None. No funding was received for this project.

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
NOTE: The exams can be performed with either a low frequency curvilinear (2-5 MHz) or medium to high frequency linear probe (6-12 MHz) depending on patient body habitus, probe availability, and provider preference. For the figures and scans, a curvilinear probe (C35xp, SonoSite M-Turbo) was utilized.
1. Technique for quadriceps scanning
<ol>
	<li>Quadriceps depth measurement
	<ol>
		<li>Patient positioning: Place the patient in a supine position (head of the bed elevated to 30o) with their legs extended.</li>
		<li>Probe selection: Select a low-frequency curvilinear or medium to high-frequency linear probe.</li>
		<li>Mode selection: Set the preset (i.e., exam type) on the scanner to musculoskeletal (MSK) setting.</li>
		<li>Probe placement:
		<ol>
			<li>Place the probe transversely on the anterior thigh at approximately 60% the length from the anterior superior iliac spine (ASIS) to the superior border of the patella (Figure 1).</li>
			<li>With the probe perpendicular to the long axis of the muscles, the quadriceps will appear deep to the subcutaneous tissue and superficial to the femur.</li>
			<li>Use extra contact gel to minimize underlying soft tissue distortion.</li>
		</ol>
		</li>
		<li>Image optimization:
		<ol>
			<li>To prevent the overestimation of the muscle thickness due to superficial edema, apply firm pressure to the ultrasound probe without inflicting pain25.</li>
			<li>If any difficulty identifying the rectus femoris is encountered, ask the patient to contract their thigh muscles or extend their knee. The rectus femoris, being superficial and crossing the hip joint, will show a different movement pattern compared to the deeper vastus muscles (Supplementary Video 1).</li>
		</ol>
		</li>
		<li>Measurement of quadriceps muscle thickness
		<ol>
			<li>Activate the Caliper function of the ultrasound machine by pressing Measure on the ultrasound machine.</li>
			<li>Use the cursor to measure the anterior-to-posterior distance between (1) the deep border of the vastus intermedius (just superficial to the cortex of the femur) and (2) the most superficial fascia of the rectus femoris (Figure 2). 
			NOTE: If there is any difficulty identifying the structures mentioned in 1.1.6.2, the steps mentioned in the Video 1 supplement can be repeated before activating the caliper function. The quadriceps muscle thickness is the sum of the muscle thickness of the rectus femoris and vastus intermedius (Figure 3).</li>
		</ol>
		</li>
		<li>Image acquisition: click on Acquire to save a video clip of this sonographic view.</li>
		<li>Repeat measurement (steps 1.1.6-1.1.7) three times and average values to minimize variability.</li>
	</ol>
	</li>
</ol>
2. Technique for rectus femoris scanning
<ol>
	<li>Rectus femoris cross-sectional area (CSA) measurement
	<ol>
		<li>Patient positioning: follow step 1.1.1.</li>
		<li>Probe selection: follow step 1.1.2.</li>
		<li>Mode selection: follow step 1.1.3.</li>
		<li>Probe placement: follow step 1.1.4.</li>
		<li>Image optimization:
		<ol>
			<li>Adjust the depth using the vertical ruler on the right side of the displayed scan. Adjust the gain using the horizontal slide bar at the bottom of the touch control panel so that the rectus femoris muscle is centered in the ultrasound frame with clear visualization of its boundaries and the underlying femur.</li>
			<li>Identify the rectus femoris muscle as a hypoechoic structure within the anterior thigh compartment, with a central echogenic line representing the intramuscular tendon.</li>
			<li>Activate the caliper function on the ultrasound machine and trace around the periphery of the rectus femoris muscle carefully to define its cross-sectional area. The ultrasound machine will calculate and display the CSA based on the tracing.</li>
		</ol>
		</li>
		<li>Image acquisition: follow step 1.1.6.</li>
		<li>Repeat measurement three times and average values to minimize variability.</li>
	</ol>
	</li>
	<li>Rectus Femoris Circumference Measurement
	<ol>
		<li>Patient positioning: follow step 1.1.1.</li>
		<li>Probe selection: follow step 1.1.2.</li>
		<li>Mode selection: follow step 1.1.3.</li>
		<li>Probe placement: follow step 1.1.4</li>
		<li>Image optimization:
		<ol>
			<li>Adjust the depth using the vertical ruler on the right side of the displayed scan. Adjust the gain using the horizontal slide bar at the bottom of the touch control panel so that the rectus femoris muscle is centered in the ultrasound frame with clear visualization of its boundaries and the underlying femur.</li>
			<li>Identify the rectus femoris muscle as a hypoechoic structure within the anterior thigh compartment, with a central echogenic line representing the intramuscular tendon.</li>
			<li>Activate the caliper function on the ultrasound machine and trace around the periphery of the rectus femoris muscle carefully to define its cross-sectional area. The ultrasound machine will calculate and display the circumference based on the tracing (Figure 4).</li>
		</ol>
		</li>
		<li>Image acquisition: follow step 1.1.6.</li>
		<li>Repeat measurement three times and average values to minimize variability.</li>
	</ol>
	</li>
</ol>

