physicians identify patients with renal colic. The lack of hydronephrosis on ultrasound makes the presence of a larger ureteral stone less likely. Stone size >5mm may be a useful predictor of 30-day events.","DOI":"10.5811/westjem.2017.04.33119","ISSN":"1936-900x","note":"PMCID: PMC5468059","journalAbbreviation":"West. J. Emerg. Med.","language":"eng","author":[{"family":"Leo","given":"M. M."},{"family":"Langlois","given":"B. K."},{"family":"Pare","given":"J. R."},{"family":"Mitchell","given":"P."},{"family":"Linden","given":"J."},{"family":"Nelson","given":"K. P."},{"family":"Amanti","given":"C."},{"family":"Carmody","given":"K. A."}],"issued":{"date-parts":[["2017",6]]}}},{"id":8362,"uris":[""],"uri":[""],"itemData":{"id":8362,"type":"article-journal","title":"Sensitivity of Emergency Bedside Ultrasound to Detect Hydronephrosis in Patients with Computed Tomography-proven Stones","container-title":"Western Journal of Emergency Medicine","page":"96-100","volume":"15","issue":"1","abstract":"INTRODUCTION: Non-contrast computed tomography (CT) is widely regarded as the gold standard for diagnosis of urolithiasis in emergency department (ED) patients. However, it is costly, time-consuming and exposes patients to significant doses of ionizing radiation. Hydronephrosis on bedside ultrasound is a sign of a ureteral stone, and has a reported sensitivity of 72-83% for identification of unilateral hydronephrosis when compared to CT. The purpose of this study was to evaluate trends in sensitivity related to stone size and number. METHODS: This was a structured, explicit, retrospective chart review. Two blinded investigators used reviewed charts of all adult patients over a 6-month period with a final diagnosis of renal colic. Of these charts, those with CT evidence of renal calculus by attending radiologist read were examined for results of bedside ultrasound performed by an emergency physician. We included only those patient encounters with both CT-proven renal calculi and documented bedside ultrasound results. RESULTS: 125 patients met inclusion criteria. The overall sensitivity of ultrasound for detection of hydronephrosis was 78.4% [95% confidence interval (CI)=70.2-85.3%]. The overall sensitivity of a positive ultrasound finding of either hydronephrosis or visualized stones was 82.4% [95%CI: 75.6%, 89.2%]. Based on a prior assumption that ultrasound would detect hydronephrosis more often in patients with larger stones, we found a statistically significant (p=0.016) difference in detecting hydronephrosis in patients with a stone >/=6 mm (sensitivity=90% [95% CI=82-98%]) compared to a stone <6 mm (sensitivity=75% [95% CI=65-86%]). For those with 3 or more stones, sensitivity was 100% [95% CI=63-100%]. There were no patients with stones >/=6 mm that had both a negative ultrasound and lack of hematuria. CONCLUSION: In a population with CT-proven urolithiasis, ED bedside ultrasonography had similar overall sensitivity to previous reports but showed better sensitivity with increasing stone size and number. We identified 100% of patients with stones >/=6 mm that would benefit from medical expulsive therapy by either the presence of hematuria or abnormal ultrasound findings.","DOI":"10.5811/westjem.2013.9.15874","ISSN":"1936-900X (Print) 1936-900X (Linking)","note":"PMCID: PMC3935794","journalAbbreviation":"West. J. Emerg. Med.","language":"eng","author":[{"family":"Riddell","given":"J."},{"family":"Case","given":"A."},{"family":"Wopat","given":"R."},{"family":"Beckham","given":"S."},{"family":"Lucas","given":"M."},{"family":"McClung","given":"C. D."},{"family":"Swadron","given":"S."}],"issued":{"date-parts":[["2014",2]]}}},{"id":9762,"uris":[""],"uri":[""],"itemData":{"id":9762,"type":"article-journal","title":"STONE PLUS: Evaluation of Emergency Department Patients With Suspected Renal Colic, Using a Clinical Prediction Tool Combined With Point-of-Care Limited Ultrasonography","container-title":"Annals of Emergency Medicine","page":"439-448","volume":"67","issue":"4","source":"PubMed","abstract":"STUDY OBJECTIVE: We determine whether renal point-of-care limited ultrasonography (PLUS) used in conjunction with the?Sex, Timing, Origin, Nausea, Erythrocytes (STONE) clinical prediction score can aid identification of emergency department (ED) patients with uncomplicated ureteral stone or need for urologic intervention.\nMETHODS: This was a prospective observational study of adult ED patients undergoing computed tomography (CT) scan?for suspected ureteral stone. The previously validated STONE score classifies patients into risk categories of low?(≈10%), moderate (≈50%), or high (≈90%) for symptomatic stone. Renal PLUS assessed for presence of hydronephrosis before CT scanning. The primary outcomes of symptomatic ureteral stone or acutely important alternative finding were abstracted from CT reports. The secondary outcome, urologic intervention, was assessed by 90-day follow-up interview and record review.\nRESULTS: Of 835 enrolled patients, ureteral stone was identified in 53%, whereas 6.5% had an acutely important alternative finding on CT. Renal PLUS modestly increased sensitivity for symptomatic stone among low and moderate STONE score categories. Moderate or greater hydronephrosis improved specificity from 67% (62% to 72%) to 98% (93% to 99%) and 42% (37% to 47%) to 92% (86% to 95%) in low- and moderate-risk patients, with likelihood ratios of 22?(95% CI, 4.2-111) and 4.9 (95% CI, 2.9-8.3), respectively. Test characteristics among high-risk patients were unchanged by renal PLUS. For urologic intervention, any hydronephrosis was 66% sensitive (57% to 74%), whereas moderate or greater hydronephrosis was 86% specific overall (83% to 89%) and 81% (69% to 90%) sensitive and 79% 95% CI, (73-84) specific among patients with the highest likelihood of symptomatic stone.\nCONCLUSION: Hydronephrosis on renal PLUS modestly improved risk stratification in low- and moderate-risk STONE score patients. The presence or absence of hydronephrosis among high-risk patients did not significantly alter likelihood of symptomatic stone but may aid in identifying patients more likely to require urologic intervention.","DOI":"10.1016/j.annemergmed.2015.10.020","ISSN":"1097-6760","note":"PMID: 26747219\nPMCID: PMC5074842","shortTitle":"STONE PLUS","journalAbbreviation":"Ann Emerg Med","language":"eng","author":[{"family":"Daniels","given":"Brock"},{"family":"Gross","given":"Cary P."},{"family":"Molinaro","given":"Annette"},{"family":"Singh","given":"Dinesh"},{"family":"Luty","given":"Seth"},{"family":"Jessey","given":"Richelle"},{"family":"Moore","given":"Christopher L."}],"issued":{"date-parts":[["2016",4]]}}}],"schema":""} 64–66Renal size: Ultrasound may detect reduced renal size, reduced cortical thickness, and increased cortical echogenicity; suggesting chronic rather than acute renal disease. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"38rw9en0","properties":{"formattedCitation":"\\super 67,68\\nosupersub{}","plainCitation":"67,68","noteIndex":0},"citationItems":[{"id":4385,"uris":[""],"uri":[""],"itemData":{"id":4385,"type":"article-journal","title":"Renal sonography in the intensive care unit: when is it necessary?","container-title":"Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine","page":"517-20","volume":"21","issue":"5","abstract":"OBJECTIVE: To evaluate the efficacy of renal sonography performed in intensive care units on patients with the diagnosis of acute or acute-on-chronic renal failure. METHODS: We reviewed all renal sonograms performed in our institution during 1 year on critically ill patients for evaluation of renal failure. Renal failure was defined as a serum creatinine level greater than 1.5 mg/dL or an increase of greater than 20% from the baseline creatinine level. Exclusion criteria included patient age younger than 18 years and signs or symptoms of obstructive uropathy. Using the electronic medical record, we recorded patient age, sex, blood urea nitrogen level, serum creatinine level, blood urea nitrogen-creatinine ratio, and clinical indication for intensive care unit admission. Sonographic reports were reviewed for the presence or absence of hydronephrosis. The total cost of these examinations was estimated with the use of Medicare reimbursement rates for 2000. RESULTS: One hundred five renal sonographic examinations were performed on 104 patients meeting all inclusion criteria. Only 1 study had positive results for hydronephrosis, which was graded as mild. Incidental findings not immediately affecting patient care and including ascites and simple renal cysts were identified in 91 patients. The estimated total cost of the examinations was $13,350.75. CONCLUSIONS: In critically ill patients with acute renal failure and no physical findings suggesting obstructive uropathy, renal sonography to evaluate for hydronephrosis is probably not indicated. This holds true regardless of patient age, sex, medical or surgical disposition, and blood urea nitrogen-creatinine ratio.","ISSN":"0278-4297 (Print) 0278-4297","journalAbbreviation":"J. Ultrasound Med.","language":"eng","author":[{"family":"Keyserling","given":"H. F."},{"family":"Fielding","given":"J. R."},{"family":"Mittelstaedt","given":"C. A."}],"issued":{"date-parts":[["2002",5]]}}},{"id":4824,"uris":[""],"uri":[""],"itemData":{"id":4824,"type":"article-journal","title":"Role of renal sonography in the intensive care unit","container-title":"Journal of Clinical Ultrasound","page":"72-5","volume":"33","issue":"2","abstract":"PURPOSE: This study was conducted to evaluate the role of portable renal sonography in the intensive care unit (ICU). METHODS: We conducted a retrospective study of 402 ICU patients who underwent renal sonography. We recorded demographic data, underlying disease, type of ICU, renal function test results, etiology of renal failure, need for dialysis, and outcome for patients with acute renal failure (ARF). The indications for and results of sonography were analyzed. RESULTS: The most common indication for a renal sonographic examination was ARF (320/402, 79.6%). Hydronephrosis was found in 5 patients with ARF. Chronic renal failure was confirmed by sonography in 40% of the patients with an indeterminate cause of renal failure. In 33% of cases of complicated urinary tract infections, sonography revealed abnormalities. Renal sonography was also useful for follow-up assessment of patients treated with percutaneous nephrostomy and patients with a history of renal tumor, hydronephrosis, adrenal tumor, hematuria of unknown cause, or fever of unknown origin. CONCLUSIONS: Since renal disease is common in the ICU, renal sonography is a convenient and useful diagnostic tool in this setting.","DOI":"10.1002/jcu.20087","ISSN":"0091-2751 (Print) 0091-2751","journalAbbreviation":"J. Clin. Ultrasound","language":"eng","author":[{"family":"Huang","given":"S. W."},{"family":"Lee","given":"C. T."},{"family":"Chen","given":"C. H."},{"family":"Chuang","given":"C. H."},{"family":"Chen","given":"J. B."}],"issued":{"date-parts":[["2005",2]]}}}],"schema":""} 67,68 Evaluation of complex renal cysts and masses for malignant potential is outside the scope of POCUS.Bladder volume: Bladder volume may be reliably estimated with POCUS to determine if there is urinary retention or obstruction. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"6ABEvCs7","properties":{"formattedCitation":"\\super 69,70\\nosupersub{}","plainCitation":"69,70","noteIndex":0},"citationItems":[{"id":3895,"uris":[""],"uri":[""],"itemData":{"id":3895,"type":"article-journal","title":"Noninvasive bladder volume measurement","container-title":"Journal of Neuroscience Nursing","page":"309-12","volume":"25","issue":"5","abstract":"The aim of this study was to compare the accuracy of bladder volume measurements using a portable ultrasound machine to measurement by catheterization. For 13 consecutive weeks, all patients admitted to the stroke unit at Royal Perth Hospital were studied by both methods when urinary retention was suspected. The accuracy of ultrasound bladder volume measurements and interobserver reliability were evaluated. Ninety ultrasound examinations were performed prior to catheterization, 70 were by one nurse, and 20 independently by two nurses. Correlation of ultrasound measurements with actual catheterized volume was highly significant (r = 0.983) as was interobserver reliability. The study showed that noninvasive bladder volume measurements using ultrasound are safe, effective, inexpensive and a useful adjunct to preventive bladder management and continence management in stroke patients.","ISSN":"0888-0395 (Print) 0888-0395","journalAbbreviation":"J. Neurosci. Nurs.","language":"eng","author":[{"family":"Chan","given":"H."}],"issued":{"date-parts":[["1993",10]]}}},{"id":8637,"uris":[""],"uri":[""],"itemData":{"id":8637,"type":"article-journal","title":"Diagnosis of Postoperative Urinary Retention Using a Simplified Ultrasound Bladder Measurement","container-title":"Anesthesia and Analgesia","page":"1033-8","volume":"120","issue":"5","abstract":"BACKGROUND: In this study, we sought to determine whether a simplified ultrasound measurement of the largest transverse diameter, using a standard ultrasound machine, could be used to diagnose postoperative urinary retention (POUR). This method may replace expensive bladder volume measuring devices or a more complex ultrasound procedure (involving the measurement of 3 bladder diameters). METHODS: Patients at risk of POUR if unable to void after orthopedic surgery were evaluated in the postanesthesia care unit before discharge. Bladder diameter was first measured using a portable ultrasound device (Vscan(R); GE Healthcare, Wauwatosa, WI). An automated evaluation of bladder volume was then performed (Bladderscan(R) BVI 3000; Diagnostic Ultrasound, Redmond, WA). Finally, when a bladder catheterization was performed, the actual urinary volume was measured. The main outcome was a bladder volume >/=600 mL as measured using the automated ultrasound scanner (Bladderscan BVI 3000) or by catheterization. Correlations between bladder volumes and diameter were studied and receiver operating characteristic curves were constructed to determine the performance in predicting a bladder volume >/=600 mL. A \"gray zone\" approach was developed because a single cutoff value may not always be clinically significant. RESULTS: One hundred patients were included and underwent a Bladderscan measurement. Urinary volume after catheterization was obtained in 49 patients. A significant correlation was found between the largest transverse diameter and urinary volumes assessed by the 2 methods (Bladderscan and catheterization). Pearson correlation coefficients were r = 0.80 (95% confidence interval [CI], 0.72-0.86; P < 0.001) and r = 0.79 (95% CI, 0.65-0.88; P < 0.001), respectively. The area under the receiver operating characteristic curves for the prediction of a bladder volume >/=600 mL were 0.94 (95% CI, 0.88-0.98) and 0.91 (95% CI, 0.79-0.97), respectively, for urinary volumes assessed by Bladderscan and catheterization. The optimal cutoff value was 9.7 cm for both methods. The gray zone was narrow, ranging from 9.7 to 10.7 cm thus limiting inconclusive measurements. CONCLUSIONS: A simple ultrasound measurement of the largest transverse bladder diameter seemed to be helpful to exclude or confirm POUR.","DOI":"10.1213/ane.0000000000000595","ISSN":"0003-2999","journalAbbreviation":"Anesth. Analg.","language":"eng","author":[{"family":"Daurat","given":"A."},{"family":"Choquet","given":"O."},{"family":"Bringuier","given":"S."},{"family":"Charbit","given":"J."},{"family":"Egan","given":"M."},{"family":"Capdevila","given":"X."}],"issued":{"date-parts":[["2015",5]]}}}],"schema":""} 69,70 POCUS can confirm correct placement of a Foley catheter by visualizing the balloon within the bladder.Hepatobiliary: Several studies have shown that non-radiologists can be trained to assess the gallbladder for signs of cholelithiasis (sensitivity 96%, specificity 88%) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"uTdS1YWM","properties":{"formattedCitation":"\\super 71\\nosupersub{}","plainCitation":"71","noteIndex":0},"citationItems":[{"id":4301,"uris":[""],"uri":[""],"itemData":{"id":4301,"type":"article-journal","title":"Performance and interpretation of focused right upper quadrant ultrasound by emergency physicians","container-title":"Journal of Emergency Medicine","page":"7-13","volume":"21","issue":"1","abstract":"The objectives of this study were to determine the accuracy of Emergency Physicians (EP) performing focused right upper quadrant (RUQ) ultrasound, to quantify how sonographic experience affects accuracy for gallbladder pathology, and to establish the time needed to complete a focused RUQ ultrasound. A convenience sample of patients with suspected gallbladder disease received a focused RUQ ultrasound by an EP. Sonographic findings, number of previous RUQ ultrasounds performed, and time for examination completion were recorded. Each patient then had a formal RUQ ultrasound by a sonographer blinded to the focused RUQ ultrasound results. Focused RUQ and formal ultrasound findings were compared, with the exception of the sonographic Murphy sign, which was compared to pathology reports. One hundred nine patients were enrolled. Fifty-one had gallstones. Forty-nine were detected by EPs, yielding a sensitivity of 96% [95% confidence interval (CI).87-.99]. Of the 58 patients without gallstones, 51 were correctly diagnosed by EPs (specificity = 88%, 95% CI.77-.95). The sonographic Murphy sign was present during 54 emergency examinations, but in only 24 formal studies. When compared to pathology reports, the emergency sonographic Murphy sign had a sensitivity of 75% compared to the formal ultrasound sensitivity of 45% for acute cholecystitis. EPs were less accurate for other sonographic findings, and level of experience had little effect on sensitivity or specificity for detecting gallstones. Eighty-three percent of emergency studies were completed in less than 10 min. Gallstones are accurately detected by EPs in a timely fashion. Additionally, compared to the radiologist's interpretation, the EP-detected sonographic Murphy sign was more sensitive for diagnosing acute cholecystitis.","ISSN":"0736-4679 (Print) 0736-4679","journalAbbreviation":"J. Emerg. Med.","language":"eng","author":[{"family":"Kendall","given":"J. L."},{"family":"Shimp","given":"R. J."}],"issued":{"date-parts":[["2001",7]]}}}],"schema":""} 71 and acute cholecystitis (sensitivity 87%, specificity 82%) ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"KYduE11M","properties":{"formattedCitation":"\\super 72\\nosupersub{}","plainCitation":"72","noteIndex":0},"citationItems":[{"id":6292,"uris":[""],"uri":[""],"itemData":{"id":6292,"type":"article-journal","title":"A prospective evaluation of emergency department bedside ultrasonography for the detection of acute cholecystitis","container-title":"Annals of Emergency Medicine","page":"114-22","volume":"56","issue":"2","abstract":"STUDY OBJECTIVE: We assess the diagnostic accuracy of emergency physician-performed bedside ultrasonography and radiology ultrasonography for the detection of cholecystitis, as determined by surgical pathology. METHODS: We conducted a prospective, observational study on a convenience sample of emergency department (ED) patients presenting with suspected cholecystitis from May 2006 to February 2008. Bedside gallbladder ultrasonography was performed by emergency medicine residents and attending physicians at an academic institution. Emergency physicians assessed for gallstones, a sonographic Murphy's sign, gallbladder wall thickness, and pericholecystic fluid, and the findings were recorded before formal imaging. The test characteristics of bedside and radiology ultrasonography were determined by comparing their respective results to pathology reports and clinical follow-up at 2 weeks. RESULTS: Of the 193 patients enrolled, 189 were evaluated by bedside ultrasonography. Forty-three emergency physicians conducted the ultrasonography, and each physician performed a median of 2 tests. After the bedside ultrasonography, 125 patients received additional radiology ultrasonography. Twenty-six patients underwent cholecystectomy, 23 had pathology-confirmed cholecystitis, and 163 were discharged home to follow-up. Twenty-five were excluded (23 lost to follow-up and 2 unavailable pathology). The test characteristics of bedside ultrasonography were sensitivity 87% (95% confidence interval [CI] 66% to 97%), specificity 82% (95% CI 74% to 88%), positive likelihood ratio 4.7 (95% CI 3.2 to 6.9), negative likelihood ratio 0.16 (95% CI 0.06 to 0.46), positive predictive value 44% (95% CI 29% to 59%), and negative predictive value 97% (95% CI 93% to 99%). The test characteristics of radiology ultrasonography were sensitivity 83% (95% CI 61% to 95%), specificity 86% (95% CI 77% to 92%), positive likelihood ratio 5.7 (95% CI 3.3 to 9.8), negative likelihood ratio 0.20 (95% CI 0.08 to 0.50), positive predictive value 59% (95% CI 41% to 76%), and negative predictive value 95% (95% CI 88% to 99%). CONCLUSION: The test characteristics of emergency physician-performed bedside ultrasonography for the detection of acute cholecystitis are similar to the test characteristics of radiology ultrasonography. Patients with a negative ED bedside ultrasonography result are unlikely to require cholecystectomy or admission for cholecystitis within 2 weeks of their initial presentation.","DOI":"10.1016/j.annemergmed.2010.01.014","ISSN":"0196-0644","journalAbbreviation":"Ann. Emerg. Med.","language":"eng","author":[{"family":"Summers","given":"S. M."},{"family":"Scruggs","given":"W."},{"family":"Menchine","given":"M. D."},{"family":"Lahham","given":"S."},{"family":"Anderson","given":"C."},{"family":"Amr","given":"O."},{"family":"Lotfipour","given":"S."},{"family":"Cusick","given":"S. S."},{"family":"Fox","given":"J. C."}],"issued":{"date-parts":[["2010",8]]}}}],"schema":""} 72 and may be similar to results performed by radiology. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"H7sBtP2h","properties":{"formattedCitation":"\\super 72\\nosupersub{}","plainCitation":"72","noteIndex":0},"citationItems":[{"id":6292,"uris":[""],"uri":[""],"itemData":{"id":6292,"type":"article-journal","title":"A prospective evaluation of emergency department bedside ultrasonography for the detection of acute cholecystitis","container-title":"Annals of Emergency Medicine","page":"114-22","volume":"56","issue":"2","abstract":"STUDY OBJECTIVE: We assess the diagnostic accuracy of emergency physician-performed bedside ultrasonography and radiology ultrasonography for the detection of cholecystitis, as determined by surgical pathology. METHODS: We conducted a prospective, observational study on a convenience sample of emergency department (ED) patients presenting with suspected cholecystitis from May 2006 to February 2008. Bedside gallbladder ultrasonography was performed by emergency medicine residents and attending physicians at an academic institution. Emergency physicians assessed for gallstones, a sonographic Murphy's sign, gallbladder wall thickness, and pericholecystic fluid, and the findings were recorded before formal imaging. The test characteristics of bedside and radiology ultrasonography were determined by comparing their respective results to pathology reports and clinical follow-up at 2 weeks. RESULTS: Of the 193 patients enrolled, 189 were evaluated by bedside ultrasonography. Forty-three emergency physicians conducted the ultrasonography, and each physician performed a median of 2 tests. After the bedside ultrasonography, 125 patients received additional radiology ultrasonography. Twenty-six patients underwent cholecystectomy, 23 had pathology-confirmed cholecystitis, and 163 were discharged home to follow-up. Twenty-five were excluded (23 lost to follow-up and 2 unavailable pathology). The test characteristics of bedside ultrasonography were sensitivity 87% (95% confidence interval [CI] 66% to 97%), specificity 82% (95% CI 74% to 88%), positive likelihood ratio 4.7 (95% CI 3.2 to 6.9), negative likelihood ratio 0.16 (95% CI 0.06 to 0.46), positive predictive value 44% (95% CI 29% to 59%), and negative predictive value 97% (95% CI 93% to 99%). The test characteristics of radiology ultrasonography were sensitivity 83% (95% CI 61% to 95%), specificity 86% (95% CI 77% to 92%), positive likelihood ratio 5.7 (95% CI 3.3 to 9.8), negative likelihood ratio 0.20 (95% CI 0.08 to 0.50), positive predictive value 59% (95% CI 41% to 76%), and negative predictive value 95% (95% CI 88% to 99%). CONCLUSION: The test characteristics of emergency physician-performed bedside ultrasonography for the detection of acute cholecystitis are similar to the test characteristics of radiology ultrasonography. Patients with a negative ED bedside ultrasonography result are unlikely to require cholecystectomy or admission for cholecystitis within 2 weeks of their initial presentation.","DOI":"10.1016/j.annemergmed.2010.01.014","ISSN":"0196-0644","journalAbbreviation":"Ann. Emerg. Med.","language":"eng","author":[{"family":"Summers","given":"S. M."},{"family":"Scruggs","given":"W."},{"family":"Menchine","given":"M. D."},{"family":"Lahham","given":"S."},{"family":"Anderson","given":"C."},{"family":"Amr","given":"O."},{"family":"Lotfipour","given":"S."},{"family":"Cusick","given":"S. S."},{"family":"Fox","given":"J. C."}],"issued":{"date-parts":[["2010",8]]}}}],"schema":""} 72 While visualization and evaluation of the gallbladder can be performed by novice ultrasound users after a short training period, identification and accurate measurement of the common bile duct may be a more advanced application requiring longer training. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"pjIgkxHM","properties":{"formattedCitation":"\\super 73,74\\nosupersub{}","plainCitation":"73,74","noteIndex":0},"citationItems":[{"id":5758,"uris":[""],"uri":[""],"itemData":{"id":5758,"type":"article-journal","title":"Learning curve of bedside ultrasound of the gallbladder","container-title":"Journal of Emergency Medicine","page":"51-6","volume":"37","issue":"1","abstract":"Existing guidelines for the number of ultrasounds required before clinical competency are based not on scientific study but on consensus opinion. The objective of this study was to describe the learning curve of limited right upper quadrant ultrasound. This was a prospective descriptive study. Ultrasounds collected over 1 year were reviewed for interpretive and technical errors. Possible errors during bedside ultrasound of the gallbladder include incorrect interpretation, incomplete image acquisition, and improper or poor imaging techniques resulting in poor image quality. The ultrasound image quality was rated on a 4-point scale, with 1 = barely interpretable and 4 = excellent image quality. Required images were rated on an additional 4-point scale, with 4 = all required images were included and 1 = minimal images were recorded. There were 352 patients enrolled by 42 emergency physicians (35 residents and 7 attendings). Gallstones were identified in 13.9% of the patients, and 4.3% of the ultrasounds were indeterminate. Interpretive and technical error rates decreased as the clinician gained experience. The number of poor quality ultrasounds decreased after an average of seven ultrasounds. Inclusion of all required images increased after 25 ultrasounds. Sonographers who had performed over 25 ultrasounds showed excellent agreement with the expert over-read, with only two disagreements, both from a single individual. It was concluded that clinicians are clinically competent after performing 25 ultrasounds of the gallbladder.","DOI":"10.1016/j.jemermed.2007.10.070","ISSN":"0736-4679 (Print) 0736-4679","journalAbbreviation":"J. Emerg. Med.","language":"eng","author":[{"family":"Gaspari","given":"R. J."},{"family":"Dickman","given":"E."},{"family":"Blehar","given":"D."}],"issued":{"date-parts":[["2009",7]]}}},{"id":7900,"uris":[""],"uri":[""],"itemData":{"id":7900,"type":"article-journal","title":"Emergency biliary sonography: utility of common bile duct measurement in the diagnosis of cholecystitis and choledocholithiasis","container-title":"Journal of Emergency Medicine","page":"54-60","volume":"46","issue":"1","abstract":"BACKGROUND: Measurement of the common bile duct (CBD) has traditionally been considered an integral part of gallbladder sonography, but accurate identification of the CBD can be difficult for novice sonographers. OBJECTIVE: To determine the prevalence of isolated sonographic CBD dilation in emergency department (ED) patients with cholecystitis or choledocholithiasis without laboratory abnormalities or other pathologic findings on biliary ultrasound. METHODS: We conducted a retrospective chart review on two separate ED patient cohorts between June 2000 and June 2010. The first cohort comprised all ED patients undergoing a biliary ultrasound and subsequent cholecystectomy for presumed cholecystitis. The second cohort consisted of all ED patients receiving a biliary ultrasound who were ultimately diagnosed with choledocholithiasis. Ultrasound data and contemporaneous laboratory values were collected. Postoperative gallbladder pathology reports and endoscopic retrograde cholangiopancreatography (ERCP) reports were used as the criterion standard for final diagnosis. RESULTS: Of 666 cases of cholecystitis, there were 251 (37.7%) with a dilated CBD > 6 mm and only 2 cases (0.3%; 95% confidence interval [CI] 0.0-0.7%) of isolated CBD dilation with an otherwise negative ultrasound and normal laboratory values. Of 111 cases of choledocholithiasis, there were 80 (72.0%) with a dilated CBD and only 1 case (0.9%; 95% CI 0.0-2.7%) with an otherwise negative ultrasound and normal laboratory values. CONCLUSION: The prevalence of isolated sonographic CBD dilation in cholecystitis and choledocholithiasis is <1%. Omission of CBD measurement is unlikely to result in missed cholecystitis or choledocholithiasis in the setting of a routine ED evaluation with an otherwise normal ultrasound and normal laboratory values.","DOI":"10.1016/j.jemermed.2013.03.024","ISSN":"0736-4679 (Print) 0736-4679","journalAbbreviation":"J. Emerg. Med.","language":"eng","author":[{"family":"Becker","given":"B. A."},{"family":"Chin","given":"E."},{"family":"Mervis","given":"E."},{"family":"Anderson","given":"C. L."},{"family":"Oshita","given":"M. H."},{"family":"Fox","given":"J. C."}],"issued":{"date-parts":[["2014",1]]}}}],"schema":""} 73,74Hepatomegaly and splenomegaly: Ultrasound may be used reliably to detect hepatomegaly and splenomegaly. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"XOpv2WWX","properties":{"formattedCitation":"\\super 75\\uc0\\u8211{}78\\nosupersub{}","plainCitation":"75–78","noteIndex":0},"citationItems":[{"id":3749,"uris":[""],"uri":[""],"itemData":{"id":3749,"type":"article-journal","title":"Ultrasonic determination of hepatomegaly","container-title":"Journal of Clinical Ultrasound","page":"37-44","volume":"9","issue":"1","abstract":"Retrospective evaluation of abdominal ultrasound examinations were made in 36 patients who came to autopsy within 1 month after the ultrasound study. Without knowledge of clinical or autopsy data, two observers made independent determinations of the midhepatic line measurement of the liver on the ultrasound study using supine and left lateral decubitus longitudinal scans. Autopsy determination of hepatomegaly was made using hepatic weight, patient's total body weight, and patient age correlated with pertinent clinical history. Results of the autopsy/ultrasound correlation demonstrated that those livers measuring 13.0 cm or less in the midhepatic line (both supine and left lateral decubitus positions) were normal in 93% of the cases. Similarly, it was demonstrated that when the liver measured 15.5 cm or greater, it was enlarged in 75% of the cases. Used together, these two criteria result in an 87% accuracy rate in determining the presence or absence of hepatomegaly. Approximately 25% of the cases in our study fell into the borderline category of 13.0-15.5 cm.","ISSN":"0091-2751 (Print) 0091-2751","journalAbbreviation":"J. Clin. Ultrasound","language":"eng","author":[{"family":"Gosink","given":"B. B."},{"family":"Leymaster","given":"C. E."}],"issued":{"date-parts":[["1981",1]]}}},{"id":4634,"uris":[""],"uri":[""],"itemData":{"id":4634,"type":"article-journal","title":"Accuracy and reliability of palpation and percussion for detecting hepatomegaly: a rural hospital-based study","container-title":"Indian Journal of Gastroenterology","page":"171-4","volume":"23","issue":"5","abstract":"BACKGROUND: Palpation and percussion are standard bedside techniques used to diagnose hepatomegaly. Ultrasonography is a noninvasive and accurate method for measurement of liver size, but many patients in developing countries have limited access to it. We compared the accuracy of palpation and percussion in a rural population in central India, using ultrasonography as a reference standard. METHODS: The study design was a blinded, cross-sectional analysis of a hospital-based case series. Three physicians, blind to clinical data and to each other's results, independently used palpation and percussion to detect hepatomegaly. Diagnostic accuracy was measured by computing sensitivity, specificity, and likelihood ratio values. Inter-physician agreement was assessed using the kappa statistic. RESULTS: Of the 180 study patients, 36 (20%) had enlarged liver on ultrasonography. The likelihood ratios for findings at both palpation (2.2, 3.0, and 2.5 for the three physicians, respectively) and percussion (1.1 for all three physicians) as predictors of true hepatomegaly were low. The kappa values for inter-observer agreement between three physicians for the presence of hepatomegaly at palpation (=0.44-0.53) and percussion (=0.17-0.33) were low, indicating poor reliability of these techniques. CONCLUSION: Clinical assessment of hepatomegaly by palpation and percussion lacks both accuracy and reliability.","ISSN":"0254-8860 (Print) 0254-8860","journalAbbreviation":"Indian J. Gastroenterol.","language":"eng","author":[{"family":"Joshi","given":"R."},{"family":"Singh","given":"A."},{"family":"Jajoo","given":"N."},{"family":"Pai","given":"M."},{"family":"Kalantri","given":"S. P."}],"issued":{"date-parts":[["2004",10]]}}},{"id":3837,"uris":[""],"uri":[""],"itemData":{"id":3837,"type":"article-journal","title":"The bedside assessment of splenic enlargement","container-title":"American Journal of Medicine","page":"512-8","volume":"91","issue":"5","abstract":"STUDY OBJECTIVE: To evaluate the clinical assessment of splenic enlargement using specific bedside maneuvers including Traube's space percussion, the splenic percussion sign, Middleton's maneuver, supine palpation, and right lateral decubitus palpation. DESIGN: Quasi-experimental prospective study of cases and controls selected according to the results of abdominal ultrasonographic examinations. SETTING: Selected inpatients of a tertiary care hospital. MAIN RESULTS: Comparing the areas under the receiver operating characteristic curves for each bedside maneuver demonstrated that Traube's space percussion and palpation were significant discriminators (p less than 0.001) of splenic enlargement with respective areas of 0.70 +/- 0.04 and 0.76 +/- 0.04. No one palpation maneuver was superior to another, and right lateral decubitus palpation was not useful when performed after supine palpation. The splenic percussion sign (sensitivity 79%, specificity 46%) was no better than Traube's space percussion (sensitivity 62% and specificity 72%) in assessing splenic enlargement. The palpation maneuvers appeared more sensitive and more specific than Traube's space percussion. Palpation was a significant clinical discriminator when performed on patients who exhibited percussion dullness of Traube's space (area = 0.87 +/- 0.04, p less than 0.0001) but was of little value among those without percussion dullness (area = 0.55 +/- 0.08). Also, palpation was significantly more accurate when performed on lean patients versus obese patients (areas = 0.83 +/- 0.04 versus 0.65 +/- 0.08, p less than 0.05). When a positive bedside examination was defined as positive palpation and positive percussion (concordant-positive), the combined test sensitivity and specificity were 46% and 97% respectively. CONCLUSIONS: The optimal clinical assessment of splenic enlargement includes the percussion of Traube's space. If Traube's space is dull, palpation of the spleen is warranted. This assessment is most accurate in lean patients.","ISSN":"0002-9343 (Print) 0002-9343","journalAbbreviation":"Am. J. Med.","language":"eng","author":[{"family":"Barkun","given":"A. N."