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Focused Cardiac Ultrasound Training: How Much Is Enough?

ArticleinJournal of Emergency Medicine 44(4) · January 2013with10 Reads
DOI: 10.1016/j.jemermed.2012.07.092 · Source: PubMed
Abstract
BACKGROUND: Focused transthoracic echocardiography (F-TTE) is an important tool to assess hemodynamically unstable patients in the Emergency Department. Although its scope has been defined by the American College of Emergency Physicians, more research is needed to define an optimal F-TTE training program, including assessment of proficiency. OBJECTIVE: The goal of this study was to determine the effectiveness of current standards in post-residency training to reach proficiency in F-TTE. METHODS: Fourteen staff Emergency Physicians were enrolled in a standardized teaching curriculum specifically designed to meet the 2008 American College of Emergency Physicians' guidelines for general ultrasound training applied to echocardiography. This training program consisted of 6 h of didactics and 6 h of scanning training, followed by independent scanning over a 5-month period. Acquisition of echocardiographic knowledge was assessed by an online pre- and post-test. At the conclusion of the study, a hands-on skills test assessed the trainees' ability to perform and interpret F-TTE. RESULTS: Ninety percent of trainees passed the written post-test. Two views, the parasternal long and short axis, were easily obtainable, regardless of the level of training or the number of ultrasounds completed. Other views were more difficult to master, but strong trends toward increased competency were evident after 10 h of mixed didactic and scanning training and > 45 ultrasounds. CONCLUSIONS: A short, 12-h didactic training in F-TTE provided proficiency in image interpretation and in obtaining adequate images from the parasternal window. More extensive training is needed to master the apical and subcostal windows in a timely manner.
    • "Hence, alternative non-invasive and practical methods for assessment of fluid responsiveness in septic shock should be investigated. This is a limitation of point-of-care echocardiography in the ICU because the procurement of different acoustic windows varies and presents different degrees of difficulty for mastery [21]. Moreover, Young et al. demonstrated that TTE failed to evaluate the ejection fraction in 69 % of the patients in the ICU [22]. "
    [Show abstract] [Hide abstract] ABSTRACT: The evaluation of fluid responsiveness in patients with hemodynamic instability remains to be challenging. This investigation aimed to determine whether respiratory variation in carotid Doppler peak velocity (ΔCDPV) predicts fluid responsiveness in patients with septic shock and lung protective mechanical ventilation with a tidal volume of 6 ml/kg. We performed a prospective cohort study at an intensive care unit, studying the effect of 59 fluid challenges on 19 mechanically ventilated patients with septic shock. Pre-fluid challenge ΔCDPV and other static or dynamic measurements were obtained. Fluid challenge responders were defined as patients whose stroke volume index increased more than 15 % on transpulmonary thermodilution. The area under the receiver operating characteristic curve (AUROC) was compared for each predictive parameter. Fluid responsiveness rate was 51 %. The ΔCDPV had an AUROC of 0.88 (95 % confidence interval (CI) 0.77-0.95); followed by stroke volume variation (0.72, 95 % CI 0.63-0.88), passive leg raising (0.69, 95 % CI 0.56-0.80), and pulse pressure variation (0.63, 95 % CI 0.49-0.75). The ΔCDPV was a statistically significant superior predictor when compared with the other parameters. Sensitivity, specificity, and positive and negative predictive values were also the highest for ΔCDPV, with an optimal cutoff at 14 %. There was good correlation between ΔCDPV and SVI increment after the fluid challenge (r = 0.84; p < 0.001). ΔCDPV can be more accurate than other methods for assessing fluid responsiveness in patients with septic shock receiving lung protective mechanical ventilation. ΔCDPV also has a high correlation with SVI increase after fluid challenge.
    Full-text · Article · Dec 2015
    • "Two groups of physicians were defined: EEP and NEP. The threshold for defining EEP or NEP was more or fewer than 50 echocardiographies already performed, respectively, after initial training [11]. To assess the quality and interpretability of ultrasound views, a five-point scale [12] was used: 1 = no image; 2 = poor and unusable image quality; 3 = usable image quality; 4 = good image quality; and 5 = perfect image quality. "
    [Show abstract] [Hide abstract] ABSTRACT: The use of focused cardiac ultrasound (FoCUS) in a prehospital setting is recommended. Pocket ultrasound devices (PUDs) appear to be well suited to prehospital FoCUS. The main aim of our study was to evaluate the interpretability of echocardiography performed in a prehospital setting using a PUD based on the experience of the emergency physician (EP). This was a monocentric prospective observational study. We defined experienced emergency physicians (EEPs) and novice emergency physicians (NEPs) as echocardiographers if they had performed 50 echocardiographies since their initial university training (theoretical training and at least 25 echocardiographies performed with a mentor). Each patient undergoing prehospital echocardiography with a PUD was included. Four diagnostic items based on FoCUS were analyzed: pericardial effusions (PE), right ventricular dilation (RVD), qualitative left ventricular function assessment (LVEF), and inferior vena cava compliance (IVCC). Two independent experts blindly evaluated the interpretability of each item by examining recorded video loops. If their opinions were divided, then a third expert concluded. Fourteen EPs participated: eight (57 %) EEPs and six (43 %) NEPs. Eighty-five patients were included: 34 (40 %) had an echocardiography by an NEP and 51 (60 %) by an EEP. The mean number of interpretable items by echocardiography was three [1; 4]; one [0; 2.25] in the NEP group, four [3; 4] in EEP (p < .01). The patient position was also associated with interpretable items: supine three [2; 4], "45°" three [1; 4], sitting two [1; 4] (p = .02). In multivariate analysis, only EP experience was associated with the number of interpretable items (p = .02). Interpretability by NEPs and EEPs was: 56 % vs. 96 % for LVF, 29 % vs. 98 % for PE, 26 % vs. 92 % for RVD, and 21 % vs. 67 % for IVCC (p < .01 for all). FoCUS with PUD in prehospital conditions was possible for EEPs, It is difficult and the diagnostic yield is poor for NEPs.
    Full-text · Article · Jul 2015
  • [Show abstract] [Hide abstract] ABSTRACT: The genes alg-1 and alg-2 (referred to as "alg-1/2") encode the Argonaute proteins affiliated to the microRNA (miRNA) pathway in C. elegans. Bound to miRNAs they form the effector complex that effects post-transcriptional gene silencing. In order to define biological features important to understand the mode of action of these Argonautes, we characterize aspects of these genes during development. We establish that alg-1/2 display an overlapping spatio-temporal expression profile and shared association to a miRNAs set, but with gene-specific predominant expression in various cells and increased relative association to defined miRNAs. Congruent with their spatio-temporal coincidence and regardless of alg-1/2 drastic post-embryonic differences, only loss of both genes leads to embryonic lethality. Embryos without zygotic alg-1/2 predominantly arrest during the morphogenetic process of elongation with defects in the epidermal-muscle attachment structures. Altogether our results highlight similarities and specificities of the alg-1/2 likely to be explained at different cellular and molecular levels.
    Full-text · Article · Mar 2012
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