This work was supported in part by the Center for Experiential Learning and Assessment (CELA) at Vanderbilt University Medical Center (VUMC), Nashville, TN, USA.&#160; The authors would also like to thank the staff, faculty, and personal at CELA for their guidance, assistance, and support throughout this project.&#160; Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the views of CELA or VUMC.

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Vanderbilt University Medical Center institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The protocol was derived after a review of the published literature by an expert panel of intensivists16,21,22,23,25,28,32,33 representing five health systems across the United States. Imaging was performed on the authors themselves for the normal images and as part of routine educational ultrasound scans done for teaching purposes for the positive images. The inclusion criterion was any patient on V-A ECMO, and the exclusion criterion was a refusal to undergo an ultrasound exam. The equipment used in the study is listed in the Table of Materials.
1. Safety procedures
<ol>
	<li>Utilize nitrile or latex-free gloves. Follow infection control processes for the individual institution as applicable. 
	NOTE: If the patient has surgical wounds in stages of active healing, use sterile, individually processed ultrasound jelly packets.</li>
</ol>
2. Probe selection 
<ol>
	<li>Utilize a sector arc or sector array probe (colloquially called a &#8220;phased-array probe-)34,35,36,37.</li>
</ol>
3. Machine preset
<ol>
	<li>Set the machine to the cardiology (CARDIAC) preset function, which will then have the indicator on the right-hand side of the ultrasound screen.</li>
</ol>
4. Patient positioning
<ol>
	<li>Place the patient in a supine position. 
	NOTE: If supine is not possible, maintain the patient in the most favorable position so that ECMO cannulas are not displaced.</li>
	<li>Place blankets or ramps to slightly position the patient in a left-side down trajectory while maintaining safety with ECMO cannula placement if image quality is substandard.</li>
</ol>
5. Patient monitoring
<ol>
	<li>Parasternal long-axis view
	<ol>
		<li>Obtain the parasternal long-axis view38 of the heart (Figure 1) and click on Acquire.</li>
		<li>Assess the aortic valve3,13,14,18,38.
		<ol>
			<li>Assess for the valve opening: well vs. not at all (Figure 2; Video 1). Assess for aortic root thrombus: present vs. absent vs. indeterminate (Figure 2).</li>
		</ol>
		</li>
		<li>Left ventricular internal dimension (LVIDD)38
		<ol>
			<li>Activate the caliper tool. Measure LVIDD during the R wave of the QRS tracing on EKG (Figure 2) and click on Acquire.</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>Apical 4-chamber view
	<ol>
		<li>Obtain apical 4-chamber view38 (Figure 3) and click on Acquire. Assess LV cavity for presence of thrombus: present vs. absent vs. indeterminate10,11 (Figure 2; Video 2).</li>
	</ol>
	</li>
</ol>
6. Assessing tolerance of V-A ECMO weaning
NOTE: For details on the procedure, refer to previously published reports32,33.
<ol>
	<li>Evaluate cardiac recovery and feasibility of V-A ECMO weaning by asking the following questions to the patients:
	<ol>
		<li>Assess whether there has been recovery from the underlying disease process that prompted the initiation of V-A ECMO.</li>
		<li>Determine if the patient has regained hemodynamic stability, defined by institution-specific standards16,32,33.</li>
		<li>Confirm whether oxygenation and ventilation problems are no longer severe (e.g., check if paO2/FiO2 &#62; 100 and paCO2 &#60; 60)32. 
		NOTE: There is no agreed-upon protocol to determine when a patient has recovered from their underlying etiology, which caused them to be cannulated for V-A ECMO. It is recommended that a multidisciplinary team and approach be used to make this clinical decision.</li>
	</ol>
	</li>
	<li>Perform V-A ECMO weaning trial if patient answers to checklist questions are yes32. 
	NOTE: Weaning protocols differ between centers, and there is no agreed-upon standardized protocol.
	<ol>
		<li>Decrease ECMO flow rates in increments of 0.5 L/min under constant echocardiographic surveillance. 
		NOTE: At each incremental drop in ECMO flow, if the MAP falls more than 10-15 mmHg or below 65 mmHg, consider resuming full flow, as this suggests the patient is not yet ready to wean.</li>
		<li>Perform echocardiographic evaluation of each ECMO wean.
		<ol>
			<li>Parasternal long-axis view
			<ol>
				<li>Obtain the parasternal long-axis view38 and click on Acquire. Repeat Step 5.1.3. Qualitatively assess LV systolic function (akinetic vs. some degree of function)39 (Video 3).</li>
			</ol>
			</li>
			<li>Apical 4-chamber view
			<ol>
				<li>Obtain the apical 4-chamber view38 and click on Acquire. Qualitatively assess the RV/LV size ratio40 (Figure 4). Activate M-mode to measure Tricuspid Valve Annular Plane Systolic Excursion (TAPSE)40 (Figure 5).</li>
				<li>Perform Active tissue Doppler imaging. Measure RV S&#39;40 (Figure 6). Measure the lateral mitral annular S&#39;38&#160;(Figure 7).</li>
			</ol>
			</li>
		</ol>
		</li>
		<li>Apical 5-chamber view
		<ol>
			<li>Obtain the apical 5-chamber view38,41 and click on Acquire (Figure 8).</li>
			<li>To perform left ventricular outflow tract (LVOT) velocity time integral (VTI), activate pulse-wave Doppler (PWD). Place the PWD box in LVOT. Measure LVOT VTI41 (Figure 9).</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>Decrease the flows to 1-1.5 L/min ECMO flow if previous ECMO weans are tolerated.</li>
	<li>Perform echocardiographic evaluation under minimal ECMO settings following steps 6.2.2.2.</li>
</ol>
7. Follow-up procedures
<ol>
	<li>After the patient passes a bedside tolerance for V-A ECMO weaning based on successful echocardiographic screening, stable hemodynamics, and end-organ function, perform an assessment for decannulation based on institutional protocols with multidisciplinary input.</li>
	<li>Continuously monitor for signs of ECMO-related complications such as bleeding, infection, thromboembolism, or organ dysfunction. Adjust treatment as necessary.</li>
</ol>