},{"family":"Camus","given":"M."},{"family":"Green","given":"L."},{"family":"Meagher","given":"T."},{"family":"Coupal","given":"L."},{"family":"De Stempel","given":"J."},{"family":"Grover","given":"S. A."}],"issued":{"date-parts":[["1991",11]]}}},{"id":9275,"uris":[""],"uri":[""],"itemData":{"id":9275,"type":"article-journal","title":"Safety and Accuracy of Percutaneous Image-Guided Core Biopsy of the Spleen","container-title":"AJR: American Journal of Roentgenology","page":"655-9","volume":"206","issue":"3","abstract":"OBJECTIVE: The purpose of this study is to assess the complication rate and diagnostic accuracy of percutaneous image-guided core needle biopsy (CNB) of the spleen at a single center over the course of 12 years. MATERIALS AND METHODS: A retrospective review of an institutionally maintained biopsy database was used to identify CNBs of the spleen performed between October 2002 and January 2015. Clinical notes were reviewed from the date of biopsy to 3 months after biopsy to ascertain whether any immediate or delayed complications had occurred. Minor complications included pain requiring analgesia and incidental asymptomatic bleeding. Major complications were those scored at or above grade 3 according to the National Institutes of Health's Common Terminology Criteria for Adverse Events, version 4.0. The pathology reports issued for each specimen were evaluated and compared with results obtained from splenectomy, biopsy performed at another anatomic site, or longitudinal clinical or imaging follow-up. Sensitivity, specificity, and accuracy were calculated. RESULTS: A total of 97 CNBs of the spleen were performed, 23 of which were CT guided and 74 of which were ultrasound guided. There were seven (7.2%) minor complications and a single (1.0%) major complication; the overall complication rate was 8.2% (n = 8). The diagnostic yield-defined as adequate tissue to establish a diagnosis-of CNB was 93.8%, the sensitivity was 90.7%, the specificity was 100%, and the accuracy was 94.5%. CONCLUSION: Percutaneous image-guided CNB of the spleen is safe and effective in achieving a tissue diagnosis.","DOI":"10.2214/ajr.15.15125","ISSN":"0361-803x","journalAbbreviation":"AJR Am. J. Roentgenol.","language":"eng","author":[{"family":"Olson","given":"M. C."},{"family":"Atwell","given":"T. D."},{"family":"Harmsen","given":"W. S."},{"family":"Konrad","given":"A."},{"family":"King","given":"R. L."},{"family":"Lin","given":"Y."},{"family":"Wall","given":"D. J."}],"issued":{"date-parts":[["2016",3]]}}}],"schema":""} 75–78Abdominal aortic aneurysm (AAA): A 2014 meta-analysis of 11 studies of non-radiologists’ ability to use ultrasound for the detection of AAA demonstrated a pooled sensitivity of 97.5% and pooled specificity of 98.9% when compared to gold standard testing. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"O539pvpg","properties":{"formattedCitation":"\\super 79\\nosupersub{}","plainCitation":"79","noteIndex":0},"citationItems":[{"id":7967,"uris":[""],"uri":[""],"itemData":{"id":7967,"type":"article-journal","title":"Diagnostic accuracy of non-radiologist performed ultrasound for abdominal aortic aneurysm: systematic review and meta-analysis","container-title":"International Journal of Clinical Practice","page":"1122-9","volume":"68","issue":"9","abstract":"BACKGROUND: Ultrasonography is increasingly used by clinicians to identify abdominal aortic aneurysms (AAA). We performed a systematic review and meta-analysis comparing the accuracy of non-radiologist performed ultrasound (NRPUS) for AAA disease to the 'gold standard' of radiologist performed aortic imaging (RPI), intra-operative findings or postmortem findings. METHODS: Cochrane Library, MEDLINE, EMBASE, SCOPUS-V.4, trial registries, conference proceedings, and article reference lists were searched to identify studies comparing NRPUS with RPI as the reference standard. Data abstracted from eligible studies was used to generate 2 x 2 contingency tables allowing calculation of pooled sensitivity and specificity values. RESULTS: 11 studies (944 patients) evaluated NRPUS for AAA detection. NRPUS had a pooled sensitivity of 0.975 [95% confidence interval (CI), 0.942-0.992] for AAA detection and a pooled specificity of 0.989 (95% CI, 0.979-0.995). CONCLUSIONS: Non-radiologist performed ultrasound achieves acceptable sensitivity and specificity for both detection and measurement of AAA. There was no evidence of significant heterogeneity with respect to pooled sensitivity or specificity.","DOI":"10.1111/ijcp.12453","ISSN":"1368-5031","journalAbbreviation":"Int. J. Clin. Pract.","language":"eng","author":[{"family":"Concannon","given":"E."},{"family":"McHugh","given":"S."},{"family":"Healy","given":"D. A."},{"family":"Kavanagh","given":"E."},{"family":"Burke","given":"P."},{"family":"Clarke Moloney","given":"M."},{"family":"Walsh","given":"S. R."}],"issued":{"date-parts":[["2014",9]]}}}],"schema":""} 79Paracentesis: Use of ultrasound guidance for paracentesis has become the standard of care. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"JaBAY1oJ","properties":{"formattedCitation":"\\super 80\\nosupersub{}","plainCitation":"80","noteIndex":0},"citationItems":[{"id":9615,"uris":[""],"uri":[""],"itemData":{"id":9615,"type":"article-journal","title":"Deep Needle Procedures: Improving Safety With Ultrasound Visualization","container-title":"J Patient Saf","page":"103-108","volume":"13","issue":"2","abstract":"Promoting patient safety and increasing health care quality have dominated the health care landscape during the last 15 years. Health care regulators and payers are now tying patient safety outcomes and best practices to hospital reimbursement. Many health care leaders are searching for new technologies that not only make health care for patients safer but also reduce overall health care costs. New advances in ultrasonography have made this technology available to health care providers at the patient's bedside. Point-of-care ultrasound assistance now aids providers with real-time diagnosis and with visualization for procedural guidance. This is especially true for common deep needle procedures such as central venous catheter insertion, thoracentesis, and paracentesis.There is now mounting evidence that clinician-performed point-of-care ultrasound improves patient safety, enhances health care quality, and reduces health care cost for deep needle procedures. Furthermore, the miniaturization, ease of use, and the evolving affordability of ultrasound have now made this technology widely available. The adoption of point-of-care ultrasonography has reached a tipping point and should be seriously considered the safety standard for all hospital-based deep needle procedures.","DOI":"10.1097/pts.0000000000000110","ISSN":"1549-8417","note":"PMCID: PMC5438097","journalAbbreviation":"Journal of patient safety","language":"eng","author":[{"family":"Peabody","given":"C. R."},{"family":"Mandavia","given":"D."}],"issued":{"date-parts":[["2017",6]]}}}],"schema":""} 80 Ultrasound outperforms physical examination in selecting an optimal needle insertion site. It allows detection of small amounts of ascites as low as 100 ml, ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"fCJ9ZNgk","properties":{"formattedCitation":"\\super 81\\nosupersub{}","plainCitation":"81","noteIndex":0},"citationItems":[{"id":3687,"uris":[""],"uri":[""],"itemData":{"id":3687,"type":"article-journal","title":"Evaluation of ascites by ultrasound","container-title":"Radiology","page":"15-22","volume":"96","issue":"1","DOI":"10.1148/96.1.15","ISSN":"0033-8419 (Print) 0033-8419 (Linking)","journalAbbreviation":"Radiology","language":"eng","author":[{"family":"Goldberg","given":"B. B."},{"family":"Goodman","given":"G. A."},{"family":"Clearfield","given":"H. R."}],"issued":{"date-parts":[["1970",7]]}}}],"schema":""} 81 identification of underlying abdominal organs and loops of bowel, ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"nXj1f6Qg","properties":{"formattedCitation":"\\super 82,83\\nosupersub{}","plainCitation":"82,83","noteIndex":0},"citationItems":[{"id":4902,"uris":[""],"uri":[""],"itemData":{"id":4902,"type":"article-journal","title":"Choosing the location for non-image guided abdominal paracentesis","container-title":"Liver Int","page":"984-6","volume":"25","issue":"5","abstract":"OBJECTIVES: The optimal location for paracentesis has not been studied scientifically. The evolving obesity epidemic has changed the physique of many patients with cirrhosis and ascites such that needles inserted into the abdominal wall may not reach fluid. We aimed to determine the location for paracentesis that would have the thinnest abdominal wall and the deepest amount of fluid. METHODS: Ultrasound measurements of abdominal wall thickness and depth of ascites were recorded in two locations, the infraumbilical midline (ML) and the left lower quadrant (LLQ), in 52 patients with cirrhosis and ascites admitted to a single inpatient liver unit. RESULTS: The abdominal wall was significantly thinner (1.8 vs. 2.4 cm; P<0.001) and the depth of ascites greater (2.86 vs. 2.29 cm; P=0.017) in the LLQ as compared with the infraumbilical ML position. In the left lateral oblique position, the difference in the depth of ascites was more pronounced when comparing the LLQ with the infraumbilical ML (4.57 vs. 2.78 cm; P<0.0001). CONCLUSIONS: The LLQ is preferable to the ML infraumbilical location for performing paracentesis.","DOI":"10.1111/j.1478-3231.2005.01149.x","ISSN":"1478-3223 (Print) 1478-3223","journalAbbreviation":"Liver international : official journal of the International Association for the Study of the Liver","language":"eng","author":[{"family":"Sakai","given":"H."},{"family":"Sheer","given":"T. A."},{"family":"Mendler","given":"M. H."},{"family":"Runyon","given":"B. A."}],"issued":{"date-parts":[["2005",10]]}}},{"id":3793,"uris":[""],"uri":[""],"itemData":{"id":3793,"type":"article-journal","title":"Ascites: ultrasound guidance or blind paracentesis?","container-title":"CMAJ: Canadian Medical Association Journal","page":"209-10","volume":"135","issue":"3","abstract":"The classic site for paracentesis in generalized ascites is in the left lower quadrant of the abdomen at a position equivalent to McBurney's point. Its use has an average success rate of 58%, depending on the amount of liquid. To assess the efficacy of paracentesis at this site and to establish the ideal site for blind puncture, we studied 27 consecutive patients with ascites detected by abdominal ultrasonography. The amount of ascites was graded from 1 to 4. Free fluid had accumulated mostly in the perihepatic region, then around the bladder and in the right paracolic gutter, and finally in the left flank. In six of the eight patients in whom fluid was found in the left or right flank, air-filled bowel loops were observed between the abdominal wall and the fluid, in the expected path of a blind puncture. These findings suggest that the safety and efficacy of paracentesis would be greatly improved by ultrasonographic guidance.","ISSN":"0820-3946 (Print) 0820-3946","note":"PMCID: PMC1491159","journalAbbreviation":"CMAJ","language":"eng","author":[{"family":"Bard","given":"C."},{"family":"Lafortune","given":"M."},{"family":"Breton","given":"G."}],"issued":{"date-parts":[["1986",8,1]]}}}],"schema":""} 82,83 visualization of loculations and superficial abdominal wall vessels, ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"F0992wud","properties":{"formattedCitation":"\\super 84\\uc0\\u8211{}86\\nosupersub{}","plainCitation":"84–86","noteIndex":0},"citationItems":[{"id":7655,"uris":[""],"uri":[""],"itemData":{"id":7655,"type":"article-journal","title":"A fatal complication of ultrasound-guided abdominal paracentesis","container-title":"Journal of Clinical Ultrasound","page":"457-60","volume":"41","issue":"7","abstract":"Ultrasound-guided abdominal paracentesis is a procedure that is frequently performed by radiologists for both diagnostic and therapeutic purposes. This procedure has been shown to be safe with few complications. We report the case of a patient who underwent an ultrasound-guided therapeutic abdominal paracentesis for refractory ascites complicated by intraperitoneal hemorrhage leading to death. This case suggests that ultrasound-guided paracentesis may need to become a more standardized procedure and that in the event of hemorrhage, alternative treatment options such as embolization or surgical intervention should be utilized when manual compression fails.","DOI":"10.1002/jcu.22050","ISSN":"0091-2751","journalAbbreviation":"J. Clin. Ultrasound","language":"eng","author":[{"family":"Seidler","given":"M."},{"family":"Sayegh","given":"K."},{"family":"Roy","given":"A."},{"family":"Mesurolle","given":"B."}],"issued":{"date-parts":[["2013",9]]}}},{"id":7659,"uris":[""],"uri":[""],"itemData":{"id":7659,"type":"article-journal","title":"Making paracentesis safer: a proposal for the use of bedside abdominal and vascular ultrasonography to prevent a fatal complication","container-title":"Chest","page":"1136-1139","volume":"143","issue":"4","abstract":"Paracentesis has been considered a relatively safe procedure; however, hemorrhagic complications do occur and can be fatal, especially in the context of coagulopathy. We describe the case of a 47-year-old man with coagulopathy secondary to end-stage liver disease, whose hospital course was complicated by paracentesis-related hemoperitoneum leading to abdominal compartment syndrome. Emergent laparotomy revealed left inferior epigastric artery laceration caused by paracentesis. Despite operative control of bleeding, postoperatively, the patient developed severe metabolic acidosis, disseminated intravascular coagulation, and ultimately died from complications of hemorrhagic shock. Understanding key anatomic structures is essential for patient safety in the setting of paracentesis. While recognizing the lack of clinical studies demonstrating the effectiveness of ultrasonography use in paracentesis, we discuss the benefit of bedside abdominal ultrasonography to locate ascites and avoid intraabdominal structures, as well as vascular ultrasonography, during needle insertion to avoid abdominal wall vessels.","DOI":"10.1378/chest.12-0871","ISSN":"0012-3692","journalAbbreviation":"Chest","language":"eng","author":[{"family":"Sekiguchi","given":"H."},{"family":"Suzuki","given":"J."},{"family":"Daniels","given":"C. E."}],"issued":{"date-parts":[["2013",4]]}}},{"id":8982,"uris":[""],"uri":[""],"itemData":{"id":8982,"type":"article-journal","title":"Feasibility of sonographic localization of the inferior epigastric artery before ultrasound-guided paracentesis","container-title":"American Journal of Emergency Medicine","page":"1795-8","volume":"33","issue":"12","abstract":"BACKGROUND: Ultrasound-guided paracentesis is commonly performed in the emergency department (ED) setting. Injury to the inferior epigastric artery (IEA) is an uncommon but potentially life-threatening complication of paracentesis. Use of anatomic landmarks has been recommended to avoid this structure. If feasible, sonographic localization of the IEA before ultrasound-guided paracentesis may provide the operator with anatomic mapping of this vascular structure. CASE REPORTS: We present 5 cases demonstrating the feasibility of identifying the IEA in ED patients with ascites. Why should an emergency physician be aware of this? Sonographic localization of the IEA before ultrasound-guided paracentesis may provide a more reliable means of avoiding iatrogenic injury to this vessel. Further study is warranted to determine whether routine IEA visualization before paracentesis results in a decreased complication rate.","DOI":"10.1016/j.ajem.2015.06.067","ISSN":"0735-6757","journalAbbreviation":"Am. J. Emerg. Med.","language":"eng","author":[{"family":"Stone","given":"J. C."},{"family":"Moak","given":"J. H."}],"issued":{"date-parts":[["2015",12]]}}}],"schema":""} 84–86 and measurement of abdominal wall thickness. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"IKnTd0ee","properties":{"formattedCitation":"\\super 87\\nosupersub{}","plainCitation":"87","noteIndex":0},"citationItems":[{"id":8009,"uris":[""],"uri":[""],"itemData":{"id":8009,"type":"article-journal","title":"Ultrasound for Detection of Ascites and for Guidance of the Paracentesis Procedure: Technique and Review of the Literature","container-title":"International Journal of Clinical Medicine","page":"17","volume":"Vol.05No.20","DOI":"10.4236/ijcm.2014.520163","journalAbbreviation":"Int. J. Clin. Med.","author":[{"family":"Ennis","given":"J"},{"family":"Schultz","given":"G"},{"family":"Perera","given":"P"},{"family":"Williams","given":"S"},{"family":"Gharahbaghian","given":"L"},{"family":"Mandavia","given":"D"}],"issued":{"date-parts":[["2014"]]}}}],"schema":""} 87 Use of ultrasound guidance for paracentesis has been shown to increase success rates of fluid aspiration, ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"y3ZeU6Ug","properties":{"formattedCitation":"\\super 88\\nosupersub{}","plainCitation":"88","noteIndex":0},"citationItems":[{"id":4868,"uris":[""],"uri":[""],"itemData":{"id":4868,"type":"article-journal","title":"Ultrasound-assisted paracentesis performed by emergency physicians vs the traditional technique: a prospective, randomized study","container-title":"American Journal of Emergency Medicine","page":"363-7","volume":"23","issue":"3","abstract":"STUDY OBJECTIVE: To determine if emergency center ultrasound (ECUS) can be of value to emergency physicians in the evaluation of possible ascites and accompanying decisions to perform emergent paracentesis. METHODS: During a 7-month period, patients suspected of having ascites and potentially requiring paracentesis were prospectively entered into a randomized study in an urban public hospital emergency center (>140 000 annual visits). Patients were randomized to receive paracentesis using the traditional or the bedside ECUS-assisted technique. Indications for paracentesis included known liver disease and obvious ascites as well as suspected ascites or suspected subacute bacterial peritonitis. Participating physicians had received a minimum of 1 hour of formal didactic ultrasound training that included gallbladder, renal, vascular, and bladder studies as well as the focused abdominal sonography for trauma examination for trauma and the detection of ascites. A portable Terason 2000 laptop ultrasound machine with a 5-MHz probe was used to scan the patients. Data collected included the patients' characteristics, estimation of ascitic fluid volume, number of attempts made to obtain fluid, speed of paracentesis, and the operator's overall evaluation of the ECUS-assisted technique, if used. RESULTS: Of 100 enrolled patients, 56 received the ECUS-assisted technique. Of 42 patients with ascites, 40 (95%) were successfully aspirated and 14 (25%) did not receive paracentesis because no ascites or insignificant amount of ascites was visualized. One patient was noted to have a large cystic mass in the left lower quadrant and another patient had a ventral hernia. Of the 44 patients randomized to the traditional technique, 27 (61%) were successfully aspirated. In 17 (39%) of these patients, fluid could not be obtained using traditional methods. Of these 17 failed attempts by traditional methods, 15 patients received ECUS in a \"break\" from the study protocol. Ascitic fluid was obtained in 13 of these 15 patients; of the 2 remaining patients, 1 did not have enough fluid to be sampled and the other had no fluid visualized. CONCLUSION: Ninety-five percent (P=.0003) of the patients who were randomized in the ECUS group and in whom a needle paracentesis was performed had ascitic fluid successfully obtained, as compared with the traditional method group.","ISSN":"0735-6757 (Print) 0735-6757","journalAbbreviation":"Am. J. Emerg. Med.","language":"eng","author":[{"family":"Nazeer","given":"S. R."},{"family":"Dewbre","given":"H."},{"family":"Miller","given":"A. H."}],"issued":{"date-parts":[["2005",5]]}}}],"schema":""} 88 reduce post-procedural bleeding regardless of INR or platelet count, ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"s3rAExRX","properties":{"formattedCitation":"\\super 53,89\\nosupersub{}","plainCitation":"53,89","noteIndex":0},"citationItems":[{"id":3494,"uris":[""],"uri":[""],"itemData":{"id":3494,"type":"article-journal","title":"Ultrasound guidance decreases complications and improves the cost of care among patients undergoing thoracentesis and paracentesis","container-title":"Chest","page":"532-538","volume":"143","issue":"2","source":"PubMed","abstract":"Ultrasound guidance enables visualization of the needle insertion site for thoracentesis and paracentesis. The improved accuracy of needle placement using ultrasound may reduce risk of complications and their costs associated with these procedures. Using claims data from the Premier Perspective hospital database from January 1, 2007, through December 31, 2008, we conducted an observational cohort study examining the effect of ultrasound guidance on risk of pneumothorax among patients undergoing thoracentesis and on risk of bleeding complications after paracentesis. Patients at elevated risk of these outcomes for reasons beyond the procedure of interest were excluded. Adjusted risk of events was assessed using multivariate logistic regression controlling for patient and hospitalization characteristics. Hospitalization cost and length of stay (LOS) were estimated using multivariate ordinary least squares regression of log-transformed values. We analyzed 61,261 thoracentesis and 69,859 paracentesis patient records. Approximately 45% of these procedures were ultrasound guided. Pneumothorax occurred in 2.7% (n = 1,670) of patients undergoing thoracentesis. Of patients undergoing paracentesis, 0.8% (n = 565) experienced bleeding complications. After adjustment, ultrasound guidance reduced the risk of pneumothorax after thoracentesis by 19% (OR, 0.81; 95% CI, 0.74-0.90) and by 68% for bleeding complications after paracentesis (OR, 0.32; 95% CI, 0.25-0.41). Pneumothorax increased the total cost of hospitalization by $2,801 (P &lt; .001) and LOS by 1.5 days (P &lt; .001). Bleeding complications increased cost by $19,066 (P &lt; .0001) and LOS by 4.3 days (P &lt; .0001). The data indicate that ultrasound guidance is associated with decreased risk of pneumothorax with thoracentesis and of bleeding complications with paracentesis. These complications resulted in measurable increases in hospitalization costs and LOS.","DOI":"10.1378/chest.12-0447","ISSN":"1931-3543","note":"PMID: 23381318","journalAbbreviation":"Chest","language":"eng","author":[{"family":"Mercaldi","given":"Catherine J."},{"family":"Lanes","given":"Stephan F."}],"issued":{"date-parts":[["2013",2,1]]}}},{"id":8772,"uris":[""],"uri":[""],"itemData":{"id":8772,"type":"article-journal","title":"Bleeding Rate for Ultrasound-Guided Paracentesis in Thrombocytopenic Patients","container-title":"Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine","page":"1833-8","volume":"34","issue":"10","abstract":"OBJECTIVES: The purpose of this study was to determine the rate of major bleeding complications for ultrasound-guided paracentesis performed in thrombocytopenic patients. METHODS: We retrospectively reviewed the electronic medical records of patients with platelet counts of less than 50,000/muL who had ultrasound-guided paracenteses performed in the Department of Radiology without correcting preprocedural platelet transfusions between 2005 and 2011. Medical records were evaluated for evidence of major bleeding complications (grade 3 or higher as defined by the National Institutes of Health's Common Terminology Criteria for Adverse Events, version 4.03) and their clinical sequelae. Platelet count and bleeding complications were evaluated for an association, and a sensitivity analysis was performed to determine whether analysis of a control group of patients without thrombocytopenia would yield added confidence in this assessment. RESULTS: Among 304 procedures in 205 thrombocytopenic patients (69% male; mean age +/- SD, 56.6 +/- 11.9 years), the mean platelet count was 38,400 +/- 9300/muL (range, 9000-49,000/muL). Three major bleeding complications requiring red blood cell transfusion were observed in patients with platelet counts of 41,000 to 46,000/muL, for a complication rate of 0.99% (95% confidence interval, 0.3%-2.9%). No patient required an additional procedure or died because of the bleeding complication. There was no association of platelet count with bleeding complications. The sensitivity analysis showed that further evaluation of patients with normal platelet counts would not add to the conclusion. CONCLUSIONS: The risk of major bleeding after ultrasound-guided paracentesis in thrombocytopenic patients is very low. In most patients, routine assessment of the preprocedural serum platelet concentration is not necessary, and correction of such an abnormal laboratory value is not indicated.","DOI":"10.7863/ultra.14.10034","ISSN":"0278-4297","journalAbbreviation":"J. Ultrasound Med.","language":"eng","author":[{"family":"Kurup","given":"A. N."},{"family":"Lekah","given":"A."},{"family":"Reardon","given":"S. T."},{"family":"Schmit","given":"G. D."},{"family":"McDonald","given":"J. S."},{"family":"Carter","given":"R. E."},{"family":"Kamath","given":"P. S."},{"family":"Callstrom","given":"M. R."},{"family":"Atwell","given":"T. D."}],"issued":{"date-parts":[["2015",10]]}}}],"schema":""} 53,89 and has been associated with reduced hospitalization costs and mortality. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"fu65WiHt","properties":{"formattedCitation":"\\super 53,54\\nosupersub{}","plainCitation":"53,54","noteIndex":0},"citationItems":[{"id":3494,"uris":[""],"uri":[""],"itemData":{"id":3494,"type":"article-journal","title":"Ultrasound guidance decreases complications and improves the cost of care among patients undergoing thoracentesis and paracentesis","container-title":"Chest","page":"532-538","volume":"143","issue":"2","source":"PubMed","abstract":"Ultrasound guidance enables visualization of the needle insertion site for thoracentesis and paracentesis. The improved accuracy of needle placement using ultrasound may reduce risk of complications and their costs associated with these procedures. Using claims data from the Premier Perspective hospital database from January 1, 2007, through December 31, 2008, we conducted an observational cohort study examining the effect of ultrasound guidance on risk of pneumothorax among patients undergoing thoracentesis and on risk of bleeding complications after paracentesis. Patients at elevated risk of these outcomes for reasons beyond the procedure of interest were excluded. Adjusted risk of events was assessed using multivariate logistic regression controlling for patient and hospitalization characteristics. Hospitalization cost and length of stay (LOS) were estimated using multivariate ordinary least squares regression of log-transformed values. We analyzed 61,261 thoracentesis and 69,859 paracentesis patient records. Approximately 45% of these procedures were ultrasound guided. Pneumothorax occurred in 2.7% (n = 1,670) of patients undergoing thoracentesis. Of patients undergoing paracentesis, 0.8% (n = 565) experienced bleeding complications. After adjustment, ultrasound guidance reduced the risk of pneumothorax after thoracentesis by 19% (OR, 0.81; 95% CI, 0.74-0.90) and by 68% for bleeding complications after paracentesis (OR, 0.32; 95% CI, 0.25-0.41). Pneumothorax increased the total cost of hospitalization by $2,801 (P &lt; .001) and LOS by 1.5 days (P &lt; .001). Bleeding complications increased cost by $19,066 (P &lt; .0001) and LOS by 4.3 days (P &lt; .0001). The data indicate that ultrasound guidance is associated with decreased risk of pneumothorax with thoracentesis and of bleeding complications with paracentesis. These complications resulted in measurable increases in hospitalization costs and LOS.","DOI":"10.1378/chest.12-0447","ISSN":"1931-3543","note":"PMID: 23381318","journalAbbreviation":"Chest","language":"eng","author":[{"family":"Mercaldi","given":"Catherine J."},{"family":"Lanes","given":"Stephan F."}],"issued":{"date-parts":[["2013",2,1]]}}},{"id":7074,"uris":[""],"uri":[""],"itemData":{"id":7074,"type":"article-journal","title":"Ultrasonography guidance reduces complications and costs associated with thoracentesis procedures","container-title":"Journal of Clinical Ultrasound","page":"135-41","volume":"40","issue":"3","abstract":"PURPOSE.: We performed an analysis of hospitalizations involving thoracentesis procedures to determine whether the use of ultrasonographic (US) guidance is associated with differences in complications or hospital costs as compared with not using US guidance. METHODS.: We used the Premier hospital database to identify patients with ICD-9 coded thoracentesis in 2008. Use of US guidance was identified using CPT-4 codes. We performed univariate and multivariable analyses of cost data and adjusted for patient demographics, hospital characteristics, patient morbidity severity, and mortality. Logistic regression models were developed for pneumothorax and hemorrhage adverse events, controlling for patient demographics, morbidity severity, mortality, and hospital size. RESULTS.: Of 19,339 thoracentesis procedures, 46% were performed with US guidance. Mean total hospitalization costs were $11,786 (+/-$10,535) and $12,408 (+/-$13,157) for patients with and without US guidance, respectively (p < 0.001). Unadjusted risk of pneumothorax or hemorrhage was lower with US guidance (p = 0.019 and 0.078, respectively). Logistic regression analyses demonstrate that US is associated with a 16.3% reduction likelihood of pneumothorax (adjusted odds ratio 0.837, 95% CI: 0.73-0.96; p= 0.014), and 38.7% reduction in likelihood of hemorrhage (adjusted odds ratio 0.613, 95% CI: 0.36-1.04; p = 0.071). CONCLUSIONS.: US-guided thoracentesis is associated with lower total hospital stay costs and lower incidence of pneumothorax and hemorrhage. (c) 2011 Wiley Periodicals, Inc. J Clin Ultrasound, 2011.","DOI":"10.1002/jcu.20884","ISSN":"1097-0096 (Electronic) 0091-2751 (Linking)","journalAbbreviation":"J. Clin. Ultrasound","language":"eng","author":[{"family":"Patel","given":"P. A."},{"family":"Ernst","given":"F. R."},{"family":"Gunnarsson","given":"C. L."}],"issued":{"date-parts":[["2012",4]]}}}],"schema":""} 53,54 To maximize benefits of using ultrasound, experts recommend a “2-probe technique” with a low-frequency probe for fluid localization and a high-frequency probe for vessel identification along the anticipated needle path. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"eZ66N7DC","properties":{"formattedCitation":"\\super 85,86,90\\nosupersub{}","plainCitation":"85,86,90","noteIndex":0},"citationItems":[{"id":7659,"uris":[""],"uri":[""],"itemData":{"id":7659,"type":"article-journal","title":"Making paracentesis safer: a proposal for the use of bedside abdominal and vascular ultrasonography to prevent a fatal complication","container-title":"Chest","page":"1136-1139","volume":"143","issue":"4","abstract":"Paracentesis has been considered a relatively safe procedure; however, hemorrhagic complications do occur and can be fatal, especially in the context of coagulopathy. We describe the case of a 47-year-old man with coagulopathy secondary to end-stage liver disease, whose hospital course was complicated by paracentesis-related hemoperitoneum leading to abdominal compartment syndrome. Emergent laparotomy revealed left inferior epigastric artery laceration caused by paracentesis. Despite operative control of bleeding, postoperatively, the patient developed severe metabolic acidosis, disseminated intravascular coagulation, and ultimately died from complications of hemorrhagic shock. Understanding key anatomic structures is essential for patient safety in the setting of paracentesis. While recognizing the lack of clinical studies demonstrating the effectiveness of ultrasonography use in paracentesis, we discuss the benefit of bedside abdominal ultrasonography to locate ascites and avoid intraabdominal structures, as well as vascular ultrasonography, during needle insertion to avoid abdominal wall vessels.","DOI":"10.1378/chest.12-0871","ISSN":"0012-3692","journalAbbreviation":"Chest","language":"eng","author":[{"family":"Sekiguchi","given":"H."},{"family":"Suzuki","given":"J."},{"family":"Daniels","given":"C. E."}],"issued":{"date-parts":[["2013",4]]}}},{"id":8982,"uris":[""],"uri":[""],"itemData":{"id":8982,"type":"article-journal","title":"Feasibility of sonographic localization of the inferior epigastric artery before ultrasound-guided paracentesis","container-title":"American Journal of Emergency Medicine","page":"1795-8","volume":"33","issue":"12","abstract":"BACKGROUND: Ultrasound-guided paracentesis is commonly performed in the emergency department (ED) setting. Injury to the inferior epigastric artery (IEA) is an uncommon but potentially life-threatening complication of paracentesis. Use of anatomic landmarks has been recommended to avoid this structure. If feasible, sonographic localization of the IEA before ultrasound-guided paracentesis may provide the operator with anatomic mapping of this vascular structure. CASE REPORTS: We present 5 cases demonstrating the feasibility of identifying the IEA in ED patients with ascites. Why should an emergency physician be aware of this? Sonographic localization of the IEA before ultrasound-guided paracentesis may provide a more reliable means of avoiding iatrogenic injury to this vessel. Further study is warranted to determine whether routine IEA visualization before paracentesis results in a decreased complication rate.","DOI":"10.1016/j.ajem.2015.06.067","ISSN":"0735-6757","journalAbbreviation":"Am. J. Emerg. Med.","language":"eng","author":[{"family":"Stone","given":"J. C."},{"family":"Moak","given":"J. H."}],"issued":{"date-parts":[["2015",12]]}}},{"id":9714,"uris":[""],"uri":[""],"itemData":{"id":9714,"type":"article-journal","title":"Vascular Ultrasonography: A Novel Method to Reduce Paracentesis Related Major Bleeding","container-title":"Journal of Hospital Medicine","page":"30-33","volume":"13","issue":"1","abstract":"Paracentesis is a core competency for hospitalists. Using ultrasound for fluid localization is standard practice and involves a low-frequency probe. Experts recommend a \"2-probe technique, \" which incorporates a high-frequency ultrasound probe in addition to the low-frequency probe to identify blood vessels within the intended needle path. Evidence is currently lacking to support this 2-probe technique, so we performed a pre- to postintervention study to evaluate its effect on paracentesis-related bleeding complications. From February 2010 to August 2011, procedures were performed using only low-frequency probes (preintervention group), while the 2-probe technique was used from September 2011 to February 2016 (postintervention group). A total of 5777 procedures were performed. Paracentesis-related minor bleeding was similar between groups. Major bleeding was lower in the postintervention group (3 [0.3%], n = 1000 vs 4 [0.08%], n = 4777; P = 0.07). This clinically meaningful trend suggests that using the 2-probe technique might prevent paracentesis-related major bleeding.","DOI":"10.12788/jhm.2863","ISSN":"1553-5592","journalAbbreviation":"J. Hosp. Med.","language":"eng","author":[{"family":"Barsuk","given":"J. H."