Diagnostic Point of Care Ultrasound For Hospitalists Nima Afshar MD Associate Professor Trevor Jensen MD MS Assistant Professor Department of Medicine, UCSF Oct 2018 POCUS is the future of the physical exam Case Demo Evidence --Summary 1
Mr. Hocus 49M unknown pmh p/w R>>L LE swelling and erythema & fevers x 5 days Afebrile. HR 107 BP 120/60 RR 22 94% RA WBC 17.4, Lactate 4.3, Na 127, Cr 5.12, Trop 0.7, BNP 3000 Diagnosed with RLE cellulitis with sepsis, admitted to medicine. Intern: Do you think he has a DVT and/or PE? 2
DVT POCUS Soni et al. Point of Care Ultrasound. Elsevier. 2015 DEMO 3
What is a positive finding? DVT POCUS Literature POCUS compression DVT exam Meta-analysis, Thromb Haemost, 2013 Sensitivity 96% Specificity 96% 4
What is POCUS Soni, Diagnostic POCUS for Hospitalists. JHM, 2015 How to use POCUS Soni, Diagnostic POCUS for Hospitalists. JHM, 2015 5
Back to Mr. Hocus WBC 17.4, Lactate 4.3, Na 127, Cr 5.12, Trop 0.7, BNP 3000 Intern: Should we worry about urinary obstruction? Renal POCUS Soni et al. Point of Care Ultrasound. Elsevier. 2015 6
LIVE DEMO What is a positive finding? 7
Hydronephrosis Literature POCUS can assist with diagnosis of moderate to severe hydronephrosis Meta-analysis, Canadian J Emerg Med, 2017 Sensitivity 70% Specificity 75% Back to Mr. Hocus Received 3L IVF in ED Lactate downtrends to 2.7 Continued tachycardia to 110s Increasingly SOB, O2 89% on RA Intern: I m a little concerned about Mr H s respiratory status with IVF resuscitation 8
Comprehensive Volume Status IJ for JVP IVC Pulmonary Edema Pleural Effusion Gross LV Function JVP by Ultrasound 9
DEMO Mr. Hocus 10
JVP Literature IJ height to BNP (1 small study): corr coeff (CC) 0.67 IJ height to CVP (3 studies, 142 pts): CC 0.65, ROC 0.78 IJ cross-sectional area to CVP (1 study): CC 0.56 IJ diameter at 30 deg vs. 0 deg to CVP (1 study): ROC 0.78 IJ resp variation at 90 deg to SV change c fluids (1 study): CC 0.65 One negative study (Ann Thor Med, 15, 40pts) 21 IVC POCUS 11
DEMO Mr. Hocus 12
Two meta-analyses IVC Literature Cardiovascular Ultrasound, Aug 16 21 studies, 1400 cases IVC diameter to CVP ~ 0.76-0.91 IVC collapsibility to CVP ~ 0.66-0.93 Acta Radiologica, Aug 16 37 studies, 2800 cases IVC to CVP ~ 0.44-0.68 25 Pulmonary Edema 13
DEMO Mr. Hocus 14
Pulmonary Edema Literature Ultrasound as good or better than CXR for pulm edema Rapid diagnosis & Dynamic monitoring Academic Emerg Med, 2014 (systematic review) 94% sensitive, 92% specific for Acute cardiogenic pulmonary edema 29 Pleural Effusion 15
DEMO Mr. Hocus 16
Pleural Effusion Literature Ultrasound highly sensitive for pleural effusion - better than CXR, equal to CT Kataoka, Japanese cardiologist, 3 studies (231 pts) 74-91% sensitive for decompensated heart failure 33 Intern: Why did he get so overloaded so fast? 17
Focused Cardiac US: LV Function & Pericardial Effusion Soni et al. Point of Care Ultrasound. Elsevier. 2015 DEMO 18
Mr. Hocus What is a positive finding? 19
Gross LV function Literature Chest, 2009 Intensivists in Hennepin County Med Center (Univ of Minnesota) 2hrs didactic + 4hrs hands-on training in LV function Within 2hrs of formal echo, intensivists did bedside echo Intensivist dx d normal vs. mild-mod reduced vs. severely reduced LV fxn Accuracy 82% 39 Two similar studies of EM physicians showed 84-86% accuracy Pericardial Effusion Literature Annals of Emergency Medicine, 2001 Emergency physicians at USC 1hr didactic + 4hrs hands-on training in ultrasound for peric eff 515 ED patients c high-risk for peric effusion (>20% had effusion) EM physicians performed cardiac scans and interpreted them Single cardiologist provided final read 93% technically adequate 96% sensitivity, 98% specificity 40 20
Mr Hocus resolution Diagnoses: Sepsis AKI HFrEF Hypoxemic respiratory failure POCUS & Mr H Fast Possibly avoided some formal tests (DVT, Renal US, CXRs) Likely sped up other tests (TTE) Early involvement of appropriate consult services (Cardiology) Helpful for monitoring going forward Why POCUS really? Allows earlier diagnosis and treatment Avoids tests/reduces radiation exposure Reduces length of stay Reduces cost of stay Increases patient satisfaction (hands-on) 21
What is the scope of HM POCUS? A NEJM Perspective Solomon. Point-of-Care US in Medical Education. NEJM 2014 22
The larger issue now is to decide whether we believe that building competency in ultrasound among generalist physicians in this case hospitalists will enhance patient safety, quality, and value. Personally, I do. - BW 2012 LV systolic function Pericardial effusion Chamber size RV strain Pleural effusion Pulmonary edema Pneumonia Pneumothorax Ascites Aortic aneurysm Hydronephrosis Bladder Volume Organomegaly IVC IJ AAA DVT Journal of Hospital Medicine 2015 23
SHM Position Statement Watch this space Major Challenges Training Credentialing and Privileging Hardware Research 24
Remember this POCUS is the future of the physical exam Scope depends on level of training and the patient population Utility depends on: The specific question you re asking Quality of the exam How to learn more Email us: Trevor.Jensen@ucsf.edu Nima.Afshar@ucsf.edu Self learning (Soni, Mallin & Dawson) Go to workshops (SHM, ACP, AIUM UCSF) Use local experts (EM or CCM colleagues) Undertake a certificate program (ACCP, SHM) 25
Credit: University of South Carolina Point of Care US 26