The Authors declare no relevant disclosures.

Significance with respect to existing methods 
The utilization of V-A ECMO as a rescue therapy for acute decompensated cardiac failure has been on the rise1. Peripheral V-A ECMO is utilized as a temporary intervention to allow time for the acutely failing heart to recover while optimizing end-organ function2,3. Although there is a lack of established guidelines regarding the application of echocardiography in the cont...

Extracorporeal membrane oxygenation (ECMO) is a potentially life-saving temporizing strategy for patients, which has seen an ever-increasing utilization rate1,2. ECMO has two different configurations: veno-venous (V-V) and veno-arterial (V-A). Over the past several decades, V-A ECMO has emerged as a fundamental tool in the care of patients with severe cardiogenic shock and cardiopulmonary failure3,4,5,6. The two cannulation strategies for V-A ECMO are central and peripheral7. Central V-A ECMO usually requires sternotomy for direct cannulation of the right atrium for venous drainage and proximal aorta for antegrade arterial return. On the other hand, peripheral V-A ECMO has arterial return via the femoral artery via a retrograde mechanism. This retrograde flow can cause the following issues: differential oxygenation of the upper and lower body, worsening biventricular function, and LV distension, particularly if there is no strategy in place to unload the LV8. These complications of peripheral V-A ECMO, in addition to the inherent risks with ECMO, necessitate frequent, vigilant monitoring9,10,11. Due to the inherent instability of these patients, it is not practical to frequently transfer them out of the intensive care unit (ICU) for diagnostic testing and evaluation of their mechanical circulatory support and evolving cardiopulmonary status3,6. Therefore, bedside diagnostic tools are essential in their daily care. One such tool is point-of-care ultrasound (POCUS)12,13,14,15 of the heart, which can be used to assess all of the following non-invasively: left ventricular (LV) performance (size, systolic function, stroke volume, aortic valve opening)3,13,14,16,17,18,19, right ventricular (RV) performance (size, systolic function)20,21, and presence versus absence of intra-cardiac thrombus10,11. Furthermore, POCUS can be used to assess readiness for V-A ECMO weaning and eventual decannulation22,23,24,25,26,27,28.
Diagnostic ultrasound generally falls into two categories: point-of-care and consultative29,30 Consultative ultrasound is an exam requested by a patient&#39;s primary treating provider but performed by a separate specialist team29,30, whereas point-of-care ultrasound is performed and interpreted by a patient&#39;s primary treating provider29,30,31. Although ultrasound assessment of the heart on V-A ECMO has traditionally been performed through consultative services, such services are not always immediately available around the clock to meet an ECMO unit&#39;s high-volume and unpredictable sonographic needs. Thus, it behooves ECMO intensivists to be able to perform serial cardiac point-of-care ultrasound (POCUS) exams on their own patients for more efficient and timely patient care.
The utilization of POCUS in the V-A ECMO setting, however, remains heterogeneous due to the variability in training among providers. This study aims to address this gap in training by describing the POCUS image acquisition in peripheral V-A ECMO, particularly in the absence of LV venting, including details on patient positioning, transducer selection, probe placement, acquisition sequence, and image optimization. Other ECMO scenarios, such as LV venting in place, will be covered separately in other manuscripts in this special collection on diagnostic POCUS image acquisition.

