The author would like to thank Dr. James Rippey, Sonologist at Sir Charles Gairdner Hospital, Nedlands, Western Australia, for guidance and instructions on how to create the used simulation model in the experiment. This project did not receive any institutional financial support.

This study was approved by the Human Research Ethics Committee of Edith Cowan University, Reference Number REMS 2021-02489-STEINWANDEL. Informed consent was obtained from workshop participants, and a copy of a participant information sheet was provided. Only workshop participants who participated in one of the ultrasound workshops during the delivery period between the years 2021 and 2022 were invited to participate and included in this study. All subsequent workshop participants in 2023 and 2024 were excluded from participation in this study.
1. Creation and preparation of the simulation model12
<ol>
	<li>Cut a regular raw chicken breast with a sharp kitchen knife horizontally to allow for the insertion of three or more fluid-filled artificial blood vessels, which will simulate human blood vessels in this experiment.</li>
	<li>Preparation of the artificial blood vessels
	<ol>
		<li>Fill modeling balloons (size 260Q) with cold rosehip tea or water prepared with red food color using a 50 mL catheter-tipped syringe. Fill the modeling balloon with the prepared fluid and remove any surplus air from the balloon.</li>
		<li>Push the fluid in the balloon and remove any air bubbles at the same time by repeatedly pushing the syringe in and out of the modeling balloon. When this repetitive process is completed, the balloon must be free of air bubbles and slightly pressurized.</li>
		<li>Tighten the modeling balloon with a knot to avoid any fluid leaks.</li>
	</ol>
	</li>
	<li>Place the fluid-filled modeling balloon on the lower half of the chicken breast. Fold the other chicken breast half over (placed) on top. Wrap this chicken breast simulation model with a transparent film and place it on a tray (Figure 1).</li>
</ol>
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/66905/66905fig01.jpg" /> 
Figure 1: Simulation model. The simulation model was created from raw chicken breast and fluid-filled modeling balloons (260Q). <a href="https://www.jove.com/files/ftp_upload/66905/66905fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
2. Simulated vascular access cannulation
<ol>
	<li>Place a charged POCUS device (portable or stationary) with a linear probe and a probe cover onto this simulation model of patient tissue prepared in step 1.</li>
	<li>Apply some ultrasound gel to the area of interest in the simulation model. Don a pair of non-sterile gloves.</li>
</ol>
3. Measurement of the depth and caliper of a vessel
<ol>
	<li>In a transverse view of the simulated blood vessel in the simulation model, visualize a simulated vessel and achieve a good vision of the vessel of interest by placing the ultrasound probe on top of the simulation model and centering the view of the vessel in the middle of the screen of the ultrasound device, where it will appear as a black circular structure. Ensure a reasonable size of the vessel can be identified, taking up at least 1/3rd of the screen.</li>
	<li>Place this vessel in the center of the screen of the POCUS device by moving the ultrasound probe across the simulation model so that the whole vascular structure is visible. Adjust image size and contrast settings on the ultrasound device, if required, to obtain optimal vision of the vessel and surrounding tissue, to distinguish between vessel space and surrounding tissue. Freeze the image by pressing the Freeze function button on the ultrasound device.</li>
	<li>On the frozen image, place digital markers, to indicate the depth of the center of the vessel. Place digital markers as well to measure the diameter (caliper) of the vessel (Figure 2). 
	NOTE: This information helps the observer make critical decisions on the size and length of cannula needed, which may be suitable for potentially reaching this particular blood vessel and enabling successful cannulation.</li>
