Feasibility of cardiac output measurements in critically ill patients by medical students

The Ultrasound Journal - 2020
Geert Koster1, Thomas Kaufmann2, Bart Hiemstra1, Renske Wiersema1, Madelon E Vos1, Devon Dijkhuizen1, Adrian Wong3, Thomas Scheeren2, Yoran M. Hummel4, Frederik Keus1, Iwan C. C. van der Horst5
1Department of Critical Care, University of Groningen, University Medical Center Groningen, P.O. Box 30.001, 9700 RB, Groningen, The Netherlands.
2Department of Anaesthesiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
3Department of Anaesthesia and Intensive Care, Royal Surrey Hospital, Guildford, UK
4Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
5Department of Intensive Care, Maastricht University Medical Center+, University Maastricht, Maastricht, The Netherlands

Tóm tắt

Abstract Background Critical care ultrasonography (CCUS) is increasingly applied also in the intensive care unit (ICU) and performed by non-experts, including even medical students. There is limited data on the training efforts necessary for novices to attain images of sufficient quality. There is no data on medical students performing CCUS for the measurement of cardiac output (CO), a hemodynamic variable of importance for daily critical care. Objective The aim of this study was to explore the agreement of cardiac output measurements as well as the quality of images obtained by medical students in critically ill patients compared to the measurements obtained by experts in these images. Methods In a prospective observational cohort study, all acutely admitted adults with an expected ICU stay over 24 h were included. CCUS was performed by students within 24 h of admission. CCUS included the images required to measure the CO, i.e., the left ventricular outflow tract (LVOT) diameter and the velocity time integral (VTI) in the LVOT. Echocardiography experts were involved in the evaluation of the quality of images obtained and the quality of the CO measurements. Results There was an opportunity for a CCUS attempt in 1155 of the 1212 eligible patients (95%) and in 1075 of the 1212 patients (89%) CCUS examination was performed by medical students. In 871 out of 1075 patients (81%) medical students measured CO. Experts measured CO in 783 patients (73%). In 760 patients (71%) CO was measured by both which allowed for comparison; bias of CO was 0.0 L min−1 with limits of agreement of − 2.6 L min−1 to 2.7 L min−1. The percentage error was 50%, reflecting poor agreement of the CO measurement by students compared with the experts CO measurement. Conclusions Medical students seem capable of obtaining sufficient quality CCUS images for CO measurement in the majority of critically ill patients. Measurements of CO by medical students, however, had poor agreement with expert measurements. Experts remain indispensable for reliable CO measurements. Trial registration Clinicaltrials.gov; http://www.clinicaltrials.gov; registration number NCT02912624

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Tài liệu tham khảo

Mayo PH, Beaulieu Y, Doelken P, Feller-Kopman D, Harrod C, Kaplan A, Oropello J, Vieillard-Baron A, Axler O, Lichtenstein D, Maury E, Slama M, Vignon P (2009) American College of Chest Physicians/La Société de Réanimation de Langue Française statement on competence in critical care ultrasonography. Chest 135:1050–1060. https://doi.org/10.1378/chest.08-2305

Koster G, Van Der Horst ICC (2017) Critical care ultrasonography in circulatory shock. Curr Opin Crit Care 23:326–333. https://doi.org/10.1097/MCC.0000000000000428

Filipiak-Strzecka D, John B, Kasprzak J, Michalski B, Lipiec P (2013) Pocket-size echocardiograph—a valuable tool for non-experts or just a portable device for echocardiographers? Adv Med Sci 58:67–72. https://doi.org/10.2478/v10039-012-0054-2

AlEassa EM, Ziesmann MT, Kirkpatrick AW, Wurster CL, Gillman LM (2016) Point of care ultrasonography use and training among trauma providers across Canada. Can J Surg 59:6–8. https://doi.org/10.1503/cjs.010215

