Learning process and improvement of point-of-care ultrasound technique for subxiphoid visualization of the inferior vena cava

Background: Medical residents' training in ultrasonography usually follows the recommendations of the American College of Emergency Physicians (ACEP), even though these do not provide specific technical guidelines. Adequate training is considered to require 25 practical iterations in the majority of ultrasound procedures. However, the effectiveness of this approach has not been verified experimentally. We set out to determine the number of repetitions required for an acceptable ultrasound procedure of the inferior vena cava (IVC), as an important and emerging ultrasound procedure in cardiology. Methods: Using three human models, each of eight medical residents in the Emergency Medicine (EM) Program at the Universidad del Rosario performed 25 iterations of the recommended procedure, with image quality evaluation by an EM physician expert in the technique. Logistic regression analysis was used to determine the lowest number of repetitions required to achieve an adjusted probability of success of 80 and 90 %, respectively. Results: We obtained 200 ultrasound images. The percentage success by each resident ranged from 52 to 96 %. There was no statistical significance in the relation between gender and success (p = 0.83), but there was an association between year of residency and success (p  less than  0.001). The average time taken for each procedure was 17.3 s (SD 8.1); there was no association between the time taken and either repetition number or image quality. We demonstrate that eleven repetitions are required to achieve acceptable image quality in 80 %, and that 21 repetitions are required to achieve acceptable image quality in 90 %. Conclusions: This is the first study to formally evaluate the effectiveness of recommended training in ultrasound techniques. Our findings demonstrate that training comprising 25 procedural repetitions is easily sufficient to achieve optimal image quality, and they also provide empiric knowledge toward elucidating the times and minimum repetitions needed to acquire and improve ultrasonographic technique in novice operators to a level which fulfills quality requirements for interpretation. © 2016, Gómez Betancourt et al

Ultrasound-guided insertion of intra-aortic balloon counterpulsation in intensive care: description of the technique

Intra-aortic balloon counterpulsation (IAoBC) is a mechanical circulatory support device that has been used for more than 50 years, mainly for cardiogenic shock. Although its effect on mortality is controversial, IAoBC is still used in a wide variety of pre- and postoperative clinical settings in cardiac surgery centers. IAoBC has a complication rate of approximately 30%, mostly associated with problems during insertion and malpositioning. Thus, an insertion technique based on the use of ultrasound at the patient’s bedside in the intensive care unit (ICU) is proposed. © 2020, The Author(s)

Characteristics of emergency medicine residency programs in Colombia

Q2Q1Artículo original1120-1127Introduction: Emergency medicine (EM) is in different stages of development around the world. Colombia has made significant strides in EM development in the last two decades and recognized it as a medical specialty in 2005. The country now has seven EM residency programs: three in the capital city of Bogotá, two in Medellin, one in Manizales, and one in Cali. The seven residency programs are in different stages of maturity, with the oldest founded 20 years ago and two founded in the last two years. The objective of this study was to characterize these seven residency programs. Methods: We conducted semi-structured interviews with faculty and residents from all the existing programs in 2013-2016. Topics included program characteristics and curricula. Results: Colombian EM residencies are three-year programs, with the exception of one four-year program. Programs accept 3-10 applicants yearly. Only one program has free tuition and the rest charge tuition. The number of EM faculty ranges from 2-15. EM rotation requirements range from 11-33% of total clinical time. One program does not have a pediatric rotation. The other programs require 1-2 months of pediatrics or pediatric EM. Critical care requirements range from 4-7 months. Other common rotations include anesthesia, general surgery, internal medicine, obstetrics, gynecology, orthopedics, ophthalmology, radiology, toxicology, psychiatry, neurology, cardiology, pulmonology, and trauma. All programs offer 4-6 hours of protected didactic time each week. Some programs require Advanced Cardiac Life Support, Pediatric Advanced Life Support and Advanced Trauma Life Support, with some programs providing these trainings in-house or subsidizing the cost. Most programs require one research project for graduation. Resident evaluations consist of written tests and oral exams several times per year. Point-of-care ultrasound training is provided in four of the seven programs. Conclusion: As emergency medicine continues to develop in Colombia, more residency programs are expected to emerge. Faculty development and sustainability of academic pursuits will be critically important. In the long term, the specialty will need to move toward certifying board exams and professional development through a national EM organization to promote standardization across programs