<table><tbody><tr><td>Affiniti&amp;nbsp;</td><td>Philips</td><td>Affiniti&amp;nbsp;70</td><td></td></tr><tr><td>Edge 1 ultrasound machine</td><td>SonoSite</td><td>Edge II</td><td></td></tr><tr><td>Vivid iq</td><td>GE</td><td></td><td></td></tr></tbody></table>

point-of-care ultrasound for peripheral veno-arterial extracorporeal membrane oxygenation without left ventricular venting

Over the past several decades, veno-arterial extracorporeal membrane oxygenation (V-A ECMO) has become a critical tool in the management of patients with severe cardiogenic shock and cardiopulmonary failure. Due to the inherent instability of these patients, their transport away from intensive care units is fraught with risk. As a result, bedside diagnostic tools are essential for their daily care. One such tool is point-of-care ultrasound (POCUS) of the heart, which can non-invasively assess several parameters: left ventricular (LV) performance (size, systolic function, stroke volume, aortic valve opening), right ventricular (RV) performance (size, systolic function), and the presence of intracardiac thrombus. Additionally, POCUS can assist in evaluating readiness for V-A ECMO weaning and eventual decannulation. Despite its potential, the use of POCUS in the context of V-A ECMO remains inconsistent due to variability in provider training. This study aims to address this gap by detailing POCUS image acquisition in V-A ECMO, particularly in the absence of LV venting. It covers key aspects such as patient positioning, transducer selection, probe placement, acquisition sequence, and image optimization.

This article describes the interpretation of point-of-care cardiac ultrasound in patients supported on peripheral V-A ECMO in two clinical scenarios: (1) As a monitoring tool during ECMO support to assess for the presence of left ventricular (LV) distension and the presence of intracardiac or aortic root thrombus, and (2) as a screening tool to evaluate readiness from liberation of mechanical support.
There is no single accepted...

This protocol outlines the use of point-of-care ultrasound (POCUS) to monitor patients on peripheral veno-arterial extracorporeal membrane oxygenation (V-A ECMO) without left ventricular venting. It evaluates left ventricular distension, intracardiac or aortic root thrombus, and identifies useful cardiac POCUS parameters for weaning from V-A ECMO.

Point-of-Care Ultrasound for Peripheral Veno-Arterial Extracorporeal Membrane Oxygenation Without Left Ventricular Venting

Over the past several decades, veno-arterial extracorporeal membrane oxygenation (V-A ECMO) has become a critical tool in the management of patients with ...

point-care-ultrasound-for-peripheral-veno-arterial-extracorporeal

Research

JoVE Journal

Medicine

248 Views.  Vanderbilt University Medical Center. Dit manuscript schetst het gebruik van cardiale point-of-care-echografie of POCUS om patiënten op perifere VA-ECMO te monitoren, met name bij patiënten zonder linkerventrikelventilatie. Het legt uit hoe kan worden gescreend op belangrijke pathologieën tijdens de onderhoudsfase van VA-ECMO, en hoe cardiale POCUS kan worden opgenomen in het spenen van ECMO. Het gebruik van cardiale POCUS in de context van VA-ECMO blijft inconsistent vanwege de variabiliteit ...