Funcke S, Sander M, Goepfert MS, Groesdonk H, Heringlake M, Hirsch J, Kluge S, Krenn C, Maggiorini M, Meybohm P, Salzwedel C, Saugel B, Wagenpfeil G, Wagenpfeil S, Reuter DA (2016) Practice of hemodynamic monitoring and management in German, Austrian, and Swiss intensive care units: the multicenter cross-sectional ICU-CardioMan Study. Ann Intensive Care 6:49. https://doi.org/10.1186/s13613-016-0148-2

Yang Y, Royse C, Royse A, Williams K, Canty D (2016) Survey of the training and use of echocardiography and lung ultrasound in Australasian intensive care units. Crit Care 20:339. https://doi.org/10.1186/s13054-016-1444-9

Panoulas VF, Daigeler A-L, Malaweera ASN, Lota AS, Baskaran D, Rahman S, Nihoyannopoulos P (2013) Pocket-size hand-held cardiac ultrasound as an adjunct to clinical examination in the hands of medical students and junior doctors. Eur Hear J Cardiovasc Imaging 14:323–330. https://doi.org/10.1093/ehjci/jes140

Ho AM-H, Critchley LAH, Leung JYC, Kan PKY, Au SS, Ng SK, Chan SKC, Lam PKN, Choi GYS, Wai JKM, Lee APW, Chan SO (2015) Introducing final-year medical students to pocket-sized ultrasound imaging: teaching transthoracic echocardiography on a 2-week anesthesia rotation. Teach Learn Med 27:307–313. https://doi.org/10.1080/10401334.2015.1044657

Krause C, Krause R, Krause R, Gomez N, Jafry Z, Dinh VA (2017) Effectiveness of a 1-hour extended focused assessment with sonography in trauma session in the medical student surgery clerkship. J Surg Educ 74:968–974. https://doi.org/10.1016/j.jsurg.2017.03.007

Udrea DS, Sumnicht A, Lo D, Villarreal L, Gondra S, Chyan R, Wisham A, Dinh VA (2017) Effects of student-performed point-of-care ultrasound on physician diagnosis and management of patients in the emergency department. J Emerg Med 53:102–109. https://doi.org/10.1016/j.jemermed.2017.01.021

Bobbia X, Chabannon M, Chevallier T, de La Coussaye JE, Lefrant JY, Pujol S, Claret P-G, Zieleskiewicz L, Roger C, Muller L (2018) Assessment of five different probes for lung ultrasound in critically ill patients: a pilot study. Am J Emerg Med 36:1265–1269. https://doi.org/10.1016/j.ajem.2018.03.077

Rice BT, Vu H, Tran LD, Vo QX, Mowafi H (2015) Survey of point of care ultrasound usage in emergency medicine by Vietnamese physicians. Emerg Med Australas 27:580–583. https://doi.org/10.1111/1742-6723.12476

Nielsen K, Lauridsen JRM, Laursen CB, Brabrand M (2015) Physicians using ultrasound in Danish emergency departments are mostly summoned specialists. Scand J Trauma Resusc Emerg Med 23:51. https://doi.org/10.1186/s13049-015-0131-1

Sanders J, Noble V, Raja A, Sullivan A, Camargo C (2015) Access to and use of point-of-care ultrasound in the emergency department. West J Emerg Med 16:747–752. https://doi.org/10.5811/westjem.2015.7.27216

Neskovic AN, Skinner H, Price S, Via G, De Hert S, Stankovic I, Galderisi M, Donal E, Muraru D, Sloth E, Gargani L, Cardim N, Stefanidis A, Cameli M, Habib G, Cosyns B, Lancellotti P, Edvardsen T, Popescu BA, Reviewers: This document was reviewed by members of the 2016–2018 EACVI Scientific Documents Committee (2018) Focus cardiac ultrasound core curriculum and core syllabus of the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 19:475–481. https://doi.org/10.1093/ehjci/jey006