Ultrasound Protocol for Perioperative Frailty Assessment

<ol>
	<li>Etzioni, D. A., Liu, J. H., O'Connell, J. B., Maggard, M. A., Ko, C. Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Elderly+patients+in+surgical+workloads:+A+population-based+analysis.">Elderly patients in surgical workloads: A population-based analysis.</a> Am Surg. 69 (11), 961-965 (2003).</li><li>Rohrmann, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Epidemiology+of+frailty+in+older+people.">Epidemiology of frailty in older people.</a> Adv Exp Med Biol. 1216, 21-27 (2020).</li><li>Clegg, A., Young, J., Iliffe, S., Rikkert, M. O., Rockwood, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Frailty+in+elderly+people.">Frailty in elderly people.</a> Lancet. 381 (9868), 752-762 (2013).</li><li>Torpy, J. M., Lynm, C., Glass, R. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Frailty+in+older+adults.">Frailty in older adults.</a> JAMA. 296 (18), 2280 (2006).</li><li>Arya, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Frailty+increases+the+risk+of+30-day+mortality,+morbidity,+and+failure+to+rescue+after+elective+abdominal+aortic+aneurysm+repair+independent+of+age+and+comorbidities.">Frailty increases the risk of 30-day mortality, morbidity, and failure to rescue after elective abdominal aortic aneurysm repair independent of age and comorbidities.</a> J Vasc Surg. 61 (2), 324-331 (2015).</li><li>Engelhardt, K. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Frailty+screening+and+a+frailty+pathway+decrease+length+of+stay,+loss+of+independence,+and+30-day+readmission+rates+in+frail+geriatric+trauma+and+emergency+general+surgery+patients.">Frailty screening and a frailty pathway decrease length of stay, loss of independence, and 30-day readmission rates in frail geriatric trauma and emergency general surgery patients.</a> J Trauma Acute Care Surg. 85 (1), 167-173 (2018).</li><li>Gans, E. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Frailty+and+treatment+decisions+in+older+patients+with+vulvar+cancer:+A+single-center+cohort+study.">Frailty and treatment decisions in older patients with vulvar cancer: A single-center cohort study.</a> J Geriatr Oncol. 14 (2), 101442 (2023).</li><li>Carlstrom, L. P., Helal, A., Perry, A., Lakomkin, N., Graffeo, C. S., Clarke, M. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Too+frail+is+to+fail:+Frailty+portends+poor+outcomes+in+the+elderly+with+type+II+odontoid+fractures+independent+of+management+strategy.">Too frail is to fail: Frailty portends poor outcomes in the elderly with type II odontoid fractures independent of management strategy.</a> J Clin Neurosci. 93, 48-53 (2021).</li><li>Ho, V. P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Health+status,+frailty,+and+multimorbidity+in+patients+with+emergency+general+surgery+conditions.">Health status, frailty, and multimorbidity in patients with emergency general surgery conditions.</a> Surgery. 172 (1), 446-452 (2022).</li><li>Modrall, J. G., Tsai, S., Ramanan, B., Rosero, E. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Frailty+as+a+predictor+of+mortality+for+fenestrated+EVAR+and+open+surgical+repair+of+aortic+aneurysms+involving+visceral+vessels.">Frailty as a predictor of mortality for fenestrated EVAR and open surgical repair of aortic aneurysms involving visceral vessels.</a> Ann Vasc Surg. 80, 29-36 (2022).</li><li>Lee, A. C. H., Lee, S. M., Ferguson, M. K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Frailty+is+associated+with+adverse+postoperative+outcomes+after+lung+cancer+resection.">Frailty is associated with adverse postoperative outcomes after lung cancer resection.</a> JTO Clin Res Rep. 3 (11), 100414 (2022).</li><li>Mah, S. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+five-factor+modified+frailty+index+predicts+adverse+postoperative+and+chemotherapy+outcomes+in+gynecologic+oncology.">The five-factor modified frailty index predicts adverse postoperative and chemotherapy outcomes in gynecologic oncology.</a> Gynecol Oncol. 166 (1), 154-161 (2022).</li><li>Ogawa, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Impact+of+frailty+on+postoperative+dysphagia+in+patients+undergoing+elective+cardiovascular+surgery.">Impact of frailty on postoperative dysphagia in patients undergoing elective cardiovascular surgery.</a> JACC Asia. 2 (1), 104-113 (2022).</li><li>Huq, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Frailty+in+patients+undergoing+surgery+for+brain+tumors:+A+systematic+review+of+the+literature.">Frailty in patients undergoing surgery for brain tumors: A systematic review of the literature.</a> World Neurosurg. 166, 268-278 (2022).</li><li>Owodunni, O. P., Mostales, J. C., Qin, C. X., Gabre-Kidan, A., Magnuson, T., Gearhart, S. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Preoperative+frailty+assessment,+operative+severity+score,+and+early+postoperative+loss+of+independence+in+surgical+patients+age+65+years+or+older.">Preoperative frailty assessment, operative severity score, and early postoperative loss of independence in surgical patients age 65 years or older.</a> J Am Coll Surg. 232 (4), 387-395 (2021).</li><li>DeAngelo, M. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Impact+of+frailty+on+risk+of+long-term+functional+decline+following+vascular+surgery.">Impact of frailty on risk of long-term functional decline following vascular surgery.</a> J Vasc Surg. 77 (2), 515-522 (2023).</li><li>Rothenberg, K. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Association+of+frailty+and+postoperative+complications+with+unplanned+readmissions+after+elective+outpatient+surgery.">Association of frailty and postoperative complications with unplanned readmissions after elective outpatient surgery.</a> JAMA Netw Open. 2 (5), e194330 (2019).</li><li>Sastry, R. A., Pertsch, N. J., Tang, O., Shao, B., Toms, S. A., Weil, R. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Frailty+and+outcomes+after+craniotomy+for+brain+tumor.">Frailty and outcomes after craniotomy for brain tumor.</a> J Clin Neurosci. 81, 95-100 (2020).</li><li>Shinall, M. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Association+of+preoperative+patient+frailty+and+operative+stress+with+postoperative+mortality.">Association of preoperative patient frailty and operative stress with postoperative mortality.</a> JAMA Surg. 155 (1), e194620 (2020).</li><li>Kennedy, C. A., Shipway, D., Barry, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Frailty+and+emergency+abdominal+surgery:+A+systematic+review+and+meta-analysis.">Frailty and emergency abdominal surgery: A systematic review and meta-analysis.</a> Surgeon. 20 (6), e307-e314 (2022).</li><li>Fried, L. P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Frailty+in+older+adults:+Evidence+for+a+phenotype.">Frailty in older adults: Evidence for a phenotype.</a> J Gerontol A Biol Sci Med Sci. 56 (3), M146-M157 (2001).</li><li>Knoedler, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Impact+of+sarcopenia+on+outcomes+in+surgical+patients:+A+systematic+review+and+meta-analysis.">Impact of sarcopenia on outcomes in surgical patients: A systematic review and meta-analysis.</a> Int J Surg. 109 (12), 4238-4262 (2023).</li><li>Canales, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Preoperative+point-of-care+ultrasound+to+identify+frailty+and+predict+postoperative+outcomes:+A+diagnostic+accuracy+study.">Preoperative point-of-care ultrasound to identify frailty and predict postoperative outcomes: A diagnostic accuracy study.</a> Anesthesiology. 136 (2), 268-278 (2022).