},{"family":"Rosen","given":"B. T."},{"family":"Cohen","given":"E. R."},{"family":"Feinglass","given":"J."},{"family":"Ault","given":"M. J."}],"issued":{"date-parts":[["2018",1,1]]}}}],"schema":""} 85,86,90 Post-procedurally, re-evaluation of the abdomen and needle insertion site permits assessment for residual fluid and screening for abdominal hematoma and hemoperitoneum in a timely manner at the bedside. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"c2ARQBTk","properties":{"formattedCitation":"\\super 91\\nosupersub{}","plainCitation":"91","noteIndex":0},"citationItems":[{"id":5346,"uris":[""],"uri":[""],"itemData":{"id":5346,"type":"article-journal","title":"Accuracy of physical and ultrasonographic examinations by emergency physicians for the early diagnosis of intraabdominal haemorrhage in blunt abdominal trauma","container-title":"Injury","page":"564-9","volume":"38","issue":"5","abstract":"OBJECTIVE: To determine the accuracy of physical examination and ultrasonographic evaluation performed by emergency physicians in cases of blunt abdominal trauma for the early diagnosis of intraabdominal haemorrhage. METHODS: In this clinical prospective study, trauma patients were evaluated with four-quadrant ultrasonography by emergency physicians after initial stabilisation and physical examination. Diagnoses based on demographic data, physical examination and emergency physician's ultrasonography were compared with the subsequent clinical course. RESULTS: A total of 442 patients participated in the study. The sensitivity and specificity of emergency physician's ultrasonographic examination to detect intraabdominal haemorrhage were 86 and 99%, respectively. Pre-test sensitivity and specificity of physical examination to detect intraabdominal haemorrhage were 39 and 90%, respectively. CONCLUSIONS: Physical examination was not a reliable method to detect intraabdominal haemorrhage in cases of blunt abdominal trauma. In contrast, abdominal ultrasonography performed by emergency physicians was a reliable diagnostic tool. Emergency physicians should be familiar with abdominal ultrasonographic examination, which should be routine in cases of blunt abdominal trauma.","DOI":"10.1016/j.injury.2007.01.010","ISSN":"0020-1383 (Print) 0020-1383","journalAbbreviation":"Injury","language":"eng","author":[{"family":"Soyuncu","given":"S."},{"family":"Cete","given":"Y."},{"family":"Bozan","given":"H."},{"family":"Kartal","given":"M."},{"family":"Akyol","given":"A. J."}],"issued":{"date-parts":[["2007",5]]}}}],"schema":""} 91Appendix 4: Vascular UltrasoundPOCUS can accurately detect lower extremity deep venous thrombosis by compression ultrasonography. Use of ultrasound guidance is critical for safe insertion of central venous catheters, and is useful for performance of other vascular access procedures, including peripheral intravenous (IV) and arterial line placement.Deep venous thrombosis (DVT): POCUS can detect lower extremity DVTs. Two-dimensional compression ultrasound is used to evaluate the femoral and popliteal regions for proximal lower extremity DVTs. A 2012 meta-analysis of 16 studies that compared emergency physician-performed compression ultrasonography to color flow Duplex ultrasound or angiography by radiology demonstrated a weighted mean sensitivity of 96.1% and specificity of 96.8%. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"CpxXdZBd","properties":{"formattedCitation":"\\super 92\\nosupersub{}","plainCitation":"92","noteIndex":0},"citationItems":[{"id":7598,"uris":[""],"uri":[""],"itemData":{"id":7598,"type":"article-journal","title":"Accuracy of emergency physician-performed ultrasonography in the diagnosis of deep-vein thrombosis: a systematic review and meta-analysis","container-title":"Thrombosis and Haemostasis","page":"137-45","volume":"109","issue":"1","abstract":"Duplex ultrasound is the first-line diagnostic test for detecting lower limb deep-vein thrombosis (DVT) but it is time consuming, requires patient transport, and cannot be interpreted by most physicians. The accuracy of emergency physician-performed ultrasound (EPPU) for the diagnosis of DVT, when performed at the bedside, is unclear. We did a systematic review and meta-analysis of the literature, aiming to provide reliable data on the accuracy of EPPU in the diagnosis of DVT. The MEDLINE and EMBASE databases (up to August 2012) were systematically searched for studies evaluating the accuracy of EPPU compared to either colour-flow duplex ultrasound performed by a radiology department or vascular laboratory, or to angiography, in the diagnosis of DVT. Weighted mean sensitivity and specificity and associated 95% confidence intervals (CIs) were calculated using a bivariate random-effects regression approach. There were 16 studies included, with 2,379 patients. The pooled prevalence of DVT was 23.1% (498 in 2,379 patients), ranging from 7.4% to 47.3%. Using the bivariate approach, the weighted mean sensitivity of EPPU compared to the reference imaging test was 96.1% (95%CI 90.6-98.5%), and with a weighted mean specificity of 96.8% (95%CI:94.6-98.1%). Our findings suggest that EPPU may be useful in the management of patients with suspected DVT. Future prospective studies are warranted to confirm these findings.","DOI":"10.1160/th12-07-0473","ISSN":"0340-6245 (Print) 0340-6245 (Linking)","journalAbbreviation":"Thromb. Haemost.","language":"eng","author":[{"family":"Pomero","given":"F."},{"family":"Dentali","given":"F."},{"family":"Borretta","given":"V."},{"family":"Bonzini","given":"M."},{"family":"Melchio","given":"R."},{"family":"Douketis","given":"J. D."},{"family":"Fenoglio","given":"L. M."}],"issued":{"date-parts":[["2013",1]]}}}],"schema":""} 92 A 2100 patient randomized, multi-center trial comparing emergency physician-performed POCUS exams and D-dimer to radiology-performed exams found the two diagnostic strategies to be equivalent. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ygRAsQtM","properties":{"formattedCitation":"\\super 93\\nosupersub{}","plainCitation":"93","noteIndex":0},"citationItems":[{"id":5394,"uris":[""],"uri":[""],"itemData":{"id":5394,"type":"article-journal","title":"Serial 2-point ultrasonography plus D-dimer vs whole-leg color-coded Doppler ultrasonography for diagnosing suspected symptomatic deep vein thrombosis: a randomized controlled trial","container-title":"JAMA","page":"1653-9","volume":"300","issue":"14","abstract":"CONTEXT: Patients with suspected deep vein thrombosis (DVT) of the lower extremities are usually investigated with ultrasonography either by the proximal veins (2-point ultrasonography) or the entire deep vein system (whole-leg ultrasonography). The latter approach is thought to be better based on its ability to detect isolated calf vein thrombosis; however, it requires skilled operators and is mainly available only during working hours. No randomized comparisons are yet available evaluating the relative values of these 2 strategies. OBJECTIVE: To assess if the 2 diagnostic strategies are equivalent for the management of symptomatic outpatients with suspected DVT of the lower extremities. DESIGN, SETTING, AND PATIENTS: A prospective, randomized, multicenter study of consecutive symptomatic outpatients (n = 2465) with a first episode of suspected DVT of the lower extremities who were randomized to undergo 2-point or whole-leg ultrasonography. Data were taken from ultrasound laboratories of 14 Italian universities or civic hospitals between January 1, 2003, and December 21, 2006. Patients with normal ultrasound findings were followed up for 3 months, with study completion on March 20, 2007. MAIN OUTCOME MEASURE: Objectively confirmed 3-month incidence of symptomatic venous thromboembolism in patients with an initially normal diagnostic workup. RESULTS: Of 2465 eligible patients, 345 met 1 or more exclusion criteria and 22 refused to participate; therefore, 2098 patients were randomized to either 2-point (n = 1045) or whole-leg (n = 1053) ultrasonography. Symptomatic venous thromboembolism occurred in 7 of 801 patients (incidence, 0.9%; 95% confidence interval [CI], 0.3%-1.8%) in the 2-point strategy group and in 9 of 763 patients (incidence, 1.2%; 95% CI, 0.5%-2.2%) in the whole-leg strategy group. This met the established equivalence criterion (observed difference, 0.3%;95% CI, -1.4% to 0.8%). CONCLUSION: The 2 diagnostic strategies are equivalent when used for the management of symptomatic outpatients with suspected DVT of the lower extremities. TRIAL REGISTRATION: Identifier: NCT00353093.","DOI":"10.1001/jama.300.14.1653","ISSN":"0098-7484","journalAbbreviation":"JAMA","language":"eng","author":[{"family":"Bernardi","given":"E."},{"family":"Camporese","given":"G."},{"family":"Buller","given":"H. R."},{"family":"Siragusa","given":"S."},{"family":"Imberti","given":"D."},{"family":"Berchio","given":"A."},{"family":"Ghirarduzzi","given":"A."},{"family":"Verlato","given":"F."},{"family":"Anastasio","given":"R."},{"family":"Prati","given":"C."},{"family":"Piccioli","given":"A."},{"family":"Pesavento","given":"R."},{"family":"Bova","given":"C."},{"family":"Maltempi","given":"P."},{"family":"Zanatta","given":"N."},{"family":"Cogo","given":"A."},{"family":"Cappelli","given":"R."},{"family":"Bucherini","given":"E."},{"family":"Cuppini","given":"S."},{"family":"Noventa","given":"F."},{"family":"Prandoni","given":"P."}],"issued":{"date-parts":[["2008",10,8]]}}}],"schema":""} 93 High sensitivity has also been demonstrated in critically ill patients. In one critical care study, 14 hours passed between ordering and reporting of the radiology-performed lower extremity DVT examinations. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Q4l2kQNN","properties":{"formattedCitation":"\\super 94\\nosupersub{}","plainCitation":"94","noteIndex":0},"citationItems":[{"id":6566,"uris":[""],"uri":[""],"itemData":{"id":6566,"type":"article-journal","title":"Accuracy of ultrasonography performed by critical care physicians for the diagnosis of DVT","container-title":"Chest","page":"538-42","volume":"139","issue":"3","abstract":"BACKGROUND: DVT is common among critically ill patients. A rapid and accurate diagnosis is essential for patient care. We assessed the accuracy and timeliness of intensivist-performed compression ultrasonography studies (IP-CUS) for proximal lower extremity DVT (PLEDVT) by comparing results with the formal vascular study (FVS) performed by ultrasonography technicians and interpreted by radiologists. METHODS: We conducted a multicenter, retrospective review of IP-CUS examinations performed in an ICU by pulmonary and critical care fellows and attending physicians. Patients suspected of having DVT underwent IP-CUS, using a standard two-dimensional compression ultrasonography protocol for the diagnosis of PLEDVT. The IP-CUS data were collected prospectively as part of a quality-improvement initiative. The IP-CUS interpretation was recorded and timed at the end of the examination on a standardized report form. An FVS was then ordered, and the FVS result was used as the criterion standard for calculating sensitivity and specificity. Time delays between the IP-CUS and FVS were recorded. RESULTS: A total of 128 IP-CUS were compared with an FVS. Eighty-one percent of the IP-CUS were performed by fellows with <2 years of clinical ultrasonography experience. Prevalence of DVT was 20%. IP-CUS studies yielded a sensitivity of 86% and a specificity of 96% with a diagnostic accuracy of 95%. Median time delay between the ordering of FVS and the FVS result was 13.8 h. CONCLUSIONS: Rapid and accurate diagnosis of proximal lower extremity DVT can be achieved by intensivists performing compression ultrasonography at the bedside.","DOI":"10.1378/chest.10-1479","ISSN":"1931-3543 (Electronic) 0012-3692 (Linking)","journalAbbreviation":"Chest","language":"eng","author":[{"family":"Kory","given":"P. D."},{"family":"Pellecchia","given":"C. M."},{"family":"Shiloh","given":"A. L."},{"family":"Mayo","given":"P. H."},{"family":"DiBello","given":"C."},{"family":"Koenig","given":"S."}],"issued":{"date-parts":[["2011",3]]}}}],"schema":""} 94Central venous line insertion: The advantages of using real-time ultrasound guidance for insertion of central venous catheters have been well demonstrated in the medical literature. The use of ultrasound increases overall procedure success rate and the number of successful first-pass attempts, while reducing the mechanical and infectious complications, number of needle passes, and time to cannulation. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"cQx7QoBb","properties":{"formattedCitation":"\\super 95,96\\nosupersub{}","plainCitation":"95,96","noteIndex":0},"citationItems":[{"id":3476,"uris":[""],"uri":[""],"itemData":{"id":3476,"type":"article-journal","title":"Ultrasound guidance versus anatomical landmarks for internal jugular vein catheterization","container-title":"The Cochrane Database of Systematic Reviews","page":"CD006962","volume":"1","source":"PubMed","abstract":"BACKGROUND: Central venous catheters (CVCs) can help with diagnosis and treatment of the critically ill. The catheter may be placed in a large vein in the neck (internal jugular vein), upper chest (subclavian vein) or groin (femoral vein). Whilst this is beneficial overall, inserting the catheter risks arterial puncture and other complications and should be performed with as few attempts as possible. Traditionally, anatomical 'landmarks' on the body surface were used to find the correct place in which to insert catheters, but ultrasound imaging is now available. A Doppler mode is sometimes used to supplement plain 'two-dimensional' ultrasound.\nOBJECTIVES: The primary objective of this review was to evaluate the effectiveness and safety of two-dimensional (imaging ultrasound (US) or ultrasound Doppler (USD)) guided puncture techniques for insertion of central venous catheters via the internal jugular vein in adults and children. We assessed whether there was a difference in complication rates between traditional landmark-guided and any ultrasound-guided central vein puncture.Our secondary objectives were to assess whether the effect differs between US and USD; whether the effect differs between ultrasound used throughout the puncture ('direct') and ultrasound used only to identify and mark the vein before the start of the puncture procedure (indirect'); and whether the effect differs between different groups of patients or between different levels of experience among those inserting the catheters.\nSEARCH METHODS: We searched the Central Register of Controlled Trials (CENTRAL) (2013, Issue 1), MEDLINE (1966 to 15 January 2013), EMBASE (1966 to 15 January 2013), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 15 January 2013 ), reference lists of articles, 'grey literature' and dissertations. An additional handsearch focused on intensive care and anaesthesia journals and abstracts and proceedings of scientific meetings. We attempted to identify unpublished or ongoing studies by contacting companies and experts in the field, and we searched trial registers. We reran the search in August 2014. We will deal with identified studies of interest when we update the review.\nSELECTION CRITERIA: We included randomized and quasi-randomized controlled trials comparing two-dimensional ultrasound or Doppler ultrasound with an anatomical 'landmark' technique during insertion of internal jugular venous catheters in both adults and children.\nDATA COLLECTION AND ANALYSIS: Three review authors independently extracted data on methodological quality, participants, interventions and outcomes of interest using a standardized form. A priori, we aimed to perform subgroup analyses, when possible, for adults and children, and for experienced operators and inexperienced operators.\nMAIN RESULTS: Of 735 identified citations, 35 studies enrolling 5108 participants fulfilled the inclusion criteria. The quality of evidence was very low for most of the outcomes and was moderate at best for four of the outcomes. Most trials had an unclear risk of bias across the six domains, and heterogeneity among the studies was significant.Use of two-dimensional ultrasound reduced the rate of total complications overall by 71% (14 trials, 2406 participants, risk ratio (RR) 0.29, 95% confidence interval (CI) 0.17 to 0.52; P value < 0.0001, I? = 57%), and the number of participants with an inadvertent arterial puncture by 72% (22 trials, 4388 participants, RR 0.28, 95% CI 0.18 to 0.44; P value < 0.00001, I? = 35%). Overall success rates were modestly increased in all groups combined at 12% (23 trials, 4340 participants, RR 1.12, 95% CI 1.08 to 1.17; P value < 0.00001, I? = 85%), and similar benefit was noted across all subgroups. The number of attempts needed for successful cannulation was decreased overall (16 trials, 3302 participants, mean difference (MD) -1.19 attempts, 95% CI -1.45 to -0.92; P value < 0.00001, I? = 96%) and in all subgroups. Use of two-dimensional ultrasound increased the chance of success at the first attempt by 57% (18 trials, 2681 participants, RR 1.57, 95% CI 1.36 to 1.82; P value < 0.00001, I? = 82%) and reduced the chance of haematoma formation (overall reduction 73%, 13 trials, 3233 participants, RR 0.27, 95% CI 0.13 to 0.55; P value 0.0004, I? = 54%). Use of two-dimensional ultrasound decreased the time to successful cannulation by 30.52 seconds (MD -30.52 seconds, 95% CI -55.21 to -5.82; P value 0.02, I? = 97%). Additional data are available to support use of ultrasound during, not simply before, line insertion.Use of Doppler ultrasound increased the chance of success at the first attempt by 58% (four trials, 199 participants, RR 1.58, 95% CI 1.02 to 2.43; P value 0.04, I? = 57%). No evidence showed a difference for the total numbers of perioperative and postoperative complications/adverse events (three trials, 93 participants, RR 0.52, 95% CI 0.16 to 1.71; P value 0.28), the overall success rate (seven trials, 289 participants, RR 1.09, 95% CI 0.95 to 1.25; P value 0.20), the total number of attempts until success (two trials, 69 participants, MD -0.63, 95% CI -1.92 to 0.66; P value 0.34), the overall number of participants with an arterial puncture (six trials, 213 participants, RR 0.61, 95% CI 0.21 to 1.73; P value 0.35) and time to successful cannulation (five trials, 214 participants, each using a different definition for this outcome; MD 62.04 seconds, 95% CI -13.47 to 137.55; P value 0.11) when Doppler ultrasound was used. It was not possible to perform analyses for the other outcomes because they were reported in only one trial.\nAUTHORS' CONCLUSIONS: Based on available data, we conclude that two-dimensional ultrasound offers gains in safety and quality when compared with an anatomical landmark technique. Because of missing data, we did not compare effects with experienced versus inexperienced operators for all outcomes (arterial puncture, haematoma formation, other complications, success with attempt number one), and so the relative utility of ultrasound in these groups remains unclear and no data are available on use of this technique in patients at high risk of complications. The results for Doppler ultrasound techniques versus anatomical landmark techniques are also uncertain.","DOI":"10.1002/14651858.CD006962.pub2","ISSN":"1469-493X","note":"PMID: 25575244","journalAbbreviation":"Cochrane Database Syst Rev","language":"eng","author":[{"family":"Brass","given":"Patrick"},{"family":"Hellmich","given":"Martin"},{"family":"Kolodziej","given":"Laurentius"},{"family":"Schick","given":"Guido"},{"family":"Smith","given":"Andrew F."}],"issued":{"date-parts":[["2015",1,9]]}}},{"id":8585,"uris":[""],"uri":[""],"itemData":{"id":8585,"type":"article-journal","title":"Ultrasound guidance versus anatomical landmarks for subclavian or femoral vein catheterization","container-title":"Cochrane Database Syst Rev","page":"CD011447","volume":"1","abstract":"BACKGROUND: Central venous catheters can help with diagnosis and treatment of the critically ill. The catheter may be placed in a large vein in the neck (internal jugular vein), upper chest (subclavian vein) or groin (femoral vein). Whilst this is beneficial overall, inserting the catheter risks arterial puncture and other complications and should be performed in as few attempts as possible.In the past, anatomical 'landmarks' on the body surface were used to find the correct place to insert these catheters, but ultrasound imaging is now available. A Doppler mode is sometimes used to supplement plain 'two-dimensional' ultrasound. OBJECTIVES: The primary objective of this review was to evaluate the effectiveness and safety of two-dimensional ultrasound (US)- or Doppler ultrasound (USD)-guided puncture techniques for subclavian vein, axillary vein and femoral vein puncture during central venous catheter insertion in adults and children. We assessed whether there was a difference in complication rates between traditional landmark-guided and any ultrasound-guided central vein puncture.When possible, we also assessed the following secondary objectives: whether a possible difference could be verified with use of the US technique versus the USD technique; whether there was a difference between using ultrasound throughout the puncture ('direct') and using it only to identify and mark the vein before starting the puncture procedure ('indirect'); and whether these possible differences might be evident in different groups of patients or with different levels of experience among those inserting the catheters. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 1), MEDLINE (1966 to 15 January 2013), EMBASE (1966 to 15 January 2013), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 15 January 2013), reference lists of articles, 'grey literature' and dissertations. An additional handsearch focused on intensive care and anaesthesia journals and abstracts and proceedings of scientific meetings. We attempted to identify unpublished or ongoing studies by contacting companies and experts in the field, and we searched trial registers. We reran the search in August 2014. We will deal with any studies of interest when we update the review. SELECTION CRITERIA: Randomized and quasi-randomized controlled trials comparing two-dimensional ultrasound or Doppler ultrasound versus an anatomical 'landmark' technique during insertion of subclavian or femoral venous catheters in both adults and children. DATA COLLECTION AND ANALYSIS: Three review authors independently extracted data on methodological quality, participants, interventions and outcomes of interest using a standardized form. We performed a priori subgroup analyses. MAIN RESULTS: Altogether 13 studies enrolling 2341 participants (and involving 2360 procedures) fulfilled the inclusion criteria. The quality of evidence was very low (subclavian vein N = 3) or low (subclavian vein N = 4, femoral vein N = 2) for most outcomes, moderate for one outcome (femoral vein) and high at best for two outcomes (subclavian vein N = 1, femoral vein N = 1). Most of the trials had unclear risk of bias across the six domains, and heterogeneity among the studies was significant.For the subclavian vein (nine studies, 2030 participants, 2049 procedures), two-dimensional ultrasound reduced the risk of inadvertent arterial puncture (three trials, 498 participants, risk ratio (RR) 0.21, 95% confidence interval (CI) 0.06 to 0.82; P value 0.02, I(2) = 0%) and haematoma formation (three trials, 498 participants, RR 0.26, 95% CI 0.09 to 0.76; P value 0.01, I(2) = 0%). No evidence was found of a difference in total or other complications (together, US, USD), overall (together, US, USD), number of attempts until success (US) or first-time (US) success rates or time taken to insert the catheter (US).For the femoral vein, fewer data were available for analysis (four studies, 311 participants, 311 procedures). No evidence was found of a difference in inadvertent arterial puncture or other complications. However, success on the first attempt was more likely with ultrasound (three trials, 224 participants, RR 1.73, 95% CI 1.34 to 2.22; P value < 0.0001, I(2) = 31%), and a small increase in the overall success rate was noted (RR 1.11, 95% CI 1.00 to 1.23; P value 0.06, I(2) = 50%). No data on mortality or participant-reported outcomes were provided. AUTHORS' CONCLUSIONS: On the basis of available data, we conclude that two-dimensional ultrasound offers small gains in safety and quality when compared with an anatomical landmark technique for subclavian (arterial puncture, haematoma formation) or femoral vein (success on the first attempt) cannulation for central vein catheterization. Data on insertion by inexperienced or experienced users, or on patients at high risk for complications, are lacking. The results for Doppler ultrasound techniques versus anatomical landmark techniques are uncertain.","DOI":"10.1002/14651858.cd011447","ISSN":"1469-493X (Electronic) 1361-6137 (Linking)","journalAbbreviation":"The Cochrane database of systematic reviews","language":"eng","author":[{"family":"Brass","given":"P."},{"family":"Hellmich","given":"M."},{"family":"Kolodziej","given":"L."},{"family":"Schick","given":"G."},{"family":"Smith","given":"A. F."}],"issued":{"date-parts":[["2015"]]}}}],"schema":""} 95,96 Ultrasound is used to survey the target vessel(s) and surrounding structures, and several studies have elucidated the anatomic variations between the internal jugular vein (IJV) and common carotid artery (CCA). ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"LGpLezSb","properties":{"formattedCitation":"\\super 97\\nosupersub{}","plainCitation":"97","noteIndex":0},"citationItems":[{"id":3840,"uris":[""],"uri":[""],"itemData":{"id":3840,"type":"article-journal","title":"Anatomical variations of internal jugular vein location: impact on central venous access","container-title":"Critical Care Medicine","page":"1516-9","volume":"19","issue":"12","abstract":"OBJECTIVE: To evaluate whether underlying anatomical variations in the position of the internal jugular vein may account for difficulty in obtaining central venous access in individual patients. DESIGN: Consecutive series. SETTING: Cardiac catheterization laboratory, coronary care unit, and ICU. PATIENTS: Two hundred patients (52 +/- 7 yrs, 147 males) who were undergoing internal jugular vein cannulation for hemodynamic monitoring or endomyocardial biopsy. INTERVENTION: The internal jugular vein and carotid artery were visualized with two-dimensional ultrasound and their position was compared with their projected location from external landmarks. RESULTS: In 183 (92%) patients, the position of the internal jugular vein was lateral and anterior to the carotid artery and increased in diameter during a Valsalva maneuver. In five (2.5%) patients, the internal jugular vein was not visualized and was probably thrombosed, as the internal jugular vein was normal on the other side. In six (3%) patients, the internal jugular vein was unusually small and did not increase in diameter during the Valsalva maneuver. In two (1%) patients, the internal jugular vein was positioned greater than 1 cm lateral to the carotid artery. Four (2%) patients had a medially positioned internal jugular vein overlying the carotid artery. In 5.5% of the patients, the position of the internal jugular vein was outside the path that had been predicted by the external landmarks. CONCLUSIONS: These findings suggest that anatomical variation may partly account for the inability to cannulate the internal jugular vein in certain patients. In these cases, ultrasound examination quickly establishes the position of the internal jugular vein and may allow for easy and rapid access.","ISSN":"0090-3493 (Print) 0090-3493","journalAbbreviation":"Crit. Care Med.","language":"eng","author":[{"family":"Denys","given":"B. G."},{"family":"Uretsky","given":"B. F."}],"issued":{"date-parts":[["1991",12]]}}}],"schema":""} 97 Moreover, in one study 75% of hemodialysis patients had sonographic venous abnormalities (such as thrombosis) that required a change in venous access approach, especially in patients with previous catheters. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"fgvvUyXs","properties":{"formattedCitation":"\\super 98\\nosupersub{}","plainCitation":"98","noteIndex":0},"citationItems":[{"id":4178,"uris":[""],"uri":[""],"itemData":{"id":4178,"type":"article-journal","title":"Importance of US findings in access planning during jugular vein hemodialysis catheter placements","container-title":"Journal of Vascular and Interventional Radiology","page":"233-8","volume":"11","issue":"2 Pt 1","abstract":"PURPOSE: To evaluate the significance of internal jugular vein ultrasound (US) findings in long-term hemodialysis patients and to assess how frequently these findings lead to a change in access approach. MATERIALS AND METHODS: One hundred consecutive hemodialysis catheter placements in 79 patients were retrospectively analyzed. Prior to catheter insertion, each patient underwent an US examination of the proposed access site by an interventional radiologist or interventional radiology fellow. The examinations were recorded on VHS tapes. The procedure notes, dictated radiology reports, and VHS tapes were reviewed for evidence of total occlusion, non-occlusive thrombus, presence of venous collaterals, stenosis, or variation in normal anatomy. The number of months that the patient required hemodialysis prior to catheter placement was also noted. RESULTS: Significant US findings were present in 28 patients (35%). Findings included total occlusion (n = 18), non-occlusive thrombus (n = 11), stenosis (n = 5), and anatomic variation (n = 1). These required a change in access approach in 21 patients. Unexpectedly, 54% of the patients with US findings had been undergoing dialysis for 12 months or less. CONCLUSION: These results underscore the importance of sonography in planning and performing vascular access procedures. A thorough US examination of the internal jugular veins is warranted prior to hemodialysis catheter placement, especially in patients with previous temporary or tunneled catheters. Three-quarters of patients with sonographic abnormalities required a change in access approach.","ISSN":"1051-0443 (Print) 1051-0443","journalAbbreviation":"J. Vasc. Interv. Radiol.","language":"eng","author":[{"family":"Forauer","given":"A. R."},{"family":"Glockner","given":"J. F."}],"issued":{"date-parts":[["2000",2]]}}}],"schema":""} 98 Ultrasound can also be used to visualize the guidewire in the lumen of the target vein with high sensitivity prior to dilation. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"DbTrWLWM","properties":{"formattedCitation":"\\super 99,100\\nosupersub{}","plainCitation":"99,100","noteIndex":0},"citationItems":[{"id":6637,"uris":[""],"uri":[""],"itemData":{"id":6637,"type":"article-journal","title":"Needle and guidewire visualization in ultrasound-guided internal jugular vein cannulation","container-title":"American Journal of Emergency Medicine","page":"432-6","volume":"29","issue":"4","abstract":"STUDY OBJECTIVE: Reimbursement for ultrasound-guided central lines requires documenting the needle entering the vessel lumen. We hypothesized that physicians often successfully perform ultrasound-guided internal jugular (IJ) cannulation without visualizing the needle in the lumen and that guidewire visualization occurs more frequently. METHODS: This prospective, observational study enrolled emergency physicians performing ultrasound-guided IJ cannulations over an 8-month period. Physicians reported sonographic visualization of the needle or guidewire and recorded DVD images for subsequent review. Outcome measures were the proportion of successful procedures in which the operator reported seeing the needle or guidewire in the vessel lumen and the proportion of successful, recorded procedures, in which a reviewer noted the same findings. Procedures were deemed successful when functioning central venous catheters were placed. Fisher exact test was used for comparisons. RESULTS: Of 41 attempted catheterizations, 35 (85.4%) were successful. Eighteen of these were recorded on DVD for review. The operator reported visualizing the needle within the vessel lumen in 23 (65.7%) of 35 successful cannulations (95% confidence interval [CI], 47.7%-80.3%). In 27 cases, the operator attempted to view the guidewire and reported doing so in 24 cases (88.9%; 95% CI, 69.7%-97.1%). On expert review, the needle was seen penetrating the vessel lumen in 1 (5.6%) of 18 cases (95% CI, 0.3%-29.4%). Among recorded procedures in which the operator also attempted wire visualization, the reviewer could identify the wire within the vessel lumen in 12 (75.0%) of 16 cases (95% CI, 47.4%-91.7%). CONCLUSIONS: During successful ultrasound-guided IJ cannulation, physicians can visualize the guidewire more readily than the needle.","DOI":"10.1016/j.ajem.2010.01.004","ISSN":"0735-6757","journalAbbreviation":"Am. J. Emerg. Med.","language":"eng","author":[{"family":"Moak","given":"J. H."},{"family":"Lyons","given":"M. S."},{"family":"Wright","given":"S. W."},{"family":"Lindsell","given":"C. J."}],"issued":{"date-parts":[["2011",5]]}}},{"id":6284,"uris":[""],"uri":[""],"itemData":{"id":6284,"type":"article-journal","title":"Ultrasound detection of guidewire position during central venous catheterization","container-title":"American Journal of Emergency Medicine","page":"82-4","volume":"28","issue":"1","abstract":"INTRODUCTION: Ultrasound guidance decreases complications of central venous catheter (CVC) placement, but risks of arterial puncture and inadvertent arterial catheter placement exist. Ultrasound-assisted detection of guidewire position in the internal jugular vein could predict correct catheter position before dilation and catheter placement. METHODS: Ultrasound examinations were performed in an attempt to identify the guidewire before dilation and catheter insertion in 20 adult patients requiring CVC placement. Central venous pressures were measured after completion of the procedure. RESULTS: Guidewires were visible within the lumen of the internal jugular vein in all subjects. Central venous pressures confirmed venous placement of catheters. Ultrasound visualization of the guidewire predicted venous CVC placement with 100% sensitivity (95% confidence interval 80-100%) and 100% specificity (95% confidence interval 80%-100%). CONCLUSIONS: Ultrasound reliably detects the guidewire during CVC placement and visualization of the wire before dilation and catheter insertion may provide an additional measure of safety during ultrasound-guided CVC placement.","DOI":"10.1016/j.ajem.2008.09.019","ISSN":"0735-6757","journalAbbreviation":"Am. J. Emerg. Med.","language":"eng","author":[{"family":"Stone","given":"M. B."},{"family":"Nagdev","given":"A."},{"family":"Murphy","given":"M. C."},{"family":"Sisson","given":"C. A."}],"issued":{"date-parts":[["2010",1]]}}}],"schema":""} 99,100 Post-procedure pneumothorax can be ruled out with high sensitivity using a high-frequency linear-array transducer to detect bilateral lung sliding following a neck or chest cannulation. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Mewh8GmC","properties":{"formattedCitation":"\\super 47,58,59,101\\nosupersub{}","plainCitation":"47,58,59,101","noteIndex":0},"citationItems":[{"id":7214,"uris":[""],"uri":[""],"itemData":{"id":7214,"type":"article-journal","title":"Pleural ultrasonography versus chest radiography for the diagnosis of pneumothorax: review of the literature and meta-analysis","container-title":"Critical Care (London, England)","page":"R208","volume":"17","issue":"5","abstract":"INTRODUCTION: Ultrasonography is being increasingly utilized in acute care settings with expanding applications. Pneumothorax evaluation by ultrasonography is a fast, safe, easy and inexpensive alternative to chest radiographs. In this review, we provide a comprehensive analysis of the current literature comparing ultrasonography and chest radiography for the diagnosis of pneumothorax. METHODS: We searched English-language articles in MEDLINE, EMBASE and Cochrane Library dealing with both ultrasonography and chest radiography for diagnosis of pneumothorax. In eligible studies that met strict inclusion criteria, we conducted a meta-analysis to evaluate the diagnostic accuracy of pleural ultrasonography in comparison with chest radiography for the diagnosis of pneumothorax. RESULTS: We reviewed 601 articles and selected 25 original research articles for detailed review. Only 13 articles met all of our inclusion criteria and were included in the final analysis. One study used lung sliding sign alone, 12 studies used lung sliding and comet tail signs, and 6 studies searched for lung point in addition to the other two signs. Ultrasonography had a pooled sensitivity of 78.6% (95% CI, 68.1 to 98.1) and a specificity of 98.4% (95% CI, 97.3 to 99.5). Chest radiography had a pooled sensitivity of 39.8% (95% CI, 29.4 to 50.3) and a specificity of 99.3% (95% CI, 98.4 to 100). Our meta-regression and subgroup analyses indicate that consecutive sampling of patients compared to convenience sampling provided higher sensitivity results for both ultrasonography and chest radiography. Consecutive versus nonconsecutive sampling and trauma versus nontrauma settings were significant sources of heterogeneity. In addition, subgroup analysis showed significant variations related to operator and type of probe used. CONCLUSIONS: Our study indicates that ultrasonography is more accurate than chest radiography for detection of pneumothorax. The results support the previous investigations in this field, add new valuable information obtained from subgroup analysis, and provide accurate estimates for the performance parameters of both bedside ultrasonography and chest radiography for pneumothorax evaluation.","DOI":"10.1186/cc13016","ISSN":"1466-609X (Electronic) 1364-8535 (Linking)","journalAbbreviation":"Crit. Care","language":"Eng","author":[{"family":"Alrajab","given":"S."},{"family":"Youssef","given":"A. M."},{"family":"Akkus","given":"N. I."},{"family":"Caldito","given":"G."}],"issued":{"date-parts":[["2013",9,23]]}}},{"id":6469,"uris":[""],"uri":[""],"itemData":{"id":6469,"type":"article-journal","title":"Diagnosis of pneumothorax by radiography and ultrasonography: a meta-analysis","container-title":"Chest","page":"859-66","volume":"140","issue":"4","abstract":"OBJECTIVE: This study compares, by meta-analysis, the use of anterior-posterior chest radiography (CR) with transthoracic ultrasonography for the diagnosis of pneumothorax. METHODS: English-language articles on the performance of CR and ultrasonography in the diagnosis of a pneumothorax were selected. In eligible studies, data were recalculated, and the forest plots and summary receiver operating characteristic (sROC) curves were analyzed. RESULTS: Pooled sensitivity and specificity were 0.88 and 0.99, respectively, for ultrasonography, and 0.52 and 1.00, respectively, for CR. For ultrasonography performed by clinicians other than radiologists, pooled sensitivity and specificity were 0.89 and 0.99, respectively. The sROC areas under the curve were compared, and no significant differences between ultrasonography and CR were found. Meta-regression analysis implied that the operator is strongly associated with accuracy (relative diagnostic OR, 0.21; 95% CI, 0.05-0.96; P = .0455). CONCLUSIONS: The meta-analysis indicated that bedside ultrasonography performed by clinicians had higher sensitivity and similar specificity compared with CR in the diagnosis of pneumothorax, but the accuracy of ultrasonography in the diagnosis of pneumothorax depended on the skill of the operators.","DOI":"10.1378/chest.10-2946","ISSN":"1931-3543 (Electronic) 0012-3692 (Linking)","journalAbbreviation":"Chest","language":"eng","author":[{"family":"Ding","given":"W."},{"family":"Shen","given":"Y."},{"family":"Yang","given":"J."},{"family":"He","given":"X."},{"family":"Zhang","given":"M."}],"issued":{"date-parts":[["2011",10]]}}},{"id":6784,"uris":[""],"uri":[""],"itemData":{"id":6784,"type":"article-journal","title":"Test characteristics of ultrasonography for the detection of pneumothorax: a systematic review and meta-analysis","container-title":"Chest","page":"703-8","volume":"141","issue":"3","abstract":"BACKGROUND: A pneumothorax is a potentially life-threatening condition. Although CT scan is the reference standard for diagnosis, chest radiographs are commonly used to rule out the diagnosis. We compared the test characteristics of ultrasonography and supine chest radiography in adult patients clinically suspected of having a pneumothorax, using CT scan or release of air on chest tube placement as reference standard. METHODS: We searched for English literature in MEDLINE and EMBASE and performed hand searches. Two independent investigators used standardized forms to review articles for inclusion, quality (QUADAS tool), and data extraction. We calculated kappa agreement for study selection and evaluated clinical and quality homogeneity before meta-analysis. RESULTS: We reviewed 570 articles and selected 21 for full review (kappa, 0.89); eight articles (total of 1,048 patients) met all inclusion criteria (kappa, 0.81). All studies but one used the ultrasonographic signs of lung sliding and comet tail to rule out pneumothorax. Chest radiography data were available for 864 of 1,048 patients evaluated with ultrasonography. Ultrasonography was 90.9% sensitive (95% CI, 86.5-93.9) and 98.2% specific (95% CI, 97.0-99.0) for the detection of pneumothorax. Chest radiography was 50.2% sensitive (95% CI, 43.5-57.0) and 99.4% specific (95% CI, 98.3-99.8). CONCLUSIONS: Performance of ultrasonography for the detection of pneumothorax is excellent and is superior to supine chest radiography. Considering the rapid access to bedside ultrasonography and the excellent performance of this simple test, this study supports the routine use of ultrasonography for the detection of pneumothorax.","DOI":"10.1378/chest.11-0131","ISSN":"1931-3543 (Electronic) 0012-3692 (Linking)","journalAbbreviation":"Chest","language":"eng","author":[{"family":"Alrajhi","given":"K."},{"family":"Woo","given":"M. Y."},{"family":"Vaillancourt","given":"C."}],"issued":{"date-parts":[["2012",3]]}}},{"id":9414,"uris":[""],"uri":[""],"itemData":{"id":9414,"type":"article-journal","title":"Diagnostic Accuracy of Central Venous Catheter Confirmation by Bedside Ultrasound Versus Chest Radiography in Critically Ill Patients: A Systematic Review and Meta-Analysis","container-title":"Critical Care Medicine","page":"715-724","volume":"45","issue":"4","abstract":"OBJECTIVE: We performed a systematic review and meta-analysis to examine the accuracy of bedside ultrasound for confirmation of central venous catheter position and exclusion of pneumothorax compared with chest radiography. DATA SOURCES: PubMed, Embase, Cochrane Central Register of Controlled Trials, reference lists, conference proceedings and . STUDY SELECTION: Articles and abstracts describing the diagnostic accuracy of bedside ultrasound compared with chest radiography for confirmation of central venous catheters in sufficient detail to reconstruct 2 x 2 contingency tables were reviewed. Primary outcomes included the accuracy of confirming catheter positioning and detecting a pneumothorax. Secondary outcomes included feasibility, interrater reliability, and efficiency to complete bedside ultrasound confirmation of central venous catheter position. DATA EXTRACTION: Investigators abstracted study details including research design and sonographic imaging technique to detect catheter malposition and procedure-related pneumothorax. Diagnostic accuracy measures included pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio. DATA SYNTHESIS: Fifteen studies with 1,553 central venous catheter placements were identified with a pooled sensitivity and specificity of catheter malposition by ultrasound of 0.82 (0.77-0.86) and 0.98 (0.97-0.99), respectively. The pooled positive and negative likelihood ratios of catheter malposition by ultrasound were 31.12 (14.72-65.78) and 0.25 (0.13-0.47). The sensitivity and specificity of ultrasound for pneumothorax detection was nearly 100% in the participating studies. Bedside ultrasound reduced mean central venous catheter confirmation time by 58.3 minutes. Risk of bias and clinical heterogeneity in the studies were high. CONCLUSIONS: Bedside ultrasound is faster than radiography at identifying pneumothorax after central venous catheter insertion. When a central venous catheter malposition exists, bedside ultrasound will identify four out of every five earlier than chest radiography.","DOI":"10.1097/ccm.0000000000002188","ISSN":"0090-3493","note":"PMCID: PMC5350032","journalAbbreviation":"Crit. Care Med.","language":"eng","author":[{"family":"Ablordeppey","given":"E. A."},{"family":"Drewry","given":"A. M."},{"family":"Beyer","given":"A. B."},{"family":"Theodoro","given":"D. L."},{"family":"Fowler","given":"S. A."},{"family":"Fuller","given":"B. M."},{"family":"Carpenter","given":"C. R."}],"issued":{"date-parts":[["2017",4]]}}}],"schema":""} 47,58,59,101Peripheral venous line insertion: Ultrasound-guided peripheral IV cannulation is most useful for patients with difficult venous access (patients that have had 2 unsuccessful landmark-based attempts at PIV access or a history of difficult access due to edema, obesity, intravenous drug use, chemotherapy, vasculopathy, or multiple prior hospitalizations). Use of ultrasound guidance reduces procedure time, needle insertion attempts, and needle redirections compared to traditional approaches among patients with difficult venous access. In a study of the placement of PIV catheters in difficult-access patients by emergency physicians, the use of ultrasound guidance for peripheral venous access had higher success rate than traditional “blind” techniques (97% vs. 33%), required less time (13 vs. 30 min), decreased the number of percutaneous punctures (1.7 vs. 3.7), and improved patient satisfaction. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Uqsl2XFN","properties":{"formattedCitation":"\\super 102\\nosupersub{}","plainCitation":"102","noteIndex":0},"citationItems":[{"id":6052,"uris":[""],"uri":[""],"itemData":{"id":6052,"type":"article-journal","title":"Ultrasound-guided peripheral venous access vs. the external jugular vein as the initial approach to the patient with difficult vascular access","container-title":"Journal of Emergency Medicine","page":"462-7","volume":"39","issue":"4","abstract":"BACKGROUND: Traditionally, Emergency Physicians (EPs) have used the external jugular (EJ) vein to gain vascular access in patients who have failed nursing attempts at peripheral access. Recently, some EPs have used ultrasound (USIV) to gain peripheral access. STUDY OBJECTIVE: This study seeks to determine which initial approach by EPs would lead to greater success. METHODS: This was a prospective, randomized study of all adult patients who presented to the Emergency Department (ED) between June and December 2007. Inclusion criteria were failed nursing attempts at peripheral access (at least three). EPs were 2(nd)- or 3(rd)-year residents who had previously performed more than five each of EJs and USIVs. Patients were randomized into either an initial EJ or USIV approach. RESULTS: Sixty patients were enrolled, 32 in the ultrasound group, 28 in the EJ group. Fifteen different EPs performed access. Initial Success: USIV 84% (95% confidence interval [CI] 68-93%) vs. EJ 50% (95% CI 33-67%), p = 0.006. Success if EJ visible: USIV 84% vs. EJ 66% (p = 0.18). Overall success, including data from the crossover pathway: a total of 41 lines were successfully placed by ultrasound out of 46 attempts (89%) vs. 18 out of 33 for EJ (55%), p = 0.001. In total, 59/60 patients (98%) had a peripheral i.v. successfully placed. The percentage of functioning lines when the patient left the ED was: USIV 89% (95% CI 72-96%) vs. EJ 93% (95% CI 68-98%), p = 0.88. CONCLUSION: As an initial approach to all patients with difficult venous access, ultrasound-guided peripheral lines are superior to the EJ approach. However if the EJ was visible, there was no difference in success among the initial approaches. Both techniques, when used together, could achieve peripheral vascular access in 98% of difficult access patients.","DOI":"10.1016/j.jemermed.2009.02.004","ISSN":"0736-4679 (Print) 0736-4679","journalAbbreviation":"J. Emerg. Med.","language":"eng","author":[{"family":"Costantino","given":"T. G."},{"family":"Kirtz","given":"J. F."},{"family":"Satz","given":"W. A."}],"issued":{"date-parts":[["2010",10]]}}}],"schema":""} 102 In a study with pediatric patients with difficult venous access, use of ultrasound increased overall success rate (80% vs 64%), reduced total procedure time (6.3 vs 14.4 minutes), required fewer attempts (1 vs 3), and had fewer needle redirections (2 vs 10). ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"GFavZsAT","properties":{"formattedCitation":"\\super 103\\nosupersub{}","plainCitation":"103","noteIndex":0},"citationItems":[{"id":5727,"uris":[""],"uri":[""],"itemData":{"id":5727,"type":"article-journal","title":"Randomized controlled trial of ultrasound-guided peripheral intravenous catheter placement versus traditional techniques in difficult-access pediatric patients","container-title":"Pediatric Emergency Care","page":"154-9","volume":"25","issue":"3","abstract":"OBJECTIVES: We hypothesized that the use of ultrasound guidance would improve the success rate of peripheral intravenous catheter placement in pediatric patients with difficult access in a pediatric emergency department (ED). Our secondary hypotheses were that ultrasound guidance would reduce the number of attempts, the number of needle redirections, and the overall time to catheter placement. METHODS: This was a prospective randomized study of pediatric ED patients younger than 10 years old requiring intravenous access, presenting between August 2006 and May 2007. Inclusion criteria were 2 unsuccessful traditional attempts at peripheral intravenous access or history of difficult access. Exclusion was critical illness or instability. Patients were randomized to undergo peripheral intravenous catheter placement using continued traditional approaches or real-time, dual-operator ultrasound-guided technique. Measured outcomes were success of cannulation, number of attempts, number of needle redirections, and overall time to catheter placement. RESULTS: Fifty patients were enrolled, with 25 patients randomized to each group. The overall success rates for the ultrasound-guided group were 80% and for the traditional-attempts group, 64%, with a difference in proportions of 16% (95% confidence interval, -9% to 38%, P = 0.208). The ultrasound-guided group required less overall time (6.3 vs 14.4 minutes, difference of -8.1 minutes [95% confidence interval, -12.5 to -3.6], P = 0.001), fewer attempts (median, 1 vs 3; P = 0.004), and fewer needle redirections (median, 2 vs 10; P G 0.0001) than traditional approaches. CONCLUSIONS: In a sample of pediatric ED patients with difficult access, ultrasound-guided intravenous cannulation required less overall time, fewer attempts, and fewer needle redirections than traditional approaches.","DOI":"10.1097/PEC.0b013e31819a8946","ISSN":"0749-5161","journalAbbreviation":"Pediatr. Emerg. Care","language":"eng","author":[{"family":"Doniger","given":"S. J."},{"family":"Ishimine","given":"P."},{"family":"Fox","given":"J. C."},{"family":"Kanegaye","given":"J. T."}],"issued":{"date-parts":[["2009",3]]}}}],"schema":""} 103Arterial Line Insertion: Several randomized controlled trials have assessed the value of ultrasound guidance for arterial catheter insertion. Shiver et al randomized 60 patients admitted to a tertiary center emergency department to either palpation or ultrasound-guided arterial cannulation. They demonstrated a first-pass success rate of 87% in the ultrasound group compared with 50% in the landmark technique group. In the same study, the use of ultrasound was also associated with reduced time to establish arterial access and a 43% reduction in development of hematoma at the insertion site. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"qytjeTjM","properties":{"formattedCitation":"\\super 104\\nosupersub{}","plainCitation":"104","noteIndex":0},"citationItems":[{"id":5115,"uris":[""],"uri":[""],"itemData":{"id":5115,"type":"article-journal","title":"A prospective comparison of ultrasound-guided and blindly placed radial arterial catheters","container-title":"Academic Emergency Medicine","page":"1275-9","volume":"13","issue":"12","abstract":"BACKGROUND: Arterial cannulation for continuous blood-pressure measurement and frequent arterial-blood sampling commonly are required in critically ill patients. OBJECTIVES: To compare ultrasound (US)-guided versus traditional palpation placement of arterial lines for time to placement, number of attempts, sites used, and complications. METHODS: This was a prospective, randomized interventional study at a Level 1 academic urban emergency department with an annual census of 78,000 patients. Patients were randomized to either palpation or US-guided groups. Inclusion criteria were any adult patient who required an arterial line according to the treating attending. Patients who had previous attempts at an arterial line during the visit, or who could not be randomized because of time constraints, were excluded. Enrollment was on a convenience basis, during hours worked by researchers over a six-month period. Patients in either group who had three failed attempts were rescued with the other technique for patient comfort. Statistical analysis included Fisher's exact, Mann-Whitney, and Student's t-tests. RESULTS: Sixty patients were enrolled, with 30 patients randomized to each group. Patients randomized to the US group had a shorter time required for arterial line placement (107 vs. 314 seconds; difference, 207 seconds; p = 0.0004), fewer placement attempts (1.2 vs. 2.2; difference, 1; p = 0.001), and fewer sites required for successful line placement (1.1 vs. 1.6; difference, 0.5; p = 0.001), as compared with the palpation group. CONCLUSIONS: In this study, US guidance for arterial cannulation was successful more frequently and it took less time to establish the arterial line as compared with the palpation method.","DOI":"10.1197/j.aem.2006.07.015","ISSN":"1069-6563","journalAbbreviation":"Acad. Emerg. Med.","language":"eng","author":[{"family":"Shiver","given":"S."},{"family":"Blaivas","given":"M."},{"family":"Lyon","given":"M."}],"issued":{"date-parts":[["2006",12]]}}}],"schema":""} 104 Levin et al demonstrated a first-pass success rate of 62% using ultrasound versus 34% by palpation alone in 69 patients requiring intra-operative invasive hemodynamic monitoring. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"6DrO0y1u","properties":{"formattedCitation":"\\super 105\\nosupersub{}","plainCitation":"105","noteIndex":0},"citationItems":[{"id":4490,"uris":[""],"uri":[""],"itemData":{"id":4490,"type":"article-journal","title":"Use of ultrasound guidance in the insertion of radial artery catheters","container-title":"Critical Care Medicine","page":"481-4","volume":"31","issue":"2","abstract":"OBJECTIVE: To assess the role of a portable ultrasound device in the insertion of radial artery catheters. DESIGN: Prospective, randomized, comparative study. SETTING: Tertiary university hospital. PATIENTS: Elective surgery patients requiring arterial catheter insertion for intraoperative monitoring. INTERVENTIONS: A portable ultrasound device was used to visualize the radial artery at the wrist and to direct arterial catheter insertion. This new technique of arterial catheter insertion was compared with the classic palpation technique. MEASUREMENTS AND MAIN RESULTS: A total of 69 patients requiring an arterial catheter were randomized to either the ultrasound (34 patients) or palpation technique (35 patients). The time taken from skin puncture to successful arterial catheter insertion, the time taken per insertion attempt, the number of attempts required, and the number of cannulae used were recorded for each group. The arterial cannula was inserted on the first attempt in 21 (62%) cases using ultrasound vs. 12 (34%) cases by palpation (p =.03). Significantly fewer attempts were required for catheter insertion using ultrasound as compared with palpation (mean +/- sd, 1.6 +/- 1.0 vs. 3.1 +/- 2.4; p=.003); however, the time taken for each successful attempt was longer (26.1 +/- 2.0 vs. 17.3 +/- 1.6 secs, p=.001). A trend toward shorter overall time required for catheter insertion was found for the ultrasound group (55.5 +/- 63.8 vs. 111.5 +/- 121.5 secs, p=.17). There were four failures in the ultrasound group and one in the palpation group (not significant). CONCLUSIONS: Ultrasound is a useful adjunct to arterial catheter insertion and increases the rate of success at first attempt. The technique is easy to learn and may reduce the time taken to insert the catheter.","DOI":"10.1097/m.0000050452.17304.2f","ISSN":"0090-3493 (Print) 0090-3493","journalAbbreviation":"Crit. Care Med.","language":"eng","author":[{"family":"Levin","given":"P. D."},{"family":"Sheinin","given":"O."},{"family":"Gozal","given":"Y."}],"issued":{"date-parts":[["2003",2]]}}}],"schema":""} 105 A meta-analysis, including 4 trials and 311 patients showed that ultrasound guidance for arterial catheterization was associated with a 71% improvement in the likelihood of first pass successful attempt (relative risk: 1.71, 95% CI 1.25-2.32). ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"xyFFEjAD","properties":{"formattedCitation":"\\super 106\\nosupersub{}","plainCitation":"106","noteIndex":0},"citationItems":[{"id":6728,"uris":[""],"uri":[""],"itemData":{"id":6728,"type":"article-journal","title":"Ultrasound-guided catheterization of the radial artery: a systematic review and meta-analysis of randomized controlled trials","container-title":"Chest","page":"524-9","volume":"139","issue":"3","abstract":"BACKGROUND: Ultrasound guidance commonly is used for the placement of central venous catheters (CVCs). The Agency for Healthcare Research and Quality recommends the use of ultrasound for CVC placement as one of its 11 practices to improve patient care. Despite increased access to portable ultrasound machines and comfort with ultrasound-guided CVC access, fewer clinicians are familiar with ultrasound-guided techniques of arterial catheterization. The goal of this systematic review and meta-analysis was to determine the utility of real-time two-dimensional ultrasound guidance for radial artery catheterization. METHODS: A comprehensive literature search of Medline, Excerpta Medica Database, and the Cochrane Central Register of Controlled Trials by two independent reviewers identified prospective, randomized controlled trials comparing ultrasound guidance with traditional palpation techniques of radial artery catheterization. Data were extracted on study design, study size, operator and patient characteristics, and the rate of first-attempt success. A meta-analysis was constructed to analyze the data. RESULTS: Four trials with a total of 311 subjects were included in the review, with 152 subjects included in the palpation group and 159 in the ultrasound-guided group. Compared with the palpation method, ultrasound guidance for arterial catheterization was associated with a 71% improvement in the likelihood of first-attempt success (relative risk, 1.71; 95% CI, 1.25-2.32). CONCLUSIONS: The use of real-time two-dimensional ultrasound guidance for radial artery catheterization improved first-pass success rate.","DOI":"10.1378/chest.10-0919","ISSN":"1931-3543 (Electronic) 0012-3692 (Linking)","journalAbbreviation":"Chest","language":"eng","author":[{"family":"Shiloh","given":"A. L."},{"family":"Savel","given":"R. H."},{"family":"Paulin","given":"L. M."},{"family":"Eisen","given":"L. A."}],"issued":{"date-parts":[["2011",3]]}}}],"schema":""} 106 Another meta-analysis that analyzed seven RCT’s with 482 patients showed that ultrasound guidance significantly increased first-attempt success rates of radial artery catheterization (RR 1.51; 95%CI 1.07-2.14, P=0.02). Ultrasound guidance significantly reduced mean attempts to success, mean time to successful cannulation, and risk of hematoma (RR 0.17, 95%CI 0.07-0.41; P=0.0001). ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"GiG4hIPw","properties":{"formattedCitation":"\\super 107\\nosupersub{}","plainCitation":"107","noteIndex":0},"citationItems":[{"id":8410,"uris":[""],"uri":[""],"itemData":{"id":8410,"type":"article-journal","title":"Ultrasound guidance for radial artery catheterization: an updated meta-analysis of randomized controlled trials","container-title":"PloS One","page":"e111527","volume":"9","issue":"11","abstract":"BACKGROUND: Since a previous meta-analysis reported that ultrasound guidance was associated with a higher first-attempt success rate in catheterization of the radial artery, a number of randomized controlled trials (RCTs) have reported inconsistent results. The aim of the present study is to conduct an updated meta-analysis to clarify the role of ultrasound guidance for radial artery catheterization. METHODS: A systematic literature search of PubMed, Embase, and Cochrane Central Register of Controlled Trials was conducted using specific search terms. Eligible studies were RCTs that compared ultrasound guidance with traditional palpation for radial artery catheterization. The Mantel-Haenszel method using the random effects model was adopted in this meta-analysis. RESULTS: Seven RCTs with 482 patients were included. Compared with traditional palpation, ultrasound guidance significantly increased the first-attempt success rate of radial artery catheterization (RR 1.51, 95% CI 1.07-2.14, P = 0.02). Subgroup analyses suggested that the superiority of ultrasound guidance for radial artery catheterization was significant when the technique was operated by experienced users, performed in small children and infants, and on elective procedures in the operating room. In addition, ultrasound guidance significantly reduced mean-attempts to success (WMD -1.13, 95% CI -1.58 to -0.69, P<0.00001), mean-time to success (WMD -74.77s, 95% CI -137.89s to -11.64s, P = 0.02), and the occurrence of hematoma (RR 0.17, 95% CI 0.07-0.41, P = 0.0001). CONCLUSIONS: The present meta-analysis suggests a clear benefit from ultrasound guidance for radial artery catheterization compared with the traditional palpation. Preliminary training and familiarization with the ultrasound-guided technique is needed before applying it for radial artery catheterization, especially for inexperienced operators.","DOI":"10.1371/journal.pone.0111527","ISSN":"1932-6203","note":"PMCID: Pmc4222952","journalAbbreviation":"PLoS One","language":"eng","author":[{"family":"Tang","given":"L."},{"family":"Wang","given":"F."},{"family":"Li","given":"Y."},{"family":"Zhao","given":"L."},{"family":"Xi","given":"H."},{"family":"Guo","given":"Z."},{"family":"Li","given":"X."},{"family":"Gao","given":"C."},{"family":"Wang","given":"J."},{"family":"Zhou","given":"L."}],"issued":{"date-parts":[["2014"]]}}}],"schema":""} 107Appendix 5: Musculoskeletal UltrasoundPOCUS is a useful tool in the evaluation of soft tissues and the musculoskeletal system. Applications of interest to the hospitalist include the detection of cellulitis and abscess, joint effusions, fractures, tendon injuries, and bursitis, as well as use of ultrasound guidance for arthrocentesis and lumbar puncture.Cellulitis and abscess: Ultrasound has been shown to improve the clinical assessment of patients with cellulitis and possible abscess in several studies and has further been shown to improve decision-making and choice of treatment. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"QszgOyFd","properties":{"formattedCitation":"\\super 108,109\\nosupersub{}","plainCitation":"108,109","noteIndex":0},"citationItems":[{"id":5119,"uris":[""],"uri":[""],"itemData":{"id":5119,"type":"article-journal","title":"The effect of soft-tissue ultrasound on the management of cellulitis in the emergency department","container-title":"Academic Emergency Medicine","page":"384-8","volume":"13","issue":"4","abstract":"OBJECTIVES: To evaluate the effect of diagnostic soft-tissue ultrasound (US) on management of emergency department (ED) patients with clinical cellulitis. METHODS: This was a prospective observational study in an urban ED of adult patients with clinical soft-tissue infection without obvious abscess. The treating physician's pretest opinions regarding the need for further drainage procedures and the probability of subcutaneous fluid collection were determined. Emergency sonologists then performed US of the infected area, and the effect on management plan was recorded. RESULTS: Ultrasound changed the management of patients with cellulitis in 71/126 (56%) of cases. In the pretest group that was believed not to need further drainage, US changed the management in 39/82 (48%), with 33 receiving drainage and 6 receiving further diagnostics or consultation. In the pretest group in which further drainage was believed to be needed, US changed the management in 32/44 (73%), including 16 in whom drainage was eliminated and 16 who had further diagnostic interventions. US had a management effect in all pretest probabilities for fluid from 10% to 90%. CONCLUSIONS: Soft-tissue US changes physician management in approximately half of patients in the ED with clinical cellulitis. US may guide management of cellulitis by detection of occult abscess, prevention of invasive procedures, and guidance for further imaging or consultation.","DOI":"10.1197/j.aem.2005.11.074","ISSN":"1069-6563","journalAbbreviation":"Acad. Emerg. Med.","language":"eng","author":[{"family":"Tayal","given":"V. S."},{"family":"Hasan","given":"N."},{"family":"Norton","given":"H. J."},{"family":"Tomaszewski","given":"C. A."}],"issued":{"date-parts":[["2006",4]]}}},{"id":4909,"uris":[""],"uri":[""],"itemData":{"id":4909,"type":"article-journal","title":"ABSCESS: applied bedside sonography for convenient evaluation of superficial soft tissue infections","container-title":"Academic Emergency Medicine","page":"601-6","volume":"12","issue":"7","abstract":"OBJECTIVES: Soft tissue infections are a common presenting complaint in the emergency department (ED). The authors sought to determine the utility of ED bedside ultrasonography (US) in detecting subcutaneous abscesses. METHODS: Between August 2003 and November 2004, a prospective, convenience sample of adult patients with a chief complaint suggestive of cellulitis and/or abscess was enrolled. US was performed by attending physicians or residents who had attended a 30-minute training session in soft tissue US. The treating physician recorded a yes/no assessment of whether he or she believed an abscess was present before and after the US examination. Incision and drainage (I + D) was the criterion standard when performed, while resolution on seven-day follow-up was the criterion standard when I + D was not performed. RESULTS: Sixty-four of 107 patients had I + D-proven abscess, 17 of 107 had negative I + D, and 26 of 107 improved with antibiotic therapy alone. The sensitivity of clinical examination for abscesses was 86% (95% confidence interval [CI] = 76% to 93%), and the specificity was 70% (95% CI = 55% to 82%). The positive predictive value was 81% (95% CI = 70% to 90%), and the negative predictive value was 77% (95% CI = 62% to 88%). The sensitivity of US for abscess was 98% (95% CI = 93% to 100%), and the specificity was 88% (95% CI = 76% to 96%). The positive predictive value was 93% (95% CI = 84% to 97%), and the negative predictive value was 97% (95% CI = 88% to 100%). Of 18 cases in which US disagreed with the clinical examination, US was correct in 17 (94% of cases with disagreement, chi(2) = 14.2, p = 0.0002). CONCLUSIONS: ED bedside US improves accuracy in detection of superficial abscesses.","DOI":"10.1197/j.aem.2005.01.016","ISSN":"1069-6563","journalAbbreviation":"Acad. Emerg. Med.","language":"eng","author":[{"family":"Squire","given":"B. T."},{"family":"Fox","given":"J. C."},{"family":"Anderson","given":"C."}],"issued":{"date-parts":[["2005",7]]}}}],"schema":""} 108,109Joint effusions and arthrocentesis: POCUS allows clinicians to detect joint effusions and differentiate them from other soft tissue abnormalities. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"u08IOKMe","properties":{"formattedCitation":"\\super 110\\nosupersub{}","plainCitation":"110","noteIndex":0},"citationItems":[{"id":6003,"uris":[""],"uri":[""],"itemData":{"id":6003,"type":"article-journal","title":"Utility of bedside sonography to distinguish soft tissue abnormalities from joint effusions in the emergency department","container-title":"Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine","page":"519-26","volume":"29","issue":"4","abstract":"OBJECTIVE: The purpose of this study was to determine the utility of bedside sonography to differentiate soft tissue abnormalities from joint effusions. METHODS: We conducted a retrospective review of emergency department (ED) patients presenting with joint pain, erythema, and swelling who received bedside sonography. The ED sonographic examinations were performed by emergency physician sonologists who were not involved in clinical assessment and management of these patients. The treating physician's opinions regarding the probability of joint effusion and need for aspiration were documented in the sonography log before the sonographic examination was performed. The bedside sonograms of all patients included in this study were also reviewed for accuracy. Descriptive statistics were used to summarize the data. RESULTS: A total of 54 patients (mean age +/- SD, 41 +/- 18.9 years) were identified over a 1-year period. The symptomatic joints in our study subjects were as follows: knee, 24 of 54 (44%); elbow, 21 of 54 (38%); ankle, 8 of 54 (15%); and metatarsophalangeal joint, 1 of 54 (2%). Twenty-two of 54 patients (40.7%; 95% confidence interval [CI], 27.6%-53.8%) were found to have joint effusions on sonography. Sonography altered management in 35 of 54 patients (65%; 95% CI, 52%-77.5%). Joint aspiration was planned in 39 of 54 cases (72.2%; 95% CI, 60.2%-84.1%) before sonography. After sonography, only 20 of these patients (37%; 95% CI, 24.1%-49.9%) underwent joint aspiration. There was a statistically significant difference in treatment plans after the addition of bedside sonographic results (P < .01). CONCLUSIONS: Our study suggests that bedside sonography is useful in differentiating joint effusions from soft tissue abnormalities and directing appropriate therapy.","ISSN":"0278-4297","journalAbbreviation":"J. Ultrasound Med.","language":"eng","author":[{"family":"Adhikari","given":"S."},{"family":"Blaivas","given":"M."}],"issued":{"date-parts":[["2010",4]]}}}],"schema":""} 110 Ultrasound-guided arthrocentesis and knee injection are superior to traditional landmark-based arthrocentesis using palpation alone. Studies have demonstrated significantly less procedural pain, improved procedural success rates, greater synovial fluid yield, and improved clinical outcomes. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"tNyp1lUv","properties":{"formattedCitation":"\\super 111\\uc0\\u8211{}116\\nosupersub{}","plainCitation":"111–116","noteIndex":0},"citationItems":[{"id":7498,"uris":[""],"uri":[""],"itemData":{"id":7498,"type":"article-journal","title":"Where and how to inject the knee--a systematic review","container-title":"Seminars in Arthritis and Rheumatism","page":"195-203","volume":"43","issue":"2","abstract":"OBJECTIVES: The knee can be injected at different anatomic sites with or without image-guidance. We undertook a systematic review to determine the accuracy of intra-articular knee injection (IAKI) and whether this varied by site, use of image-guidance, and experience of injectors, and whether accuracy of injection, site, or use of image-guidance influenced outcomes following IAKIs. METHODS: Medline, Embase, AMED, CINAHL, Web of Knowledge, Cochrane Central Registers for Controlled Trials up to Dec 2012 were searched for studies that evaluated either accuracy of IAKIs or outcomes related to accuracy, knee injection sites, or use of image-guidance. Within-study and between-study analyses were performed. RESULTS: Data from 23 publications were included. Within-study analyses suggested IAKIs at the superomedial patellar, medial midpatellar (MMP), superolateral patellar (SLP) and lateral suprapatellar bursae sites were more accurate when using image-guidance than when blinded (ranges of pooled risk difference 0.09-0.19). Pooling data across studies suggested blinded IAKIs at the SLP site were most accurate (87%) while MMP (64%) and anterolateral joint line (ALJL) sites were (70%) least accurate. Overall about one in five blinded IAKIs were inaccurate. There was some evidence that experience of the injector was linked with improved accuracy for blinded though not image-guided injections. Based on a small number of studies, short but not longer-term outcomes for ultrasound-guided were found to be superior to blinded IAKIs. CONCLUSIONS: Image-guided IAKIs are modestly more accurate than blinded IAKIs especially at the MMP and ALJL sites. Blinded injections at SLP site had good accuracy especially if performed by experienced injectors. Further studies are required to address the question whether accurate localization is linked with an improved response.","DOI":"10.1016/j.semarthrit.2013.04.010","ISSN":"1532-866X (Electronic) 0049-0172 (Linking)","note":"PMCID: PMC3820023","journalAbbreviation":"Semin. Arthritis Rheum.","language":"eng","author":[{"family":"Maricar","given":"N."},{"family":"Parkes","given":"M. J."},{"family":"Callaghan","given":"M. J."},{"family":"Felson","given":"D. T."},{"family":"O'Neill","given":"T. W."}],"issued":{"date-parts":[["2013",10]]}}},{"id":6328,"uris":[""],"uri":[""],"itemData":{"id":6328,"type":"article-journal","title":"Comparison of ultrasound-guided and standard landmark techniques for knee arthrocentesis","container-title":"Journal of Emergency Medicine","page":"76-82","volume":"39","issue":"1","abstract":"BACKGROUND: Ultrasound is a useful adjunct to many Emergency Department (ED) procedures. Arthrocentesis is typically performed using a landmark technique but ultrasound may provide an opportunity to improve arthrocentesis performance. OBJECTIVE: To assess the success of emergency physicians performing landmark (LM) vs. ultrasound (US)-guided knee arthrocentesis techniques. METHODS: This was a prospective, randomized, controlled study of patients requiring knee arthrocentesis who presented to one urban university ED and two community EDs between June 2005 and February 2007. RESULTS: There were 66 patients enrolled (39 US-guided, 27 LM). Among all users, there was no difference in arthrocentesis success (US 37/39 vs. LM 25/27); p = 1.0. SECONDARY ENDPOINTS: 1) Patients reported less pain with ultrasound; US-guided 3.71 (95% confidence interval [CI] 2.61-4.80) cm vs. LM 5.19 (95% CI 3.94-6.45) cm; p = 0.02. 2) Providers felt the US-guided technique was easier to perform than LM; 1.67 units on 5-point scale (95% CI 1.37-1.97) vs. 2.11 (95% CI 1.79-2.42) units; p = 0.02. 3) The total procedure time was shorter with the US-guided technique; 10.58 (95% CI 7.36-13.80) min vs. LM 13.37 (95% CI 9.83-16.92) min; p = 0.05. 4) There was no difference in the amount of fluid obtained between techniques; US-guided 45.33 (95% CI 35.45-55.21) mL vs. LM 34.7 (95% CI 26.09-43.32) mL; p = 0.17. CONCLUSION: US-guided knee arthrocentesis technique does not improve overall success of obtaining joint fluid aspirate vs. the standard LM and palpation technique. An US-guided approach does not result in more pain for the patient, takes no additional time to perform and, at least for novice physicians, leads to more fluid aspiration and greater novice provider confidence with the procedure. Further studies with more participants and standardization of anesthetic quantity are required to validate these findings.","DOI":"10.1016/j.jemermed.2008.05.012","ISSN":"0736-4679 (Print) 0736-4679 (Linking)","journalAbbreviation":"J. Emerg. Med.","language":"eng","author":[{"family":"Wiler","given":"J. L."},{"family":"Costantino","given":"T. G."},{"family":"Filippone","given":"L."},{"family":"Satz","given":"W."}],"issued":{"date-parts":[["2010",7]]}}},{"id":7129,"uris":[""],"uri":[""],"itemData":{"id":7129,"type":"article-journal","title":"Does ultrasound guidance improve the outcomes of arthrocentesis and corticosteroid injection of the knee?","container-title":"Scandinavian Journal of Rheumatology","page":"66-72","volume":"41","issue":"1","abstract":"OBJECTIVE: The present randomized controlled trial compared arthrocentesis of the effusive knee followed by corticosteroid injection performed by the conventional anatomic landmark palpation-guided technique to the same procedure performed with ultrasound (US) needle guidance. METHODS: Sixty-four palpably effusive knees were randomized to (i) palpation-guided arthrocentesis with a conventional 20-mL syringe (22 knees), (ii) US-guided arthrocentesis with a 25-mL reciprocating procedure device (RPD) mechanical aspirating syringe (22 knees), or (iii) US-guided arthrocentesis with a 60-mL automatic aspirating syringe (20 knees). The one-needle two-syringe technique was used. Outcome measures included patient pain by the Visual Analogue Scale (VAS) for pain (0-10 cm), the proportion of diagnostic samples, synovial fluid volume yield, complications, and therapeutic outcome at 2 weeks. RESULTS: Sonographic guidance resulted in 48% less procedural pan (VAS; palpation-guided: 5.8 +/- 3.0 cm, US-guided: 3.0 +/- 2.8 cm, p < 0.001), 183% increased aspirated synovial fluid volumes (palpation-guided: 12 +/- 10 mL, US-guided: 34 +/- 25 mL, p < 0.0001), and improved outcomes at 2 weeks (VAS; palpation-guided: 2.8 +/- 2.4 cm, US-guided: 1.5 +/- 1.9 cm, p = 0.034). Outcomes of sonographic guidance with the mechanical syringe and automatic syringe were comparable in all outcome measures. CONCLUSIONS: US-guided arthrocentesis and injection of the knee are superior to anatomic landmark palpation-guided arthrocentesis, resulting in significantly less procedural pain, improved arthrocentesis success, greater synovial fluid yield, more complete joint decompression, and improved clinical outcomes.","DOI":"10.3109/03009742.2011.599071","ISSN":"1502-7732 (Electronic) 0300-9742 (Linking)","journalAbbreviation":"Scand. J. Rheumatol.","language":"eng","author":[{"family":"Sibbitt","given":"W. L."},{"family":"Kettwich","given":"L. G."},{"family":"Band","given":"P. A."},{"family":"Chavez-Chiang","given":"N. R."},{"family":"DeLea","given":"S. L."},{"family":"Haseler","given":"L. J."},{"family":"Bankhurst","given":"A. D."}],"issued":{"date-parts":[["2012",2]]}}},{"id":5214,"uris":[""],"uri":[""],"itemData":{"id":5214,"type":"article-journal","title":"Ultrasound-guided hip arthrocentesis in the ED","container-title":"American Journal of Emergency Medicine","page":"80-6","volume":"25","issue":"1","abstract":"In patients presenting with atraumatic joint pain and swelling, diagnosis is typically made by synovial fluid analysis. Management of an acute suspected hip joint arthritis can present a challenge to the emergency physician (EP). Hip joint effusions are somewhat more difficult to identify and aspirate than effusions in other joints that are commonly managed by EPs. Identification and aspiration of a hip joint effusion under ultrasound guidance is a well-established procedure in the fields of orthopedic surgery and interventional radiology. Here, we report 4 cases of ultrasound-guided hip arthrocentesis at the bedside by EPs; relevant technical details of the procedure are reviewed. These cases demonstrate the feasibility of ultrasound-guided hip arthrocentesis in the emergency department (ED) by EPs. With increasing availability of bedside ultrasound in the ED, suspected hip joint arthritis or infection may be evaluated and managed by the trained EP in a fashion similar to other joint arthritides.","DOI":"10.1016/j.ajem.2006.08.002","ISSN":"0735-6757 (Print) 0735-6757 (Linking)","journalAbbreviation":"Am. J. Emerg. Med.","language":"eng","author":[{"family":"Freeman","given":"K."},{"family":"Dewitz","given":"A."},{"family":"Baker","given":"W. E."}],"issued":{"date-parts":[["2007",1]]}}},{"id":4145,"uris":[""],"uri":[""],"itemData":{"id":4145,"type":"article-journal","title":"Ultrasound-assisted ankle arthrocentesis","container-title":"American Journal of Emergency Medicine","page":"300-1","volume":"17","issue":"3","abstract":"Difficulty is frequently encountered in performing ankle arthrocentesis. This report describes an ultrasound-assisted technique that can be readily learned by emergency physicians. It involves using the ultrasound beam to accurately locate the tibiotalar joint, thereby increasing the probability of obtaining joint fluid on aspiration.","ISSN":"0735-6757 (Print) 0735-6757","journalAbbreviation":"Am. J. Emerg. Med.","language":"eng","author":[{"family":"Roy","given":"S."},{"family":"Dewitz","given":"A."},{"family":"Paul","given":"I."}],"issued":{"date-parts":[["1999",5]]}}},{"id":9382,"uris":[""],"uri":[""],"itemData":{"id":9382,"type":"article-journal","title":"Ultrasound-guided versus landmark in knee arthrocentesis: A systematic review","container-title":"Seminars in Arthritis and Rheumatism","page":"627-32","volume":"45","issue":"5","abstract":"OBJECTIVES: The objective was to assess the efficacy of ultrasound-guided (USG) versus landmark (LM) knee arthrocentesis in adults with knee pain or effusion. METHODS: A systematic review of the literature was performed until August 2015. All controlled trials reporting the accuracy or clinical efficacy between USG and LM knee joint arthrocentesis were selected. Pooled weighted mean difference (WMD) using the D-L fixed models for continuous outcomes and the risk ratio (RR) for dichotomous outcomes were assessed by meta-analysis. Heterogeneity between studies was estimated by I(2) statistic. RESULTS: Nine studies including 715 adult patients (725 knee joints) were eligible for this review versus LM group; there was a statistically significant difference in favor of USG for knee arthrocentesis accuracy rate (risk ratio = 1.21; 95% CI: 1.13-1.29; P < 0.001; I(2) = 37%), lower procedural pain scores (WMD = -2.24; 95% CI: -2.92 to -1.56; P < 0.001; I(2) = 4%), more aspiration volume (WMD = 17.06; 95% CI: 5.98-28.13; P = 0.003; I(2) = 57%), and decreased pain score 2 weeks after injection (WMD = 0.84; 95% CI: 0.42-1.27; P < 0.001; I(2) = 0). There was no statistically significant difference in procedural duration between two groups (WMD = -0.8; 95% CI: -2.24 to 0.74; P = 0.31; I(2) = 0). CONCLUSIONS: Ultrasound-guided knee joint arthrocentesis offer a significantly greater accuracy and clinical improvement over landmark technique in adults with knee pain or joint effusion.","DOI":"10.1016/j.semarthrit.2015.10.011","ISSN":"0049-0172","journalAbbreviation":"Semin. Arthritis Rheum.","language":"eng","author":[{"family":"Wu","given":"T."},{"family":"Dong","given":"Y."},{"family":"Song","given":"Hx"},{"family":"Fu","given":"Y."},{"family":"Li","given":"J. H."}],"issued":{"date-parts":[["2016",4]]}}}],"schema":""} 111–116Fractures and tendon injuries: Ultrasound detection of bone fractures has been studied in the emergency medicine setting showing reasonable diagnostic accuracy. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"SzyLlp7x","properties":{"formattedCitation":"\\super 117\\nosupersub{}","plainCitation":"117","noteIndex":0},"citationItems":[{"id":4669,"uris":[""],"uri":[""],"itemData":{"id":4669,"type":"article-journal","title":"Goal-directed ultrasound in the detection of long-bone fractures","container-title":"Journal of Trauma","page":"329-32","volume":"57","issue":"2","abstract":"BACKGROUND: New portable ultrasound (US) systems are capable of detecting fractures in the remote setting. However, the accuracy of ultrasound by physicians with minimal ultrasound training is unknown. METHODS: After one hour of standardized training, physicians with minimal US experience clinically evaluated patients presenting with pain and trauma to the upper arm or leg. The investigators then performed a long-bone US evaluation, recording their impression of fracture presence or absence. Results of the examination were compared with routine plain or computer aided radiography (CT). RESULTS: 58 patients were examined. The sensitivity and specificity of US were 92.9% and 83.3%, and of the physical examination were 78.6% and 90.0%, respectively. US provided improved sensitivity with less specificity compared with physical examination in the detection of fractures in long bones. CONCLUSION: Ultrasound scans by minimally trained clinicians may be used to rule out a long-bone fracture in patients with a medium to low probability of fracture.","ISSN":"0022-5282 (Print) 0022-5282","journalAbbreviation":"J. Trauma","language":"eng","author":[{"family":"Marshburn","given":"T. H."},{"family":"Legome","given":"E."},{"family":"Sargsyan","given":"A."},{"family":"Li","given":"S. M."},{"family":"Noble","given":"V. A."},{"family":"Dulchavsky","given":"S. A."},{"family":"Sims","given":"C."},{"family":"Robinson","given":"D."}],"issued":{"date-parts":[["2004",8]]}}}],"schema":""} 117 Ultrasound may also be useful in detection of tendon and ligament injury. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Y5toto4C","properties":{"formattedCitation":"\\super 118,119\\nosupersub{}","plainCitation":"118,119","noteIndex":0},"citationItems":[{"id":5322,"uris":[""],"uri":[""],"itemData":{"id":5322,"type":"article-journal","title":"Use of emergency musculoskeletal sonography in diagnosis of an open fracture of the hand","container-title":"Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine","page":"679-82","volume":"26","issue":"5","ISSN":"0278-4297 (Print) 0278-4297","journalAbbreviation":"J. Ultrasound Med.","language":"eng","author":[{"family":"O'Malley","given":"P."},{"family":"Tayal","given":"V. S."}],"issued":{"date-parts":[["2007",5]]}}},{"id":6226,"uris":[""],"uri":[""],"itemData":{"id":6226,"type":"article-journal","title":"Ultrasound diagnosis of bilateral quadriceps tendon rupture after statin use","container-title":"Western Journal of Emergency Medicine","page":"306-9","volume":"11","issue":"4","abstract":"Simultaneous bilateral quadriceps tendon rupture is a rare injury. We report the case of bilateral quadriceps tendon rupture sustained with minimal force while refereeing a football game. The injury was suspected to be associated with statin use as the patient had no other identifiable risk factors. The diagnosis was confirmed using bedside ultrasound.","ISSN":"1936-900x","note":"PMCID: PMC2967677","journalAbbreviation":"West. J. Emerg. Med.","language":"eng","author":[{"family":"Nesselroade","given":"R. D."},{"family":"Nickels","given":"L. C."}],"issued":{"date-parts":[["2010",9]]}}}],"schema":""} 118,119Bursitis: Ultrasound allows the rapid, bedside differentiation between arthritis and bursitis with early goal directed treatment. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"srgSRQzQ","properties":{"formattedCitation":"\\super 120\\nosupersub{}","plainCitation":"120","noteIndex":0},"citationItems":[{"id":5186,"uris":[""],"uri":[""],"itemData":{"id":5186,"type":"article-journal","title":"Septic arthritis and bursitis: emergency ultrasound can facilitate diagnosis","container-title":"Journal of Emergency Medicine","page":"295-7","volume":"32","issue":"3","abstract":"This article reports the case of a 52-year-old woman with septic arthritis and bursitis of her shoulder. Due to a minor musculoskeletal injury and lack of fever, the diagnosis was missed on her first Emergency Department visit. Sonographic guidance of the shoulder arthrocentesis led to successful aspiration of the larger fluid collection in the subacromial bursa and allowed the diagnosis and treatment to proceed more rapidly. Septic arthritis is a challenging clinical diagnosis, and when it occurs in more difficult to aspirate joints, the diagnosis can become more challenging still. Ultrasound provides a means for the emergency physician to establish the diagnosis more readily.","DOI":"10.1016/j.jemermed.2006.08.012","ISSN":"0736-4679 (Print) 0736-4679 (Linking)","journalAbbreviation":"J. Emerg. Med.","language":"eng","author":[{"family":"Costantino","given":"T. G."},{"family":"Roemer","given":"B."},{"family":"Leber","given":"E. H."}],"issued":{"date-parts":[["2007",4]]}}}],"schema":""} 120Lumbar puncture: Use of ultrasound to mark a needle insertion site prior to performance of lumbar puncture improves procedural success rates and may reduce complication rates. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"rY9b4BKw","properties":{"formattedCitation":"\\super 121,122\\nosupersub{}","plainCitation":"121,122","noteIndex":0},"citationItems":[{"id":3596,"uris":[""],"uri":[""],"itemData":{"id":3596,"type":"article-journal","title":"Ultrasound guided lumbar puncture in emergency department: Time saving and less complications","container-title":"Journal of Research in Medical Sciences: The Official Journal of Isfahan University of Medical Sciences","page":"303-307","volume":"18","issue":"4","source":"PubMed","abstract":"BACKGROUND: Lumbar puncture (LP) is an essential procedure in the diagnosis and treatment of several critical situations. This procedure is routinely performed by palpating external landmarks to find the most appropriate inter-spinous space. In the current study, we compared surface landmark and ultrasound (US) guided LP in different aspects.\nMATERIALS AND METHODS: This clinical trial study was conducted at the emergency department (ED) of a teaching hospital from March 2009 to March 2010. Eighty patients were allocated randomly in two equal groups. In first group, LP was performed by US-guided method and in the control group by palpation of external landmarks of spinal column. Pain score, number of attempts for successful dural penetration, numbers of traumatic LP, and procedure time were compared between two groups. The performance of US-guided LP was assessed with regard to body mass index (BMI) of patients too.\nRESULTS: The mean of procedure time and pain scores were markedly higher in land mark group in comparison to US group (6.4 ± 1.2 and 7.4 ± 1.1 vs. 3.3 ± 1.2 and 4.4 ± 1.4 respectively). Number of attempts and number of traumatic LPs were significantly lower in US group too. In patients with different subgroups of BMI, US-guided LP showed better results and less complication when compared with surface landmark guided technique. All of these results were statistically significant.\nCONCLUSION: This study showed that US was able to find pertinent landmarks to facilitate the LP in patients admitted to ED and resulted in less pain and less time wasting. Moreover, patients who have high BMI may benefit more than others.","ISSN":"1735-1995","note":"PMID: 24124427\nPMCID: PMC3793375","shortTitle":"Ultrasound guided lumbar puncture in emergency department","journalAbbreviation":"J Res Med Sci","language":"eng","author":[{"family":"Mofidi","given":"Mani"},{"family":"Mohammadi","given":"Masoud"},{"family":"Saidi","given":"Hossein"},{"family":"Kianmehr","given":"Nahid"},{"family":"Ghasemi","given":"Ahmad"},{"family":"Hafezimoghadam","given":"Peyman"},{"family":"Rezai","given":"Mahdi"}],"issued":{"date-parts":[["2013",4]]}}},{"id":3490,"uris":[""],"uri":[""],"itemData":{"id":3490,"type":"article-journal","title":"Ultrasound imaging for lumbar punctures and epidural catheterisations: systematic review and meta-analysis","container-title":"BMJ (Clinical research ed.)","page":"f1720","volume":"346","source":"PubMed","abstract":"OBJECTIVE: To determine whether ultrasound imaging can reduce the risk of failed lumbar punctures or epidural catheterisations, when compared with standard palpation methods, and whether ultrasound imaging can reduce traumatic procedures, insertion attempts, and needle redirections.\nDESIGN: Systematic review and meta-analysis of randomised controlled trials.\nDATA SOURCES: Ovid Medline, Embase, and Cochrane Central Register of Controlled Trials up to May 2012, without restriction by language or publication status.\nREVIEW METHODS: Randomised trials that compared ultrasound imaging with standard methods (no imaging) in the performance of a lumbar puncture or epidural catheterisation were identified.\nRESULTS: 14 studies with a total of 1334 patients were included (674 patients assigned to the ultrasound group, 660 to the control group). Five studies evaluated lumbar punctures and nine evaluated epidural catheterisations. Six of 624 procedures conducted in the ultrasound group failed; 44 of 610 procedures in the control group failed. Ultrasound imaging reduced the risk of failed procedures (risk ratio 0.21 (95% confidence interval 0.10 to 0.43), P<0.001). Risk reduction was similar when subgroup analysis was performed for lumbar punctures (risk ratio 0.19 (0.07 to 0.56), P=0.002) or epidural catheterisations (0.23 (0.09 to 0.60), P=0.003). Ultrasound imaging also significantly reduced the risk of traumatic procedures (risk ratio 0.27 (0.11 to 0.67), P=0.005), the number of insertion attempts (mean difference -0.44 (-0.64 to -0.24), P<0.001), and the number of needle redirections (mean difference -1.00 (-1.24 to -0.75), P<0.001).\nCONCLUSIONS: Ultrasound imaging can reduce the risk of failed or traumatic lumbar punctures and epidural catheterisations, as well as the number of needle insertions and redirections. Ultrasound may be a useful adjunct for these procedures.","ISSN":"1756-1833","note":"PMID: 23532866","shortTitle":"Ultrasound imaging for lumbar punctures and epidural catheterisations","journalAbbreviation":"BMJ","language":"eng","author":[{"family":"Shaikh","given":"Furqan"},{"family":"Brzezinski","given":"Jack"},{"family":"Alexander","given":"Sarah"},{"family":"Arzola","given":"Cristian"},{"family":"Carvalho","given":"Jose C. A."},{"family":"Beyene","given":"Joseph"},{"family":"Sung","given":"Lillian"}],"issued":{"date-parts":[["2013",3,26]]}}}],"schema":""} 121,122 Ultrasound can be used for lumbar spine mapping to select the widest interspinous space for needle insertion and to estimate the needle insertion depth required to access the subarachnoid space. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"lo5KnASA","properties":{"formattedCitation":"\\super 123\\uc0\\u8211{}127\\nosupersub{}","plainCitation":"123–127","noteIndex":0},"citationItems":[{"id":5152,"uris":[""],"uri":[""],"itemData":{"id":5152,"type":"article-journal","title":"Ultrasound using the transverse approach to the lumbar spine provides reliable landmarks for labor epidurals","container-title":"Anesthesia and Analgesia","page":"1188-92, tables of contents","volume":"104","issue":"5","abstract":"BACKGROUND: Ultrasound imaging of the spine has recently been proposed to facilitate identification of the epidural space. In this study, we assessed the accuracy and precision of the transverse approach, using a \"single-screen\" method, to facilitate labor epidurals. METHODS: We enrolled 61 patients requesting labor epidurals. Ultrasound imaging (transverse approach, 2-5 MHz curved array probe) identified the midline, the intervertebral space, and the distance from the skin to the epidural space (ultrasound depth/UD). During the epidural puncture, we recorded the success of the insertion point, and measured the distance to the epidural space to the nearest half-centimeter of the marked Tuohy needle (needle depth/ND). We calculated the agreement between UD and ND by the concordance correlation coefficient and Bland-Altman analysis with 95% limits of agreement. RESULTS: The average maternal age was 33 +/- 4.6 yr, body mass index 29.7 +/- 4.8, UD 4.66 +/- 0.68 cm, and ND 4.65 +/- 0.72 cm. The success of the insertion point was 91.8%, with no need to redirect the needle in 73.8% of the patients. The concordance correlation coefficient between UD and ND was 0.881 (95% CI 0.820-0.942). The 95% limits of agreement were -0.666 to 0.687 cm. CONCLUSIONS: We found a good level of success in the ultrasound-determined insertion point, and very good agreement between UD and ND. This suggests that our proposed ultrasound single-screen method, using the transverse approach, can be a reliable guide to facilitate labor epidural insertion.","DOI":"10.1213/01.ane.0000250912.66057.41","ISSN":"0003-2999","journalAbbreviation":"Anesth. Analg.","language":"eng","author":[{"family":"Arzola","given":"C."},{"family":"Davies","given":"S."},{"family":"Rofaeel","given":"A."},{"family":"Carvalho","given":"J. C."}],"issued":{"date-parts":[["2007",5]]}}},{"id":5665,"uris":[""],"uri":[""],"itemData":{"id":5665,"type":"article-journal","title":"Ultrasound imaging of the lumbar spine in the transverse plane: the correlation between estimated and actual depth to the epidural space in obese parturients","container-title":"Anesthesia and Analgesia","page":"1876-81","volume":"108","issue":"6","abstract":"BACKGROUND: Prepuncture lumbar ultrasound scanning is a reliable tool to facilitate labor epidural needle placement in nonobese parturients. In this study, we assessed prepuncture lumbar ultrasound scanning as a tool for estimating the depth to the epidural space and determining the optimal insertion point in obese parturients. METHODS: We studied 46 obese parturients, with prepregnancy body mass index (BMI) >30 kg/m(2), requesting labor epidural analgesia. Ultrasound imaging was done by one of the investigators to identify the midline, the intervertebral space, and the distance from the skin to the epidural space (ultrasound depth, UD) at the level of L3-4. Subsequently, an anesthesiologist blinded to the UD located the epidural space through the predetermined insertion point and marked the actual distance from the skin to the epidural space (needle depth, ND) on the needle with a sterile marker. The agreement between the UD and the ND was calculated using the Pearson correlation coefficient and a paired t-test. Bland-Altman analysis was used to determine the 95% limits of agreement between the UD and the ND. RESULTS: The prepregnancy BMI ranged from 30 to 79 kg/m(2), and the BMI at delivery was 33-86 kg/m(2). The Pearson correlation coefficient between the UD and the ND was 0.85 (95% confidence interval: 0.75-0.91), and the concordance correlation coefficient was 0.79 (95% confidence interval: 0.71-0.88). The mean (+/-SD) ND and UD were 6.6 +/- 1.0 cm and 6.3 +/- 0.8 cm, respectively (difference = 0.3 cm, P = 0.002). The 95% limits of agreement were 1.3 cm to -0.7 cm. Epidural needle placement using the predetermined insertion point was done without reinsertion at a different puncture site in 76.1% of parturients and without redirection in 67.4%. CONCLUSIONS: We found a strong correlation between the ultrasound-estimated distance to the epidural space and the actual measured needle distance in obese parturients. We suggest that prepuncture lumbar ultrasound may be a useful guide to facilitate the placement of epidural needles in obese parturients.","DOI":"10.1213/ane.0b013e3181a323f6","ISSN":"0003-2999","journalAbbreviation":"Anesth. Analg.","language":"eng","author":[{"family":"Balki","given":"M."},{"family":"Lee","given":"Y."},{"family":"Halpern","given":"S."},{"family":"Carvalho","given":"J. C."}],"issued":{"date-parts":[["2009",6]]}}},{"id":7302,"uris":[""],"uri":[""],"itemData":{"id":7302,"type":"article-journal","title":"The utility of ultrasound imaging in predicting ease of performance of spinal anesthesia in an orthopedic patient population","container-title":"Regional Anesthesia and Pain Medicine","page":"34-8","volume":"38","issue":"1","abstract":"BACKGROUND AND OBJECTIVES: Ultrasonography of the spine improves technical performance of spinal anesthesia, but what is unclear is whether it can predict difficulty. We tested the hypothesis that a good ultrasound view at a given intervertebral level is associated with absence of technical difficulty. METHODS: We performed preprocedural ultrasound of the L1-S1 intervertebral spaces in 100 patients undergoing orthopedic surgery. Visibility of the ligamentum flavum-dura mater and the posterior longitudinal ligament was evaluated using paramedian sagittal oblique and transverse midline (TM) views. Views were classified as good if both of these structures were visible on ultrasound. An operator, blinded to the ultrasound scan, performed surface landmark-guided spinal anesthesia using a midline approach. Absence of technical difficulty was defined as successful dural puncture within 2 skin punctures or 10 needle passes. RESULTS: A good TM view had the best diagnostic accuracy; if this view was obtained, absence of technical difficulty with dural puncture at that level was highly likely (positive predictive value, 85%). Dural puncture could still be feasible despite the absence of a good TM view, as reflected by a negative predictive value of 30%. This was attributed to the limitations of ultrasound imaging in this patient population, as well as the low overall prevalence of difficult dural puncture. Parasagittal oblique views did not have significant diagnostic utility for a midline needle approach. CONCLUSIONS: Ultrasound can be useful in predicting the absence of technical difficulty in performing dural puncture and thus in selecting the optimal intervertebral level for spinal anesthesia.","DOI":"10.1097/AAP.0b013e3182734927","ISSN":"1098-7339","journalAbbreviation":"Reg. Anesth. Pain Med.","language":"eng","author":[{"family":"Chin","given":"K. J."},{"family":"Ramlogan","given":"R."},{"family":"Arzola","given":"C."},{"family":"Singh","given":"M."},{"family":"Chan","given":"V."}],"issued":{"date-parts":[["2013",2]]}}},{"id":6890,"uris":[""],"uri":[""],"itemData":{"id":6890,"type":"article-journal","title":"Assessing the depth of the subarachnoid space by ultrasound","container-title":"Revista Brasileira de Anestesiologia","page":"520-30","volume":"62","issue":"4","abstract":"BACKGROUND AND OBJECTIVES: To assess the accuracy of the ultrasound (US) to predict the depth to reach lumbar intrathecal and epidural spaces in order to decrease the number of puncture attempts. METHODS: Thirty-one patients (25 males and 6 females), ASA I or II participated in this study. The transversal ultrasound image of the lumbar spine was obtained at the level of the L3-L4 space. An anesthesiologist without prior information performed the spinal anesthesia through the predicted target area. The distance between the skin and the anterior portion of the flavum ligamentum which is supposedly the bottom limit of the intrathecal depth or an approximation of the depth of the epidural space (ED-US) was measured by ultrasound and it was compared with the distance between the skin and the anterior portion of the flavum ligamentum on the needle (ED-N). RESULTS: ED-US and ED-N were respectively 5.15+/-0.95cm and 5.14+/-0.97cm; these distances were not significantly different (p>0.0001). A significant correlation r=0.982 [95% CI 0.963-0.992, p>0.0001] was observed between the ED-US and ED-N measurements. Bland-Altman analysis showed an accuracy of 0.18cm; tolerated variations ranged from -0.14cm to -0.58cm. CONCLUSIONS: This study supports the idea that the US transversal plane allows the identification of axial anatomical structures and provides physicians with efficient information to perform spinal anesthesia.","DOI":"10.1016/s0034-7094(12)70150-2","ISSN":"0034-7094","journalAbbreviation":"Rev. Bras. Anestesiol.","language":"eng","author":[{"family":"Gnaho","given":"A."},{"family":"Nguyen","given":"V."},{"family":"Villevielle","given":"T."},{"family":"Frota","given":"M."},{"family":"Marret","given":"E."},{"family":"Gentili","given":"M. E."}],"issued":{"date-parts":[["2012",7]]}}},{"id":3590,"uris":[""],"uri":[""],"itemData":{"id":3590,"type":"article-journal","title":"Ultrasound imaging facilitates localization of the epidural space during combined spinal and epidural anesthesia","container-title":"Regional Anesthesia and Pain Medicine","page":"64-67","volume":"26","issue":"1","source":"PubMed","DOI":"10.1053/rapm.2001.19633","ISSN":"1098-7339","note":"PMID: 11172514","journalAbbreviation":"Reg Anesth Pain Med","language":"eng","author":[{"family":"Grau","given":"T."},{"family":"Leipold","given":"R. W."},{"family":"Conradi","given":"R."},{"family":"Martin","given":"E."},{"family":"Motsch","given":"J."}],"issued":{"date-parts":[["2001",2]]}}}],"schema":""} 123–127 Compared to a traditional landmark-based lumbar puncture technique, use of ultrasound to identify the optimal needle insertion site can result in improved procedure success rates and a decrease in the number of attempts and needle redirections. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"FcYoTUCq","properties":{"formattedCitation":"\\super 122,128\\uc0\\u8211{}130\\nosupersub{}","plainCitation":"122,128–130","noteIndex":0},"citationItems":[{"id":3490,"uris":[""],"uri":[""],"itemData":{"id":3490,"type":"article-journal","title":"Ultrasound imaging for lumbar punctures and epidural catheterisations: systematic review and meta-analysis","container-title":"BMJ (Clinical research ed.)","page":"f1720","volume":"346","source":"PubMed","abstract":"OBJECTIVE: To determine whether ultrasound imaging can reduce the risk of failed lumbar punctures or epidural catheterisations, when compared with standard palpation methods, and whether ultrasound imaging can reduce traumatic procedures, insertion attempts, and needle redirections.\nDESIGN: Systematic review and meta-analysis of randomised controlled trials.\nDATA SOURCES: Ovid Medline, Embase, and Cochrane Central Register of Controlled Trials up to May 2012, without restriction by language or publication status.\nREVIEW METHODS: Randomised trials that compared ultrasound imaging with standard methods (no imaging) in the performance of a lumbar puncture or epidural catheterisation were identified.\nRESULTS: 14 studies with a total of 1334 patients were included (674 patients assigned to the ultrasound group, 660 to the control group). Five studies evaluated lumbar punctures and nine evaluated epidural catheterisations. Six of 624 procedures conducted in the ultrasound group failed; 44 of 610 procedures in the control group failed. Ultrasound imaging reduced the risk of failed procedures (risk ratio 0.21 (95% confidence interval 0.10 to 0.43), P<0.001). Risk reduction was similar when subgroup analysis was performed for lumbar punctures (risk ratio 0.19 (0.07 to 0.56), P=0.002) or epidural catheterisations (0.23 (0.09 to 0.60), P=0.003). Ultrasound imaging also significantly reduced the risk of traumatic procedures (risk ratio 0.27 (0.11 to 0.67), P=0.005), the number of insertion attempts (mean difference -0.44 (-0.64 to -0.24), P<0.001), and the number of needle redirections (mean difference -1.00 (-1.24 to -0.75), P<0.001).\nCONCLUSIONS: Ultrasound imaging can reduce the risk of failed or traumatic lumbar punctures and epidural catheterisations, as well as the number of needle insertions and redirections. Ultrasound may be a useful adjunct for these procedures.","ISSN":"1756-1833","note":"PMID: 23532866","shortTitle":"Ultrasound imaging for lumbar punctures and epidural catheterisations","journalAbbreviation":"BMJ","language":"eng","author":[{"family":"Shaikh","given":"Furqan"},{"family":"Brzezinski","given":"Jack"},{"family":"Alexander","given":"Sarah"},{"family":"Arzola","given":"Cristian"},{"family":"Carvalho","given":"Jose C. A."