Video: Point-of-care echografie voor perifere veno-arteriële extracorporale membraanoxygenatie zonder linkerventrikel ontluchting

Noninvasive and Invasive Renal Hypoxia Monitoring in a Porcine Model of Hemorrhagic Shock

Up to 50% of patients with trauma develop acute kidney injury (AKI), in part due to poor renal perfusion after severe blood loss. AKI is currently diagnosed based on a change in serum creatinine concentration from baseline or prolonged periods of decreased urine output. Unfortunately, baseline serum creatinine concentration data is unavailable in most patients with trauma, and current estimation methods are inaccurate. In addition, serum creatinine concentration may not change until 24-48 h after the injury. Lastly, oliguria must persist for a minimum of 6 h to diagnose AKI, making it impractical for early diagnosis. AKI diagnostic approaches available today are not useful for predicting risk during the resuscitation of patients with trauma. Studies suggest that urinary partial pressure of oxygen (PuO2) may be useful for assessing renal hypoxia. A monitor that connects the urinary catheter and the urine collection bag was developed to measure PuO2 noninvasively. The device incorporates an optical oxygen sensor that estimates PuO2 based on luminescence quenching principles. In addition, the device measures urinary flow and temperature, the latter to adjust for confounding effects of temperature changes. Urinary flow is measured to compensate for the effects of oxygen ingress during periods of low urine flow. This article describes a porcine model of hemorrhagic shock to study the relationship between noninvasive PuO2, renal hypoxia, and AKI development. A key element of the model is the ultrasound-guided surgical placement in the renal medulla of an oxygen probe, which is based on an unsheathed optical microfiber. PuO2 will also be measured in the bladder and compared to the kidney and noninvasive PuO2 measurements. This model can be used to test PuO2 as an early marker of AKI and assess PuO2 as a resuscitative endpoint after hemorrhage that is indicative of end-organ rather than systemic oxygenation.

Presented here is a protocol to measure renal oxygenation in the medulla and noninvasive urine oxygen partial pressure in a hemorrhagic shock porcine model to establish urine oxygen partial pressure as an early indicator of acute kidney injury (AKI) and a novel resuscitative endpoint.

Up to 50% of patients with trauma develop acute kidney injury (AKI), in part due to poor renal perfusion after severe blood loss. AKI is currently ...

Bioengineering

Veno-Venous Extracorporeal Membrane Oxygenation in a Mouse

The use of extracorporeal membrane oxygenation (ECMO) has increased substantially in recent years. ECMO has become a reliable and effective therapy for acute as well as end-stage lung diseases. With the increase in clinical demand and prolonged use of ECMO, procedural optimization and prevention of multi-organ damage are of critical importance. The aim of this protocol is to present a detailed technique of veno-venous ECMO in a non-intubated, spontaneously breathing mouse. This protocol demonstrates the technical design of the ECMO and surgical steps. This murine ECMO model will facilitate the study of pathophysiology related to ECMO (e.g., inflammation,bleeding and thromboembolic events). Due to the abundance of genetically modified mice, the molecular mechanisms involved in ECMO-related complications can also be dissected.

Here we present a protocol describing the technique of veno-venous extracorporeal membrane oxygenation (ECMO) in a non-intubated, spontaneously breathing mouse. This murine model of ECMO can be effectively implemented in experimental studies of acute and end-stage lung diseases.

The use of extracorporeal membrane oxygenation (ECMO) has increased substantially in recent years. ECMO has become a reliable and effective therapy for ...