</li><li>Pasta, G., Nanni, G., Molini, L., Bianchi, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Sonography+of+the+quadriceps+muscle:+Examination+technique,+normal+anatomy,+and+traumatic+lesions.">Sonography of the quadriceps muscle: Examination technique, normal anatomy, and traumatic lesions.</a> J Ultrasound. 13 (2), 76-84 (2010).</li><li>Pardo, E., El Behi, H., Boizeau, P., Verdonk, F., Alberti, C., Lescot, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reliability+of+ultrasound+measurements+of+quadriceps+muscle+thickness+in+critically+ill+patients.">Reliability of ultrasound measurements of quadriceps muscle thickness in critically ill patients.</a> BMC Anesthesiol. 18 (1), 205 (2018).</li><li>Nijholt, W., Scafoglieri, A., Jager-Wittenaar, H., Hobbelen, J. S. M., Van Der Schans, C. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+reliability+and+validity+of+ultrasound+to+quantify+muscles+in+older+adults:+a+systematic+review.">The reliability and validity of ultrasound to quantify muscles in older adults: a systematic review.</a> J Cachexia Sarcopenia Muscle. 8 (5), 702-712 (2017).</li><li>Hogenbirk, R. N. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Thickness+of+biceps+and+quadriceps+femoris+muscle+measured+using+point-of-care+ultrasound+as+a+representation+of+total+skeletal+muscle+mass.">Thickness of biceps and quadriceps femoris muscle measured using point-of-care ultrasound as a representation of total skeletal muscle mass.</a> J Clin Med. 11 (22), 6606 (2022).</li><li>Lambell, K. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+ultrasound-derived+muscle+thickness+with+computed+tomography+muscle+cross-sectional+area+on+admission+to+the+intensive+care+unit:+A+pilot+cross-sectional+study.">Comparison of ultrasound-derived muscle thickness with computed tomography muscle cross-sectional area on admission to the intensive care unit: A pilot cross-sectional study.</a> JPEN J Parenter Enteral Nutr. 45 (1), 136-145 (2021).</li><li>Zhao, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Evaluation+of+appendicular+muscle+mass+in+sarcopenia+in+older+adults+using+ultrasonography:+A+systematic+review+and+meta-analysis.">Evaluation of appendicular muscle mass in sarcopenia in older adults using ultrasonography: A systematic review and meta-analysis.</a> Gerontology. 68 (10), 1174-1198 (2022).</li><li>Ghaffarian, A. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prognostic+implications+of+diagnosing+frailty+and+sarcopenia+in+vascular+surgery+practice.">Prognostic implications of diagnosing frailty and sarcopenia in vascular surgery practice.</a> J Vasc Surg. 70 (3), 892-900 (2019).</li><li>Martin, F. C., Ranhoff, A. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Frailty+and+Sarcopenia.">Frailty and Sarcopenia.</a> Orthogeriatrics: The Management of Older Patients with Fragility Fractures. , (2021).</li><li>Davies, B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Differential+association+of+frailty+and+sarcopenia+with+mortality+and+disability:+Insight+supporting+clinical+subtypes+of+frailty.">Differential association of frailty and sarcopenia with mortality and disability: Insight supporting clinical subtypes of frailty.</a> J Am Med Dir Assoc. 23 (10), 1712-1716 (2022).</li><li>Ben-Menachem, E., Ashes, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Point-of-care+ultrasound+frailty+assessments.">Point-of-care ultrasound frailty assessments.</a> Comment. Anesthesiology. 137 (3), 373-374 (2022).</li><li>Ijaz, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Interventions+for+frailty+among+older+adults+with+cardiovascular+disease.">Interventions for frailty among older adults with cardiovascular disease.</a> J Am Collo Cardiol. 79 (5), 482-503 (2022).</li><li>Thompson, C., Dodds, R. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+ageing+syndromes+of+sarcopenia+and+frailty.">The ageing syndromes of sarcopenia and frailty.</a> Medicine. 49 (1), 6-9 (2021).</li></ol>