},{"family":"Beyene","given":"Joseph"},{"family":"Sung","given":"Lillian"}],"issued":{"date-parts":[["2013",3,26]]}}},{"id":3582,"uris":[""],"uri":[""],"itemData":{"id":3582,"type":"article-journal","title":"Ultrasound-guided intrathecal anesthesia: Does scanning help?","container-title":"Egyptian Journal of Anaesthesia","page":"389-394","volume":"29","issue":"4","source":"Crossref","DOI":"10.1016/j.egja.2013.06.003","ISSN":"11101849","shortTitle":"Ultrasound-guided intrathecal anesthesia","language":"en","author":[{"family":"Abdelhamid","given":"Sherif A."},{"family":"Mansour","given":"Magdy A."}],"issued":{"date-parts":[["2013",10]]}}},{"id":3585,"uris":[""],"uri":[""],"itemData":{"id":3585,"type":"article-journal","title":"Ultrasound imaging facilitates spinal anesthesia in adults with difficult surface anatomic landmarks","container-title":"Anesthesiology","page":"94-101","volume":"115","issue":"1","source":"PubMed","abstract":"BACKGROUND: Poor surface anatomic landmarks are highly predictive of technical difficulty in neuraxial blockade. The authors examined the use of ultrasound imaging to reduce this difficulty.\nMETHODS: The authors recruited 120 orthopedic patients with one of the following: body mass index more than 35 kg/m? and poorly palpable spinous processes; moderate to severe lumbar scoliosis; or previous lumbar spine surgery. Patients were randomized to receive spinal anesthetic by the conventional surface landmark-guided technique (group LM) or by an ultrasound-guided technique (group US). Patients in group US had a preprocedural ultrasound scan to locate and mark a suitable needle insertion point. The primary outcome was the rate of successful dural puncture on the first needle insertion attempt. Normally distributed data were summarized as mean ± SD and nonnormally distributed data were summarized as median [interquartile range].\nRESULTS: The first-attempt success rate was twice as high in group US than in group LM (65% vs. 32%; P < 0.001). There was a twofold difference between groups in the number of needle insertion attempts (group US, 1 [1-2] vs. group LM, 2 [1-4]; P < 0.001) and number of needle passes (group US, 6 [1-10] vs. group LM, 13 [5-21]; P = 0.003). More time was required to establish landmarks in group US (6.7 ± 3.1; group LM, 0.6 ± 0.5 min; P < 0.001), but this was partially offset by a shorter spinal anesthesia performance time (group US, 5.0 ± 4.9 vs. group LM, 7.3 ± 7.6 min; P = 0.038). Similar results were seen in subgroup analyses of patients with body mass index more than 35 kg/m and patients with poorly palpable landmarks.\nCONCLUSION: Preprocedural ultrasound imaging facilitates the performance of spinal anesthesia in the nonobstetric patient population with difficult anatomic landmarks.","DOI":"10.1097/ALN.0b013e31821a8ad4","ISSN":"1528-1175","note":"PMID: 21572316","journalAbbreviation":"Anesthesiology","language":"eng","author":[{"family":"Chin","given":"Ki Jinn"},{"family":"Perlas","given":"Anahi"},{"family":"Chan","given":"Vincent"},{"family":"Brown-Shreves","given":"Danielle"},{"family":"Koshkin","given":"Arkadiy"},{"family":"Vaishnav","given":"Vandana"}],"issued":{"date-parts":[["2011",7]]}}},{"id":7401,"uris":[""],"uri":[""],"itemData":{"id":7401,"type":"article-journal","title":"Ultrasound-guided lumbar puncture as a diagnostic aid to reduce number of attempts and complication rates","container-title":"Ultrasound","page":"170","volume":"21","issue":"4","abstract":"Ultrasound-guided lumbar puncture (LP) could be beneficial in situations where anatomical landmarks are difficult to identify. There is some evidence that it is associated with increased success rates and procedural ease. Its effect on complication rates has not been explored. This mixed retrospective-prospective case-control study over 6 months compares unguided (retrospective data, n = 28) and ultrasound-guided LPs (prospective data, n = 23) in non-emergency patients. Presence of factors making LPs difficult (DF) i.e. BMI ≥30 kg/m2, scoliosis and previous lumbar spinal surgery were recorded. There was a significant difference in attempt rates between unguided and ultrasound-guided LPs (median 2 vs. 1; p = 0.01) with complication rates of 50% and 26.1%, respectively (p = 0.15). In a subgroup analysis, complication rates were significantly different in those with DF (76.9%, unguided LPs (n = 13) vs. 33.3%, ultrasound-guided LPs (n = 12); p = 0.03), with an absolute risk reduction of complications of 43.6% (NNT of 2.3) in ultrasound-guided vs. unguided LPs. In those with DF, the back pain rates were significantly reduced (53.8% unguided LPs vs. 8.3% ultrasound-guided LPs; p = 0.02). In the ultrasound-guided LP group, there was no blood contaminated cerebrospinal fluid samples, whereas this occurred in 14% of unguided LPs.Ultrasound-guidance significantly reduced the number of LP attempts. In those with DF, the use of ultrasound significantly reduced post-procedural complication, particularly back pain. Ultrasound-guidance during LP procedures can reduce patient discomfort and encourage patient safety, thereby improving clinical practice.","DOI":"10.1177/1742271x13504332","ISSN":"1742-271X","journalAbbreviation":"Ultrasound (Leeds, England)","language":"English","author":[{"family":"Honarbakhsh","given":"Shohreh"},{"family":"Osman","given":"Chinar"},{"family":"Teo","given":"James T. H."},{"family":"Gabriel","given":"Carolyn"}],"issued":{"date-parts":[["2013"]]}}}],"schema":""} 122,128–130 A limited number of studies have reported higher success rates and reduced number of attempts using real-time ultrasound guided lumbar punctures, although direct comparison with ultrasound-guided site marking has not been performed. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ayVHNnEO","properties":{"formattedCitation":"\\super 131\\uc0\\u8211{}134\\nosupersub{}","plainCitation":"131–134","noteIndex":0},"citationItems":[{"id":7321,"uris":[""],"uri":[""],"itemData":{"id":7321,"type":"article-journal","title":"Real-time ultrasound-guided spinal anaesthesia: a prospective observational study of a new approach","container-title":"Anesthesiology Research and Practice","page":"525818","volume":"2013","abstract":"Identification of the subarachnoid space has traditionally been achieved by either a blind landmark-guided approach or using prepuncture ultrasound assistance. To assess the feasibility of performing spinal anaesthesia under real-time ultrasound guidance in routine clinical practice we conducted a single center prospective observational study among patients undergoing lower limb orthopaedic surgery. A spinal needle was inserted unassisted within the ultrasound transducer imaging plane using a paramedian approach (i.e., the operator held the transducer in one hand and the spinal needle in the other). The primary outcome measure was the success rate of CSF acquisition under real-time ultrasound guidance with CSF being located in 97 out of 100 consecutive patients within median three needle passes (IQR 1-6). CSF was not acquired in three patients. Subsequent attempts combining landmark palpation and pre-puncture ultrasound scanning resulted in successful spinal anaesthesia in two of these patients with the third patient requiring general anaesthesia. Median time from spinal needle insertion until intrathecal injection completion was 1.2 minutes (IQR 0.83-4.1) demonstrating the feasibility of this technique in routine clinical practice.","DOI":"10.1155/2013/525818","ISSN":"1687-6962 (Print) 1687-6962","note":"PMCID: Pmc3556419","journalAbbreviation":"Anesthesiol. Res. Pract.","language":"eng","author":[{"family":"Conroy","given":"P. H."},{"family":"Luyet","given":"C."},{"family":"McCartney","given":"C. J."},{"family":"McHardy","given":"P. G."}],"issued":{"date-parts":[["2013"]]}}},{"id":3594,"uris":[""],"uri":[""],"itemData":{"id":3594,"type":"article-journal","title":"Real-time ultrasonic observation of combined spinal-epidural anaesthesia","container-title":"European Journal of Anaesthesiology","page":"25-31","volume":"21","issue":"1","source":"PubMed","abstract":"BACKGROUND AND OBJECTIVE: The quality of combined spinal-epidural anaesthesia mainly depends on accurate identification of the epidural space. The real-time ultrasound control of the procedure for puncture was therefore evaluated.\nMETHODS: Thirty parturients scheduled for Caesarean section were randomized to three equal groups. Ten control patients received conventional combined spinal-epidural anaesthesia. Ten of the remaining patients received ultrasonic scans by an offline scan technique, and 10 received online imaging of the lumbar region during epidural puncture. The epidural space was identified and needle advancement was surveyed through the interspinal and flaval ligaments. The number of attempts to advance the needle to achieve a successful puncture was measured and compared, as well as the number of vertebral interspaces punctured before successful entry into the epidural space.\nRESULTS: There was no difference between patient characteristics in the three groups. The visualization of the epidural structures and of the needle manipulations was very effective. In the ultrasound group, the reduction in the number of attempts at puncture was significant (P < 0.036). The number of interspaces necessary for puncture was reduced (P < 0.036) in the ultrasound online group compared with controls. The number of spinal needle manipulations was significantly reduced (P < 0.036).\nCONCLUSIONS: Real-time ultrasonic scanning of the lumbar spine is an easy procedure. It provides an accurate reading of the location of the needle tip and facilitates the performance of combined spinal-epidural anaesthesia.","ISSN":"0265-0215","note":"PMID: 14768920","journalAbbreviation":"Eur J Anaesthesiol","language":"eng","author":[{"family":"Grau","given":"T."},{"family":"Leipold","given":"R. W."},{"family":"Fatehi","given":"S."},{"family":"Martin","given":"E."},{"family":"Motsch","given":"J."}],"issued":{"date-parts":[["2004",1]]}}},{"id":5786,"uris":[""],"uri":[""],"itemData":{"id":5786,"type":"article-journal","title":"Real-time ultrasound-guided paramedian epidural access: evaluation of a novel in-plane technique","container-title":"British Journal of Anaesthesia","page":"845-54","volume":"102","issue":"6","abstract":"BACKGROUND: Current methods of locating the epidural space rely on surface anatomical landmarks and loss-of-resistance (LOR). We are not aware of any data describing real-time ultrasound (US)-guided epidural access in adults. METHODS: We evaluated the feasibility of performing real-time US-guided paramedian epidural access with the epidural needle inserted in the plane of the US beam in 15 adults who were undergoing groin or lower limb surgery under an epidural or combined spinal-epidural anaesthesia. RESULTS: The epidural space was successfully identified in 14 of 15 (93.3%) patients in 1 (1-3) attempt using the technique described. There was a failure to locate the epidural space in one elderly man. In 8 of 15 (53.3%) patients, studied neuraxial changes, that is, anterior displacement of the posterior dura and widening of the posterior epidural space, were seen immediately after entry of the Tuohy needle and expulsion of the pressurized saline from the LOR syringe into the epidural space at the level of needle insertion. Compression of the thecal sac was also seen in two of these patients. There were no inadvertent dural punctures or complications directly related to the technique described. Anaesthesia adequate for surgery developed in all patients after the initial spinal or epidural injection and recovery from the epidural or spinal anaesthesia was also uneventful. CONCLUSIONS: We have demonstrated the successful use of real-time US guidance in combination with LOR to saline for paramedian epidural access with the epidural needle inserted in the plane of the US beam.","DOI":"10.1093/bja/aep079","ISSN":"1471-6771 (Electronic) 0007-0912 (Linking)","journalAbbreviation":"Br. J. Anaesth.","language":"eng","author":[{"family":"Karmakar","given":"M. K."},{"family":"Li","given":"X."},{"family":"Ho","given":"A. M."},{"family":"Kwok","given":"W. H."},{"family":"Chui","given":"P. T."}],"issued":{"date-parts":[["2009",6]]}}},{"id":6302,"uris":[""],"uri":[""],"itemData":{"id":6302,"type":"article-journal","title":"Single-operator real-time ultrasound-guidance to aim and insert a lumbar epidural needle","container-title":"Canadian Journal of Anaesthesia","page":"313-21","volume":"57","issue":"4","abstract":"PURPOSE: In conventional practice of epidural needle placement, determining the interspinous level and choosing the puncture site are based on palpation of anatomical landmarks, which can be difficult with some subjects. Thereafter, the correct passage of the needle towards the epidural space is a blind \"feel as you go\" method. An aim-and-insert single-operator ultrasound-guided epidural needle placement is described and demonstrated. METHOD: Nineteen subjects undergoing elective Cesarean delivery consented to undergo both a pre-puncture ultrasound scan and real-time paramedian ultrasound-guidance for needle insertion. Following were the study objectives: to measure the success of a combined spinal-epidural needle insertion under real-time guidance, to compare the locations of the chosen interspinous levels as determined by both ultrasound and palpation, to measure the change in depth of the epidural space from the skin surface as pressure is applied to the ultrasound transducer, and to investigate the geometric limitations of using a fixed needle guide. RESULTS: One subject did not participate in the study because pre-puncture ultrasound examination showed unrecognizable bony landmarks. In 18 of 19 subjects, the epidural needle entered the epidural space successfully, as defined by a loss-of-resistance. In two subjects, entry into the epidural space was not achieved despite ultrasound guidance.Eighteen of the 19 interspinous spaces that were identified using palpation were consistent with those determined by ultrasound. The transducer pressure changed the depth of the epidural space by 2.8 mm. The measurements of the insertion lengths corresponded with the geometrical model of the needle guide, but the needle required a larger insertion angle than would be needed without the guide. CONCLUSION: This small study demonstrates the feasibility of the ultrasound-guidance technique. Areas for further development are identified for both ultrasound software and physical design.","DOI":"10.1007/s12630-009-9252-1","ISSN":"0832-610x","journalAbbreviation":"Can. J. Anaesth.","language":"eng","author":[{"family":"Tran","given":"D."},{"family":"Kamani","given":"A. A."},{"family":"Al-Attas","given":"E."},{"family":"Lessoway","given":"V. A."},{"family":"Massey","given":"S."},{"family":"Rohling","given":"R. N."}],"issued":{"date-parts":[["2010",4]]}}}],"schema":""} 131–134 Use of ultrasound for lumbar puncture site selection decreases the risk of a traumatic tap as well as post-procedure back pain. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"xcHFearV","properties":{"formattedCitation":"\\super 121,122,130,135\\nosupersub{}","plainCitation":"121,122,130,135","noteIndex":0},"citationItems":[{"id":3596,"uris":[""],"uri":[""],"itemData":{"id":3596,"type":"article-journal","title":"Ultrasound guided lumbar puncture in emergency department: Time saving and less complications","container-title":"Journal of Research in Medical Sciences: The Official Journal of Isfahan University of Medical Sciences","page":"303-307","volume":"18","issue":"4","source":"PubMed","abstract":"BACKGROUND: Lumbar puncture (LP) is an essential procedure in the diagnosis and treatment of several critical situations. This procedure is routinely performed by palpating external landmarks to find the most appropriate inter-spinous space. In the current study, we compared surface landmark and ultrasound (US) guided LP in different aspects.\nMATERIALS AND METHODS: This clinical trial study was conducted at the emergency department (ED) of a teaching hospital from March 2009 to March 2010. Eighty patients were allocated randomly in two equal groups. In first group, LP was performed by US-guided method and in the control group by palpation of external landmarks of spinal column. Pain score, number of attempts for successful dural penetration, numbers of traumatic LP, and procedure time were compared between two groups. The performance of US-guided LP was assessed with regard to body mass index (BMI) of patients too.\nRESULTS: The mean of procedure time and pain scores were markedly higher in land mark group in comparison to US group (6.4 ± 1.2 and 7.4 ± 1.1 vs. 3.3 ± 1.2 and 4.4 ± 1.4 respectively). Number of attempts and number of traumatic LPs were significantly lower in US group too. In patients with different subgroups of BMI, US-guided LP showed better results and less complication when compared with surface landmark guided technique. All of these results were statistically significant.\nCONCLUSION: This study showed that US was able to find pertinent landmarks to facilitate the LP in patients admitted to ED and resulted in less pain and less time wasting. Moreover, patients who have high BMI may benefit more than others.","ISSN":"1735-1995","note":"PMID: 24124427\nPMCID: PMC3793375","shortTitle":"Ultrasound guided lumbar puncture in emergency department","journalAbbreviation":"J Res Med Sci","language":"eng","author":[{"family":"Mofidi","given":"Mani"},{"family":"Mohammadi","given":"Masoud"},{"family":"Saidi","given":"Hossein"},{"family":"Kianmehr","given":"Nahid"},{"family":"Ghasemi","given":"Ahmad"},{"family":"Hafezimoghadam","given":"Peyman"},{"family":"Rezai","given":"Mahdi"}],"issued":{"date-parts":[["2013",4]]}}},{"id":3490,"uris":[""],"uri":[""],"itemData":{"id":3490,"type":"article-journal","title":"Ultrasound imaging for lumbar punctures and epidural catheterisations: systematic review and meta-analysis","container-title":"BMJ (Clinical research ed.)","page":"f1720","volume":"346","source":"PubMed","abstract":"OBJECTIVE: To determine whether ultrasound imaging can reduce the risk of failed lumbar punctures or epidural catheterisations, when compared with standard palpation methods, and whether ultrasound imaging can reduce traumatic procedures, insertion attempts, and needle redirections.\nDESIGN: Systematic review and meta-analysis of randomised controlled trials.\nDATA SOURCES: Ovid Medline, Embase, and Cochrane Central Register of Controlled Trials up to May 2012, without restriction by language or publication status.\nREVIEW METHODS: Randomised trials that compared ultrasound imaging with standard methods (no imaging) in the performance of a lumbar puncture or epidural catheterisation were identified.\nRESULTS: 14 studies with a total of 1334 patients were included (674 patients assigned to the ultrasound group, 660 to the control group). Five studies evaluated lumbar punctures and nine evaluated epidural catheterisations. Six of 624 procedures conducted in the ultrasound group failed; 44 of 610 procedures in the control group failed. Ultrasound imaging reduced the risk of failed procedures (risk ratio 0.21 (95% confidence interval 0.10 to 0.43), P<0.001). Risk reduction was similar when subgroup analysis was performed for lumbar punctures (risk ratio 0.19 (0.07 to 0.56), P=0.002) or epidural catheterisations (0.23 (0.09 to 0.60), P=0.003). Ultrasound imaging also significantly reduced the risk of traumatic procedures (risk ratio 0.27 (0.11 to 0.67), P=0.005), the number of insertion attempts (mean difference -0.44 (-0.64 to -0.24), P<0.001), and the number of needle redirections (mean difference -1.00 (-1.24 to -0.75), P<0.001).\nCONCLUSIONS: Ultrasound imaging can reduce the risk of failed or traumatic lumbar punctures and epidural catheterisations, as well as the number of needle insertions and redirections. Ultrasound may be a useful adjunct for these procedures.","ISSN":"1756-1833","note":"PMID: 23532866","shortTitle":"Ultrasound imaging for lumbar punctures and epidural catheterisations","journalAbbreviation":"BMJ","language":"eng","author":[{"family":"Shaikh","given":"Furqan"},{"family":"Brzezinski","given":"Jack"},{"family":"Alexander","given":"Sarah"},{"family":"Arzola","given":"Cristian"},{"family":"Carvalho","given":"Jose C. A."},{"family":"Beyene","given":"Joseph"},{"family":"Sung","given":"Lillian"}],"issued":{"date-parts":[["2013",3,26]]}}},{"id":7401,"uris":[""],"uri":[""],"itemData":{"id":7401,"type":"article-journal","title":"Ultrasound-guided lumbar puncture as a diagnostic aid to reduce number of attempts and complication rates","container-title":"Ultrasound","page":"170","volume":"21","issue":"4","abstract":"Ultrasound-guided lumbar puncture (LP) could be beneficial in situations where anatomical landmarks are difficult to identify. There is some evidence that it is associated with increased success rates and procedural ease. Its effect on complication rates has not been explored. This mixed retrospective-prospective case-control study over 6 months compares unguided (retrospective data, n = 28) and ultrasound-guided LPs (prospective data, n = 23) in non-emergency patients. Presence of factors making LPs difficult (DF) i.e. BMI ≥30 kg/m2, scoliosis and previous lumbar spinal surgery were recorded. There was a significant difference in attempt rates between unguided and ultrasound-guided LPs (median 2 vs. 1; p = 0.01) with complication rates of 50% and 26.1%, respectively (p = 0.15). In a subgroup analysis, complication rates were significantly different in those with DF (76.9%, unguided LPs (n = 13) vs. 33.3%, ultrasound-guided LPs (n = 12); p = 0.03), with an absolute risk reduction of complications of 43.6% (NNT of 2.3) in ultrasound-guided vs. unguided LPs. In those with DF, the back pain rates were significantly reduced (53.8% unguided LPs vs. 8.3% ultrasound-guided LPs; p = 0.02). In the ultrasound-guided LP group, there was no blood contaminated cerebrospinal fluid samples, whereas this occurred in 14% of unguided LPs.Ultrasound-guidance significantly reduced the number of LP attempts. In those with DF, the use of ultrasound significantly reduced post-procedural complication, particularly back pain. Ultrasound-guidance during LP procedures can reduce patient discomfort and encourage patient safety, thereby improving clinical practice.","DOI":"10.1177/1742271x13504332","ISSN":"1742-271X","journalAbbreviation":"Ultrasound (Leeds, England)","language":"English","author":[{"family":"Honarbakhsh","given":"Shohreh"},{"family":"Osman","given":"Chinar"},{"family":"Teo","given":"James T. H."},{"family":"Gabriel","given":"Carolyn"}],"issued":{"date-parts":[["2013"]]}}},{"id":3600,"uris":[""],"uri":[""],"itemData":{"id":3600,"type":"article-journal","title":"A randomized controlled trial of ultrasound-assisted lumbar puncture","container-title":"Journal of Ultrasound in Medicine: Official Journal of the American Institute of Ultrasound in Medicine","page":"1341-1348","volume":"26","issue":"10","source":"PubMed","abstract":"OBJECTIVE: Evidence showing the systematic utility of ultrasound imaging during lumbar puncture (LP) in the emergency department is lacking. Our hypothesis was that ultrasound-assisted LP would increase the success rate and ease of performing LP with a greater benefit in obese patients.\nMETHODS: This was an Institutional Review Board-approved, randomized, prospective, double-blind study conducted at the emergency department of a teaching institution. Patients undergoing LP from January to December 2004 were eligible for enrollment. Patients were randomized to undergo LP using palpation landmarks (PLs) or ultrasound landmarks (ULs). Data collected included age, body mass index, number of attempts, ease of performance and patient comfort on a 10-cm Visual Analog Scale, procedure time, success, and traumatic LP. Statistical analysis of data included relative risk (RR), the Mann-Whitney U test, and the Student t test.\nRESULTS: A total of 46 patients were enrolled, 22 randomized to PLs and 24 to ULs. There were no differences between the groups in mean age or body mass index. Six of 22 attempts failed with PLs versus 1 of 24 with ULs (RR, 1.32; 95% confidence interval, 1.01-1.72). In 12 obese patients, 4 of 7 PL attempts failed versus 0 of 5 UL attempts (RR, 2.33; 95% confidence interval, 0.99-5.49). The ease of the procedure was better with ULs versus PLs. There were no statistical differences in the number of attempts, traumatic LPs, patient comfort, or procedure length.\nCONCLUSIONS: The use of ultrasound for LP significantly reduced the number of failures in all patients and improved the ease of the procedure in obese patients.","ISSN":"0278-4297","note":"PMID: 17901137","journalAbbreviation":"J Ultrasound Med","language":"eng","author":[{"family":"Nomura","given":"Jason T."},{"family":"Leech","given":"Stephen J."},{"family":"Shenbagamurthi","given":"Srikala"},{"family":"Sierzenski","given":"Paul R."},{"family":"O'Connor","given":"Robert E."},{"family":"Bollinger","given":"Melissa"},{"family":"Humphrey","given":"Margaret"},{"family":"Gukhool","given":"Jason A."}],"issued":{"date-parts":[["2007",10]]}}}],"schema":""} 121,122,130,135 Though a reduction in post-procedure headache was reported in a study where spinal anesthesia was administered under ultrasound guidance, similar results have not yet been reported for ultrasound-guided lumbar punctures. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"0AaMYBvN","properties":{"formattedCitation":"\\super 136\\nosupersub{}","plainCitation":"136","noteIndex":0},"citationItems":[{"id":3592,"uris":[""],"uri":[""],"itemData":{"id":3592,"type":"article-journal","title":"Efficacy of ultrasound imaging in obstetric epidural anesthesia","container-title":"Journal of Clinical Anesthesia","page":"169-175","volume":"14","issue":"3","source":"PubMed","abstract":"STUDY OBJECTIVE: To assess the clinical use of ultrasonographic localization of the epidural space, and to evaluate the clinical efficacy of ultrasound diagnostics in obstetric anesthesia.\nDESIGN: Randomized prospective study.\nSETTING: University Clinic of Obstetrics and Gynecology.\nPATIENTS: 300 parturients, 85 of whom had conventional delivery and 65 who underwent cesarean section.\nINTERVENTIONS: Patients underwent ultrasonography for the identification of the intervertebral structures. Puncture depth and angle were measured to improve the placement of the Tuohy needle.\nMEASUREMENTS: In the ultrasound group, additional puncture data, optimized puncture point, expected puncture depth, and angle were used to optimize the puncture technique. To control for side effects, we compiled data on the number of puncture attempts and the number of necessary puncture levels, visual analog scale (VAS) scores, the rate of side effects, and the patient acceptance of the technique.\nMAIN RESULTS: The two groups were similar regarding demographic data. Using ultrasound for structure detection, the rate of puncture attempts were significantly (p < 0.013) reduced from 2.18 +/- 1.07 to 1.35 +/- 0.61. The mean rate of necessary puncture levels was 1.30 +/- 0.55 and with ultrasound detection 1.136 +/- 0.36 (p < 0.029). Complete analgesia was achieved in 147 patients with ultrasound detection versus 138 patients in the Control group (p < 0,03). The maximum VAS pain score in the control group was 1.3 +/- 2.1 versus 0.8 +/- 1.5 in the Ultrasound group (p < 0.006). The rate of side effects were reduced significantly: 99 patients in the Control group had no side effects compared with 120 patients from the Ultrasound group who were free of side effects. Patient acceptance of the technique in the Ultrasound group was significantly higher than in the Control group.\nCONCLUSION: The clinical use of ultrasound for epidural catheter placement may improve regional anesthesia. The use of ultrasound resulted in superior quality in all measured endpoints.","ISSN":"0952-8180","note":"PMID: 12031746","journalAbbreviation":"J Clin Anesth","language":"eng","author":[{"family":"Grau","given":"Thomas"},{"family":"Leipold","given":"Rudiger Wolfgang"},{"family":"Conradi","given":"Renate"},{"family":"Martin","given":"Eike"},{"family":"Motsch","given":"Johann"}],"issued":{"date-parts":[["2002",5]]}}}],"schema":""} 136 Use of a low frequency probe with color flow Doppler allows for imaging of interspinous blood vessels as small as 0.5mm. However, studies have not yet demonstrated a reduction in epidural bleeding when lumbar puncture is performed using ultrasound guidance. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"INDgwkQp","properties":{"formattedCitation":"\\super 137\\nosupersub{}","plainCitation":"137","noteIndex":0},"citationItems":[{"id":4297,"uris":[""],"uri":[""],"itemData":{"id":4297,"type":"article-journal","title":"Colour Doppler imaging of the interspinous and epidural space","container-title":"European Journal of Anaesthesiology","page":"706-12","volume":"18","issue":"11","abstract":"BACKGROUND AND OBJECTIVE: In recent studies, ultrasonic diagnostic imaging has proved useful in the screening of the trajectory of the epidural needle. With regard to possible side-effects of spinal and epidural anaesthesia caused by vessel injury, we aimed to evaluate the usability of Colour Doppler imaging for the depiction of interspinous vessels in prepuncture examination. METHODS: Ultrasonic examination of the L3/4 interspace area was performed in 20 volunteers. Using a 4-MHz and a 7-MHz probe with B-mode and Colour Doppler imaging, respectively, we compared four settings for the quality of vessel depiction in the puncture area. Overall resolution was evaluated according to the distinction of landmarks. Vascular structures were identified by pulsation (B-mode) or blood flow (Doppler). RESULTS: Colour Doppler imaging of the L3/4 interspace was unachievable using the 7-MHz transducer. Vessel detection was possible in 50% of the B-mode images and in all of the 4-MHz Doppler images. Vessels were perceptible from a diameter of 0.5 mm. Veins were the predominantly visible structures. Overall vessel visibility was best using 4-MHz Colour Doppler. CONCLUSIONS: Prepuncture Doppler imaging can provide the epiduralist with information regarding the position of vessels in the needle trajectory. This might help to reduce complications in regional anaesthesia.","ISSN":"0265-0215 (Print) 0265-0215 (Linking)","journalAbbreviation":"Eur. J. Anaesthesiol.","language":"eng","author":[{"family":"Grau","given":"T."},{"family":"Leipold","given":"R. W."},{"family":"Horter","given":"J."},{"family":"Martin","given":"E."},{"family":"Motsch","given":"J."}],"issued":{"date-parts":[["2001",11]]}}}],"schema":""} 137Appendix 6: Hypotension, Pulseless Electric Activity, and ResuscitationA multi-system approach with POCUS may be used in the systematic evaluation of shock, hypotension, and pulseless electrical activity (PEA) arrest, and may be used to guide resuscitation.Shock and hypotension: Shock and hypotension may be evaluated using a systematic ultrasound examination of the heart, lungs, abdomen, and lower extremities. These examinations can differentiate shock types and detect potentially reversible life-threatening etiologies, such as cardiac tamponade, acute core pulmonale, and tension pneumothorax. Studies have suggested that POCUS may improve diagnostic accuracy in shock evaluation and shorten the diagnostic process. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"X1CHdFLu","properties":{"formattedCitation":"\\super 138\\uc0\\u8211{}140\\nosupersub{}","plainCitation":"138–140","noteIndex":0},"citationItems":[{"id":9253,"uris":[""],"uri":[""],"itemData":{"id":9253,"type":"article-journal","title":"Make it SIMPLE: enhanced shock management by focused cardiac ultrasound","container-title":"J Intensive Care","page":"51","volume":"4","abstract":"BACKGROUND: Shock is a spectrum of circulatory failure that, if not properly managed, would lead to high mortality. Special diagnostic and treatment strategies are essential to save lives. However, clinical and laboratory findings are always non-specific, resulting in clinical dilemmas. MAIN CONTENT: Focused cardiac ultrasound (FoCUS) has emerged as one of the power tools for clinicians to answer simple clinical questions and guide subsequent management in hypotensive patients. This article will review the development and utility of FoCUS in different types of shock. The sonographic features and ultrasound enhanced management of hypotensive patients by a de novo \"SIMPLE\" approach will be described. Current evidence on FoCUS will also be reviewed. CONCLUSION: Focused cardiac ultrasound provides timely and valuable information for the evaluation of shock. It helps to improve the diagnostic accuracy, narrow the possible differential diagnoses, and guide specific management. SIMPLE is an easy-to-remember mnemonic for non-cardiologists or novice clinical sonographers to apply FoCUS and interpret the specific sonographic findings when evaluating patients in shock.","DOI":"10.1186/s40560-016-0176-x","ISSN":"2052-0492 (Print) 2052-0492","note":"PMCID: PMC4983798","journalAbbreviation":"Journal of intensive care","language":"eng","author":[{"family":"Mok","given":"K. L."}],"issued":{"date-parts":[["2016"]]}}},{"id":4631,"uris":[""],"uri":[""],"itemData":{"id":4631,"type":"article-journal","title":"Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients","container-title":"Critical Care Medicine","page":"1703-8","volume":"32","issue":"8","abstract":"OBJECTIVE: We examined a physician-performed, goal-directed ultrasound protocol for the emergency department management of nontraumatic, symptomatic, undifferentiated hypotension. DESIGN: Randomized, controlled trial of immediate vs. delayed ultrasound. SETTING: Urban, tertiary emergency department, census >100,000. PATIENTS: Nontrauma emergency department patients, aged >17 yrs, and initial emergency department vital signs consistent with shock (systolic blood pressure <100 mm Hg or shock index >1.0), and agreement of two independent observers for at least one sign and symptom of inadequate tissue perfusion. INTERVENTIONS: Group 1 (immediate ultrasound) received standard care plus goal-directed ultrasound at time 0. Group 2 (delayed ultrasound) received standard care for 15 mins and goal-directed ultrasound with standard care between 15 and 30 mins after time 0. MEASUREMENTS AND MAIN RESULTS: Outcomes included the number of viable physician diagnoses at 15 mins and the rank of their likelihood of occurrence at both 15 and 30 mins. One hundred eighty-four patients were included. Group 1 (n = 88) had a smaller median number of viable diagnoses at 15 mins (median = 4) than did group 2 (n = 96, median = 9, Mann-Whitney U test, p <.0001). Physicians indicated the correct final diagnosis as most likely among their viable diagnosis list at 15 mins in 80% (95% confidence interval, 70-87%) of group 1 subjects vs. 50% (95% confidence interval, 40-60%) in group 2, difference of 30% (95% confidence interval, 16-42%). CONCLUSIONS: Incorporation of a goal-directed ultrasound protocol in the evaluation of nontraumatic, symptomatic, undifferentiated hypotension in adult patients results in fewer viable diagnostic etiologies and a more accurate physician impression of final diagnosis.","ISSN":"0090-3493 (Print) 0090-3493","journalAbbreviation":"Crit. Care Med.","language":"eng","author":[{"family":"Jones","given":"A. E."},{"family":"Tayal","given":"V. S."},{"family":"Sullivan","given":"D. M."},{"family":"Kline","given":"J. A."