Feasibility Evaluation of Commercially Available Video Conferencing Devices to Technically Direct Untrained Nonmedical Personnel to Perform a Rapid Trauma Ultrasound Examination.

Introduction: Point-of-care ultrasound (POCUS) is a rapidly expanding discipline that has proven to be a valuable modality in the hospital setting. Recent evidence has demonstrated the utility of commercially available video conferencing technologies, namely, FaceTime (Apple Inc, Cupertino, CA, USA) and Google Glass (Google Inc, Mountain View, CA, USA), to allow an expert POCUS examiner to remotely guide a novice medical professional. However, few studies have evaluated the ability to use these teleultrasound technologies to guide a nonmedical novice to perform an acute care POCUS examination for cardiac, pulmonary, and abdominal assessments. Additionally, few studies have shown the ability of a POCUS-trained cardiac anesthesiologist to perform the role of an expert instructor. This study sought to evaluate the ability of a POCUS-trained anesthesiologist to remotely guide a nonmedically trained participant to perform an acute care POCUS examination. Methods: A total of 21 nonmedically trained undergraduate students who had no prior ultrasound experience were recruited to perform a three-part ultrasound examination on a standardized patient with the guidance of a remote expert who was a POCUS-trained cardiac anesthesiologist. The examination included the following acute care POCUS topics: (1) cardiac function via parasternal long/short axis views, (2) pneumothorax assessment via pleural sliding exam via anterior lung views, and (3) abdominal free fluid exam via right upper quadrant abdominal view. Each examiner was given a handout with static images of probe placement and actual ultrasound images for the three views. After a brief 8 min tutorial on the teleultrasound technologies, a connection was established with the expert, and they were guided through the acute care POCUS exam. Each view was deemed to be complete when the expert sonographer was satisfied with the obtained image or if the expert sonographer determined that the image could not be obtained after 5 min. Image quality was scored on a previously validated 0 to 4 grading scale. The entire session was recorded, and the image quality was scored during the exam by the remote expert instructor as well as by a separate POCUS-trained, blinded expert anesthesiologist. Results: A total of 21 subjects completed the study. The average total time for the exam was 8.5 min (standard deviation = 4.6). A comparison between the live expert examiner and the blinded postexam reviewer showed a 100% agreement between image interpretations. A review of the exams rated as three or higher demonstrated that 87% of abdominal, 90% of cardiac, and 95% of pulmonary exams achieved this level of image quality. A satisfaction survey of the novice users demonstrated higher ease of following commands for the cardiac and pulmonary exams compared to the abdominal exam. Conclusions: The results from this pilot study demonstrate that nonmedically trained individuals can be guided to complete a relevant ultrasound examination within a short period. Further evaluation of using telemedicine technologies to promote POCUS should be evaluated

Feasibility Evaluation of Commercially Available Video Conferencing Devices to Technically Direct Untrained Nonmedical Personnel to Perform a Rapid Trauma Ultrasound Examination

Introduction: Point-of-care ultrasound (POCUS) is a rapidly expanding discipline that has proven to be a valuable modality in the hospital setting. Recent evidence has demonstrated the utility of commercially available video conferencing technologies, namely, FaceTime (Apple Inc, Cupertino, CA, USA) and Google Glass (Google Inc, Mountain View, CA, USA), to allow an expert POCUS examiner to remotely guide a novice medical professional. However, few studies have evaluated the ability to use these teleultrasound technologies to guide a nonmedical novice to perform an acute care POCUS examination for cardiac, pulmonary, and abdominal assessments. Additionally, few studies have shown the ability of a POCUS-trained cardiac anesthesiologist to perform the role of an expert instructor. This study sought to evaluate the ability of a POCUS-trained anesthesiologist to remotely guide a nonmedically trained participant to perform an acute care POCUS examination. Methods: A total of 21 nonmedically trained undergraduate students who had no prior ultrasound experience were recruited to perform a three-part ultrasound examination on a standardized patient with the guidance of a remote expert who was a POCUS-trained cardiac anesthesiologist. The examination included the following acute care POCUS topics: (1) cardiac function via parasternal long/short axis views, (2) pneumothorax assessment via pleural sliding exam via anterior lung views, and (3) abdominal free fluid exam via right upper quadrant abdominal view. Each examiner was given a handout with static images of probe placement and actual ultrasound images for the three views. After a brief 8 min tutorial on the teleultrasound technologies, a connection was established with the expert, and they were guided through the acute care POCUS exam. Each view was deemed to be complete when the expert sonographer was satisfied with the obtained image or if the expert sonographer determined that the image could not be obtained after 5 min. Image quality was scored on a previously validated 0 to 4 grading scale. The entire session was recorded, and the image quality was scored during the exam by the remote expert instructor as well as by a separate POCUS-trained, blinded expert anesthesiologist. Results: A total of 21 subjects completed the study. The average total time for the exam was 8.5 min (standard deviation = 4.6). A comparison between the live expert examiner and the blinded postexam reviewer showed a 100% agreement between image interpretations. A review of the exams rated as three or higher demonstrated that 87% of abdominal, 90% of cardiac, and 95% of pulmonary exams achieved this level of image quality. A satisfaction survey of the novice users demonstrated higher ease of following commands for the cardiac and pulmonary exams compared to the abdominal exam. Conclusions: The results from this pilot study demonstrate that nonmedically trained individuals can be guided to complete a relevant ultrasound examination within a short period. Further evaluation of using telemedicine technologies to promote POCUS should be evaluated

