Yanick Beaulieu

Point-of-care ultrasound education: the increasing role of simulation and multimedia resources.

This article reviews the current technology, literature, teaching models, and methods associated with simulation‐based point‐of‐care ultrasound training. Patient simulation appears particularly well suited for learning point‐of‐care ultrasound, which is a required core competency for emergency medicine and other specialties. Work hour limitations have reduced the opportunities for clinical practice, and simulation enables practicing a skill multiple times before it may be used on patients. Ultrasound simulators can be categorized into 2 groups: low and high fidelity. Low‐fidelity simulators are usually static simulators, meaning that they have nonchanging anatomic examples for sonographic practice. Advantages are that the model may be reused over time, and some simulators can be homemade. High‐fidelity simulators are usually high‐tech and frequently consist of many computer‐generated cases of virtual sonographic anatomy that can be scanned with a mock probe. This type of equipment is produced commercially and is more expensive. High‐fidelity simulators provide students with an active and safe learning environment and make a reproducible standardized assessment of many different ultrasound cases possible. The advantages and disadvantages of using low‐ versus high‐fidelity simulators are reviewed. An additional concept used in simulation‐based ultrasound training is blended learning. Blended learning may include face‐to‐face or online learning often in combination with a learning management system. Increasingly, with simulation and Web‐based learning technologies, tools are now available to medical educators for the standardization of both ultrasound skills training and competency assessment.

Perioperative Intravenous Amiodarone Does Not Reduce the Burden of Atrial Fibrillation in Patients Undergoing Cardiac Valvular Surgery

Background:Atrial fibrillation is a common complication after cardiac surgery. Postoperative atrial fibrillation is associated with increased risks of morbidity and mortality, and, therefore, preventive strategies using oral amiodarone have been developed but are often unpractical. Intravenous amiodarone administered after the induction of anesthesia and continued postoperatively for 48 h could represent an effective strategy to prevent postoperative atrial fibrillation in patients undergoing cardiac valvular surgery. Methods:Single-center, double-blinded, double-dummy, randomized controlled trial in patients undergoing valvular surgery. Patients received either an intravenous loading dose of 300 mg of amiodarone or placebo in the operating room, followed by a perfusion of 15 mg · kg−1 · 24 h−1 for 2 days. The primary endpoint was the development of atrial fibrillation occurring at any time within the postoperative period. Results:One hundred twenty patients were randomly assigned (mean age was 65 ± 11 yr). Overall atrial fibrillation occurred more frequently in the perioperative intravenous amiodarone group compared with the placebo group (59.3 vs. 40.0%; P = 0.035). Four preoperative factors were found to be independently associated with a higher risk of developing postoperative atrial fibrillation: older age (P = 0.0003), recent myocardial infarction (<6 months; P = 0.026), preoperative angina (P = 0.0326), and use of a calcium channel blocker preoperatively (P = 0.0078) when controlling for groups. Conclusion:In patients undergoing cardiac valvular surgery, a strategy using intravenous amiodarone for 48 h is not efficacious in reducing the risk of atrial fibrillation during cardiac valvular surgery.

The Diagnostic and Therapeutic Impact of Point-of-Care Ultrasonography in the Intensive Care Unit.

Purpose: In light of point-of-care ultrasonography’s (POCUS) recent rise in popularity, assessment of its impact on diagnosis and treatment in the intensive care unit (ICU) is of key importance. Methods: Ultrasound examinations were collected through an ultrasound reporting software in 6 multidisciplinary ICU units from 3 university hospitals in Canada and the United States. This database included a self-reporting questionnaire to assess the impact of the ultrasound findings on diagnosis and treatment. We retrieved the results of these questionnaires and analyzed them in relation to which organs were assessed during the ultrasound examination. Results: One thousand two hundred and fifteen ultrasound studies were performed on 968 patients. Intensivists considered the image quality of cardiac ultrasound to be adequate in 94.7% compared to 99.7% for general ultrasound (P < .001). The median duration of a cardiac examination was 10 (interquartile range [IQR] 10) minutes compared to 5 (IQR 8) minutes for a general examination (P < .001). Overall, ultrasound findings led to a change in diagnosis in 302 studies (24.9%) and to a change in management in 534 studies (44.0%). A change in diagnosis or management was reported more frequently for cardiac ultrasound than for general ultrasound (108 [37.1%] vs 127 [16.5%], P < .001) and (170 [58.4%] vs 270 [35.1%], P < .001). Assessment of the inferior vena cava for fluid status emerged as the critical care ultrasound application associated with the greatest impact on management. Conclusion: Point-of-care ultrasonography has the potential to optimize care of the critically ill patients when added to the clinical armamentarium of the intensive care physician.