Effects of Extracorporeal Membrane Oxygenation on the Coagulation System

This study aimed to investigate the effects of long-term awake extracorporeal membrane oxygenation (ECMO) on the coagulation system in a sheep model. A total of ten healthy sheep were included in the study, with 5 sheep in each group. In the veno-arterial ECMO (V-A ECMO) group, cannulation was performed in the right carotid artery and the right external jugular vein. In the veno-venous ECMO (V-V ECMO) group, a dual-lumen catheter was utilized to insert into the right external jugular vein. After initiating ECMO, the sheep were recovered from anesthesia and remained awake for 7 days. The target activated clotting time (ACT) goal was set at 220-250 s. In both groups, the actual ACT fluctuated around 250 s with the dose of heparin gradually increasing, reaching almost 60 IU/kg/min at the end of the experiments. Moreover, the activated partial thromboplastin time (APTT) and thrombin time (TT) values were significantly higher in the V-A ECMO group compared to the V-V ECMO group, despite receiving the same doses of heparin. Although laboratory test results fluctuated within a normal and reasonable range, infarct foci in the kidneys were observed in both groups at the end of the study.

We present a protocol for establishing a long-term awake extracorporeal membrane oxygenation (ECMO) model in sheep. Special attention is given to the management and evaluation of the coagulation system during the ECMO model.

This study aimed to investigate the effects of long-term awake extracorporeal membrane oxygenation (ECMO) on the coagulation system in a sheep model. A ...

Real-Time Assessment of Spinal Cord Microperfusion in a Porcine Model of Ischemia/Reperfusion

Spinal cord injury is a devastating complication of aortic repair. Despite developments for the prevention and treatment of spinal cord injury, its incidence is still considerably high and therefore, influences patient outcome. Microcirculation plays a key role in tissue perfusion and oxygen supply and is often dissociated from macrohemodynamics. Thus, direct evaluation of spinal cord microcirculation is essential for the development of microcirculation-targeted therapies and the evaluation of existing approaches in regard to spinal cord microcirculation. However, most of the methods do not provide real-time assessment of spinal cord microcirculation. The aim of this study is to describe a standardized protocol for real-time spinal cord microcirculatory evaluation using laser-Doppler needle probes directly inserted in the spinal cord. We used a porcine model of ischemia/reperfusion to induce deterioration of the spinal cord microcirculation. In addition, a fluorescent microsphere injection technique was used. Initially, animals were anesthetized and mechanically ventilated. Thereafter, laser-Doppler needle probe insertion was performed, followed by the placement of cerebrospinal fluid drainage. A median sternotomy was performed for exposure of the descending aorta to perform aortic cross-clamping. Ischemia/reperfusion was induced by supra-celiac aortic cross-clamping for a total of 48 min, followed by reperfusion and hemodynamic stabilization. Laser-Doppler Flux was performed in parallel with macrohemodynamic evaluation. In addition, automated cerebrospinal fluid drainage was used to maintain a stable cerebrospinal pressure. After completion of the protocol, animals were sacrificed, and the spinal cord was harvested for histopathological and microsphere analysis. The protocol reveals the feasibility of spinal cord microperfusion measurements using laser-Doppler probes and shows a marked decrease during ischemia as well as recovery after reperfusion. Results showed comparable behavior to fluorescent microsphere evaluation. In conclusion, this new protocol might provide a useful large animal model for future studies using real-time spinal cord microperfusion assessment in ischemia/reperfusion conditions.

Spinal cord microcirculation plays a pivotal role in spinal cord injury. Most methods do not allow real-time assessment of spinal cord microcirculation, which is essential for the development of microcirculation-targeted therapies. Here, we propose a protocol using Laser-Doppler-Flow Needle probes in a large animal model of ischemia/reperfusion.

Spinal cord injury is a devastating complication of aortic repair. Despite developments for the prevention and treatment of spinal cord injury, its ...

