We would like to thank the University of Michigan Department of Anesthesia, Max Harry Weil Institute for Critical Care Research and Innovation, and Katelyn Murphy for their administrative and graphic design support.

This material is the authors&#39; original work, which has not been previously published elsewhere. The protocol described is for clinical use and not research purposes. De-identified images were obtained from a volunteer model in a non-clinical environment. The authors did not seek a formal &#34;Not Regulated&#34; determination from the IRB in accordance with institutional policy, as the activity falls outside of the Common Rule and FDA definitions of human subject research.
1. The transducer
<ol>
	<li>Use the phased array transducer. This is a 4-12 MHz transducer that penetrates deep into the thoracic space, due to its low frequency compared to other ultrasound transducers.
	<ol>
		<li>Select the phased array transducer using the Exam button on the machine and selecting the cardiac exam or equivalent available exam.</li>
	</ol>
	</li>
	<li>Practice with transducers from various vendors to gain experience and refine one&#39;s cognitive skill set for transducer manipulation.</li>
	<li>Practice transducer manipulation with both hands to develop ambidexterity, which may be required when working in limited clinical environments.</li>
	<li>Anchor the dominant hand while holding the ultrasound transducer on the patient, with the fat pad of the medial aspect of the hand. 
	&#8203;NOTE: This provides additional stability and reduces error caused by large movements. Holding the transducer by the base, without anchoring, results in unintended movements, preventing the ability to maintain the image axis and orientation.</li>
	<li>Use two hands for transducer manipulation to improve the ultra-fine adjustments often required for optimal views. Place the dominant hand on the base of the transducer with the non-dominant hand on the tail of the transducer, providing additional stability and guided movement.</li>
</ol>
2. Patient positioning
<ol>
	<li>Obtain the PLAX, PSAX, A4C, SC4C, and IVC views in the supine position.</li>
	<li>Instruct the patient to extend their left arm above their head and lie on their left side, and obtain images in this position if they are unable to be obtained in the supine position. 
	NOTE: This results in expansion of the intercostal spaces for larger imaging windows.
	<ol>
		<li>Place a wedge or blanket roll behind the patient&#39;s right upper torso if the patient cannot easily rotate to 45&#176;, or reposition their limbs. Postoperative and intensive care unit patients often need support to maintain appropriate positioning for FoCUS examination.</li>
	</ol>
	</li>
	<li>Drape the breast as desired by the patient, and make sure that the patient is aware of where the transducer will be placed before beginning the exam.</li>
	<li>Manipulate the breast tissue to allow for optimal image acquisition.
	<ol>
		<li>If able, instruct the patient to assist moving the breast tissue with their right hand.</li>
	</ol>
	</li>
	<li>Discuss the appropriateness of removal or relocation of monitors beforehand with bedside nurses and other relevant providers.</li>
	<li>Do not alter or remove tubes, lines, or drains for imaging purposes. Discuss the duration of the devices with the relevant providers and consider reimaging the patient following their removal.</li>
</ol>
3. Transducer manipulation
<ol>
	<li>Appreciate and understand the definitions of transducer movements to allow for optimal image acquisition, and provide consistent terminology for communication between providers, especially during teaching (Figure 1 and Table 1).</li>
</ol>
4. 2-D image optimization
<ol>
	<li>Adjust the depth (approximately 12-16 cm, depending on view) to see the structure of interest.</li>
	<li>Adjust the gain to optimize the brightness of the image.</li>
	<li>Adjust the focus to the depth of the structure of interest in order to improve resolution.</li>
</ol>
5. Motion mode (M-mode)
<ol>
	<li>Use M-mode to display a single scan line (wherever the cursor is placed) of the B-mode image (Y-axis) against time (X-axis). 
	NOTE: This mode can help operators understand the dynamic relationship of different structures over time and is useful in many different assessments, including IVC size and variability and E-point septal separation (EPSS).</li>
	<li>Use the button with the letter &#34;M&#34; on it to turn on M-mode. 
	&#8203;NOTE: M-mode will be an on/off button unique to each machine.</li>
</ol>
6. Parasternal long axis (PLAX)
NOTE: The PLAX refers to obtaining an image that is along the long axis of the heart (Figure 2).