Bedside ultrasound training using web-based e-learning and simulation early in the curriculum of residents

BackgroundFocused bedside ultrasound is rapidly becoming a standard of care to decrease the risks of complications related to invasive procedures. The purpose of this study was to assess whether adding to the curriculum of junior residents an educational intervention combining web-based e-learning and hands-on training would improve the residents’ proficiency in different clinical applications of bedside ultrasound as compared to using the traditional apprenticeship teaching method alone.MethodsJunior residents (n = 39) were provided with two educational interventions (vascular and pleural ultrasound). Each intervention consisted of a combination of web-based e-learning and bedside hands-on training. Senior residents (n = 15) were the traditionally trained group and were not provided with the educational interventions.ResultsAfter the educational intervention, performance of the junior residents on the practical tests was superior to that of the senior residents. This was true for the vascular assessment (94% ± 5% vs. 68% ± 15%, unpaired student t test: p < 0.0001, mean difference: 26 (95% CI: 20 to 31)) and even more significant for the pleural assessment (92% ± 9% vs. 57% ± 25%, unpaired student t test: p < 0.0001, mean difference: 35 (95% CI: 23 to 44)). The junior residents also had a significantly higher success rate in performing ultrasound-guided needle insertion compared to the senior residents for both the transverse (95% vs. 60%, Fisher’s exact test p = 0.0048) and longitudinal views (100% vs. 73%, Fisher’s exact test p = 0.0055).ConclusionsOur study demonstrated that a structured curriculum combining web-based education, hands-on training, and simulation integrated early in the training of the junior residents can lead to better proficiency in performing ultrasound-guided techniques compared to the traditional apprenticeship model.

Right Ventricular Depression After Cardiopulmonary Bypass for Valvular Surgery

OBJECTIVE To assess if right ventricular (RV) dysfunction is associated with increased mortality after cardiac surgery. DESIGN Post-hoc analysis of a single-center double-blind randomized controlled trial. SETTING University hospital. PARTICIPANTS A total of 120 patients undergoing simple or complex valvular surgery. INTERVENTIONS Patients were randomized to receive intravenous amiodarone or placebo intraoperatively. As secondary analysis, patients were divided into those requiring or not requiring postoperative inotropic agents. MEASUREMENTS AND MAIN RESULTS After cardiopulmonary bypass (CPB), there were significant increases in heart rate, cardiac index, systolic and mean arterial pressures, central venous pressure and pulmonary capillary wedge pressure with reduction in systemic vascular resistance (p<0.05). Right ventricular end-systolic area became larger in those without inotropes and tricuspid annular plane systolic excursion was reduced in all patients; mitral annular systolic velocities were higher in patients receiving inotropes. Both right- and left-sided Doppler signals were altered significantly after CPB, which may be attributed to increased filling pressure. Inotropic agents were required in 56 patients after CPB (47%). The use of inotropic agents was associated with increased left and right atrial velocities (p<0.05). There were no differences in postoperative complications between groups; however, the number of deaths at 6 years was increased in patients who received inotropes after CPB (p = 0.0247). CONCLUSIONS The increases in right-sided dimensions after CPB are associated with reduction in RV function and increased biventricular filling pressure, suggesting worsening biventricular function and interventricular dependence. Inotropic medications were associated with unaltered RV dimensions and increased biatrial activity.

Excellent outcomes for transcatheter aortic valve replacement within 1 year of opening a low-volume centre and consideration of requirements.

BACKGROUND After the approval of transcatheter aortic valve replacement (TAVR) for high-risk or inoperable patients with severe aortic stenosis (AS), many low- and moderate-volume TAVR programs were initiated. Contemporary outcomes from these newly initiated centres remain unknown. METHODS In March 2013, our institution was authorized by the Québec Ministry of Health to perform 30 TAVR procedures. After thorough clinical screening and imaging evaluation, suitable patients underwent transfemoral TAVR with the balloon-expandable SAPIEN XT (Edwards Lifesciences, Irvine, CA) transcatheter heart valve (THV). In-hospital and 30-day outcomes were prospectively collected and reported according to Valve Academic Research Consortium 2 guidelines. RESULTS From April 2013 to January 2014, 30 consecutive high-risk (n = 16 [53.3%]) or inoperable (n = 14 [46.7%]) patients (mean age, 84.6 years; mean Society of Thoracic Surgery score, 7) with symptomatic severe AS underwent transfemoral TAVR. No catastrophic intraprocedural complications such as annulus rupture, valve embolization, aortic dissection, or coronary occlusion occurred, and there were no deaths at 30 days. Disabling stroke occurred in 1 (3.3%) patient 48 hours after THV implantation. Major vascular complications and major bleeding occurred in 1 (3.3%) patient. No moderate or severe paravalvular leak was observed. The median length of stay was 2 (1-3) days, with 8 (26.7%) patients discharged within 24 hours after the procedure. CONCLUSIONS Excellent outcomes can be achieved in newly initiated relatively low-volume centres, which compares favorably to previously published large series. Important considerations include appropriate team training, rigorous patient screening, use of multimodality imaging techniques, a heart team approach, constant integration of lessons learned from larger published experiences, and maintaining a recommended minimum volume of 25 cases per year.