</ol>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/66905/66905fig02.jpg" /> 
Figure 2: Vessel measurement. Measurement of the simulated vessel (transverse view) on the ultrasound screen. <a href="https://www.jove.com/files/ftp_upload/66905/66905fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
4. Observation of the direction of the vessel
<ol>
	<li>Rotate the ultrasound probe by 90&#176; to obtain a longitudinal view of the blood vessel. This view allows the observer to make a decision on the direction of the vessel and the intended cannulation, providing crucial information prior to the subsequent process of the actual cannulation.</li>
	<li>Observe the direction of the vessel being aligned with the ultrasound probe. Once the vessel direction has been observed, use this to decide which direction of cannula placement might likely be useful and also successful for the insertion and placement of the cannula, even when the vessel might appear to be at a deeper level and may not be palpable or visible from the outside (Figure 3).</li>
</ol>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/66905/66905fig03.jpg" /> 
Figure 3: Longitudinal view of a simulated vessel. <a href="https://www.jove.com/files/ftp_upload/66905/66905fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
5. Cannulation of a deep vessel
NOTE: Combining all this information, a virtual picture of that vessel is created in the observer&#39;s mind; the process of vascular cannulation will follow.
<ol>
	<li>Place the linear probe in a transverse view of the vessel. Remove the protective needle cover of the PIVC cannula to commence the cannulation procedure.</li>
	<li>Place the transverse vision of the vessel centrally on the screen of the POCUS device. Slowly and carefully cannulate (perpendicular) in the middle of the linear probe the simulation model at an angle of around 40&#176; and aim for the top (upper end) of the vessel.</li>
	<li>Advance the needle tip into the tissue of the simulation model and aim for the vessel. Try to identify visually the needle tip on the screen of the POCUS device while it is advanced through the tissue by simultaneously advancing the needle but also following the needle tip with the ultrasound probe (Figure 4).</li>
	<li>Final placement of the cannula with the use of POCUS
	<ol>
		<li>Further advance the needle through the tissue towards the vessel and follow slowly with the ultrasound probe, the needle tip simultaneously in the same motion as the needle advancement. 
		&#8203;NOTE: Through this the clinician can ensure that the needle tip is always visible in the desired anatomical space within the simulation model tissue and then moving towards the intravascular space.</li>
		<li>Visualize the needle tip entering the intravascular space, then level the needle to a shallower angle and further advance the needle to finally rest it in the center of the vessel of the simulation model (final destination).</li>
		<li>Validate the position of the needle tip with the POCUS device by observing the needle tip on the screen by changing the angle of the ultrasound probe or moving the ultrasound in small (mm) increments back and forth until the needle tip visually disappears/reappears on the screen.</li>
		<li>Observe the opposite end of the PIVC for some evidence of red-colored fluid to confirm correct placement. Remove the stylet from the PIVC (Video 1).</li>
	</ol>
	</li>
</ol>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/66905/66905fig04.jpg" /> 
Figure 4: Transverse view of a simulated vessel. <a href="https://www.jove.com/files/ftp_upload/66905/66905fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
Video 1: Cannula advancement into the center of the vessel. <a href="https://www.jove.com/files/ftp_upload/66905/Video.zip" target="_blank">Please click here to download this Video.</a>