<ol>
	<li>Place the patient in the supine position. If there is difficulty obtaining the PLAX image, place the patient on their left side and extend their arm above their head, if possible.</li>
	<li>Place the transducer at an oblique angle between the third and fifth intercostal space of the left parasternal region, with the transducer marker pointing to the patient&#39;s right shoulder.
	<ol>
		<li>Visualize the right ventricle, left ventricle, left atrium, mitral valve, left ventricular outflow tract, aortic valve, and descending thoracic aorta in this image.</li>
		<li>Visualize the mitral valve and aortic valve opening and closing together, to ensure that the image is not foreshortened. Foreshortening is where the ultrasound plane does not cut through the true apex of the structure, changing the perceived image.</li>
	</ol>
	</li>
	<li>2-D image optimization
	<ol>
		<li>Start with an initial depth of approximately 15-20 cm. Adjust the depth so that the tip of the mitral valve is in the center of the image, and the descending thoracic aorta (deep to the left atrium) is visible.</li>
		<li>Adjust the gain to maximize the visibility of the myocardium and mitral valve.</li>
		<li>Move the focus to the region of interest, most focused at the depth of the mitral valve.</li>
		<li>Use M-mode for EPSS or fractional shortening.</li>
	</ol>
	</li>
</ol>
7. Parasternal short axis (PSAX; Figure 3)
<ol>
	<li>Place the patient in the same positioning for the PSAX as used for the PLAX.</li>
	<li>Place the transducer approximately 90&#176; relative to the transducer in the PLAX.
	<ol>
		<li>Obtain an optimal PLAX and rotate the transducer slowly in a clockwise fashion without lifting the transducer from the patient&#39;s chest, until the transducer is obliquely angled across the third to fifth intercostal space of the parasternal region, with the transducer marker pointing to the patient&#39;s left shoulder. 
		NOTE: Over-rotation beyond 90&#176; can lead to interventricular septal flattening, and falsely appear as right ventricular volume or pressure overload.</li>
		<li>Tilt the transducer until the mid-papillary muscles are visualized for the FoCUS assessment. 
		NOTE: The papillary muscles should move in synchrony with the left ventricle wall. If the papillary muscles appear to be bouncing or fluttering independent of the left ventricular wall, it may signify that the image is capturing the mitral valve leaflet as a result of being off axis.</li>
		<li>Tilt the transducer toward the base of the heart, to visualize the bi-leaflet mitral valve initially followed by the tri-leaflet aortic valve.</li>
	</ol>
	</li>
	<li>2-D image optimization
	<ol>
		<li>Start with a deeper image (approximately 16 cm) to identify any pleural effusion.</li>
		<li>Adjust the depth to include the full depth of the left ventricle and a few centimeters beyond, to ensure that a pericardial effusion would be fully visualized.</li>
		<li>Adjust the gain to maximize visualization of the septum and papillary muscles.</li>
		<li>Adjust the focus to the papillary muscles.</li>
	</ol>
	</li>
</ol>
8. Apical four chamber view (A4C; Figure 4)
NOTE: Images in patients with chronic obstructive pulmonary disease (COPD), and otherwise inflamed thoracic cavities, are obtained more medially, and images in patients with left ventricular hypertrophy (LVH) or heart failure with reduced ejection fraction (HFrEF) have their view more lateral.
<ol>
	<li>Position the patient with their left arm extended above their head and lying on their left side. If there is significant artifact present, have the patient exhale and hold their breath to minimize pulmonary artifact.</li>
	<li>Position the transducer in the fourth through sixth intercostal space along the left anterior axillary line (inferolateral to the left pectoral muscle), with the transducer marker pointed toward the left axilla. Move the transducer lateral, medial, or caudal, as needed to obtain an optimal A4C view.
