Robert A. Ratzlaff

Focused transthoracic echocardiography curriculum for advanced practice providers assures good concordance with intensivists at echocardiography

OBJECTIVE To describe a focused transthoracic echocardiography (FoTE) curriculum for advanced practice providers (APPs) for echocardiography-driven diagnosis of shock in critically ill patients. METHODS Twelve APPs in 4 intensive care units at an academic medical center received didactic sessions on FoTE, including 1-on-1 proctorship with a registered cardiac sonographer. For a period of 6 months the trainees performed individual studies, then they performed FoTE examinations on critically ill patients; their diagnoses were compared with those of experienced intensivists for the same patients. RESULTS After 6 months of multiple steps of training, APPs could acquire good echocardiographic views, achieving a good inter-rater agreement (Cohens κ of 0.745 [95% CI, 0.385-1.0; P < .01]) in the diagnosis of shock when compared to experienced intensivists. CONCLUSIONS Structured FoTE curriculum enables APPs to have reasonably good diagnostic concordance with intensivists in an echocardiography-driven diagnosis of shock in critically ill patients.

996: FOCUSED TRANSTHORACIC ECHOCARDIOGRAPHY CURRICULUM FOR ADVANCED PRACTICE PROVIDERS IN THE ICU

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Describe the elements of a focused transthoracic (FoTE) echocardiography curriculum for advanced practice providers (APPs), evaluate their performance in acquisition and interpretation of images and determine the concordance between APPs and experienced intensivists during an echocardiographydriven diagnosis of shock in critically ill patients. Methods: Observational, prospective study performed in medical, surgical, cardiothoracic and neurosurgical intensive care units (ICU) at a tertiary teaching hospital. Twelve APPs received a formal curriculum in FoTE. In addition, three experienced intensivists in echocardiography participated in the comparison with APP’s. Participants received didactic sessions on knobology, sonographic anatomy, clinical interpretation of FoTE in shock, and a wet lab with porcine hearts. A proctorship one on one with a registered cardiac sonographer was performed, and low-fidelity simulation sessions were assessed. The APP group echocardiographic findings were compared with experienced intensivists on ultrasound diagnosis of shock in critically ill patients. Cognitive knowledge was evaluated with a written test. Participants were evaluated on their competence for image quality, time to obtain each FoTE view, time to correct diagnosis, and cognitive post-test. The results were analyzed with descriptive statistics. Results: Twelve APPs were able to acquire good echocardiographic views and recognize the cause of shock on the first and second low-fidelity simulation cases with mean times (in seconds) of 156.9 ± 64.2 and 213.2 ± 82.8 respectively. The mean score in cognitive test at the end of training was 24.6 ± 2.4. APP’s achieved a concordance of 0.745 in diagnosis of type of shock in critically ill patients when compared to experienced intensivists. Conclusions: A structured curriculum in FoTE enables APP’s to have reasonably good ultrasound performance and integration of findings and achieved a concordance with intensivests in echocardiography – driven diagnosis of patients in shock.

Ornithine Transcarbamylase Deficiency: If at First You Do Not Diagnose, Try and Try Again

Ornithine transcarbamylase (OTC) deficiency is well known for its diagnosis in the neonatal period. Presentation often occurs after protein feeding and manifests as poor oral intake, vomiting, lethargy progressing to seizure, respiratory difficulty, and eventually coma. Presentation at adulthood is rare (and likely underdiagnosed); however, OTC deficiency can be life-threatening and requires prompt investigation and treatment. Reports and guidelines are scarce due to its rarity. Here, we present a 59-year-old woman with a past history of irritable bowel syndrome who underwent a reparative operation for rectal prolapse and enterocele. Her postoperative course was complicated by a bowel perforation (which was repaired), prolonged mechanical ventilation, tracheostomy, critical illness myopathy, protein-caloric malnutrition, and altered mental status. After standard therapy for delirium failed, further investigation showed hyperammonemia and increased urine orotic acid, ultimately leading to the diagnosis of OTC deficiency. This case highlights the importance of considering OTC deficiency in hospitalized adults, especially during the diagnostic evaluation for altered mental status.

Hemodynamic Transesophageal Echocardiography-Guided Venous-Arterial Extracorporeal Membrane Oxygenation Support in a Case of Giant Cell Myocarditis

Giant cell myocarditis (GCM) is a rare and commonly fatal form of fulminant myocarditis. During the acute phase, while immunosuppressive therapy is initiated, venoarterial extracorporeal membrane oxygenation (VA-ECMO) support is commonly used as a bridge to heart transplantation or recovery. Until recently, conventional transesophageal echocardiography and transthoracic echocardiography were the tools available for hemodynamic assessment of patients on this form of mechanical circulatory support. Nevertheless, both techniques have their limitations. We present a case of a 54-year-old man diagnosed with GCM requiring VA-ECMO support that was monitored under a novel miniaturized transesophageal echocardiography (hTEE) probe recently approved for 72 hours of continuous hemodynamic monitoring. Our case highlights the value of this novel, flexible, and disposable device for hemodynamic monitoring, accurate therapy guidance, and potential VA-ECMO weaning process of patients with this form of severe myocarditis.

Acute oxygenator failure: a new presentation of heparin-induced thrombocytopenia in a patient undergoing venovenous extracorporeal membrane oxygenation support

A 58-year-old man with medical history of thrombocytopenia was admitted to an outside hospital for a 6-day history of worsening dyspnoea requiring mechanical ventilator support. He was transferred to our institution for extracorporeal membrane oxygenation (ECMO) given his refractory hypoxaemia. On arrival, H1N1 influenza virus was confirmed and all measures to improve oxygenation were ineffective. Thus, the decision was made to start venovenous (VV)-ECMO. Although a low baseline platelet count was recognised (60–70×109/L), a sudden further decrease occurred (30×109/L) and platelet transfusion was initiated. A substantial increase in the pressure across the ECMO oxygenator was identified, and the diagnosis of type II heparin-induced thrombocytopenia was suspected and confirmed. Heparin was discontinued, the oxygenator was exchanged and argatroban was used for anticoagulation. After 28 days on VV-ECMO support, the decision was made to withdraw organ support in conjunction with the patient and family wishes.