The Use of Point-of-Care Ultrasonography in Trauma Anesthesia.

Caring for the trauma patient requires an in-depth knowledge of the pathophysiology of trauma, the ability to rapidly diagnose and intervene to reverse the derangements caused by shock states, and an aptitude for the use of advanced monitoring techniques and perioperative point-of-care ultrasonography (P-POCUS) to assist in diagnosis and delivery of care. Historically, anesthesiology has lagged behind in wholly embracing this technology. P-POCUS has the potential to allow the trauma anesthesiologist to diagnose numerous injuries, quickly guide the placement of central vascular catheters and invasive monitors, and assess the efficacy of interventions

Clinical review: Does it matter which hemodynamic monitoring system is used?

Hemodynamic monitoring and management has greatly improved during the past decade. Technologies have evolved from very invasive to non-invasive, and the philosophy has shifted from a static approach to a functional approach. However, despite these major changes, the critical care community still has potential to improve its ability to adopt the most modern standards of research methodology in order to more effectively evaluate new monitoring systems and their impact on patient outcome. Today, despite the huge enthusiasm raised by new hemodynamic monitoring systems, there is still a big gap between clinical research studies evaluating these monitors and clinical practice. A few studies, especially in the perioperative period, have shown that hemodynamic monitoring systems coupled with treatment protocols can improve patient outcome. These trials are small and, overall, the corpus of science related to this topic does not yet fit the standard of clinical research methodology encountered in other specialties such as cardiology and oncology. Larger randomized trials or quality improvement processes will probably answer questions related to the real impact of these systems

REVIEW Clinical review: Does it matter which

hemodynamic monitoring system is used

Feasibility evaluation of non-invasive cardiac function technology during echocardiography-based cardiac stress testing

Evaluation of cardiac function during periods of stress is of key importance for the perioperative setting. Non-invasive hemodynamic monitors provide markers of cardiac function. This pilot study sought to evaluate the ability of a non-invasive hemodynamic monitor to detect cardiac stress during formal stress echocardiography testing. The primary goal was to compare the change in hemodynamic values during the pre/during/post phases of stress echocardiography testing in patients who had results negative versus positive for myocardial ischemia. Adult patients scheduled for outpatient cardiac stress testing were screened. Only patients scheduled for stress-echocardiography testing were consented. Patients with history of arrhythmias were excluded. During the testing, patients wore a cuff-based hemodynamic sensor (Nexfin system, Edwards Lifesciences). Data from the hemodynamic sensor were compared to the findings of the stress study. A total of 37 patients were enrolled, with 31 patients included for analysis. Five patients had stress studies positive for coronary ischemia. Comparison of the hemodynamic variables between patients who had a positive stress study versus negative showed a significant reduction in the percentage change in dP/dt and stroke volume from baseline (p < 0.05). This pilot study indicates that patients who have abnormal stress echocardiograms also have significantly reduced values from a noninvasive hemodynamic monitor. Further evaluation of the clinical utility of this technology, to assist in the care of patients at risk for cardiac ischemia, should be carried out