The Rapid Assessment of Competency in Echocardiography Scale Validation of a Tool for Point-of-Care Ultrasound

Increased use of point‐of‐care ultrasound (US) requires the development of assessment tools that measure the competency of learners. In this study, we developed and tested a tool to assess the quality of point‐of‐care cardiac US studies performed by novices.

Outcomes from extensive training in critical care echocardiography: Identifying the optimal number of practice studies required to achieve competency

Purpose Optimal instruction and assessment of critical care ultrasound (CCUS) skills requires an assessment tool to measure learner competency and changes over time. In this study, a previously published tool was used to monitor the development of critical care echocardiography (CCE) competencies, the attainment of performance plateaus, and the extent to which previous experience influenced learning. Materials and methods A group of experts used the Rapid Assessment of Competency in Echocardiography (RACE) scale to rate a large pool of CCE studies performed by novices in a longitudinal design. A total of 380 studies performed by twelve learners were assessed; each study was independently rated by two experts. Results Learners demonstrated improvement in mean RACE scores over time, with peak performance occurring early in training and a performance plateau thereafter. Learners with little experience received the greatest benefit from training, with an average performance plateau reached at the twentieth study. Conclusions Supporting earlier results, the RACE scale provided a straightforward means to assess learner performance with minimal requirements for evaluator training. The results of the present study suggest that novices experience the greatest gains in competency during their first twenty practice studies, a threshold which should serve to guide training initiatives. HighlightsWith the rise of point‐of‐care ultrasound and competency‐based education, there is an urgent need to tools to assess competencyA previously validated assessment tool was applied to a large cohort of cardiac ultrasound scans performed by novicesLeaners improved until the twentieth practice scan; this effect was more pronounced in less experienced leanersThe results suggest a threshold of twenty practice scans for learners as a reasonable starting point in training

Left ventricular ejection fraction assessment by non-cardiologists from transverse views using a simplified wall motion score index.

For the non-cardiologist emergency physician and intensivist, performing an accurate estimation of left ventricular ejection fraction (LVEF) is essential for the management of critically ill patients, such as patients presenting with shock, severe respiratory distress or chest pain. Our objective was to develop a semi-quantitative method to improve visual LVEF evaluation. A group of 12 sets of transthoracic echocardiograms with LVEF in the range of 18–64% were interpreted by 17 experienced observers (PRO) and 103 untrained observers or novices (NOV), without previous training in echocardiography. They were asked to assess LVEF by two different methods: i) visual estimation (VIS) by analysing the three classical left ventricle (LV) short-axis views (basal, midventricular and apical short-axis LV section) and ii) semi-quantitative evaluation (base, mid and apex (BMA)) of the same three short-axis views. The results for each of these two methods for both groups (PRO and NOV) were compared with LVEF obtained by radionuclide angiography. The semi-quantitative method (BMA) improved estimation of LVEF by PRO for moderate LV dysfunction (LVEF 30–49%) and normal LVEF. The visual estimate was better for lower LVEF (<30%). In the NOV group, the semi-quantitative method was better than than the visual one in the normal group and in half of the subjects in the moderate LV dysfunction (LVEF 30–49%) group. The visual estimate was better for the lower LVEF (ejection fraction <30%) group. In conclusion, semi-quantitative evaluation of LVEF gives an overall better assessment than VIS for PRO and untrained observers.

Acute intraoperative effect of intravenous amiodarone on right ventricular function in patients undergoing valvular surgery

Background: Amiodarone is commonly used in the acute care setting. However the acute hemodynamic and echocardiographic effect of intravenous amiodarone administered intraoperatively on right ventricular (RV) systolic and diastolic function using transesophageal echocardiography (TEE) has not been described. Methods: The study design was a randomized controlled trial in elective cardiac surgical patients undergoing valvular surgery. Patients received an intravenous loading dose of 300 mg of either amiodarone or placebo in the operating room, followed by an infusion of 15 mg/kg for two days. Hemodynamic profiles, echocardiographic measurement of RV and left ventricular (LV) dimensions, Doppler interrogation of tricuspid and mitral valve, hepatic and pulmonary venous flow combined with tissue Doppler imaging of the tricuspid and mitral valve annulus were obtained before and after bolus. Results: Although more patients in the placebo group had chronic obstructive lung disease (14 vs 6, p=0.05) and diabetes (14 vs 5; p=0.0244), there was no difference in terms of baseline hemodynamic, 2D and Doppler variables. After bolus, a significant increase in pulmonary artery pressure, central venous pressure and pulmonary vascular resistance index (p<0.05) was observed in the amiodarone group with reduction in systolic to diastolic (S/D) ratio of the hepatic (p=0.0247) and pulmonary venous (p=0.0052) velocity. Conclusion: Acute administration of amiodarone is associated with alteration in RV diastolic properties and has minimal negative inotropic effect on RV systolic function in cardiac surgical patients with valvular disease.