Lawrence Melniker

International evidence-based recommendations on ultrasound-guided vascular access

PurposeTo provide clinicians with an evidence-based overview of all topics related to ultrasound vascular access.MethodsAn international evidence-based consensus provided definitions and recommendations. Medical literature on ultrasound vascular access was reviewed from January 1985 to October 2010. The GRADE and the GRADE-RAND methods were utilised to develop recommendations.ResultsThe recommendations following the conference suggest the advantage of 2D vascular screening prior to cannulation and that real-time ultrasound needle guidance with an in-plane/long-axis technique optimises the probability of needle placement. Ultrasound guidance can be used not only for central venous cannulation but also in peripheral and arterial cannulation. Ultrasound can be used in order to check for immediate and life-threatening complications as well as the catheter’s tip position. Educational courses and training are required to achieve competence and minimal skills when cannulation is performed with ultrasound guidance. A recommendation to create an ultrasound curriculum on vascular access is proposed. This technique allows the reduction of infectious and mechanical complications.ConclusionsThese definitions and recommendations based on a critical evidence review and expert consensus are proposed to assist clinicians in ultrasound-guided vascular access and as a reference for future clinical research.

Randomized, controlled clinical trial of point-of-care limited ultrasonography assistance of central venous cannulation: the Third Sonography Outcomes Assessment Program (SOAP-3) Trial.

Context:A 2001 Agency for Healthcare Research and Quality Evidence Report on patient safety addressed point-of-care limited ultrasonography guidance for central venous cannulation and strongly recommended real-time, dynamic guidance for all central cannulas. However, on the basis of one limited study, the report dismissed static assistance, a “quick look” with ultrasound to confirm vein location before preparing the sterile field, as unhelpful. Objective:The objective of this trial was to compare the overall success rate of central cannula placement with use of dynamic ultrasound (D), static ultrasound (S), and anatomical landmarks (LM). Design and Setting:A concealed, randomized, controlled, clinical trial conducted from September 2003 to February 2004 in a U.S. urban teaching hospital. Patients:Two-hundred one patients undergoing internal jugular vein central venous cannulation. Interventions:Patients were randomly assigned to three groups: 60 to D, 72 to S, and 69 to LM. An iLook25 SonoSite was used for all imaging. Measurements and Main Results:Cannulation success, first-attempt success, and number of attempts were noted. Other measures were vein size and clarity of LM. Results, controlled for pretest difficulty assessment, are stated as odds improvement (95% confidence interval) over LM for D and S. D had an odds 53.5 (6.6–440) times higher for success than LM. S had an odds 3 (1.3–7) times higher for success than LM. The unadjusted success rates were 98%, 82%, and 64% for D, S, and LM. For first-attempt success, D had an odds 5.8 (2.7–13) times higher for first success than LM, and S had an odds 3.4 (1.6–7.2) times higher for first success than LM. The unadjusted first-attempt success rates were 62%, 50%, and 23% for D, S, and LM. Conclusions:Ultrasound assistance was superior to LM techniques. D outperformed S but may require more training and personnel. All central cannula placement should be conducted with ultrasound assistance. The 2001 Agency for Healthcare Research and Quality Evidence Report dismissing static assistance was incorrect.

International Evidence-Based Recommendations for Focused Cardiac Ultrasound

BACKGROUND Focused cardiac ultrasound (FoCUS) is a simplified, clinician-performed application of echocardiography that is rapidly expanding in use, especially in emergency and critical care medicine. Performed by appropriately trained clinicians, typically not cardiologists, FoCUS ascertains the essential information needed in critical scenarios for time-sensitive clinical decision making. A need exists for quality evidence-based review and clinical recommendations on its use. METHODS The World Interactive Network Focused on Critical UltraSound conducted an international, multispecialty, evidence-based, methodologically rigorous consensus process on FoCUS. Thirty-three experts from 16 countries were involved. A systematic multiple-database, double-track literature search (January 1980 to September 2013) was performed. The Grading of Recommendation, Assessment, Development and Evaluation method was used to determine the quality of available evidence and subsequent development of the recommendations. Evidence-based panel judgment and consensus was collected and analyzed by means of the RAND appropriateness method. RESULTS During four conferences (in New Delhi, Milan, Boston, and Barcelona), 108 statements were elaborated and discussed. Face-to-face debates were held in two rounds using the modified Delphi technique. Disagreement occurred for 10 statements. Weak or conditional recommendations were made for two statements and strong or very strong recommendations for 96. These recommendations delineate the nature, applications, technique, potential benefits, clinical integration, education, and certification principles for FoCUS, both for adults and pediatric patients. CONCLUSIONS This document presents the results of the first International Conference on FoCUS. For the first time, evidence-based clinical recommendations comprehensively address this branch of point-of-care ultrasound, providing a framework for FoCUS to standardize its application in different clinical settings around the world.