Aire. Apoyo Integral Respiratorio en Emergencias

El desarrollo de la formación académica en vía aérea difícil concluyó en el texto que se presenta ahora bajo el nombre de AIRE, Apoyo Integral Respiratorio en Emergencias. Este proyecto se inició hace 5 años con el objetivo de desarrollar un curso adquirieran las aptitudes y los conocimientos necesarios para el manejo básico y avanzado de la vía aérea del paciente urgente. Así mismo, respondió a la necesidad creciente de entrenamiento para el manejo avanzado de la vía aérea en el entorno de los servicios de urgencias intra y extra hospitalarias por parte de los médicos generales, especialistas en Medicina de Emergencias, Anestesia, Cirugía General, Medicina Interna, y de todo el personal relacionado con el cuidado del paciente crítico. Fue así como un grupo de conformado por dos emergeciólogos, cuatro residentes de Medicina de Emergencias y una terapeuta respiratoria comenzamos a convertirnos en facilitadores para el aprendizaje de este difícil tema

Concordancia del diámetro de la vena cava inferior medida desde dos ventanas ecográficas distintas

INTRODUCCIÓN: En el choque, la ACEP propone la medición de los diámetros de la vena cava inferior tanto en la ventana acústica sub xifoidea o línea medio axilar derecha y con estos se calcule el índice de colapso, que permite un estimativo de la presión venosa central. Aceptando la vena cava como un cilindro, se ha dado por hecho que las mediciones desde cualquiera de las dos regiones son equivalente e igualmente confiables, pero no existen estudios que lo demuestren. OBJETIVO: Determinar la concordancia de los diámetros en inspiración y espiración de la vena cava inferior, al ser medidos desde dos regiones diferentes: la región subxifoidea y medio axilar derecha entre el séptimo y noveno espacio intercostal, en una población de individuos sanos. METODOLOGÍA: fue un estudio de observación transversal, tipo: concordancia. En este diseño se buscó una concordancia esperada de 0.7 mínimo para valores significativos; se realizó por correlaciones intra clase. RESULTADOS: la media para los valores del IVC en la ventana subxifoidea fue de 29 y para la ventana axilar fue de 22. Para los valores del diámetro inferior de la vena cava inferior fueron de 10 mm para la ventana subxifoidea y de 12 mm para la axilar. CONCLUSIÓN: Para la población de los estudiantes de la Quita de Mutis de la Universidad del Rosario, no existe concordancia estadísticamente significativa entre la ventana subxifoidea y la ventana axilar para la medición de los diámetros mayor, menor; ni tampoco para el índice de vena cava inferior.INTRODUCTION: In the shock, the ACEP proposes from the measurement of the diameter inferior vena cava in the acoustic subxiphoid zone or the right anterior midaxillary line zone, calculate the caval index in which permits an estimation of the central venous pressure. Accepting the vena cava as a cylinder, it has been assumed that measurements from any of the two regions are equivalent and equally reliable, but there are no studies to prove this. OBJECTIVE: To determine the concordance of diameters in inspiration and expiration of the inferior vena cava, to be examined of two differents approach: the subxiphoid zone or the right anterior midaxillary line zone between the seventh and ninth intercostal space, in a population of healthy individuals. METHODS: There was a study of transversal observation, type: concordance. In this design a concordance expected of minimum 0.7 for significant values was searched; it was realized by intraclass correlation. RESULTS: According to the values of CI in the subxiphoid zone was 29 and for the right anterior midaxillary line zone it was 22. For the values of the smaller diameters of the vena cava inferior were 10 mm for subxiphoid zone and 12mm for the right anterior midaxillary line zone. CONCLUSION: For the population of students of the Quinta de Mutis of the Universidad Del Rosario, there aren’t in statical significant concordance between the subxiphoid zone and the right anterior midaxillary line zone for the measurement of the taller and smaller diameters; neither for the caval index.Auto financiad

Concordancia del diámetro de la vena cava inferior medida desde dos ventanas ecográficas distintas