Use of a Percutaneous Ventricular Assist Device/Left Atrium to Femoral Artery Bypass System for Cardiogenic Shock

The left atrial to femoral artery bypass (LAFAB) system is a mechanical circulatory support (MCS) device used in cardiogenic shock (CS) that bypasses the left ventricle by draining blood from the left atrium (LA) and returning it to the systemic arterial circulation via the femoral artery. It can provide flows ranging from 2.5-5 L/min depending on the size of the cannula. Here, we discuss the mechanism of action of LAFAB, available clinical data, indications for its use in cardiogenic shock, steps of implantation, post-procedural care, and complications associated with the use of this device and their management.
We also provide a brief video of the procedural component of device therapy, including the pre-placement preparation, percutaneous placement of the device via transseptal puncture under echocardiographic guidance and the post-operative management of device parameters.

The following article describes the stepwise procedure for placement of a device (e.g., Tandemheart) in cardiogenic shock (CS) that is a percutaneous left ventricular assist device (pLVAD) and a left atrial to femoral artery bypass (LAFAB) system that bypasses and supports the left ventricle (LV) in CS.

The left atrial to femoral artery bypass (LAFAB) system is a mechanical circulatory support (MCS) device used in cardiogenic shock (CS) that bypasses the ...

Insertion, Maintenance, and Removal of the Percutaneous Dual Lumen Cannula Right Ventricular Assist Device

Right ventricular (RV) shock, classically characterized by elevated central venous pressure (CVP) with&#160;normal to low pulmonary artery (PA) and pulmonary capillary wedge pressures (PCWP),&#160;remains a significant cause of morbidity and mortality worldwide if left untreated.&#160;Therapies for the treatment of RV shock range&#160;from medical management to durable or percutaneous mechanical circulatory support (MCS). A unique MCS device, a percutaneous right ventricular assist device (pRVAD), approved for use by the Food and Drug Administration (FDA) in 2014, works by temporarily off-loading the RV through a single, dual lumen catheter with extracorporeal mechanical support and is capable of shunting blood from the right atrium (RA) to the main PA. Although initially approved as venous-venous extracorporeal membrane oxygenation (VV-ECMO) device, this work will focus on the use of RV support, as ambulatory VV-ECMO strategies have been described previously. The catheter is most commonly inserted through the right internal jugular (IJ) vein into the PA and connected to an external pump, allowing flow up to 5 L/min. This device may be an attractive choice for the treatment of RV shock due to its percutaneous, minimally invasive insertion and removal and its ability to allow patient ambulation while the device is in place. This protocol discusses in detail the equipment, hemodynamic effects, indications, contraindications, complications, currently available research in the literature, and step-by-step instructions on how to implant, manage, and extract the device, along with the guidance on use and troubleshooting complications from one of the largest, single-center experiences with the device.

The present protocol provides a detailed description of a percutaneous dual lumen right ventricular assist device and illustrates step-by-step instructions on the safe implanting, managing, and removing the device. Guidance on its use and troubleshooting complications from one of the most significant single-center experiences is also included.

Right ventricular (RV) shock, classically characterized by elevated central venous pressure (CVP) with&#160;normal to low pulmonary artery (PA) and ...

Lung Rapid Recovery Procurement Combined with Abdominal Normothermic Regional Perfusion in Controlled Donation after Circulatory Death

Controlled donation after circulatory death (cDCD) has contributed to increasing donor numbers all over the world. Experiences published in the last years confirm that the outcomes after lung transplantation from cDCD are similar to those from brain death donors; however, the utilization of lungs from asystole donors remains low. Several reasons may be involved: different legal frameworks among countries and centers with different premortem interventions, inadequate lung donor care before procurement, or even poor experience with cDCD procedures and protocols.
Initially, the rapid recovery technique was commonly employed for the procurement of thoracic and abdominal organs in cDCD, but, in the last decade, abdominal normothermic regional perfusion (ANRP) with extracorporeal membrane oxygenation devices has become a useful method to restore blood flow to abdominal organs, allowing their quality improvement and their functional assessment prior to transplantation. This makes the donation procedure more complex and generates doubts about injury to the grafts due to dual temperature.
The aim of this article is to describe a protocol based on a single center experience with Maastricht III donors combining lung cooling rapid recovery in the thorax and abdominal normothermic regional perfusion. Tips and tricks focused on premortem interventions and lung procurement procedure techniques are explained. This may help to minimize the reluctance among professionals to use this combined technique and encourage other donor centers to use it, despite the increased complexity of the procedure.