Training Novices in POCUS for Vascular Cannulation Using Simulation Models

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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=Peripheral+intravenous+catheter+insertion+and+use+of+ultrasound+in+patients+with+difficult+intravenous+access:+Australian+patient+and+practitioner+perspectives+to+inform+future+implementation+strategies.">Peripheral intravenous catheter insertion and use of ultrasound in patients with difficult intravenous access: Australian patient and practitioner perspectives to inform future implementation strategies.</a> PLoS One. 17 (6), e0269788 (2022).</li><li>Armson, A. M., Moynihan, R., Stafford, N., Jacobs, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasound-guided+cannulation+for+medical+students.">Ultrasound-guided cannulation for medical students.</a> Clin Teach. 18 (3), 295-300 (2021).</li><li>Burton, S. 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The author declares that there is no conflict of interest.

Vascular access cannulation of difficult venous conditions requires experience, manual dexterity, and continuous observation of the progress of the needle tip position while the cannula is advanced through human tissue into the intravascular space18. While the use of ultrasound has become more prevalent in the use in patients with difficult venous access2, it is also necessary that junior clinicians and novices become familiar with the use of ultrasound in connection with i...

Most patients being admitted to acute hospitals receive at least one peripheral intravenous catheter (PIVC), with the purpose of withdrawing blood, administration of fluids and/or medication, and for diagnostic purposes1. It is common that first-attempt insertions fail, and it has been reported that up to 50% of hospitalized patients have difficult intravenous access (DIVA)2. To alleviate this, the use of ultrasound-guided PIVC insertion (USGPIVC) has been demonstrated to improve insertion success rates, and training and practical education have been recommended for multiple healthcare professions3,4,5. Point-of-care ultrasound (POCUS) at the bedside is nowadays more frequently used to gain vascular access. POCUS has also been described as a useful tool for augmenting the teaching and learning of physical examination6. While several studies have described that training in USGPIVC is likely to enhance the skills of clinicians7,8,9,10, it has not yet been described in detail which specific elements of this training are the essential components to achieve the desired outcomes when applying POCUS for USGPIVC. To achieve this, a combined POCUS and USGPIVC training curriculum was developed covering the essential aspects of the training, which were considered as being the elemental aspects and learning objectives for USGPIVC workshops, including the theoretical background and practical hands-on aspects.
Training novices in the use of POCUS prior to and during vascular access cannulation requires an ideal simulation environment to enable effective learning success which replicates similar anatomical conditions as in a human anatomical environment11. Therefore, simulation models created from chicken breast and fluid-filled modeling balloons were found to be ideal and can be used to generate such a simulation model12. This approach teaches the learner the observational skill of assessing vascular conditions at an individual patient level first in a safe, simulated environment, which helps in the overall decision-making process of choosing the required cannula length, assessment of the vascular depth and width, and vessel direction for an individual patient. This allows for a critical assessment of any future patient&#39;s individual anatomical conditions, where a clinician may want to subsequently decide if the planned cannulation is likely to be successful or not. To obtain this information, POCUS-obtained images, when they are interpreted correctly, usually provide reliable and critical elements of information, which, in addition to the clinicians&#39; experience and manual dexterity, are likely to lead to cannulation success.
In the second step, the learner is taught, in this simulative environment, the development of manual dexterity for using the ultrasound probe simultaneously with the manual skill of inserting a cannula, under vision, observing the POCUS screen and the insertion site, into the simulated blood vessel. This observational skill of constantly visualizing the simulated vessel and meticulously observing the needle tip during the insertion process is the most important aspect of the overall learning goal of this simulation activity until the needle tip is ultimately placed in the anatomical area of interest, in this case in the center of a simulated vessel. This process is crucial to avoid unintended and unnecessary vessel injury, tissue, bleeding, or extravasation, as this technique is intended to be subsequently used in a patient in clinical settings by the participant.
Some authors have previously recommended implementing and integrating ultrasound into the medical school curriculum, using low-cost simulation models and small teaching groups13. Others have recommended developing structured training programs followed by a hands-on session in a simulated environment14. It has also been described that the use of ultrasound helps with procedural success and may reduce risks for patients15. Others have observed that using POCUS and USGPIVC to train clinicians in the emergency department (ED) has increased the use of this approach in the short term. Still, there may also exist a lack of consistency in formalized education programs for vascular access7,16,17. In contrast, others have described that formalized vascular access training leads to improved adherence to best practices&#160;for PIVC insertion11.
The aim of this educational approach was to simulate a comparable visual and dexterity experience for learners so that they could replicate and apply this skill in a clinical setting and on patients in the future. An observational longitudinal mixed methods study approach was chosen, and electronic surveys were used to assess the confidence level of workshop participants using ultrasound (POCUS) in connection with peripheral venous cannulation. The surveys were first used in simulation models and subsequently used in the clinical specialty of workshop participants in admitted patients.
The workshop was divided into three parts. First, participants were introduced to some basic principles and theories of using ultrasound in the space of vascular access cannulation in an interactive learning environment. In a second approach, the workshop facilitator demonstrated the vascular access assessment approach using a simulator with a simulated artificial vessel created, demonstrating the observation of vessel depth, size, and direction through transverse and longitudinal view and observation using POCUS. This was followed by a demonstrated cannulation using POCUS and the simulator through the workshop facilitator, as participants were then invited to practice this task themselves on their individual simulators. At the workshop conclusion, participants were individually assessed on their skill of identifying and measuring vessel size, depth, and direction using transverse and longitudinal views in the simulator, followed by ultrasound-guided cannulation of the simulated vessel. After the workshop attendance, participants were invited to rate their confidence skills in using USPIVC in an electronic survey. At 8 weeks after the workshop attendance, participants were again invited to respond in an electronic survey if they had applied this adopted skill in their individual clinical setting.