None of the authors have any conflicts of interest to disclose.

Previous studies have indicated that POCUS can be used to estimate muscle thickness, including the quadriceps muscle, with accuracy comparable to CT scans26,27,28. Sonographic measurement of quadriceps muscle thickness has been correlated with frailty and can be used to predict certain postoperative outcomes23. In addition, this method is helpful in situations where other methods of diagnosing frailty may...

As the average life expectancy rises globally, an increasing number of surgeries are performed on patients over the age of 651. Frailty is more common in these patients compared with their younger counterparts and represents a state of physiological vulnerability to stressors, including surgery2,3,4. Frailty in the preoperative setting has been linked with a higher risk for postoperative adverse events across many surgical subspecialties5,6,7,8,9,10,11,12,13, including longer hospital length of stay10,14, loss of independence15,16, readmission rates17,18, increased costs14, and mortality10,18,19,20. Therefore, it is of utmost importance for the perioperative healthcare team to consider a patient&#39;s frailty during preoperative decision-making.
The most commonly used method to diagnose frailty includes the Fried frailty phenotype, which comprises five factors including exhaustion, weakness (measured by grip strength), slow walking pace, weight loss, and low physical activity levels21. However, this scale was designed primarily for outpatient services and may be too time-consuming in the perioperative setting. In addition, it requires patient cooperation and is impractical in a patient with altered mental status. Moreover, CT scans are used to assess muscle mass for sarcopenia diagnosis, which can aid in frailty assessment. However, while effective, CT scans present practical challenges in resource allocation and expose patients to ionizing radiation, especially in the perioperative period.22&#160;Therefore, there is a need for bedside test that can quickly and accurately identify preoperative patients with diminished muscle mass, thus flagging those at higher surgical risk.
Recently, Canales et al. reported on a method for screening for frailty in the preoperative setting using point-of-care ultrasound23. They found that quadriceps muscle thickness accurately predicted frailty and was an independent predictor of postoperative discharge to a skilled nursing facility and delirium. The quadriceps muscle is located on the anterior thigh and is composed of four muscle bellies: the rectus femoris, the vastus medialis, vastus lateralis, and the vastus intermedius24. Using point-of-care ultrasound for frailty screening in the preoperative setting offers advantages over the Fried frailty assessment and CT imaging. Point-of-care ultrasound provides objective measures of physiologic parameters, such as muscle mass and quality, in real-time, allowing for immediate and non-invasive evaluation. This approach is more practical, efficient, and adaptable to patients who may not be able to undergo traditional assessment, enhancing perioperative risk stratification and improving outcomes23.
This paper will detail how to obtain the point-of-care ultrasound measurements of the quadriceps (including probe selection, patient positioning, and troubleshooting) and discuss the implications of this measurement in the perioperative setting.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>High Frequency Ultrasound Probe (HFL38xp)</td>
			<td>SonoSite (FujiFilm)</td>
			<td>P16038</td>
			<td></td>
		</tr>
		<tr>
			<td>Low Frequency Ultrasound Probe (C35xp)</td>
			<td>SonoSite (FujiFilm)</td>
			<td>P19617</td>
			<td></td>
		</tr>
		<tr>
			<td>SonoSite X-porte Ultrasound</td>
			<td>SonoSite (FujiFilm)</td>
			<td>P19220</td>
			<td></td>
		</tr>
		<tr>
			<td>Ultrasound Gel</td>
			<td>AquaSonic</td>
			<td>PLI 01-08</td>
			<td></td>
		</tr>
	</tbody>
</table>

identifying frailty using point-of-care ultrasonography: image acquisition and assessment

Frailty is a significant predictor of a range of adverse outcomes in surgical patients, including increased mechanical ventilation time, longer hospital stays, unplanned readmissions, stroke, delirium, and death. However, accessible tools for screening in clinical settings are limited. Computed tomography of the psoas muscle is the current standard imaging device for measuring frailty, but it is expensive, time-consuming, and exposes the patient to ionizing radiation. Recently, the use of point-of-care ultrasound (POCUS) has emerged as a potential tool to determine the presence of frailty and has been shown to accurately predict frailty and postoperative outcomes. In this article, we will describe the image acquisition of the quadriceps muscles and explain how they can be used to determine frailty and predict postoperative adverse events. We will present information on probe selection, patient positioning, and troubleshooting. Images from a demonstration will be used to present the POCUS technique and example results. The article will culminate in a discussion of the use of these images in medical decision-making and potential limitations.