}],"issued":{"date-parts":[["2004",8]]}}},{"id":4830,"uris":[""],"uri":[""],"itemData":{"id":4830,"type":"article-journal","title":"Diagnostic accuracy of left ventricular function for identifying sepsis among emergency department patients with nontraumatic symptomatic undifferentiated hypotension","container-title":"Shock","page":"513-7","volume":"24","issue":"6","abstract":"The hypothesis of this study states that in emergency department (ED) patients with non-traumatic symptomatic hypotension, the presence of hyperdynamic left ventricular function (LVF) is specific for sepsis as the etiology of shock. We performed a secondary analysis of patients with non-traumatic symptomatic hypotension enrolled in a randomized, clinical diagnostic trial. The study was done in an urban tertiary ED with a census over 100,000 visits per year. Inclusion criteria were non-trauma ED patients aged >17 years, initial vital signs consistent with shock (systolic blood pressure <100 mm Hg or shock index >1.0), and agreement of two independent observers for one sign and symptom of circulatory shock. All patients underwent focused ED echocardiography (echo) during initial resuscitation. Echos were reviewed post-hoc by a blinded physician and categorized by qualitative LVF as hyperdynamic (ejection fraction [EF] >55%), normal to moderate impairment (EF 30%-55%), and severe impairment (EF <30%). Main outcome was the criterion standard diagnosis of septic shock. Analyses include the diagnostic performance of LVF, Cohen's kappa for interobserver agreement of LVF, and logistic regression for independent predictors of sepsis. There were 103 echos that were adequate for analysis. The mean age was 57+/-16.7 years, 59% were male, and the mean initial systolic blood pressure was 83+/-11.3 mm Hg. A final diagnosis of septic shock was made in 38% (39/103) of patients. Seventeen of 103 (17%) patients had hyperdynamic LVF with an interobserver agreement of kappa=0.8. The sensitivity and specificity of hyperdynamic LVF for predicting sepsis were 33% (95% CI 19%-50%) and 94% (85%-98%), respectively. Hyperdynamic LVF had a positive likelihood ratio of 5.3 for the diagnosis of sepsis and was a strong independent predictor of sepsis as the final diagnosis with an odds ratio of 5.5 (95% CI 1.1-45). Among ED patients with non-traumatic undifferentiated symptomatic hypotension, the presence of hyperdynamic LVF on focused echo is highly specific for sepsis as the etiology of shock.","ISSN":"1073-2322 (Print) 1073-2322","journalAbbreviation":"Shock","language":"eng","author":[{"family":"Jones","given":"A. E."},{"family":"Craddock","given":"P. A."},{"family":"Tayal","given":"V. S."},{"family":"Kline","given":"J. A."}],"issued":{"date-parts":[["2005",12]]}}}],"schema":""} 138–140 Numerous protocols have been described for hypotension. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ITj3YhaU","properties":{"formattedCitation":"\\super 23,24,138,141\\nosupersub{}","plainCitation":"23,24,138,141","noteIndex":0},"citationItems":[{"id":5658,"uris":[""],"uri":[""],"itemData":{"id":5658,"type":"article-journal","title":"Abdominal and Cardiac Evaluation with Sonography in Shock (ACES): an approach by emergency physicians for the use of ultrasound in patients with undifferentiated hypotension","container-title":"Emergency Medicine Journal","page":"87-91","volume":"26","issue":"2","abstract":"BACKGROUND: Non-traumatic undifferentiated hypotension is a common critical presentation in the emergency department. In this group of patients, early diagnosis and goal-directed therapy is essential for an optimal outcome. The usefulness of focused bedside ultrasound is reviewed and a protocol for Abdominal and Cardiac Evaluation with Sonography in Shock (ACES) is proposed. METHODS: The protocol consists of six windows including cardiac, peritoneal, pleural, inferior vena cava and aortic views, and aims to shorten the time period taken to establish a diagnosis and hence to deliver the most appropriate goal-directed therapy. Its use in seven case examples is described. RESULTS: In all cases the ACES protocol helped in guiding the initial management while further information was obtained. CONCLUSION: The six-view ACES protocol is a useful adjunct to clinical examination in patients with undifferentiated hypotension in the emergency department. A prospective randomised trial or multicentre database/registry is needed to investigate the validity and impact of this protocol on the early diagnosis and management of hypotensive patients.","DOI":"10.1136/emj.2007.056242","ISSN":"1472-0205","journalAbbreviation":"Emerg. Med. J.","language":"eng","author":[{"family":"Atkinson","given":"P. R."},{"family":"McAuley","given":"D. J."},{"family":"Kendall","given":"R. J."},{"family":"Abeyakoon","given":"O."},{"family":"Reid","given":"C. G."},{"family":"Connolly","given":"J."},{"family":"Lewis","given":"D."}],"issued":{"date-parts":[["2009",2]]}}},{"id":6236,"uris":[""],"uri":[""],"itemData":{"id":6236,"type":"article-journal","title":"The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically lll","container-title":"Emergency Medicine Clinics of North America","page":"29-56, vii","volume":"28","issue":"1","abstract":"The RUSH exam (Rapid Ultrasound in SHock examination), presented in this article, represents a comprehensive algorithm for the integration of bedside ultrasound into the care of the patient in shock. By focusing on a stepwise evaluation of the shock patient defined here as \"Pump, Tank, and Pipes,\" clinicians will gain crucial anatomic and physiologic data to better care for these patients.","DOI":"10.1016/j.emc.2009.09.010","ISSN":"1558-0539 (Electronic) 0733-8627 (Linking)","journalAbbreviation":"Emerg. Med. Clin. North Am.","language":"eng","author":[{"family":"Perera","given":"P."},{"family":"Mailhot","given":"T."},{"family":"Riley","given":"D."},{"family":"Mandavia","given":"D."}],"issued":{"date-parts":[["2010",2]]}}},{"id":9253,"uris":[""],"uri":[""],"itemData":{"id":9253,"type":"article-journal","title":"Make it SIMPLE: enhanced shock management by focused cardiac ultrasound","container-title":"J Intensive Care","page":"51","volume":"4","abstract":"BACKGROUND: Shock is a spectrum of circulatory failure that, if not properly managed, would lead to high mortality. Special diagnostic and treatment strategies are essential to save lives. However, clinical and laboratory findings are always non-specific, resulting in clinical dilemmas. MAIN CONTENT: Focused cardiac ultrasound (FoCUS) has emerged as one of the power tools for clinicians to answer simple clinical questions and guide subsequent management in hypotensive patients. This article will review the development and utility of FoCUS in different types of shock. The sonographic features and ultrasound enhanced management of hypotensive patients by a de novo \"SIMPLE\" approach will be described. Current evidence on FoCUS will also be reviewed. CONCLUSION: Focused cardiac ultrasound provides timely and valuable information for the evaluation of shock. It helps to improve the diagnostic accuracy, narrow the possible differential diagnoses, and guide specific management. SIMPLE is an easy-to-remember mnemonic for non-cardiologists or novice clinical sonographers to apply FoCUS and interpret the specific sonographic findings when evaluating patients in shock.","DOI":"10.1186/s40560-016-0176-x","ISSN":"2052-0492 (Print) 2052-0492","note":"PMCID: PMC4983798","journalAbbreviation":"Journal of intensive care","language":"eng","author":[{"family":"Mok","given":"K. L."}],"issued":{"date-parts":[["2016"]]}}},{"id":9425,"uris":[""],"uri":[""],"itemData":{"id":9425,"type":"article-journal","title":"International Federation for Emergency Medicine Consensus Statement: Sonography in hypotension and cardiac arrest (SHoC): An international consensus on the use of point of care ultrasound for undifferentiated hypotension and during cardiac arrest","container-title":"Cjem","page":"459-470","volume":"19","issue":"6","abstract":"Introduction The International Federation for Emergency Medicine (IFEM) Ultrasound Special Interest Group (USIG) was tasked with development of a hierarchical consensus approach to the use of point of care ultrasound (PoCUS) in patients with hypotension and cardiac arrest. METHODS: The IFEM USIG invited 24 recognized international leaders in PoCUS from emergency medicine and critical care to form an expert panel to develop the sonography in hypotension and cardiac arrest (SHoC) protocol. The panel was provided with reported disease incidence, along with a list of recommended PoCUS views from previously published protocols and guidelines. Using a modified Delphi methodology the panel was tasked with integrating the disease incidence, their clinical experience and their knowledge of the medical literature to evaluate what role each view should play in the proposed SHoC protocol. RESULTS: Consensus on the SHoC protocols for hypotension and cardiac arrest was reached after three rounds of the modified Delphi process. The final SHoC protocol and operator checklist received over 80% consensus approval. The IFEM-approved final protocol, recommend Core, Supplementary, and Additional PoCUS views. SHoC-hypotension core views consist of cardiac, lung, and inferior vena vaca (IVC) views, with supplementary cardiac views, and additional views when clinically indicated. Subxiphoid or parasternal cardiac views, minimizing pauses in chest compressions, are recommended as core views for SHoC-cardiac arrest; supplementary views are lung and IVC, with additional views when clinically indicated. Both protocols recommend use of the \"4 F\" approach: fluid, form, function, filling. CONCLUSION: An international consensus on sonography in hypotension and cardiac arrest is presented. Future prospective validation is required.","DOI":"10.1017/cem.2016.394","ISSN":"1481-8035 (Print) 1481-8035","journalAbbreviation":"Cjem","language":"eng","author":[{"family":"Atkinson","given":"P."},{"family":"Bowra","given":"J."},{"family":"Milne","given":"J."},{"family":"Lewis","given":"D."},{"family":"Lambert","given":"M."},{"family":"Jarman","given":"B."},{"family":"Noble","given":"V. E."},{"family":"Lamprecht","given":"H."},{"family":"Harris","given":"T."},{"family":"Connolly","given":"J."}],"issued":{"date-parts":[["2017",11]]}}}],"schema":""} 23,24,138,141PEA arrest: Several common etiologies of PEA arrest may be detected rapidly with ultrasound. This task that has been demonstrated to be feasible without interfering with the resuscitation, and several protocols have been described. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"psYiz4JV","properties":{"formattedCitation":"\\super 142\\uc0\\u8211{}146\\nosupersub{}","plainCitation":"142–146","noteIndex":0},"citationItems":[{"id":5458,"uris":[""],"uri":[""],"itemData":{"id":5458,"type":"article-journal","title":"C.A.U.S.E.: Cardiac arrest ultra-sound exam--a better approach to managing patients in primary non-arrhythmogenic cardiac arrest","container-title":"Resuscitation","page":"198-206","volume":"76","issue":"2","abstract":"Cardiac arrest is a condition frequently encountered by physicians in the hospital setting including the Emergency Department, Intensive Care Unit and medical/surgical wards. This paper reviews the current literature involving the use of ultrasound in resuscitation and proposes an algorithmic approach for the use of ultrasound during cardiac arrest. At present there is the need for a means of differentiating between various causes of cardiac arrest, which are not a direct result of a primary ventricular arrhythmia. Identifying the cause of pulseless electrical activity or asystole is important as the underlying cause is what guides management in such cases. This approach, incorporating ultrasound to manage cardiac arrest aids in the diagnosis of the most common and easily reversible causes of cardiac arrest not caused by primary ventricular arrhythmia, namely; severe hypovolemia, tension pneumothorax, cardiac tamponade, and massive pulmonary embolus. These four conditions are addressed in this paper using four accepted emergency ultrasound applications to be performed during resuscitation of a cardiac arrest patient with the aim of determining the underlying cause of a cardiac arrest. Identifying the underlying cause of cardiac arrest represents the one of the greatest challenges of managing patients with asystole or PEA and accurate determination has the potential to improve management by guiding therapeutic decisions. We include several clinical images demonstrating examples of cardiac tamponade, massive pulmonary embolus, and severe hypovolemia secondary to abdominal aortic aneurysm. In conclusion, this protocol has the potential to reduce the time required to determine the etiology of a cardiac arrest and thus decrease the time between arrest and appropriate therapy.","DOI":"10.1016/j.resuscitation.2007.06.033","ISSN":"0300-9572 (Print) 0300-9572","journalAbbreviation":"Resuscitation","language":"eng","author":[{"family":"Hernandez","given":"C."},{"family":"Shuler","given":"K."},{"family":"Hannan","given":"H."},{"family":"Sonyika","given":"C."},{"family":"Likourezos","given":"A."},{"family":"Marshall","given":"J."}],"issued":{"date-parts":[["2008",2]]}}},{"id":6033,"uris":[""],"uri":[""],"itemData":{"id":6033,"type":"article-journal","title":"Focused echocardiographic evaluation in life support and peri-resuscitation of emergency patients: a prospective trial","container-title":"Resuscitation","page":"1527-33","volume":"81","issue":"11","abstract":"PURPOSE OF THE STUDY: Focused ultrasound is increasingly used in the emergency setting, with an ALS-compliant focused echocardiography algorithm proposed as an adjunct in peri-resuscitation care (FEEL). The purpose of this study was to evaluate the feasibility of FEEL in pre-hospital resuscitation, the incidence of potentially treatable conditions detected, and the influence on patient management. PATIENTS, MATERIALS AND METHODS: A prospective observational study in a pre-hospital emergency setting in patients actively undergoing cardio-pulmonary resuscitation or in a shock state. The FEEL protocol was applied by trained emergency doctors, following which a standardised report sheet was completed, including echo findings and any echo-directed change in management. These reports were then analysed independently. RESULTS: A total of 230 patients were included, with 204 undergoing a FEEL examination during ongoing cardiac arrest (100) and in a shock state (104). Images of diagnostic quality were obtained in 96%. In 35% of those with an ECG diagnosis of asystole, and 58% of those with PEA, coordinated cardiac motion was detected, and associated with increased survival. Echocardiographic findings altered management in 78% of cases. CONCLUSIONS: Application of ALS-compliant echocardiography in pre-hospital care is feasible, and alters diagnosis and management in a significant number of patients. Further research into its effect on patient outcomes is warranted.","DOI":"10.1016/j.resuscitation.2010.07.013","ISSN":"0300-9572","journalAbbreviation":"Resuscitation","language":"eng","author":[{"family":"Breitkreutz","given":"R."},{"family":"Price","given":"S."},{"family":"Steiger","given":"H. V."},{"family":"Seeger","given":"F. H."},{"family":"Ilper","given":"H."},{"family":"Ackermann","given":"H."},{"family":"Rudolph","given":"M."},{"family":"Uddin","given":"S."},{"family":"Weigand","given":"M. A."},{"family":"Muller","given":"E."},{"family":"Walcher","given":"F."}],"issued":{"date-parts":[["2010",11]]}}},{"id":4872,"uris":[""],"uri":[""],"itemData":{"id":4872,"type":"article-journal","title":"Rapid cardiac ultrasound of inpatients suffering PEA arrest performed by nonexpert sonographers","container-title":"Resuscitation","page":"81-7","volume":"67","issue":"1","abstract":"UNLABELLED: Cardiac arrest presenting as pulseless electrical activity (PEA) currently has a very low survival rate. Many of the conditions underlying PEA (cardiac tamponade, hypovolemia, and pulmonary embolus) are associated with specific cardiac ultrasound findings. The aim of this study was to evaluate a rapid cardiac ultrasound assessment performed by trained nonexpert sonographers integrated into the ACLS response system at a major medical center. METHODS: An emergency sonography system was created and deployed to each inpatient cardiac arrest occurring at Dartmouth Hitchcock Medical Center between November 1, 2003 and April 30, 2004. Thirteen internal medicine house officers received training to perform a limited subcostal cardiac ultrasound examination designed to diagnose cardiac tamponade, pulmonary embolus, severe hypovolemia, and lack of cardiac motion. Time from arrest alert to sonographic result, and correlation with over-reading by blinded echocardiography physicians were assessed. RESULTS: A complete emergency ultrasound examination was performed in five PEA arrests. The average time from arrest alert to interpretation was 7.75 min. (95% CI 2.8-18.3 min). Three of these examinations (60%, 95% CI 14.7-94.7%) were adequate for interpretation. Agreement between the nonexpert sonographer and echocardiography physician occurred in four of five (kappa=0.706) cases. CONCLUSION: Rapid cardiac sonography can be successfully integrated in the ACLS response. Nonexpert sonographers may be able to provide useful interpretive information when sufficiently trained.","DOI":"10.1016/j.resuscitation.2005.04.007","ISSN":"0300-9572 (Print) 0300-9572","journalAbbreviation":"Resuscitation","language":"eng","author":[{"family":"Niendorff","given":"D. F."},{"family":"Rassias","given":"A. J."},{"family":"Palac","given":"R."},{"family":"Beach","given":"M. L."},{"family":"Costa","given":"S."},{"family":"Greenberg","given":"M."}],"issued":{"date-parts":[["2005",10]]}}},{"id":5168,"uris":[""],"uri":[""],"itemData":{"id":5168,"type":"article-journal","title":"Focused echocardiographic evaluation in resuscitation management: concept of an advanced life support-conformed algorithm","container-title":"Critical Care Medicine","page":"S150-61","volume":"35","issue":"5 Suppl","abstract":"Emergency ultrasound is suggested to be an important tool in critical care medicine. Time-dependent scenarios occur during preresuscitation care, during cardiopulmonary resuscitation, and in postresuscitation care. Suspected myocardial insufficiency due to acute global, left, or right heart failure, pericardial tamponade, and hypovolemia should be identified. These diagnoses cannot be made with standard physical examination or the electrocardiogram. Furthermore, the differential diagnosis of pulseless electrical activity is best elucidated with echocardiography. Therefore, we developed an algorithm of focused echocardiographic evaluation in resuscitation management, a structured process of an advanced life support-conformed transthoracic echocardiography protocol to be applied to point-of-care diagnosis. The new 2005 American Heart Association/European Resuscitation Council/International Liaison Committee on Resuscitation guidelines recommended high-quality cardiopulmonary resuscitation with minimal interruptions to reduce the no-flow intervals. However, they also recommended identification and treatment of reversible causes or complicating factors. Therefore, clinicians must be trained to use echocardiography within the brief interruptions of advanced life support, taking into account practical and theoretical considerations. Focused echocardiographic evaluation in resuscitation management was evaluated by emergency physicians with respect to incorporation into the cardiopulmonary resuscitation process, performance, and physicians' ability to recognize characteristic pathology. The aim of the focused echocardiographic evaluation in resuscitation management examination is to improve the outcomes of cardiopulmonary resuscitation.","DOI":"10.1097/m.0000260626.23848.Fc","ISSN":"0090-3493 (Print) 0090-3493","journalAbbreviation":"Crit. Care Med.","language":"eng","author":[{"family":"Breitkreutz","given":"R."},{"family":"Walcher","given":"F."},{"family":"Seeger","given":"F. H."}],"issued":{"date-parts":[["2007",5]]}}},{"id":6578,"uris":[""],"uri":[""],"itemData":{"id":6578,"type":"article-journal","title":"EGLS: Echo-guided life support","container-title":"Crit Ultrasound J","page":"123-129","volume":"3","issue":"3","abstract":"The primary challenge in the initial assessment of a patient with undifferentiated shock is to quickly identify and treat any reversible causes of shock. Bedside ultrasound provides real-time information that can assist with the achievement of this goal; as a result, it has gained widespread popularity in the field of critical care and emergency medicine. Many researchers have suggested that the use of a simple ultrasound approach to guide the management of these patients would reduce the morbidity associated with delayed or inappropriate treatment and would result in better outcomes.","DOI":"10.1007/s13089-011-0083-2","ISSN":"2036-7902","journalAbbreviation":"Critical ultrasound journal","author":[{"family":"Lanct?t","given":"Jean-Fran?ois"},{"family":"Valois","given":"Maxime"},{"family":"Beaulieu","given":"Yanick"}],"issued":{"date-parts":[["2011",12,1]]}}}],"schema":""} 142–146Resuscitation: Ultrasound may influence fluid and vasopressor management in 14-50% of critically ill patients. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"aH1OuANv","properties":{"formattedCitation":"\\super 2,147,148\\nosupersub{}","plainCitation":"2,147,148","noteIndex":0},"citationItems":[{"id":3925,"uris":[""],"uri":[""],"itemData":{"id":3925,"type":"article-journal","title":"Diagnostic accuracy and therapeutic impact of transthoracic and transesophageal echocardiography in mechanically ventilated patients in the ICU","container-title":"Chest","page":"1829-34","volume":"106","issue":"6","abstract":"STUDY OBJECTIVES: To assess the respective diagnostic accuracy of transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) and their therapeutic implications in mechanically ventilated patients, in the intensive care unit (ICU). DESIGN: A prospective study. SETTINGS: Intensive care units of two tertiary referral teaching hospitals. PATIENTS: One hundred eleven ICU patients (81 men and 30 women; mean age 57 +/- 16 years). Fifty-seven percent were hospitalized for medical illnesses, 16.5 percent after thoracic surgery, 10.5 percent after other surgery, and 16.0 percent for multiple trauma. Their Simplified Acute Physiologic Score was 16 +/- 5. INTERVENTIONS: The echocardiograms were performed in order to solve well-defined clinical problems. TTE was the first step of the procedure and TEE was performed only when (1) TTE did not solve the clinical problems, and (2) TTE yielded unsuspected findings requiring TEE. During each echocardiographic study, the following were noted: ventilatory mode, clinical problems, imaging quality, results, consequence on acute care, duration of the procedure, and potential complications of TEE. Diagnostic accuracy was defined as the proportion of solved problems, and therapeutic impact was defined as changes on acute care that resulted directly from the procedure. MEASUREMENTS AND RESULTS: One hundred twenty-eight consecutive TTE and 96 TEE were performed. TTE solved 60 of 158 clinical problems (38 percent), whether positive end-expiratory pressure (> 4 cm H2O) was present or not (28 of 74 vs 32 of 84: p > 0.50). TTE allowed evaluation of left ventricular function in 77 percent of cases and pericardial effusion in every case, but it did not solve most of the other clinical problems. Indeed, the diagnostic accuracy of TEE was markedly superior (95/98 vs 60/158: p < 0.001), but TEE required a physician's presence longer (43 +/- 17 min vs 27 +/- 12 min: p < 0.001). When TTE and TEE were scheduled (n = 96), TEE yielded an additional diagnosis or excluded with more certitude a suspected diagnosis, except in two cases. TEE had a therapeutic impact more frequently than TTE (35/96 vs 20/128: p < 0.001). Cardiovascular surgery was prompted by echocardiographic findings in ten patients. TEE was well tolerated in all patients; there were no complications. CONCLUSIONS: TEE is a valuable well-tolerated imaging technique in mechanically ventilated patients. For the assessment of left ventricular systolic function and pericardial effusion; however, TTE continues to be an excellent diagnostic tool, even when positive end-expiratory pressure is present. Both TTE and TEE have a therapeutic impact in approximately 25 percent of cases.","ISSN":"0012-3692 (Print) 0012-3692","journalAbbreviation":"Chest","language":"eng","author":[{"family":"Vignon","given":"P."},{"family":"Mentec","given":"H."},{"family":"Terre","given":"S."},{"family":"Gastinne","given":"H."},{"family":"Gueret","given":"P."},{"family":"Lemaire","given":"F."}],"issued":{"date-parts":[["1994",12]]}}},{"id":4913,"uris":[""],"uri":[""],"itemData":{"id":4913,"type":"article-journal","title":"Transthoracic echocardiography: impact on diagnosis and management in tertiary care intensive care units","container-title":"Anaesthesia and Intensive Care","page":"492-6","volume":"33","issue":"4","abstract":"The purpose of this study was to evaluate the utility of transthoracic echocardiography (TTE) in an intensive care unit by determining its impact on diagnosis and management. Over a six-month time period, we performed a prospective observational study on all patients admitted to either the medical or the surgical intensive care unit. Structured interviews were conducted with referring physicians before and after the TTE to determine the referring physicians' pre-TTE diagnosis, reasons for requesting the TTE, and whether the TTE resulted in a change in diagnosis and/or management. A total of 135 TTE examinations were done in 126 patients. The referring physicians deemed that clinical information was inadequate to make a definitive diagnosis and management plan in 36/135 (27%) of the requests. In 99/135 (73%) studies, physicians indicated that there was probably sufficient clinical information to formulate a diagnosis and management plan, but ordered a TTE to corroborate their clinical findings. Overall, a change in diagnosis occurred in 39/135 (29%) of studies, and a change in management in 55/135 (41%) of studies. Diagnosis was changed in 19/99 (19%) studies with adequate clinical data, and in 20/36 (56%) studies with inadequate clinical data (P<0.001). Management was changed in 34/99 (34%) of studies with adequate clinical data and in 21/36 (58%) of studies with inadequate clinical data (P=0.017). Of the 62 management changes, 57/62 (92%) changes were minor, and 5/62 (8%) were major. In conclusion we have found that TTE frequently resulted in a change in the diagnosis and management.","ISSN":"0310-057X (Print) 0310-057x","journalAbbreviation":"Anaesth. Intensive Care","language":"eng","author":[{"family":"Stanko","given":"L. K."},{"family":"Jacobsohn","given":"E."},{"family":"Tam","given":"J. W."},{"family":"De Wet","given":"C. J."},{"family":"Avidan","given":"M."}],"issued":{"date-parts":[["2005",8]]}}},{"id":5904,"uris":[""],"uri":[""],"itemData":{"id":5904,"type":"article-journal","title":"Impact of echocardiography on patient management in the intensive care unit: an audit of district general hospital practice","container-title":"British Journal of Anaesthesia","page":"340-4","volume":"102","issue":"3","abstract":"BACKGROUND: Echocardiography has been shown to positively impact on the management of the critically ill patient. However, many published studies have a significant bias towards inclusion of cardiothoracic patients. We present an audit of the impact of echocardiography on the management of patients in a district general hospital intensive care unit (ICU). METHODS: We conducted a prospective audit of all echocardiograms, both transthoracic (TTE) and transoesophageal (TOE), performed on our ICU between October 1, 2005, and December 31, 2007. In addition to patient characteristics, we recorded the indication for the echocardiogram, and any change in management that occurred as a result of the study. RESULTS: Two hundred and fifty-eight echocardiograms were performed in 217 patients, of which 224 (86.8%) were performed by intensive care consultants. One hundred and eighty-seven studies (72.4%) were TTEs and 71 (27.8%) were TOEs. TTE provided diagnostic images in 91.3% of spontaneously breathing and 84.2% of mechanically ventilated patients. Management was changed directly as a result of information provided in 51.2% of studies. Changes included fluid administration, inotrope or drug therapy, and treatment limitation. CONCLUSIONS: Echocardiography may have a significant impact on the management of patients in the general ICU. We recommend that appropriate training in echocardiography should be incorporated into the intensive care curriculum in the UK.","DOI":"10.1093/bja/aen378","ISSN":"0007-0912","journalAbbreviation":"Br. J. Anaesth.","language":"eng","author":[{"family":"Orme","given":"R. M."},{"family":"Oram","given":"M. P."},{"family":"McKinstry","given":"C. E."}],"issued":{"date-parts":[["2009",3]]}}}],"schema":""} 2,147,148 Respiratory variation of the IVC diameter has been shown to be of utility in predicting fluid responsiveness in mechanically ventilated patients that are completely passive on the ventilator. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"G915X2nx","properties":{"formattedCitation":"\\super 25,149\\nosupersub{}","plainCitation":"25,149","noteIndex":0},"citationItems":[{"id":4600,"uris":[""],"uri":[""],"itemData":{"id":4600,"type":"article-journal","title":"The respiratory variation in inferior vena cava diameter as a guide to fluid therapy","container-title":"Intensive Care Medicine","page":"1834-7","volume":"30","issue":"9","abstract":"OBJECTIVE: To investigate whether the respiratory variation in inferior vena cava diameter (DeltaD(IVC)) could be related to fluid responsiveness in mechanically ventilated patients. DESIGN: Prospective clinical study. SETTING: Medical ICU of a non-university hospital. PATIENTS: Mechanically ventilated patients with septic shock (n=39). INTERVENTIONS: Volume loading with 8 mL/kg of 6% hydroxyethylstarch over 20 min. MEASUREMENTS AND RESULTS: Cardiac output and DeltaD(IVC) were assessed by echography before and immediately after the standardized volume load. Volume loading induced an increase in cardiac output from 5.7+/-2.0 to 6.4+/-1.9 L/min (P<0.001) and a decrease in DeltaD(IVC) from 13.8+/-13.6 vs 5.2+/-5.8% (P<0.001). Sixteen patients responded to volume loading by an increase in cardiac output > or =15% (responders). Before volume loading, the DeltaD(IVC) was greater in responders than in non-responders (25+/-15 vs 6+/-4%, P<0.001), closely correlated with the increase in cardiac output (r=0.82, P<0.001), and a 12% DeltaD(IVC) cut-off value allowed identification of responders with positive and negative predictive values of 93% and 92%, respectively. CONCLUSION: Analysis of DeltaD(IVC) is a simple and non-invasive method to detect fluid responsiveness in mechanically ventilated patients with septic shock.","DOI":"10.1007/s00134-004-2233-5","ISSN":"0342-4642 (Print) 0342-4642 (Linking)","journalAbbreviation":"Intensive Care Med.","language":"eng","author":[{"family":"Feissel","given":"M."},{"family":"Michard","given":"F."},{"family":"Faller","given":"J. P."},{"family":"Teboul","given":"J. L."}],"issued":{"date-parts":[["2004",9]]}}},{"id":4561,"uris":[""],"uri":[""],"itemData":{"id":4561,"type":"article-journal","title":"Respiratory changes in inferior vena cava diameter are helpful in predicting fluid responsiveness in ventilated septic patients","container-title":"Intensive Care Medicine","page":"1740-6","volume":"30","issue":"9","abstract":"OBJECTIVE: To evaluate the extent to which respiratory changes in inferior vena cava (IVC) diameter can be used to predict fluid responsiveness. DESIGN: Prospective clinical study. SETTING: Hospital intensive care unit. PATIENTS: Twenty-three patients with acute circulatory failure related to sepsis and mechanically ventilated because of an acute lung injury. MEASUREMENTS: Inferior vena cava diameter (D) at end-expiration (Dmin) and at end-inspiration (Dmax) was measured by echocardiography using a subcostal approach. The distensibility index of the IVC (dIVC) was calculated as the ratio of Dmax - Dmin / Dmin, and expressed as a percentage. The Doppler technique was applied in the pulmonary artery trunk to determine cardiac index (CI). Measurements were performed at baseline and after a 7 ml/kg volume expansion using a plasma expander. Patients were separated into responders (increase in CI > or =15%) and non-responders (increase in CI <15%). RESULTS: Using a threshold dIVC of 18%, responders and non-responders were discriminated with 90% sensitivity and 90% specificity. A strong relation (r = 0.9) was observed between dIVC at baseline and the CI increase following blood volume expansion. Baseline central venous pressure did not accurately predict fluid responsiveness. CONCLUSION: Our study suggests that respiratory change in IVC diameter is an accurate predictor of fluid responsiveness in septic patients.","DOI":"10.1007/s00134-004-2259-8","ISSN":"0342-4642 (Print) 0342-4642 (Linking)","journalAbbreviation":"Intensive Care Med.","language":"eng","author":[{"family":"Barbier","given":"C."},{"family":"Loubieres","given":"Y."},{"family":"Schmit","given":"C."},{"family":"Hayon","given":"J."},{"family":"Ricome","given":"J. L."},{"family":"Jardin","given":"F."},{"family":"Vieillard-Baron","given":"A."}],"issued":{"date-parts":[["2004",9]]}}}],"schema":""} 25,149 In general, in spontaneously breathing patients, when the IVC is small and collapsed it may be safe to give fluids. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"pdE8PVnu","properties":{"formattedCitation":"\\super 150\\nosupersub{}","plainCitation":"150","noteIndex":0},"citationItems":[{"id":8483,"uris":[""],"uri":[""],"itemData":{"id":8483,"type":"article-journal","title":"Ultrasonographic Measurement of the Respiratory Variation in the Inferior Vena Cava Diameter Is Predictive of Fluid Responsiveness in Critically Ill Patients: Systematic Review and Meta-analysis","container-title":"Ultrasound in Medicine and Biology","abstract":"Respiratory variation in the inferior vena cava (DeltaIVC) has been extensively studied with respect to its value in predicting fluid responsiveness, but the results are conflicting. This systematic review was aimed at investigating the diagnostic accuracy of DeltaIVC in predicting fluid responsiveness. Databases including Medline, Embase, Scopus and Web of Knowledge were searched from inception to May 2013. Studies exploring the diagnostic performance of DeltaIVC in predicting fluid responsiveness were included. To allow for more between- and within-study variance, a hierarchical summary receiver operating characteristic model was used to pool the results. Subgroup analyses were performed for patients on mechanical ventilation, spontaneously breathing patients and those challenged with colloids and crystalloids. A total of 8 studies involving 235 patients were eligible for analysis. Cutoff values of DeltaIVC varied across studies, ranging from 12% to 40%. The pooled sensitivity and specificity in the overall population were 0.76 (95% confidence interval [CI]: 0.61-0.86) and 0.86 (95% CI: 0.69-0.95), respectively. The pooled diagnostic odds ratio (DOR) was 20.2 (95% CI: 6.1-67.1). The diagnostic performance of DeltaIVC appeared to be better in patients on mechanical ventilation than in spontaneously breathing patients (DOR: 30.8 vs. 13.2). The pooled area under the receiver operating characteristic curve was 0.84 (95% CI: 0.79-0.89). Our study indicates that DeltaIVC measured with point-of-care ultrasonography is of great value in predicting fluid responsiveness, particularly in patients on controlled mechanical ventilation and those resuscitated with colloids.","DOI":"10.1016/j.ultrasmedbio.2013.12.010","ISSN":"1879-291X (Electronic) 0301-5629 (Linking)","journalAbbreviation":"Ultrasound Med. Biol.","language":"Eng","author":[{"family":"Zhang","given":"Z."},{"family":"Xu","given":"X."},{"family":"Ye","given":"S."},{"family":"Xu","given":"L."