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		<tr>
			<td>BD Insyte Autogard BC Pro shielded IV catheter with blood control technology (PIVC)</td>
			<td>BD</td>
			<td>318054</td>
			<td></td>
		</tr>
		<tr>
			<td>Catheter tipped syringe 30 or 50 ml</td>
			<td>BD Plastipak&#160;</td>
			<td>301229, 300865</td>
			<td></td>
		</tr>
		<tr>
			<td>Celeste Nitrile Powder Free Examination gloves sizes S/M/L (non-sterile)</td>
			<td>Celeste</td>
			<td>CLS121</td>
			<td></td>
		</tr>
		<tr>
			<td>Goliath Cling wrap</td>
			<td>Goliath</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>modelling balloons 260 Q</td>
			<td>Qualatex&#160;</td>
			<td>99321</td>
			<td></td>
		</tr>
		<tr>
			<td>Point-of care ultrasound device, eg. Philips Lumify or Vscan Air</td>
			<td>Philips or GE Healthcare</td>
			<td></td>
			<td>https://www.usa.philips.com/healthcare/product/HC989605450382/lumify-c5-2-curved-array-transducer</td>
		</tr>
		<tr>
			<td>probe cover for Philips lumify</td>
			<td>Philips&#160;&#160;</td>
			<td></td>
			<td>https://www.usa.philips.com/healthcare/product/HC989605450382/lumify-c5-2-curved-array-transducer</td>
		</tr>
		<tr>
			<td>raw chicken breast</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Sunsonic Ultrasound Transmission Gel 250 ml</td>
			<td>Sunsonic</td>
			<td>LG250</td>
			<td></td>
		</tr>
		<tr>
			<td>Tasty Herbal Infusion Rosehip Tea</td>
			<td>Tasty</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Victorinox Fibrox Chef&#39;s Knife 20 cm</td>
			<td>Victorinox</td>
			<td>40520</td>
			<td></td>
		</tr>
	</tbody>
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using simulation models to train clinicians in the use of point-of-care ultrasound

The use of point-of-care ultrasound (POCUS) has shown to be a beneficial non-invasive vascular access assessment method by clinicians, which can provide critical elements of visual and measurable information that proves to be useful in the context of vascular access cannulation, in combination with the practical skill of the clinician performing the cannulation. However, the use of POCUS in this context is to practically train and enable individuals who are novices in using this technique to become proficient in performing this task subsequently on patients in a careful and successful way. The simulation of these vascular conditions may be useful to help healthcare professionals learn, understand, apply, and establish such practical skills for vascular cannulation safely to achieve the desired outcomes. This project intended, through the attendance of a half-day workshop, to establish skills to use POCUS in connection with simulation models and perform specific tasks to enable clinicians to use this method in their clinical practice for vascular access cannulation in patients. A mixed-methods longitudinal study design was used to evaluate the effect of a point-of-care ultrasound workshop for peripheral intravenous cannula insertion, including specific tasks for the participants to be performed on simulation models. A total of 81 individuals participated in 11 half-day workshops through 2021 and 2022. Offering a workshop that uses simulation models in combination with various POCUS devices is useful in establishing this newly learned skill in clinicians, such as measurements of depth, caliper, and direction of a vein with POCUS prior to cannulation providing essential anatomical facts to the operator, which increases the likelihood of first-time success in cannulation.

A total of 81 individuals participated in 11 half-day workshops between 2021 and 2022. Most participants were resident medical officers (n=43, 53%), followed by staff development/clinical nurses and clinical nurse consultants (n=19, 25.3%) with a mean of 8 years of clinical experience. Half of the participants (n=40, 49%) had only 2 years or less of clinical experience. There were also some other workshop participants, such as a nuclear medicine technologist, a dental sedationist, and a diagnostic radiologist. Almost a q...

Author Spotlight: Evaluating Clinicians' Adoption of Ultrasound-Guided Vascular Cannulation Through Simulation Training

The present protocol describes an ideal solution to train novices in the use of point-of-care ultrasound devices for the practical clinical skill of visually assessing distinct individual anatomical vascular conditions prior to and during an intended venous vascular cannulation using point-of-care ultrasound in a patient.

Using Simulation Models to Train Clinicians in the Use of Point-of-Care Ultrasound

The use of point-of-care ultrasound (POCUS) has shown to be a beneficial non-invasive vascular access assessment method by clinicians, which can provide ...

using-simulation-models-to-train-clinicians-use-point-care

Research

JoVE Journal

Medicine

789 Views.  Edith Cowan University. The present protocol describes an ideal solution to train novices in the use of point-of-care ultrasound devices for the practical clinical skill of visually assessing distinct individual anatomical vascular conditions prior to and during an intended venous vascular cannulation using point-of-care ultrasound in a patient. 