INTRODUCCIÓN: En el choque, la ACEP propone la medición de los diámetros de la vena cava inferior tanto en la ventana acústica sub xifoidea o línea medio axilar derecha y con estos se calcule el índice de colapso, que permite un estimativo de la presión venosa central. Aceptando la vena cava como un cilindro, se ha dado por hecho que las mediciones desde cualquiera de las dos regiones son equivalente e igualmente confiables, pero no existen estudios que lo demuestren. OBJETIVO: Determinar la concordancia de los diámetros en inspiración y espiración de la vena cava inferior, al ser medidos desde dos regiones diferentes: la región subxifoidea y medio axilar derecha entre el séptimo y noveno espacio intercostal, en una población de individuos sanos. METODOLOGÍA: fue un estudio de observación transversal, tipo: concordancia. En este diseño se buscó una concordancia esperada de 0.7 mínimo para valores significativos; se realizó por correlaciones intra clase. RESULTADOS: la media para los valores del IVC en la ventana subxifoidea fue de 29 y para la ventana axilar fue de 22. Para los valores del diámetro inferior de la vena cava inferior fueron de 10 mm para la ventana subxifoidea y de 12 mm para la axilar. CONCLUSIÓN: Para la población de los estudiantes de la Quita de Mutis de la Universidad del Rosario, no existe concordancia estadísticamente significativa entre la ventana subxifoidea y la ventana axilar para la medición de los diámetros mayor, menor; ni tampoco para el índice de vena cava inferior.INTRODUCTION: In the shock, the ACEP proposes from the measurement of the diameter inferior vena cava in the acoustic subxiphoid zone or the right anterior midaxillary line zone, calculate the caval index in which permits an estimation of the central venous pressure. Accepting the vena cava as a cylinder, it has been assumed that measurements from any of the two regions are equivalent and equally reliable, but there are no studies to prove this. OBJECTIVE: To determine the concordance of diameters in inspiration and expiration of the inferior vena cava, to be examined of two differents approach: the subxiphoid zone or the right anterior midaxillary line zone between the seventh and ninth intercostal space, in a population of healthy individuals. METHODS: There was a study of transversal observation, type: concordance. In this design a concordance expected of minimum 0.7 for significant values was searched; it was realized by intraclass correlation. RESULTS: According to the values of CI in the subxiphoid zone was 29 and for the right anterior midaxillary line zone it was 22. For the values of the smaller diameters of the vena cava inferior were 10 mm for subxiphoid zone and 12mm for the right anterior midaxillary line zone. CONCLUSION: For the population of students of the Quinta de Mutis of the Universidad Del Rosario, there aren’t in statical significant concordance between the subxiphoid zone and the right anterior midaxillary line zone for the measurement of the taller and smaller diameters; neither for the caval index.Auto financiad

Internal jugular access using pocket ultradound in simulated medel: comparision between biplane and monoplane visualization techniques

Introducción: El uso de la ecografía en los accesos venosos centrales es el estándar actual por sus ventajas en términos de eficiencia y seguridad. La visualización en plano o fuera de plano son las técnicas utilizadas en la actualidad sin que la evidencia muestre ventaja de una sobre la otra. El objetivo de este estudio es comparar la visualización biplano con la técnica en plano y fuera de plano en términos de éxito y tiempo en modelos simulados. Metodología: Se llevo a cabo un experimento simulado en el cual 10 especialistas en medicina de emergencias participaron en 60 eventos simulados, utilizando una aleatorización de la técnica de visualización. Para cada evento de canalización de un modelo simulado para acceso venoso yugular. Los tiempos requeridos se midieron para obtener una ventana optima, visualizar la aguja dentro del vaso y el para el paso adecuado de la guía. Resultados: Se obtuvo un 100% de éxito en la canalización con las 3 técnicas. El éxito en el primero intento fue de 95% para la visualización biplano versus 100% para en plano y fuera de plano. No hubo diferencias significativas en el éxito de canulación, el redireccionamiento de la aguja o la frecuencia de punción de pared posterior de BP comparado con EP y FP. Conclusiones: La visualización biplano con el uso de ecógrafo del bolsillo para la canalización yugular interna en modelos simulados no demostró diferencias significativas al compararlo con las técnicas de visualización en plano y fuera de plano.Introduction: The use of ultrasound in central venous access is the current standard due to its advantages in terms of efficiency and safety. In-plane or out-of-plane visualization are the techniques currently used without evidence showing an advantage of one over the other. The aim of this study is to compare biplane visualization with the in-plane and out-of-plane technique in terms of success and time in simulated models. Methodology: A simulated experiment was conducted in which 10 emergency medicine specialists participated in 60 simulated events, using a randomization visualization technique. For each referral event a simulated model for jugular venous access. The times required were measured to obtain an optimal window, to visualize the needle inside the vessel and for the adequate passage of the guidewire. Results: 100% success was obtained in channeling with the 3 techniques. Success on the first attempt was 95% for biplane viewing versus 100% for in-plane and out-of-plane viewing. There were no significant differences in cannulation success, needle redirection, or posterior wall puncture frequency of BP compared with EP and FP. Conclusions: Biplane visualization with the use of pocket ultrasound for internal jugular cannulation in simulated models did not show significant differences when compared with in-plane and out-of-plane visualization techniques