Author Spotlight: Assessing Surgical Frailty with Point-of-Care Ultrasound of Quadriceps Muscles

Identifying Frailty Using Point-of-Care Ultrasonography: Image Acquisition and Assessment

Our research aims to assess frailty in surgical patients using point-of-care ultrasound measurements of the quadricep muscle. We seek to determine the accuracy of these measurements in predicting postoperative adverse events and their potential utility in clinical decision-making. Recent advancements in our field include the utilization of point-of-care ultrasound for bedside assessment of muscle mass and quality.This approach offers a non-invasive and expeditious alternative to traditional imaging techniques, enhancing perioperative risk evaluation in surgical patients. Experimental challenges include optimizing image acquisition techniques for consistent and accurate measurement of quadriceps muscle thickness, as well as ensuring reproducibility across different operators and patient populations. Compared to other techniques, such as the Fried frailty assessment and CT imaging, this protocol offers the advantage of enhancing that efficiency in the preoperative area for identifying those patients at potentially higher surgical risk secondary to frailty.In the future, our team will focus on further validating the use of point-of-care ultrasound and frailty assessment across different surgical populations and investigating interventions to improve outcomes in frail surgical patients.

By implementing this protocol for measuring quadriceps muscle thickness using real-time ultrasound, it is possible to accurately assess frailty indicators. Following the steps outlined in this protocol, we positioned the patient and selected the appropriate ultrasound probe for optimal visualization of the quadriceps muscles.
The key to success in this technique is the precise placement of the probe on the anterior thigh at approximately 60% the length from the ASIS to the superior border of t...

Here, we present a protocol to assess frailty in the perioperative setting using point-of-care ultrasound to measure quadriceps thickness. This method offers a practical, non-invasive alternative to traditional assessment methods, potentially enhancing perioperative care by quickly identifying frail patients.

Frailty is a significant predictor of a range of adverse outcomes in surgical patients, including increased mechanical ventilation time, longer hospital ...

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Research

JoVE Journal

Medicine

Ultrasound Measurement of the Quadriceps for the Identification of Frail Patients

To begin place a patient in a supine position on a surgical bed with their legs extended. Set the preset on the probe scanner to the musculoskeletal setting. Place the probe transversely on the anterior thigh at about 60%the length from the anterior superior iliac spine to the superior border of the patella.The quadriceps will appear deep to the subcutaneous tissue and superficial to the femur. To prevent the overestimation of the muscle thickness due to superficial edema, apply firm pressure to the ultrasound probe. If the rectus femoris is difficult to identify, ask the patient to contract their thigh muscles or extend their knee.Next, press distance, then measure on the ultrasound machine and activate the caliper function. With the cursor, measure the anterior to posterior distance between the deep border of the vastus intermedius and the most superficial fascia of the rectus femoris. Click on acquire to capture the sonographic view.Repeat the measurement three times, then average the values to minimize the variability. For the measurement of the rectus femoris, adjust the depth with the vertical ruler, then use the horizontal slide bar to adjust the gain until the rectus femoris muscle is centered in the ultrasound frame with clear visibility of its boundaries and the underlying femur. The rectus femoris muscle should be visible as a hypoechoic structure within the anterior thigh compartment with a central echogenic line.Now activate the caliper function, and trace around the periphery of the rectus femoris muscle carefully. The circumference of the cross section should be displayed automatically. Click on a acquire to capture the sonographic view.Average the values of three to minimize the variability. The measurements of a healthy subject showed well-defined muscle with uniform echotexture, and clear, continuous fascial planes consistent with non-frail status. A scan of an elderly frail individual showed less defined muscles, a heterogeneous echotexture, and interrupted fascial planes.

265 Views.  George Washington University.  Here, we present a protocol to assess frailty in the perioperative setting using point-of-care ultrasound to measure quadriceps thickness. This method offers a practical, non-invasive alternative to traditional assessment methods, potentially enhancing perioperative care by quickly identifying frail patients.

Ultrasound Protocol for Perioperative Frailty Assessment

Summary