Video: Author Spotlight: Evaluating Clinicians' Adoption of Ultrasound-Guided Vascular Cannulation Through Simulation Training

Rapid Point-of-Care Assay of Enoxaparin Anticoagulant Efficacy in Whole Blood

There is the need for a clinical assay to determine the extent to which a patient's blood is effectively anticoagulated by the low-molecular-weight-heparin (LMWH), enoxaparin. There are also urgent clinical situations where it would be important if this could be determined rapidly. The present assay is designed to accomplish this. We only assayed human blood samples that were spiked with known concentrations of enoxaparin. The essential feature of the present assay is the quantification of the efficacy of enoxaparin in a patient's blood sample by degrading it to complete inactivity with heparinase. Two blood samples were drawn into Vacutainer tubes (Becton-Dickenson; Franklin Lakes, NJ) that were spiked with enoxaparin; one sample was digested with heparinase for 5 min at 37 &deg;C, the other sample represented the patient's baseline anticoagulated status. The percent shortening of clotting time in the heparinase-treated sample, as compared to the baseline state, yielded the anticoagulant contribution of enoxaparin. We used the portable, battery operated Hemochron 801 apparatus for measurements of clotting times (International Technidyne Corp., Edison, NJ). The apparatus has 2 thermostatically controlled (37 &deg;C) assay tube wells. We conducted the assays in two types of assay cartridges that are available from the manufacturer of the instrument. One cartridge was modified to increase its sensitivity. We removed the kaolin from the FTK-ACT cartridge by extensive rinsing with distilled water, leaving only the glass surface of the tube, and perhaps the detection magnet, as activators. We called this our minimally activated assay (MAA). The use of a minimally activated assay has been studied by us and others. 2-4 The second cartridge that was studied was an activated partial thromboplastin time (aPTT) assay (A104). This was used as supplied from the manufacturer. The thermostated wells of the instrument were used for both the heparinase digestion and coagulation assays. The assay can be completed within 10 min. The MAA assay showed robust changes in clotting time after heparinase digestion of enoxaparin over a typical clinical concentration range. At 0.2 anti-Xa I.U. of enoxaparin per ml of blood sample, heparinase digestion caused an average decrease of 9.8% (20.4 sec) in clotting time; at 1.0 I.U. per ml of enoxaparin there was a 41.4% decrease (148.8 sec). This report only presents the experimental application of the assay; its value in a clinical setting must still be established.

Demonstration of a rapid quantitative assay of the inhibition of blood coagulation by the low-molecular-weight-heparin, enoxaparin. The contribution of enoxaparin is assessed by removing its influence through digestion with heparinase. A fuller description of the assay is detailed in our published paper.1 The assay still requires clinical confirmation.

There is the need for a clinical assay to determine the extent to which a patient's blood is effectively anticoagulated by the ...

Protocol and Guidelines for Point-of-Care Lung Ultrasound in Diagnosing Neonatal Pulmonary Diseases Based on International Expert Consensus

Ultrasound is a safe bedside imaging tool that obviates the use of ionizing radiation diagnostic procedures. Due to its convenience, the lung ultrasound has received increasing attention from neonatal physicians. Nevertheless, clear reference standards and guideline limits are needed for accurate application of this diagnostic modality. This document aims to summarize expert opinions and to provide precise guidance to help facilitate the use of the lung ultrasound in the diagnosis of neonatal lung diseases.

Lung ultrasound is a noninvasive and valuable tool for bedside evaluation of neonatal lung diseases. However, a relative lack of reference standards, protocols and guidelines may limit its application. Here, we aim to develop a standardized neonatal lung ultrasound diagnostic protocol to be used in clinical decision-making.

Ultrasound is a safe bedside imaging tool that obviates the use of ionizing radiation diagnostic procedures. Due to its convenience, the lung ultrasound ...

Point-Of-Care Ultrasound Screening for Proximal Lower Extremity Deep Venous Thrombosis

Acute lower extremity deep venous thrombosis (DVT) is a serious vascular disorder that requires accurate and early diagnosis to prevent life-threatening sequelae. While whole leg compression ultrasound with color and spectral Doppler is commonly performed in radiology and vascular labs, point-of-care ultrasound (POCUS) is becoming more common in the acute care setting. Providers appropriately trained in focused POCUS can perform a rapid bedside examination with high sensitivity and specificity in critically ill patients. This paper describes a simplified yet validated approach to POCUS by describing a three-zone protocol for lower extremity DVT POCUS image acquisition. The protocol explains the steps in obtaining vascular images at six compression points in the lower extremity. Beginning at the level of the proximal thigh and moving distally to the popliteal space, the protocol guides the user through each of the compression points in a stepwise manner: from the common femoral vein to the femoral and deep femoral vein bifurcation, and, finally, to the popliteal vein. Further, a visual aid is provided that may assist providers during real-time image acquisition. The goal in presenting this protocol is to help make proximal lower extremity DVT exams more accessible and efficient for POCUS users at the patient&#39;s bedside.