Expert Round Table on Ultrasound in ICU (2011) International expert statement on training standards for critical care ultrasonography. Intensive Care Med 37:1077–1083. https://doi.org/10.1007/s00134-011-2246-9

Price S, Via G, Sloth E, Guarracino F, Breitkreutz R, Catena E, Talmor D (2008) Echocardiography practice, training and accreditation in the intensive care: document for the World Interactive Network Focused on Critical Ultrasound (WINFOCUS). Cardiovasc Ultrasound 6:49. https://doi.org/10.1186/1476-7120-6-49

Cecconi M, De Backer D, Antonelli M, Beale R, Bakker J, Hofer C, Jaeschke R, Mebazaa A, Pinsky MR, Teboul JL, Vincent JL, Rhodes A (2014) Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Med 40:1795–1815. https://doi.org/10.1007/s00134-014-3525-z

Sakr Y, Reinhart K, Vincent J-L, Sprung CL, Moreno R, Ranieri VM, De Backer D, Payen D (2006) Does dopamine administration in shock influence outcome? Results of the Sepsis Occurrence in Acutely Ill Patients (SOAP) Study. Crit Care Med 34:589–597. https://doi.org/10.1097/01.CCM.0000201896.45809.E3

Vieillard-Baron A, Mayo PH, Vignon P, Cholley B, Slama M, Pinsky MR, McLean A, Choi G, Beaulieu Y, Arntfield R, Koenig S, Colreavy F, Canivet JL, De Backer D (2014) International consensus statement on training standards for advanced critical care echocardiography. Intensive Care Med 40:654–666. https://doi.org/10.1007/s00134-014-3228-5

Millington SJ, Goffi A, Arntfield RT (2018) Critical care echocardiography: a certification pathway for advanced users. Can J Anesth 65:345–349. https://doi.org/10.1007/s12630-018-1061-y

Dinh VA, Ko HS, Rao R, Bansal RC, Smith DD, Kim TE, Nguyen HB (2012) Measuring cardiac index with a focused cardiac ultrasound examination in the ED. Am J Emerg Med 30:1845–1851. https://doi.org/10.1016/j.ajem.2012.03.025

Lee L, Tewalde S, Allison M, Witting M, Euerle B (2014) Inter-rater reliability of doppler echocardiography assessment of cardiac output by emergency physicians. Ann Emerg Med 64:S126. https://doi.org/10.1016/j.annemergmed.2014.07.384

Andersen GN, Viset A, Mjølstad OC, Salvesen Ø, Dalen H, Haugen BO (2014) Feasibility and accuracy of point-of-care pocket-size ultrasonography performed by medical students. BMC Med Educ 14:156. https://doi.org/10.1186/1472-6920-14-156

Hiemstra B, Eck RJ, Koster G, Wetterslev J, Perner A, Pettilà V, Snieder H, Hummel YM, Wiersema R, de Smet AMGA, Keus F, van der Horst ICC (2017) Clinical examination, critical care ultrasonography and outcomes in the critically ill: cohort profile of the Simple Intensive Care Studies-I. BMJ Open 7:e017170. https://doi.org/10.1136/bmjopen-2017-017170

Hiemstra B, Koster G, Wiersema R, Hummel YM, van der Harst P, Snieder H, Eck RJ, Kaufmann T, Scheeren TWL, Perner A, Wetterslev J, de Smet AMGA, Keus F, van der Horst ICC (2019) The diagnostic accuracy of clinical examination for estimating cardiac index in critically ill patients: the Simple Intensive Care Studies-I. Intensive Care Med 45:190–200. https://doi.org/10.1007/s00134-019-05527-y

Qasim A. Echocardiographer.org. http://echocardiographer.org/. Accessed 25 Oct 2019

Baumgartner H, Hung J, Bermejo J, Chambers JB, Edvardsen T, Goldstein S, Lancellotti P, LeFevre M, Miller F, Otto CM (2017) Recommendations on the echocardiographic assessment of aortic valve stenosis: a focused update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. Eur Heart J Cardiovasc Imaging 18:254–275. https://doi.org/10.1093/ehjci/jew335