Learning process and improvement of point-of-care ultrasound technique for subxiphoid visualization of the inferior vena cava

"Background: Medical residents' training in ultrasonography usually follows the recommendations of the American College of Emergency Physicians (ACEP), even though these do not provide specific technical guidelines. Adequate training is considered to require 25 practical iterations in the majority of ultrasound procedures. However, the effectiveness of this approach has not been verified experimentally. We set out to determine the number of repetitions required for an acceptable ultrasound procedure of the inferior vena cava (IVC), as an important and emerging ultrasound procedure in cardiology. Methods: Using three human models, each of eight medical residents in the Emergency Medicine (EM) Program at the Universidad del Rosario performed 25 iterations of the recommended procedure, with image quality evaluation by an EM physician expert in the technique. Logistic regression analysis was used to determine the lowest number of repetitions required to achieve an adjusted probability of success of 80 and 90 %, respectively. Results: We obtained 200 ultrasound images. The percentage success by each resident ranged from 52 to 96 %. There was no statistical significance in the relation between gender and success (p = 0.83), but there was an association between year of residency and success (p  less than  0.001). The average time taken for each procedure was 17.3 s (SD 8.1); there was no association between the time taken and either repetition number or image quality. We demonstrate that eleven repetitions are required to achieve acceptable image quality in 80 %, and that 21 repetitions are required to achieve acceptable image quality in 90 %. Conclusions: This is the first study to formally evaluate the effectiveness of recommended training in ultrasound techniques. Our findings demonstrate that training comprising 25 procedural repetitions is easily sufficient to achieve optimal image quality, and they also provide empiric knowledge toward elucidating the times and minimum repetitions needed to acquire and improve ultrasonographic technique in novice operators to a level which fulfills quality requirements for interpretation. © 2016, Gómez Betancourt et al.

Learning process and improvement of point-of-care ultrasound technique for subxiphoid visualization of the inferior vena cava

Abstract Background Medical residents' training in ultrasonography usually follows the recommendations of the American College of Emergency Physicians (ACEP), even though these do not provide specific technical guidelines. Adequate training is considered to require 25 practical iterations in the majority of ultrasound procedures. However, the effectiveness of this approach has not been verified experimentally. We set out to determine the number of repetitions required for an acceptable ultrasound procedure of the inferior vena cava (IVC), as an important and emerging ultrasound procedure in cardiology. Methods Using three human models, each of eight medical residents in the Emergency Medicine (EM) Program at the Universidad del Rosario performed 25 iterations of the recommended procedure, with image quality evaluation by an EM physician expert in the technique. Logistic regression analysis was used to determine the lowest number of repetitions required to achieve an adjusted probability of success of 80 and 90 %, respectively. Results We obtained 200 ultrasound images. The percentage success by each resident ranged from 52 to 96 %. There was no statistical significance in the relation between gender and success (p = 0.83), but there was an association between year of residency and success (p < 0.001). The average time taken for each procedure was 17.3 s (SD 8.1); there was no association between the time taken and either repetition number or image quality. We demonstrate that eleven repetitions are required to achieve acceptable image quality in 80 %, and that 21 repetitions are required to achieve acceptable image quality in 90 %. Conclusions This is the first study to formally evaluate the effectiveness of recommended training in ultrasound techniques. Our findings demonstrate that training comprising 25 procedural repetitions is easily sufficient to achieve optimal image quality, and they also provide empiric knowledge toward elucidating the times and minimum repetitions needed to acquire and improve ultrasonographic technique in novice operators to a level which fulfills quality requirements for interpretation

Ultrasound-guided insertion of intra-aortic balloon counterpulsation in intensive care: description of the technique

Intra-aortic balloon counterpulsation (IAoBC) is a mechanical circulatory support device that has been used for more than 50 years, mainly for cardiogenic shock. Although its effect on mortality is controversial, IAoBC is still used in a wide variety of pre- and postoperative clinical settings in cardiac surgery centers. IAoBC has a complication rate of approximately 30%, mostly associated with problems during insertion and malpositioning. Thus, an insertion technique based on the use of ultrasound at the patient’s bedside in the intensive care unit (ICU) is proposed. © 2020, The Author(s)