Traditionally, lower extremity deep venous thrombosis (DVT) is diagnosed by radiology-performed venous duplex ultrasound. Providers appropriately trained in focused point-of-care ultrasound (POCUS) can perform a rapid bedside examination with high sensitivity and specificity in critically ill patients. We describe the scanning technique for focused POCUS DVT lower extremity examination.

Acute lower extremity deep venous thrombosis (DVT) is a serious vascular disorder that requires accurate and early diagnosis to prevent life-threatening ...

Point-of-Care Lung Ultrasound in Adults: Image Acquisition

Consultative ultrasound performed by radiologists has traditionally not been used for imaging the lungs, as the lungs&#39; air-filled nature normally prevents direct visualization of the lung parenchyma. When showing the lung parenchyma, ultrasound typically generates a number of non-anatomic artifacts. However, over the past several decades, these artifacts have been studied by diagnostic point-of-care ultrasound (POCUS) practitioners, who have identified findings that have value in narrowing the differential diagnoses of cardiopulmonary dysfunction. For instance, in patients presenting with dyspnea, lung POCUS is superior to chest radiography (CXR) for the diagnosis of pneumothorax, pulmonary edema, lung consolidations, and pleural effusions. Despite its known diagnostic value, the utilization of lung POCUS in clinical medicine remains variable, in part because training in this modality across hospitals remains inconsistent. To address this educational gap, this narrative review describes lung POCUS image acquisition in adults, including patient positioning, transducer selection, probe placement, acquisition sequence, and image optimization.

Point-of-care ultrasound (POCUS) of the lungs provides quick answers in rapidly changing clinical scenarios. We present an efficient and informative protocol for image acquisition for use in acute care settings.

Consultative ultrasound performed by radiologists has traditionally not been used for imaging the lungs, as the lungs&#39; air-filled nature normally ...

Point-of-Care Ultrasound: A Review of Ultrasound Parameters for Predicting Difficult Airways

Airway management remains a crucial part of perioperative care. The conventional approach to assessing potentially difficult airways emphasizes the LEMON method, which looks for and evaluates the Mallampati classification, signs of obstruction, and neck mobility. Clinical findings help predict a higher likelihood of difficult tracheal intubation, but no clinical result reliably excludes difficult intubation. Ultrasound as an adjunct to clinical examination can provide the clinician with a dynamic anatomical airway assessment, which is impossible with clinical examination alone. In the hands of anesthesiologists, ultrasound is becoming more popular in the perioperative period. This method is particularly applicable for identifying proper endotracheal tube positioning in specific patient populations, such as those who are morbidly obese and patients with head and neck cancer or trauma. The focus is on identifying the normal anatomy, correctly positioning the endotracheal tube, and refining the parameters that predict difficult intubation. Several ultrasound measurements are clinical indicators of difficult direct laryngoscopy in the literature. A meta-analysis revealed that the distance from the skin to the epiglottis (DSE) is most associated with a difficult laryngoscopy. An ultrasound of the airway could be applied in routine practice as an adjunct to the clinical examination. A full stomach, rapid sequence intubation, gross visual anatomical abnormalities, and restricted neck flexibility prevent using ultrasound to assess the airway. The airway evaluation is performed with a linear array transducer of 12-4 MHz, with the patient in the supine position, with no pillow, and with the head and neck in a neutral position. The central axis of the neck is where the ultrasound parameters are measured. These image acquisitions guide the standard ultrasound examination of the airway.

A point-of-care ultrasound (POCUS) is a simple, non-invasive, and portable tool that enables dynamic airway assessment. Several studies have attempted to determine the role of ultrasound parameters as an adjunct to clinical examination in predicting difficult laryngoscopies.

Airway management remains a crucial part of perioperative care. The conventional approach to assessing potentially difficult airways emphasizes the LEMON ...