Quiñones MA, Otto CM, Stoddard M, Waggoner A, Zoghbi WA, Doppler Quantification Task Force of the Nomenclature and Standards Committee of the American Society of Echocardiography (2002) Recommendations for quantification of Doppler echocardiography: a report from the Doppler Quantification Task Force of the Nomenclature and Standards Committee of the American Society of Echocardiography. J Am Soc Echocardiogr 15:167–184

Royse CF, Seah JL, Donelan L, Royse AG (2006) Point of care ultrasound for basic haemodynamic assessment: novice compared with an expert operator. Anaesthesia 61:849–855. https://doi.org/10.1111/j.1365-2044.2006.04746.x

Bland JM, Altman DG (1999) Measuring agreement in method comparison studies. Stat Methods Med Res 8:135–160. https://doi.org/10.1177/096228029900800204

Critchley LAH, Critchley JAJH (1999) A meta-analysis of studies using bias and precision statistics to compare cardiac output measurement techniques. J Clin Monit Comput 15:85–91. https://doi.org/10.1023/A:1009982611386

Orde S, Slama M, Hilton A, Yastrebov K, McLean A (2017) Pearls and pitfalls in comprehensive critical care echocardiography. Crit Care 21:279. https://doi.org/10.1186/s13054-017-1866-z

Betcher J, Majkrzak A, Cranford J, Kessler R, Theyyunni N, Huang R (2018) Feasibility study of advanced focused cardiac measurements within the emergency department. Crit Ultrasound J 10:10. https://doi.org/10.1186/s13089-018-0093-4

Villavicencio C, Leache J, Marin J, Oliva I, Rodriguez A, Bodí M, Soni NJ (2019) Basic critical care echocardiography training of intensivists allows reproducible and reliable measurements of cardiac output. Ultrasound J 11:5. https://doi.org/10.1186/s13089-019-0120-0

Lebeau R, Sas G, El Rayes M, Serban A (2015) Left ventricular ejection fraction assessment by non-cardiologists from transverse views using a simplified wall motion score index. Echo Res Pract 2:1–8. https://doi.org/10.1530/ERP-14-0003

Heiberg J, Hansen LS, Wemmelund K, Sørensen AH, Ilkjaer C, Cloete E, Nolte D, Roodt F, Dyer R, Swanevelder J, Sloth E (2015) Point-of-care clinical ultrasound for medical students. Ultrasound Int open 1:E58–E66. https://doi.org/10.1055/s-0035-1565173

Kobal SL, Lior Y, Ben-Sasson A, Liel-Cohen N, Galante O, Fuchs L (2017) The feasibility and efficacy of implementing a focused cardiac ultrasound course into a medical school curriculum. BMC Med Educ 17:94. https://doi.org/10.1186/s12909-017-0928-x

Wong I, Jayatilleke T, Kendall R, Atkinson P (2011) Feasibility of a focused ultrasound training programme for medical undergraduate students. Clin Teach 8:3–7. https://doi.org/10.1111/j.1743-498X.2010.00416.x

Parks AR, Verheul G, Leblanc-duchin D, Atkinson P (2019) Effect of a point-of-care ultrasound protocol on the diagnostic performance of medical learners during simulated cardiorespiratory scenarios. 17:263–269. https://doi.org/10.1017/cem.2014.41

Arora S, Cheung AC, Tarique U, Agarwal A, Firdouse M, Ailon J (2017) First-year medical students use of ultrasound or physical examination to diagnose hepatomegaly and ascites: a randomized controlled trial. J Ultrasound 20:199–204. https://doi.org/10.1007/s40477-017-0261-6

Ang J, Doyle B, Allen P, Cheek C (2018) Teaching bedside ultrasound to medical students. Clin Teach 15:331–335. https://doi.org/10.1111/tct.12692

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