Thyrotoxic periodic paralysis and intravenous propranolol in the emergency setting

A 27-year-old male of Malaysian descent presented to the Emergency Department (ED) with rapidly progressive flaccid paralysis that quickly compromised his respiratory effort. The patient was found to have a serum potassium of 1.9 meq/L, and was diagnosed as having an acute paralytic episode secondary to thyrotoxic periodic paralysis. The paralytic attack was aborted with a combination of potassium replacement and parenteral propranolol in large doses. We report the use of a rarely described, yet possibly more effective, therapy for an acute attack of thyrotoxic periodic paralysis.

Simple, almost anywhere, with almost anyone: remote low-cost telementored resuscitative lung ultrasound.

BACKGROUND Apnea (APN) and pneumothorax (PTX) are common immediately life-threatening conditions. Ultrasound is a portable tool that captures anatomy and physiology as digital information allowing it to be readily transferred by electronic means. Both APN and PTX are simply ruled out by visualizing respiratory motion at the visceral-parietal pleural interface known as lung sliding (LS), corroborated by either the M-mode or color-power Doppler depiction of LS. We thus assessed how economically and practically this information could be obtained remotely over a cellular network. METHODS Ultrasound images were obtained on handheld ultrasound machines streamed to a standard free internet service (Skype) using an iPhone. Remote expert sonographers directed remote providers (with variable to no ultrasound experience) to obtain images by viewing the transmitted ultrasound signal and by viewing the remote examiner over a head-mounted webcam. Examinations were conducted between a series of remote sites and a base station. Remote sites included two remote on-mountain sites, a small airplane in flight, and a Calgary household, with base sites located in Pisa, Rome, Philadelphia, and Calgary. RESULTS In all lung fields (20/20) on all occasions, LS could easily and quickly be seen. LS was easily corroborated and documented through capture of color-power Doppler and M-mode images. Other ultrasound applications such as the Focused Assessment with Sonography for Trauma examination, vascular anatomy, and a fetal wellness assessment were also demonstrated. CONCLUSION The emergent exclusion of APN-PTX can be immediately accomplished by a remote expert economically linked to almost any responder over cellular networks. Further work should explore the range of other physiologic functions and anatomy that could be so remotely assessed.

Ultrasound performs better than radiographs

We applaud the British Thoracic Society (BTS) for its efforts to improve patient care through scientific evidence. We thus recognise the recent guidelines on pleural procedures and thoracic ultrasound (TUS) as an important attempt to develop a rational approach to chest sonography.1 However, we are concerned that the BTS has reached conclusions based on a less complete review of TUS. The guidelines state that ‘the utility of thoracic ultrasound for diagnosing a pneumothorax is limited in hospital practice due to the ready availability of chest x-rays (CXR) and conflicting data from published reports’.1 This conclusion appears to be based on a small (but landmark) study of 11 patients from 1986 to 1989, two small studies with only four pneumothoraces in …

A Randomized Controlled Trial of Self-Management Education for Asthma Patients in the Emergency Department

STUDY OBJECTIVE Patients using the emergency department (ED) for asthma may benefit from self-management education. Our goal is to test an educational intervention in 296 asthma ED patients. METHODS This was a randomized controlled trial with concealed allocation. Controls received instruction from an asthma knowledge test, peak flowmeter training, and asthma brochures. Intervention patients received these plus a self-management workbook, a behavioral contract, inhaler training, and telephone reinforcements. The main outcome was change in Asthma Quality of Life Questionnaire (AQLQ) score at 8 weeks (a change of 1.5 is a marked clinically important difference). Secondary outcomes were repeated ED visits and change in AQLQ scores at 4, 12, and 16 weeks and 1 year. RESULTS Mean age of patients was 44 years, and 93% had the 8-week follow-up. Enrollment AQLQ scores were comparable and increased at 8 weeks by more than a marked clinically important difference in both groups. For controls, the change in score was 1.95 (95% confidence interval [CI] 1.74 to 2.16; P<.001), for intervention patients the change in score was 1.83 (95% CI 1.64 to 2.03; P<.001), and the difference between groups was 0.11 (95% CI -0.17 to 0.40; P=.43). Patients who improved more (ie, change was above the group mean) were more likely to be high school graduates (odds ratio=1.9; 95% CI 1.0 to 3.8), previous or current smokers at enrollment (odds ratio=2.2; 95% CI 1.3 to 3.5), and to have been admitted to the hospital from the ED (odds ratio=1.7; 95% CI 1.0 to 2.8). Similar variables were associated with AQLQ outcomes in hierarchic analyses during 16 weeks. Repeated ED visits occurred for 12% of patients at 8 weeks and in multivariate analysis were associated with no hospitalization for the index ED visit, difficult access to outpatient care, and previous ED visits. Fewer patients (16%) had an ED visit at 12 weeks compared with a similar time before enrollment (36%). CONCLUSION Patients in both groups had marked sustained improvements in clinical status 16 weeks after an ED visit for asthma. A self-management education intervention delivered in the ED and reinforced by telephone was successfully implemented, with high retention rates, but did not provide incremental benefit for quality of life and short-term repeated ED visit outcomes.