Optic Nerve Sheath Point of Care Ultrasound: Image Acquisition

The goal of this protocol is to develop a standardized method for acquiring images of the optic nerve sheath and measuring the optic nerve sheath diameter (ONSD). Diagnostic ultrasound of the ONSD to detect intracranial hypertension has traditionally faced many problems because of methodologic discrepancies. Due to inconsistencies in the measuring techniques, the potential for ONSD to become a non-invasive bedside monitoring tool for ICP has been hampered. However, establishing a transparent, consistent methodology for measuring the ONSD would support its use as a valid and reliable method of identifying intracranial hypertension. This is important as it has both high sensitivity and specificity in acute care settings. This narrative review describes ONSD POCUS image acquisition, including patient positioning, transducer selection, probe placement, the acquisition sequence, and image optimization. Further, visual aids are provided to assist in real-time during image acquisition. This method should be considered for patients for whom there are concerns regarding intracranial hypertension but who do not have an intracranial monitor in place.

Point-of-care ultrasound (POCUS) of the optic nerve sheath diameter (ONSD) has been shown to be useful in identifying patients with increased intracranial pressure (ICP). However, the non-standardized technique for this POCUS has hampered its use. We present a standardized image acquisition protocol for use in the acute care setting.

The goal of this protocol is to develop a standardized method for acquiring images of the optic nerve sheath and measuring the optic nerve sheath diameter ...

Imaging the Abdominal Aorta with Point-of-Care Ultrasound

An Approach to Point-Of-Care Ultrasound Evaluation of the Abdominal Aorta

Disorders of the abdominal aorta, including aneurysms and dissection, have potentially high rates of morbidity and mortality. While computed tomography (CT) is the current gold standard to image the abdominal aorta, the process of obtaining a CT may be time-consuming, requires the use of intravenous contrast dye, and involves exposure to ionizing radiation. Point-of-care Ultrasound (POCUS) can be performed at the bedside and has excellent sensitivity and specificity for the diagnosis of abdominal aortic aneurysm and excellent specificity for the diagnosis of abdominal aortic dissection. Additionally, POCUS is non-invasive, cost-effective, lacks ionizing radiation, requires no intravenous contrast dye, and can be performed without taking the patient from a critical care area. Screening for abdominal aortic aneurysm (AAA) can be done in primary care settings as well. 
This article will review the approach to POCUS of the abdominal aorta to evaluate such critical pathology. In this paper, we will review the sonographic anatomy of the abdominal aorta as well as the choice of the ultrasound probe, description of POCUS image acquisition, and some pearls and pitfalls of using POCUS to aid in the diagnosis of potentially life-threatening abdominal aortic pathology.

Author Spotlight: Using Point-of-Care Ultrasound for Comprehensive Evaluation of the Abdominal Aorta

This protocol reviews the steps to image the abdominal aorta with point-of-care ultrasound. We discuss image acquisition, troubleshooting imaging pitfalls and artifacts, and the recognition of life-threatening abdominal aortic pathology.

Disorders of the abdominal aorta, including aneurysms and dissection, have potentially high rates of morbidity and mortality. While computed tomography ...

Gastric Ultrasound Technique for Mitigating Peri-Procedural Aspiration Risk

Gastric Point of Care Ultrasound in Adults: Image Acquisition and Interpretation

Over the past two decades, diagnostic point-of-care ultrasound (POCUS) has emerged as a rapid and non-invasive bedside tool for addressing clinical inquiries related to gastric content. One emerging concern pertains to patients about to undergo sedation and/or endotracheal intubation: the elevated risk of aspiration from the patient&#39;s stomach contents. Aspiration of gastric contents into the lungs poses a serious and potentially life-threatening complication. This occurs more frequently when the stomach is considered &#34;full&#34; and can be affected by the techniques employed for airway management, making it potentially preventable. To mitigate the risk of peri-procedural aspiration, two distinct medical specialties (anesthesiology and critical care medicine) have independently developed techniques to utilize ultrasonography for identifying patients requiring &#34;full stomach&#34; precautions. Due to these separate specialties, the work of each group remains relatively unfamiliar outside its respective field. This article presents descriptions of both techniques for gastric ultrasound. Furthermore, it explains how these approaches can complement each other when one of them falls short. Regarding image acquisition, the article covers the following topics: indications and contraindications, selection of the appropriate probe, patient positioning, and troubleshooting. The article also delves into image interpretation, complete with example images. Additionally, it demonstrates how one of the two techniques can be employed to estimate gastric fluid volume. Lastly, the article briefly discusses medical decision-making based on the findings of this examination.