The protocol combines a lung cooling rapid recovery technique with abdominal normothermic regional perfusion for abdominal graft procurement in controlled asystole donors, which is a safe and useful method to expand the donor pool.

Controlled donation after circulatory death (cDCD) has contributed to increasing donor numbers all over the world. Experiences published in the last years ...

Continuous Venous-Arterial Doppler Ultrasound During a Preload Challenge

A preload challenge (PC) is a clinical maneuver that, first, increases the cardiac filling (i.e., preload) and, second, calculates the change in cardiac output. Fundamentally, a PC is a bedside approach for testing the Frank-Starling-Sarnoff (i.e., "cardiac function") curve. Normally, this curve has a steep slope such that a small change in the cardiac preload generates a large change in the stroke volume (SV) or cardiac output. However, in various disease states, the slope of this relationship flattens such that increasing the volume into the heart leads to little rise in the SV. In this pathological scenario, additional cardiac preload (e.g., intravenous fluid) is unlikely to be physiologically effective and could lead to harm if organ congestion evolves. Therefore, inferring both the cardiac preload and output is clinically useful as it may guide intravenous (IV) fluid resuscitation. Accordingly, the goal of this protocol is to describe a method for contemporaneously tracking the surrogates of cardiac preload and output using a novel, wireless, wearable ultrasound during a well-validated preload challenge.

The Frank-Starling-Sarnoff curve is clinically important and describes the relationship between cardiac preload and output. This report illustrates a novel method of simultaneous jugular venous and carotid arterial Doppler velocimetry as transient surrogates of cardiac preload and output, respectively; this approach is enabled by wireless, wearable Doppler ultrasound.

A preload challenge (PC) is a clinical maneuver that, first, increases the cardiac filling (i.e., preload) and, second, calculates the change in cardiac ...

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 ...

A Modified Sonographic Algorithm for Image Acquisition in Life-Threatening Emergencies in the Critically Ill Newborn

The use of routine point-of-care ultrasound (POCUS) is increasing in neonatal intensive care units (NICUs), with several centers advocating for 24 h equipment availability. In 2018, the sonographic algorithm for life-threatening emergencies (SAFE) protocol was published, which allows the assessment of neonates with sudden decompensation to identify abnormal contractility, tamponade, pneumothorax, and pleural effusion. In the study unit (with a consulting neonatal hemodynamics and POCUS service), the algorithm was adapted by including consolidated core steps to support at-risk newborns, aiding clinicians in managing cardiac arrest, and adding views to verify correct intubation. This paper presents a protocol that can be applied in the NICU and the delivery room (DR) in relation to three scenarios: cardiac arrest, hemodynamic deterioration, or respiratory decompensation. 
This protocol can be performed with a state-of-the-art ultrasound machine or an affordable handheld device; the image acquisition protocol is carefully detailed. This method was designed to be learned as a general competence to obtain the timely diagnosis of life-threatening scenarios; the method aims to save time but does not represent a substitute for comprehensive and standardized hemodynamic and radiological analyses by a multidisciplinary team, which might not universally be on call but needs to be involved in the process. From January 2019 to July 2022, in our center, 1,045 hemodynamic consultation/POCUS consults were performed with 25 patients requiring the modified SAFE protocol (2.3%), and a total of 19 procedures were performed. In five cases, trained fellows on call resolved life-threatening situations. Clinical examples are provided that show the importance of including this technique in the care of critical newborns.

Here, we present a protocol that can be applied in the neonatal intensive care unit and the delivery room in relation to three scenarios: cardiac arrest, hemodynamic deterioration, or respiratory decompensation. This protocol can be performed with a state-of-the-art ultrasound machine or an affordable handheld device; an image acquisition protocol is carefully detailed.

The use of routine point-of-care ultrasound (POCUS) is increasing in neonatal intensive care units (NICUs), with several centers advocating for 24 h ...

Point-of-Care Ultrasound for Peripheral Veno-Arterial Extracorporeal Membrane Oxygenation Without Left Ventricular Venting

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