Point of care ultrasound for sepsis management in resource-limited settings: time for a new paradigm for global health care.

Dear Editor, We applaud the ESICM Global Intensive Care Working Group for its pivotal contribution to the improvement of sepsis management in developing countries [1]. Dunser et al. acknowledge that health-care practices of industrialized nations are not available to the majority of humanity. On the basis of this current reality the authors offer guidelines regarding approaches to the management of sepsis in limited-resource settings. Surprisingly, we found no mention of the use of point-of-care ultrasound (POC-US) [2] beyond a generic recommendation to ‘‘use imaging techniques when available’’ [1]. Since 1985 ultrasonography has been recommended for developing countries by the World Health Organization (WHO) [3], as an inexpensive, rapidly deployable, and portable tool with minimal side effects. This is true today more than ever. Notwithstanding the lack of randomized, controlled trials on POC-US use in the specific setting of sepsis, increasing scientific evidence suggests tremendous potential for this tool in managing critical patients with infectious diseases. POC-US can be of great aid in the diagnosis of infectious diseases in rural areas [4], and generically in the detection of septic foci in febrile states [5]. It has a significant impact on mitigating diagnostic uncertainty in undifferentiated shock, narrowing differential diagnosis [6], and improving the specificity of early recognition of hypovolemia [7] and septic shock cardiovascular patterns [8]. Lung ultrasound has indeed a broad spectrum of established applications in the diagnosis and management of respiratory infectious diseases [9]—the leading cause of childhood mortality in developing countries [10]. The potential of POCUS in sepsis management is wide [11], and includes procedure-guidance applications that are increasingly acknowledged as best practice [12, 13]. With regards to education, innovative ultrasound curricula have been shaped for non-imaging specialists [14]. Short-term POC-US training programs are proven to deliver adequate knowledge and skills to novices [15]. And proof-of-concept studies have been conducted in the screening for infection sources in resource-limited settings of tropical countries [16]. Furthermore, low-cost technology can now provide minimally POC-UStrained operators (paramedics, midwives) with tele-mentoring and second-opinion facilities [17], mitigating the impracticable availability of ‘‘experienced practitioners’’ in all settings. This is of paramount importance for sustainable healthcare delivery where the patient-tophysician ratio is dramatically high. The use of POC-US represents a paradigm shift for improving health-

Derivation of a pediatric growth curve for inferior vena caval diameter in healthy pediatric patients: brief report of initial curve development

BackgroundA validated tool has long been sought to provide clinicians with a uniform and accurate method to assess hydration status in the pediatric emergency medicine population. Outpatient clinicians use CDC height- and weight-based curves for the assessment of physical development. In hospital, daily weights provide objective data; however, these are usually not available at presentation.One of the most promising techniques for the rapid assessment of volume is ultrasound (US) to obtain an indexed inferior vena cava diameter (IVCDi); as previously described. Prior studies have focused on IVCDi in dehydrated patients and have shown that it provides accurate estimates of right atrial pressure and volume status. The objective of this study is to derive an IVC growth curve in healthy pediatric patients.MethodsProspective cohort design enrolled healthy children between the ages of 4 weeks and 20 years. Patients presenting with fever, illnesses, or diagnoses known to affect the volume will be excluded. All eligible patients under 21, who have provided self or parental written consent, will undergo a brief ultrasound to obtain transverse and long images of both the IVC and the aorta; all scans will be digitally saved. Image quality will be subjectively rated as poor, fair, or good based on wall clarity. Poor quality images will be recorded but may be omitted from our analysis. Five clinicians completed a 1-h introduction to IVC-US and ten supervised scans prior to enrollment. Still images will be measured in order to determine IVCDi in both transverse and longitudinal planes. To assess inter-rater reliability, in 10% of cases, two clinicians will complete scans. All study scans will be over-read by a fellowship-trained sonologist.IVCDi will be plotted independently as functions of age, gender, BMI, and aortic diameter. Within each group, means with means or medians with 95% CIs will be calculated. Following uni- and bivariate analyses and assessment for colinearity, a variety of parametric and nonparametric regression procedures will be conducted. The smoothed curves will be approximated using a modified LMS estimation procedure.ResultsData for the initial curve derivation includes 25 patients ranging from 13 months to 20 years (mean 102 months or 8.5 years). Sixty-five percent of patients were enrolled from the ED, while 35% were enrolled from well-child clinic visits. When evaluating the size of IVC as a function of time linear growth, increasing size was found to proportionately increase with age of patient in months.ConclusionsData suggest a linear correlation between IVC size and age. Such data, when plotted as a new growth curve, may allow clinicians to plot a patients sonographic measurements in order to assess hydration health.