Author Spotlight: Point-of-Care Ultrasound for Gastric Content Assessment and Risk Stratification in Perioperative Care 

This protocol introduces two methods for image acquisition in gastric ultrasonography. Additionally, tips are provided for interpreting this information to assist in medical decision-making.

Over the past two decades, diagnostic point-of-care ultrasound (POCUS) has emerged as a rapid and non-invasive bedside tool for addressing clinical ...

Ultrasound in Evaluating Diaphragm Dysfunction and Monitoring Treatment

Measuring Diaphragm Thickness and Function Using Point-of-Care Ultrasound

The diaphragm is the main component of the respiratory muscle pump. Diaphragm dysfunction can cause dyspnea and exercise intolerance, and predisposes affected individuals to respiratory failure. In mechanically ventilated patients, the diaphragm is susceptible to atrophy and dysfunction through disuse and other mechanisms. This contributes to failure to wean and poor long-term clinical outcomes. Point-of-care ultrasound provides a valid and reproducible method for evaluating diaphragm thickness and contractile activity (thickening fraction during inspiration) that can be readily employed by clinicians and researchers alike. This article presents best practices for measuring diaphragm thickness and quantifying diaphragm thickening during tidal breathing or maximal inspiration. Once mastered, this technique can be used to diagnose and prognosticate diaphragm dysfunction, and guide and monitor response to treatment over time in both healthy individuals and acute or chronically ill patients.

Author Spotlight: Unraveling the Impact of Mechanical Ventilation on Diaphragm Function and Patient Outcomes 

Diaphragm thickness and function can be assessed in healthy individuals and critically ill patients using point-of-care ultrasound. This technique offers an accurate, reproducible, feasible, and well-tolerated method for evaluating diaphragm structure and function.

The diaphragm is the main component of the respiratory muscle pump. Diaphragm dysfunction can cause dyspnea and exercise intolerance, and predisposes ...

Integrating Transesophageal Ultrasound with an Echoendobronchoscope

Using the Endoscope for Endobronchial Ultrasound in the Esophagus

EUS-B is a procedure using the echoendobronchoscope in the esophagus and stomach. The procedure is a minimally invasive, safe, and feasible approach that pulmonologists can use to visualize and biopsy structures adjacent to the esophagus and stomach. EUS-B gives access to many structures of which some may also be reached by EBUS (mediastinal lymph nodes, lung or pleural tumors, pericardial fluid) while others cannot be reached such as retroperitoneal lymph nodes, ascites, and lesions in the liver, pancreas or left adrenal gland. The procedure is a pulmonologist- and patient- friendly version of the gastroenterologists' EUS using the thin EBUS endoscope that the pulmonologist already masters. Thus EUS-B training should be easy and a natural continuation of EBUS. With the patient under conscious sedation and in the supine position, the echoendoscope is introduced either through the nostril or mouth into the oropharynx. Then the patient is encouraged to swallow while the endoscope is slowly bent posteriorly and introduced into the esophagus and stomach. Using the ultrasonic image, the operator identifies the six landmarks by EUS-B and EUS: the left liver lobe, abdominal aorta (with the celiac trunk and superior mesenteric artery), left adrenal gland, and mediastinal lymph node stations 7, 4L, and 4R. Biopsies can be taken from suspected lesions under real-time ultrasonographic guidance- fine needle aspiration (EUS-B-FNA) using a technique similar to that used with EBUS-TBNA. The biopsy order is M1b-M1a-N3-N2-N1-T (M = metastasis, N = lymph node, T = tumor) to avoid iatrogenic upstaging. Pre- and post-procedural observation is similar to that of bronchoscopy. EUS-B is safe and feasible in the hands of experienced interventional pulmonologists and provides a significant expansion of the diagnostic possibilities in providing safe, fast, and thorough diagnosis and staging of lung cancer.

Author Spotlight: Advancing Biopsy Techniques with Transesophageal Ultrasound

Transesophageal ultrasound (EUS-B) is a safe and feasible procedure using the echoendobronchoscope (EBUS) in esophagus and stomach. After identifying six anatomical landmarks, additional structures can be identified and biopsied, sparing subsequent diagnostic sessions. Thus, EUS-B is an ideal continuation of bronchoscopy and EBUS in diagnosing lung cancer and other diseases.

EUS-B is a procedure using the echoendobronchoscope in the esophagus and stomach. The procedure is a minimally invasive, safe, and feasible approach that ...