}],"issued":{"date-parts":[["2014",2,1]]}}}],"schema":""} 150 Serial evaluations for interstitial syndromes during resuscitation allows early detection of pulmonary edema and may be useful in determining an endpoint for fluid resuscitation. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"2R9dPclG","properties":{"formattedCitation":"\\super 151\\nosupersub{}","plainCitation":"151","noteIndex":0},"citationItems":[{"id":6975,"uris":[""],"uri":[""],"itemData":{"id":6975,"type":"article-journal","title":"Fluid administration limited by lung sonography: the place of lung ultrasound in assessment of acute circulatory failure (the FALLS-protocol)","container-title":"Expert Review of Respiratory Medicine","page":"155-62","volume":"6","issue":"2","abstract":"The FALLS-protocol is included in a limited investigation to diagnose the cause of shock. After simple echocardiography has ruled out obstructive shock (tamponade, pulmonary embolism), the lung is investigated. Absence of disseminated lung rockets rules out cardiogenic shock. At this point, hypovolemic and septic shock are differential diagnoses (rarities apart), and the FALLS-protocol provides fluid therapy with constant monitoring of lung artifacts. Hypovolemic shock will eventually improve - septic shock will not, and the slight excess fluid creates an early, silent stage of interstitial edema, demonstrated by B-lines, demanding interruption of fluid therapy. This sequential approach, combined with the usual, clinical, biochemical and echocardiographic parameters, must be evaluated in multicenter studies.","DOI":"10.1586/ers.12.13","ISSN":"1747-6348","journalAbbreviation":"Expert Rev. Respir. Med.","language":"eng","author":[{"family":"Lichtenstein","given":"D."}],"issued":{"date-parts":[["2012",4]]}}}],"schema":""} 151Appendix 7: Acute Respiratory Failure and DyspneaPoint-of-care ultrasound is used in the evaluation of acute respiratory failure and dyspnea through evaluation of the lungs, heart, and lower extremity veins.Pulmonary ultrasound: Lichtenstein demonstrated that with pleural, pulmonary, and deep vein ultrasound analysis alone a trained provider could determine the etiology of acute respiratory failure in 90% of critically ill patients without any additional clinical information. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"WIChAYYz","properties":{"formattedCitation":"\\super 152\\nosupersub{}","plainCitation":"152","noteIndex":0},"citationItems":[{"id":5521,"uris":[""],"uri":[""],"itemData":{"id":5521,"type":"article-journal","title":"Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol","container-title":"Chest","page":"117-25","volume":"134","issue":"1","abstract":"BACKGROUND: This study assesses the potential of lung ultrasonography to diagnose acute respiratory failure. METHODS: This observational study was conducted in university-affiliated teaching-hospital ICUs. We performed ultrasonography on consecutive patients admitted to the ICU with acute respiratory failure, comparing lung ultrasonography results on initial presentation with the final diagnosis by the ICU team. Uncertain diagnoses and rare causes (frequency<2%) were excluded. We included 260 dyspneic patients with a definite diagnosis. Three items were assessed: artifacts (horizontal A lines or vertical B lines indicating interstitial syndrome), lung sliding, and alveolar consolidation and/or pleural effusion. Combined with venous analysis, these items were grouped to assess ultrasound profiles. RESULTS: Predominant A lines plus lung sliding indicated asthma (n=34) or COPD (n=49) with 89% sensitivity and 97% specificity. Multiple anterior diffuse B lines with lung sliding indicated pulmonary edema (n=64) with 97% sensitivity and 95% specificity. A normal anterior profile plus deep venous thrombosis indicated pulmonary embolism (n=21) with 81% sensitivity and 99% specificity. Anterior absent lung sliding plus A lines plus lung point indicated pneumothorax (n=9) with 81% sensitivity and 100% specificity. Anterior alveolar consolidations, anterior diffuse B lines with abolished lung sliding, anterior asymmetric interstitial patterns, posterior consolidations or effusions without anterior diffuse B lines indicated pneumonia (n=83) with 89% sensitivity and 94% specificity. The use of these profiles would have provided correct diagnoses in 90.5% of cases. CONCLUSIONS: Lung ultrasound can help the clinician make a rapid diagnosis in patients with acute respiratory failure, thus meeting the priority objective of saving time.","DOI":"10.1378/chest.07-2800","ISSN":"0012-3692 (Print) 0012-3692 (Linking)","note":"PMCID: PMC3734893","journalAbbreviation":"Chest","language":"eng","author":[{"family":"Lichtenstein","given":"D. A."},{"family":"Meziere","given":"G. A."}],"issued":{"date-parts":[["2008",7]]}}}],"schema":""} 152 In one study, internal medicine residents improved their diagnostic accuracy in hospitalized patients with dyspnea. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"VJ7vQbpw","properties":{"formattedCitation":"\\super 153\\nosupersub{}","plainCitation":"153","noteIndex":0},"citationItems":[{"id":8026,"uris":[""],"uri":[""],"itemData":{"id":8026,"type":"article-journal","title":"Impact of pocket ultrasound use by internal medicine housestaff in the diagnosis of dyspnea","container-title":"Journal of Hospital Medicine","page":"594-7","volume":"9","issue":"9","abstract":"BACKGROUND: Recent reports demonstrate high diagnostic accuracy of lung ultrasound for evaluation of dyspnea. We assessed the feasibility of training internal medicine residents in lung ultrasound with a pocket ultrasound device. METHODS: We performed a prospective, observational trial of residents performing lung ultrasound with a pocket ultrasound. Training consisted of two 90-minute sessions of didactics and supervised bedside performance. Two residents received an additional 2 weeks of training. Residents recorded a clinical diagnosis based on admission data. Following lung ultrasound performance, an ultrasound diagnosis was recorded integrating clinical and sonographic findings. Using receiver operating curve analysis, the area under the curve was calculated for both clinical diagnosis and ultrasound diagnosis using attending physician's final discharge diagnosis as the gold standard. RESULTS: Five residents performed 69 exams. The AUC for ultrasound diagnosis was significantly higher than that for clinical diagnosis (0.87 vs 0.81, P < 0.01). AUCs increased using lung ultrasound for diagnoses as follows: chronic obstructive pulmonary disease (0.73-0.85, P = 0.06), acute pulmonary edema (0.85-0.89, P = 0.49), pneumonia (0.77-0.88, P = 0.01), and pleural effusions (0.76-0.96, P < 0.002). CONCLUSIONS: Lung ultrasound performed by residents with a pocket ultrasound improved the diagnostic accuracy of dyspnea. Two residents undergoing extended training showed a total increase in diagnostic accuracy.","DOI":"10.1002/jhm.2219","ISSN":"1553-5606 (Electronic) 1553-5592 (Linking)","journalAbbreviation":"J. Hosp. Med.","language":"eng","author":[{"family":"Filopei","given":"J."},{"family":"Siedenburg","given":"H."},{"family":"Rattner","given":"P."},{"family":"Fukaya","given":"E."},{"family":"Kory","given":"P."}],"issued":{"date-parts":[["2014",9]]}}}],"schema":""} 153 Numerous authors have demonstrated the ability to differentiate COPD and CHF using lung ultrasound. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"JVM7MB5I","properties":{"formattedCitation":"\\super 154,155\\nosupersub{}","plainCitation":"154,155","noteIndex":0},"citationItems":[{"id":6846,"uris":[""],"uri":[""],"itemData":{"id":6846,"type":"article-journal","title":"Diagnostic accuracy and reproducibility of pleural and lung ultrasound in discriminating cardiogenic causes of acute dyspnea in the emergency department","container-title":"Internal and Emergency Medicine","page":"65-70","volume":"7","issue":"1","abstract":"Dyspnea is a common symptom in patients admitted to the Emergency Department (ED), and discriminating between cardiogenic and non-cardiogenic dyspnea is often a clinical dilemma. The initial diagnostic work-up may be inaccurate in defining the etiology and the underlying pathophysiology. The aim of this study was to evaluate the diagnostic accuracy and reproducibility of pleural and lung ultrasound (PLUS), performed by emergency physicians at the time of a patient's initial evaluation in the ED, in identifying cardiac causes of acute dyspnea. Between February and July 2007, 56 patients presenting to the ED with acute dyspnea were prospectively enrolled in this study. In all patients, PLUS was performed by emergency physicians with the purpose of identifying the presence of diffuse alveolar-interstitial syndrome (AIS) or pleural effusion. All scans were later reviewed by two other emergency physicians, expert in PLUS and blinded to clinical parameters, who were the ultimate judges of positivity for diffuse AIS and pleural effusion. A random set of 80 recorded scannings were also reviewed by two inexperienced observers to assess inter-observer variability. The entire medical record was independently reviewed by two expert physicians (an emergency medicine physician and a cardiologist) blinded to the ultrasound (US) results, in order to determine whether, for each patient, dyspnea was due to heart failure, or not. Sensitivity, specificity, and positive/negative predictive values were obtained; likelihood ratio (LR) test was used. Cohen's kappa was used to assess inter-observer agreement. The presence of diffuse AIS was highly predictive for cardiogenic dyspnea (sensitivity 93.6%, specificity 84%, positive predictive value 87.9%, negative predictive value 91.3%). On the contrary, US detection of pleural effusion was not helpful in the differential diagnosis (sensitivity 83.9%, specificity 52%, positive predictive value 68.4%, negative predictive value 72.2%). Finally, the coexistence of diffuse AIS and pleural effusion is less accurate than diffuse AIS alone for cardiogenic dyspnea (sensitivity 81.5%, specificity 82.8%, positive predictive value 81.5%, negative predictive value 82.8%). The positive LR was 5.8 for AIS [95% confidence interval (CI) 4.8-7.1] and 1.7 (95% CI 1.2-2.6) for pleural effusion, negative LR resulted 0.1 (95% CI 0.0-0.4) for AIS and 0.3 (95% CI 0.1-0.8) for pleural effusion. Agreement between experienced and inexperienced operators was 92.2% (p < 0.01) and 95% (p < 0.01) for diagnosis of AIS and pleural effusion, respectively. In early evaluation of patients presenting to the ED with dyspnea, PLUS, performed with the purpose of identifying diffuse AIS, may represent an accurate and reproducible bedside tool in discriminating between cardiogenic and non-cardiogenic dyspnea. On the contrary, US detection of pleural effusions does not allow reliable discrimination between different causes of acute dyspnea in unselected ED patients.","DOI":"10.1007/s11739-011-0709-1","ISSN":"1970-9366 (Electronic) 1828-0447 (Linking)","journalAbbreviation":"Intern. Emerg. Med.","language":"eng","author":[{"family":"Cibinel","given":"G. A."},{"family":"Casoli","given":"G."},{"family":"Elia","given":"F."},{"family":"Padoan","given":"M."},{"family":"Pivetta","given":"E."},{"family":"Lupia","given":"E."},{"family":"Goffi","given":"A."}],"issued":{"date-parts":[["2012",2]]}}},{"id":4069,"uris":[""],"uri":[""],"itemData":{"id":4069,"type":"article-journal","title":"A lung ultrasound sign allowing bedside distinction between pulmonary edema and COPD: the comet-tail artifact","container-title":"Intensive Care Medicine","page":"1331-4","volume":"24","issue":"12","abstract":"OBJECTIVE: Acute cardiogenic pulmonary edema and exacerbation of chronic obstructive pulmonary disease (COPD) can have a similar clinical presentation, and X-ray examination does not always solve the problem of differential diagnosis. The potential of lung ultrasound to distinguish these two disorders was assessed. DESIGN: Prospective clinical study. SETTING: The medical ICU of a university-affiliated teaching hospital. PATIENTS: We investigated 66 consecutive dyspneic patients: 40 with pulmonary edema and 26 with COPD. In addition, 80 patients without clinical and radiologic respiratory disorders were studied. MEASUREMENTS: The sign studied was the comet-tail artifact arising from the lung wall interface, multiple and bilaterally disseminated to the anterolateral chest wall. RESULTS: The feasibility was 100%. The length of the examination was always under 1 min. The described pattern was present in all 40 patients with pulmonary edema. It was absent in 24 of 26 cases of COPD as well as in 79 of 80 patients without respiratory disorders. The sign studied had a sensitivity of 100% and a specificity of 92% in the diagnosis of pulmonary edema when compared with COPD. CONCLUSIONS: With a described pattern present in 100% of the cases of pulmonary edema and absent in 92% of the cases of COPD and in 98.75% of the normal lungs, ultrasound detection of the comet-tail artifact arising from the lung-wall interface may help distinguish pulmonary edema from COPD.","ISSN":"0342-4642 (Print) 0342-4642 (Linking)","journalAbbreviation":"Intensive Care Med.","language":"eng","author":[{"family":"Lichtenstein","given":"D."},{"family":"Meziere","given":"G."}],"issued":{"date-parts":[["1998",12]]}}}],"schema":""} 154,155Cardiac: The use of cardiac POCUS to assess chamber size, ventricular function, pericardial effusion, and inferior vena cava size can be combined with pulmonary ultrasound in the assessment of dyspnea. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ZyTRlist","properties":{"formattedCitation":"\\super 14,156\\nosupersub{}","plainCitation":"14,156","noteIndex":0},"citationItems":[{"id":7700,"uris":[""],"uri":[""],"itemData":{"id":7700,"type":"article-journal","title":"Focused cardiac ultrasound: recommendations from the American Society of Echocardiography","container-title":"Journal of the American Society of Echocardiography","page":"567-81","volume":"26","issue":"6","DOI":"10.1016/j.echo.2013.04.001","ISSN":"1097-6795 (Electronic) 0894-7317 (Linking)","journalAbbreviation":"J. Am. Soc. Echocardiogr.","language":"eng","author":[{"family":"Spencer","given":"K. T."},{"family":"Kimura","given":"B. J."},{"family":"Korcarz","given":"C. E."},{"family":"Pellikka","given":"P. A."},{"family":"Rahko","given":"P. S."},{"family":"Siegel","given":"R. J."}],"issued":{"date-parts":[["2013",6]]}}},{"id":6550,"uris":[""],"uri":[""],"itemData":{"id":6550,"type":"article-journal","title":"Cardiopulmonary limited ultrasound examination for \"quick-look\" bedside application","container-title":"American Journal of Cardiology","page":"586-90","volume":"108","issue":"4","abstract":"Although taking a \"quick look\" at the heart using a small ultrasound device is now feasible, a formal ultrasound imaging protocol to augment the bedside physical examination has not been developed. Therefore, we sought to evaluate the diagnostic accuracy and prognostic value of a cardiopulmonary limited ultrasound examination (CLUE) using 4 simplified diagnostic criteria that would screen for left ventricular dysfunction (LV), left atrial (LA) enlargement, inferior vena cava plethora (IVC+), and ultrasound lung comet-tail artifacts (ULC+) in patients referred for echocardiography. The CLUE was tested by interpretation of only the parasternal LV long-axis, subcostal IVC, and 2 lung apical views in each of 1,016 consecutive echocardiograms performed with apical lung imaging. For inpatients, univariate and multivariate logistic regression analyses were performed to assess the relations between mortality, CLUE findings, age, and gender. In this echocardiographic referral series, 78% (n = 792) were inpatient and 22% (n = 224) were outpatient. The CLUE criteria demonstrated a sensitivity, specificity, and accuracy for a LV ejection fraction of </=40% of 69%, 91%, and 89% and for LA enlargement of 75%, 72%, and 73%, respectively. CLUE findings of LV dysfunction, LA enlargement, IVC+, and ULC+ were seen in 16%, 53%, 34%, and 28% of inpatients. The best multivariate logistic model contained 3 predictors of in-hospital mortality: ULC+, IVC+ and male gender, with adjusted odds ratios (95% confidence intervals) of 3.5 (1.4 to 8.8), 5.8 (2.1 to 16.4), and 2.3 (0.9 to 5.8), respectively. In conclusion, a CLUE consisting of 4 quick-look \"signs\" has reasonable diagnostic accuracy for bedside use and contains prognostic information.","DOI":"10.1016/j.amjcard.2011.03.091","ISSN":"1879-1913 (Electronic) 0002-9149 (Linking)","journalAbbreviation":"Am. J. Cardiol.","language":"eng","author":[{"family":"Kimura","given":"B. J."},{"family":"Yogo","given":"N."},{"family":"O'Connell","given":"C. W."},{"family":"Phan","given":"J. N."},{"family":"Showalter","given":"B. K."},{"family":"Wolfson","given":"T."}],"issued":{"date-parts":[["2011",8,15]]}}}],"schema":""} 14,156 In emergency medicine patients, a combination of cardiac and pulmonary ultrasound findings may effectively exclude acute heart failure. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a9fUXfBK","properties":{"formattedCitation":"\\super 157\\nosupersub{}","plainCitation":"157","noteIndex":0},"citationItems":[{"id":7229,"uris":[""],"uri":[""],"itemData":{"id":7229,"type":"article-journal","title":"Diagnosing heart failure among acutely dyspneic patients with cardiac, inferior vena cava, and lung ultrasonography","container-title":"American Journal of Emergency Medicine","page":"1208-14","volume":"31","issue":"8","abstract":"BACKGROUND: Rapid diagnosis (dx) of acutely decompensated heart failure (ADHF) may be challenging in the emergency department (ED). Point-of-care ultrasonography (US) allows rapid determination of cardiac function, intravascular volume status, and presence of pulmonary edema. We test the diagnostic test characteristics of these 3 parameters in making the dx of ADHF among acutely dyspneic patients in the ED. METHODS: This was a prospective observational cohort study at an urban academic ED. Inclusion criteria were as follows: dyspneic patients, at least 18 years old and able to consent, whose differential dx included ADHF. Ultrasonography performed by emergency sonologists evaluated the heart for left ventricular ejection fraction (LVEF), the inferior vena cava for collapsibility index (IVC-CI), and the pleura sampled in each of 8 thoracic regions for presence of B-lines. Cutoff values for ADHF were LVEF less than 45%, IVC-CI less than 20%, and at least 10 B-lines. The US findings were compared with the final dx determined by 2 emergency physicians blinded to the US results. RESULTS: One hundred one participants were enrolled: 52% male, median age 62 (25%-75% interquartile, 53-91). Forty-four (44%) had a final dx of ADHF. Sensitivity and specificity (including 95% confidence interval) for the presence of ADHF were as follows: 74 (65-90) and 74 (62-85) using LVEF less than 45%, 52 (38-67) and 86 (77-95) using IVC-CI less than 20%, and 70 (52-80) and 75 (64-87) using B-lines at least 10. Using all 3 modalities together, the sensitivity and specificity were 36 (22-51) and 100 (95-100). As a comparison, the sensitivity and specificity of brain natriuretic peptide greater than 500 were 75 (55-89) and 83 (67-92). CONCLUSION: In this study, US was 100% specific for the dx of ADHF.","DOI":"10.1016/j.ajem.2013.05.007","ISSN":"1532-8171 (Electronic) 0735-6757 (Linking)","journalAbbreviation":"Am. J. Emerg. Med.","language":"eng","author":[{"family":"Anderson","given":"K. L."},{"family":"Jenq","given":"K. Y."},{"family":"Fields","given":"J. M."},{"family":"Panebianco","given":"N. L."},{"family":"Dean","given":"A. J."}],"issued":{"date-parts":[["2013",8]]}}}],"schema":""} 157 Additional benefits may be found when combined with other findings, such as BNP. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"ovW93z4h","properties":{"formattedCitation":"\\super 158\\nosupersub{}","plainCitation":"158","noteIndex":0},"citationItems":[{"id":5835,"uris":[""],"uri":[""],"itemData":{"id":5835,"type":"article-journal","title":"Emergency thoracic ultrasound in the differentiation of the etiology of shortness of breath (ETUDES): sonographic B-lines and N-terminal pro-brain-type natriuretic peptide in diagnosing congestive heart failure","container-title":"Academic Emergency Medicine","page":"201-10","volume":"16","issue":"3","abstract":"OBJECTIVES: Sonographic thoracic B-lines and N-terminal pro-brain-type natriuretic peptide (NT-ProBNP) have been shown to help differentiate between congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). The authors hypothesized that ultrasound (US) could be used to predict CHF and that it would provide additional predictive information when combined with NT-ProBNP. They also sought to determine optimal two- and eight-zone scanning protocols when different thresholds for a positive scan were used. METHODS: This was a prospective, observational study of a convenience sample of adult patients presenting to the emergency department (ED) with shortness of breath. Each patient had an eight-zone thoracic US performed by one of five sonographers, and serum NT-ProBNP levels were measured. Chart review by two physicians blinded to the US results served as the criterion standard. The operating characteristics of two- and eight-zone thoracic US alone, compared to, and combined with NT-ProBNP test results for predicting CHF were calculated using both dichotomous and interval likelihood ratios (LRs). RESULTS: One-hundred patients were enrolled. Six were excluded because of incomplete data. Results of 94 patients were analyzed. A positive eight-zone US, defined as at least two positive zones on each side, had a positive likelihood ratio (LR+) of 3.88 (99% confidence interval [CI] = 1.55 to 9.73) and a negative likelihood ratio (LR-) of 0.5 (95% CI = 0.30 to 0.82), while the NT-ProBNP demonstrated a LR+ of 2.3 (95% CI = 1.41 to 3.76) and LR- of 0.24 (95% CI = 0.09 to 0.66). Using interval LRs for the eight-zone US test alone, the LR for a totally positive test (all eight zones positive) was infinite and for a totally negative test (no zones positive) was 0.22 (95% CI = 0.06 to 0.80). For two-zone US, interval LRs were 4.73 (95% CI = 2.10 to 10.63) when inferior lateral zones were positive bilaterally and 0.3 (95% CI = 0.13 to 0.71) when these were negative. These changed to 8.04 (95% CI = 1.76 to 37.33) and 0.11 (95% CI = 0.02 to 0.69), respectively, when congruent with NT-ProBNP. CONCLUSIONS: Bedside thoracic US for B-lines can be a useful test for diagnosing CHF. Predictive accuracy is greatly improved when studies are totally positive or totally negative. A two-zone protocol performs similarly to an eight-zone protocol. Thoracic US can be used alone or can provide additional predictive power to NT-ProBNP in the immediate evaluation of dyspneic patients presenting to the ED.","DOI":"10.1111/j.1553-2712.2008.00347.x","ISSN":"1069-6563","journalAbbreviation":"Acad. Emerg. Med.","language":"eng","author":[{"family":"Liteplo","given":"A. S."},{"family":"Marill","given":"K. A."},{"family":"Villen","given":"T."},{"family":"Miller","given":"R. M."},{"family":"Murray","given":"A. F."},{"family":"Croft","given":"P. E."},{"family":"Capp","given":"R."},{"family":"Noble","given":"V. E."}],"issued":{"date-parts":[["2009",3]]}}}],"schema":""} 158Ascites: Ascites as a cause of dyspnea can be confidently ruled out with abdominal POCUS (sensitivity of 95.8%). ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"2p3r7WE0","properties":{"formattedCitation":"\\super 62\\nosupersub{}","plainCitation":"62","noteIndex":0},"citationItems":[{"id":9172,"uris":[""],"uri":[""],"itemData":{"id":9172,"type":"article-journal","title":"Pocket ultrasound device as a complement to physical examination for ascites evaluation and guided paracentesis","container-title":"Internal and Emergency Medicine","page":"461-6","volume":"11","issue":"3","abstract":"The pocket ultrasound device (PUD) is a new tool that may be of use in the early detection of ascites. Abdominal ultrasound-guided paracentesis has been reported to decrease the rate of complications due to the procedure, but must be performed in a healthcare setting; this new tool may be a useful on an ambulatory basis. The aim of this study was to determine the diagnostic usefulness of the PUD in the diagnosis of ascites and the safety of guided paracentesis. We conducted a retrospective study that included adult patients suspected of having ascites and in whom an evaluation was performed with the PUD to identify it. Concordance with abdominal ultrasound (AUS) was determined with the Kappa coefficient. Sensitivity (Se), specificity (Sp) and likelihood ratios (LR) were determined and compared with physical examination, AUS, computed tomography and procurement of fluid by paracentesis. Complications resulting from the guided paracentesis were analyzed. 89 participants were included and 40 underwent a paracentesis. The PUD for ascites detection had 95.8 % Se, 81.8 % Sp, 5.27 +LR and 0.05 -LR. It had a concordance with AUS of 0.781 (p < 0.001). Technical problems during the guided paracentesis were present in only two participants (5 %) and three patients (7.5 %) developed minor complications that required no further intervention. There were no severe complications or deaths. This study suggests that the PUD is a reliable tool for ascites detection as a complement to physical examination and appears to be a safe method to perform guided paracentesis.","DOI":"10.1007/s11739-016-1406-x","ISSN":"1828-0447","journalAbbreviation":"Intern. Emerg. Med.","language":"eng","author":[{"family":"Keil-Rios","given":"D."},{"family":"Terrazas-Solis","given":"H."},{"family":"Gonzalez-Garay","given":"A."},{"family":"Sanchez-Avila","given":"J. F."},{"family":"Garcia-Juarez","given":"I."}],"issued":{"date-parts":[["2016",4]]}}}],"schema":""} 62Appendix 8: Acute Kidney InjuryPOCUS is used to assess the kidneys and bladder in patients with acute kidney injury, usually combined with an evaluation of volume status. See Appendix 3 for additional details about the kidneys and bladder.Intravascular volume: Volume depletion is a common cause of acute kidney injury. Evaluation of the heart, IVC, and other areas can guide estimation of volume status. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"nBr9ngn4","properties":{"formattedCitation":"\\super 150,159\\uc0\\u8211{}161\\nosupersub{}","plainCitation":"150,159–161","noteIndex":0},"citationItems":[{"id":8483,"uris":[""],"uri":[""],"itemData":{"id":8483,"type":"article-journal","title":"Ultrasonographic Measurement of the Respiratory Variation in the Inferior Vena Cava Diameter Is Predictive of Fluid Responsiveness in Critically Ill Patients: Systematic Review and Meta-analysis","container-title":"Ultrasound in Medicine and Biology","abstract":"Respiratory variation in the inferior vena cava (DeltaIVC) has been extensively studied with respect to its value in predicting fluid responsiveness, but the results are conflicting. This systematic review was aimed at investigating the diagnostic accuracy of DeltaIVC in predicting fluid responsiveness. Databases including Medline, Embase, Scopus and Web of Knowledge were searched from inception to May 2013. Studies exploring the diagnostic performance of DeltaIVC in predicting fluid responsiveness were included. To allow for more between- and within-study variance, a hierarchical summary receiver operating characteristic model was used to pool the results. Subgroup analyses were performed for patients on mechanical ventilation, spontaneously breathing patients and those challenged with colloids and crystalloids. A total of 8 studies involving 235 patients were eligible for analysis. Cutoff values of DeltaIVC varied across studies, ranging from 12% to 40%. The pooled sensitivity and specificity in the overall population were 0.76 (95% confidence interval [CI]: 0.61-0.86) and 0.86 (95% CI: 0.69-0.95), respectively. The pooled diagnostic odds ratio (DOR) was 20.2 (95% CI: 6.1-67.1). The diagnostic performance of DeltaIVC appeared to be better in patients on mechanical ventilation than in spontaneously breathing patients (DOR: 30.8 vs. 13.2). The pooled area under the receiver operating characteristic curve was 0.84 (95% CI: 0.79-0.89). Our study indicates that DeltaIVC measured with point-of-care ultrasonography is of great value in predicting fluid responsiveness, particularly in patients on controlled mechanical ventilation and those resuscitated with colloids.","DOI":"10.1016/j.ultrasmedbio.2013.12.010","ISSN":"1879-291X (Electronic) 0301-5629 (Linking)","journalAbbreviation":"Ultrasound Med. Biol.","language":"Eng","author":[{"family":"Zhang","given":"Z."},{"family":"Xu","given":"X."},{"family":"Ye","given":"S."},{"family":"Xu","given":"L."}],"issued":{"date-parts":[["2014",2,1]]}}},{"id":3667,"uris":[""],"uri":[""],"itemData":{"id":3667,"type":"article-journal","title":"Using Point-of-Care Bedside Ultrasound for Volume Assessment in Early Shock: An Outcome Study","container-title":"Chest","page":"A148","volume":"149","issue":"4","DOI":"10.1016/j.chest.2016.02.154","ISSN":"0012-3692","journalAbbreviation":"Chest","author":[{"family":"Mitchell","given":"Daniel"},{"family":"Leng","given":"Aaron"},{"family":"Gardiner","given":"Stuart"},{"family":"Vanderwerff","given":"Laura"},{"family":"Jones","given":"Steven"},{"family":"Thompson","given":"Dennis"},{"family":"Leng","given":"Poh"}]}},{"id":7122,"uris":[""],"uri":[""],"itemData":{"id":7122,"type":"article-journal","title":"Bedside ultrasound in resuscitation and the rapid ultrasound in shock protocol","container-title":"Critical Care Research and Practice","page":"503254","volume":"2012","abstract":"Assessment of hemodynamic status in a shock state remains a challenging issue in Emergency Medicine and Critical Care. As the use of invasive hemodynamic monitoring declines, bedside-focused ultrasound has become a valuable tool in the evaluation and management of patients in shock. No longer a means to simply evaluate organ anatomy, ultrasound has expanded to become a rapid and noninvasive method for the assessment of patient physiology. Clinicians caring for critical patients should strongly consider integrating ultrasound into their resuscitation pathways.","DOI":"10.1155/2012/503254","ISSN":"2090-1305","note":"PMCID: PMC3485910","journalAbbreviation":"Crit. Care Res. Pract.","language":"eng","author":[{"family":"Seif","given":"D."},{"family":"Perera","given":"P."},{"family":"Mailhot","given":"T."},{"family":"Riley","given":"D."},{"family":"Mandavia","given":"D."}],"issued":{"date-parts":[["2012"]]}}},{"id":9149,"uris":[""],"uri":[""],"itemData":{"id":9149,"type":"article-journal","title":"Adding point of care ultrasound to assess volume status in heart failure patients in a nurse-led outpatient clinic. A randomised study","container-title":"Heart","page":"29-34","volume":"102","issue":"1","abstract":"OBJECTIVES: Medical history, physical examination and laboratory testing are not optimal for the assessment of volume status in heart failure (HF) patients. We aimed to study the clinical influence of focused ultrasound of the pleural cavities and inferior vena cava (IVC) performed by specialised nurses to assess volume status in HF patients at an outpatient clinic. METHODS: HF outpatients were prospectively included and underwent laboratory testing, history recording and clinical examination by two nurses with and without an ultrasound examination of the pleural cavities and IVC using a pocket-size imaging device, in random order. Each nurse worked in a team with a cardiologist. The influence of the different diagnostic tests on diuretic dosing was assessed descriptively and in linear regression analyses. RESULTS: Sixty-two patients were included and 119 examinations were performed. Mean+/-SD age was 74+/-12 years, EF was 34+/-14%, and N-terminal pro-brain natriuretic peptide (NT-proBNP) value was 3761+/-3072 ng/L. Dosing of diuretics differed between the teams in 31 out of 119 consultations. Weight change and volume status assessed clinically with and without ultrasound predicted dose adjustment of diuretics at follow-up (p<0.05). Change of oedema, NT-proBNP, creatinine, and symptoms did not (p>/=0.10). In adjusted analyses, only volume status based on ultrasound predicted dose adjustments of diuretics at first visit and follow-up (all ultrasound p</=0.01, all other p>/=0.2). CONCLUSIONS: Ultrasound examinations of the pleural cavities and IVC by nurses may improve diagnostics and patient care in HF patients at an outpatient clinic, but more studies are needed to determine whether these examinations have an impact on clinical outcomes. TRIAL REGISTRATION NUMBER: NCT01794715.","DOI":"10.1136/heartjnl-2015-307798","ISSN":"1355-6037","note":"PMCID: PMC4717409","journalAbbreviation":"Heart","language":"eng","author":[{"family":"Gundersen","given":"G. H."},{"family":"Norekval","given":"T. M."},{"family":"Haug","given":"H. H."},{"family":"Skjetne","given":"K."},{"family":"Kleinau","given":"J. O."},{"family":"Graven","given":"T."},{"family":"Dalen","given":"H."}],"issued":{"date-parts":[["2016",1]]}}}],"schema":""} 150,159–161 Findings consistent with cardiorenal injury may be detected by evaluation of the heart and IVC.Urinary system: Imaging of the kidneys and bladder may detect moderate or greater hydronephrosis. A focused ultrasound examination of the bladder can reveal urinary retention or lack of urine suggestive of oliguria or anuria. Appendix 9: BillingNote for all procedures listed in Table, the use of ultrasound guidance is included in the CPT code; however, only ultrasound guidance for vascular access is billed separately.If more than one area was scanned as part of the study, more than one bill can be submitted. For example, if POCUS examination of the lungs, heart, and LE veins is performed as part of PE protocol scan, then the provider can bill for CPT codes 76604, 93308, and 93971.A peculiar caveat regarding CPT code-based billing is worth mentioning. Each code consists of 2 components: technical fee (added modifier -TC), which is the charge for using the equipment, and professional fee (added modifier -26) which is the charge for image acquisition and interpretation. A code combining both technical and professional fees is called a global fee and has no added modifier. The technical component can only be billed if the physician or practice group owns the US machine. However, Medicare rules specifically prohibit use of global billing codes in hospital setting regardless?of equipment ownership. This does not mean that physician groups cannot get reimbursed for their expenses related to purchase/rental and maintenance of the US equipment. However, in order to accomplish that physician groups will have to either bill their respective hospitals or negotiate a contract regarding reimbursement.Medicare Outpatient Prospective Payment System considers the technical fee for ultrasound-guided procedures to be a packaged service, which is paid for through reimbursement of the procedure being performed. Of note, Medicare reimbursement for technical charges is often more robust than the professional charges.Only one bill for a particular CPT code can be submitted per day.Table 1: Frequently used CPT codes for point-of-care ultrasound billingDiagnostic UltrasoundAbdominal Ultrasound, limited?93308Retroperitoneal (e.g., renal, aorta, nodes), limited76775Pelvic (non-obstetrical) or bladder, limited76857Deep venous thrombosis, limited93971Chest (lungs)76604Musculoskeletal, extremity, non-vascular (all joints)76882Soft Tissue: Neck (thyroid)76536Ocular (B-scan)76512Ultrasound, other76999Ultrasound-guided proceduresThoracentesis32555Paracentesis49083Arthrocentesis20611Non-tunneled central venous catheter36556US guided venous access (midline or peripheral) or ABG36600Ultrasonic guidance for needle placement76942Appendix 10: References for Appendices ADDIN ZOTERO_BIBL {"uncited":[],"omitted":[],"custom":[]} CSL_BIBLIOGRAPHY 1. Manasia AR, Nagaraj HM, Kodali RB, et al. 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