	<ol>
		<li>Lift the breast tissue and push superior along the inframammary fold as needed.</li>
		<li>If the left ventricular apex is not fully visualized, move the transducer lateral while orienting the transducer toward the right shoulder.</li>
		<li>Position the marker on the phased array transducer between the two and three o&#39;clock positions. In the normal heart, the apex of the left ventricle is at the top and center of the sector, the right ventricle is triangular and smaller, and the myocardium should be uniform from the apex to the atrioventricular valves. If this is not the case, the image may be foreshortened, and should be optimized and acquired from a lower intercostal space.</li>
		<li>Tilt the transducer cephalad approximately 60&#176;, so that the A4C view can capture an A4C cardiac image that includes both atria, ventricles, the interventricular septum, and the lateral portions of the tricuspid and mitral annuli. The aortic valve and left ventricular outflow tract should not be present in an A4C view, and are only present in an apical five chamber view.</li>
		<li>Visualize the mitral valve, the tricuspid valves, and the interventricular septum on the A4C image. If both valves and the interventricular septum are not visualized, the image should be further optimized.</li>
		<li>Slide the transducer up or down a rib space and tilt the base of the transducer down (cranially) to improve the image of the valves. If the base of the transducer is tilted too far down (cranially), an apical five chamber view, including the aortic valve, will appear, and the transducer should be tilted back up (caudally) to optimize the A4C view. If the base of the transducer is tilted too far up (caudally), the coronary sinus will appear, and the transducer should be tilted back down (cranially).</li>
		<li>Rotate the base of the transducer toward the patient&#39;s midline to optimize the interventricular septum position, which should be present vertical in the center of the image. Minimal rotation should be required. If over-rotated, a two chamber view will be observed.</li>
	</ol>
	</li>
	<li>2-D image optimization
	<ol>
		<li>Increase the depth to include both atria at the image&#39;s deepest point, in addition to accommodating the left and right ventricular free walls (approximately an initial depth of 20 cm).</li>
		<li>Adjust the gain to maximize visibility, often resulting in increased echogenicity, of the myocardium, the mitral valvular annulus, and the tricuspid valvular annulus.</li>
		<li>Adjust the focus to the depth of the valvular annuli (the tricuspid annulus is most commonly used). This depth will also be appropriate when transitioning to an apical five view, if desired.</li>
	</ol>
	</li>
</ol>
9. Subcostal four chamber view (SC4C; Figure 5)
<ol>
	<li>Position the patient supine for the subcostal four chamber view. Flex the patient&#39;s knees, and support them to maintain the flexed position, to reduce the abdominal muscle tone for easier transducer compression.</li>
	<li>Place the transducer nearly flat on the patient&#39;s subxiphoid abdomen, with the operator hand on top of the transducer providing cephalad pressure. Find the liver, and then drop the transducer to a shallower angle (often less than 30&#176;) against the subxiphoid portion of the patient&#39;s abdomen in a cephalad fashion, with the transducer marker to the patient&#39;s left side, approximately pointing to three o&#39;clock. Include the liver in the image so that it can be utilized as an acoustic window to obtain this image.
	<ol>
		<li>Hold the lateral aspects of the transducer with the fingers, not underneath the transducer, to flatten the transducer appropriately. Use the index finger to provide downward pressure.</li>
	</ol>
	</li>
	<li>2-D image optimization
	<ol>
		<li>Start with an initial depth of 18-24 cm. Adjust the depth to include the liver as a sonographic window for the ultrasound. The optimal depth varies from patient to patient based on patient body habitus and liver size.</li>
		<li>Decrease the gain, as the liver often provides a good medium to transmit sound waves.</li>
		<li>Increase the focal points to focus on the cardiac structures of interest below the liver.</li>
		<li>Instruct non-intubated patients to perform an inspiratory hold, as this often increases the quality of the image.</li>
	</ol>
	</li>
</ol>
10. Inferior vena cava (IVC; Figure 6)
<ol>
	<li>Position the patient supine for the IVC view.</li>
	<li>Begin with the subcostal view, then rotate the transducer counterclockwise until confluence of the right atrium and IVC is appreciated, and the transducer is placed longitudinally in the upper abdomen, to the right of the patient&#39;s midline. Optimize the image by tilting the transducer until the IVC is fully visualized, and then by rocking the transducer cephalad until the confluence of the IVC and the right atrium is fully visualized. Adjust the transducer (most frequently with minimal rotation) until the IVC is visualized across the entire screen.
	<ol>
		<li>Visualize the right atrium, IVC, liver, and hepatic vein in an optimal view.</li>
		<li>Do not confuse the IVC with the aorta. The aorta is left lateral of the IVC and will not touch the liver. The IVC will always touch the liver, and is often surrounded by liver on both sides.
		<ol>
			<li>Appreciate that hepatic veins can often be seen coming into the IVC, providing another way to prove that the structure being imaged is the IVC.</li>
			<li>Use pulse wave velocity to visualize the venous (vs. arterial) waveform, and confirm the vessel being imaged is the IVC and not the aorta.</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>Measure IVC diameters at midline and mid-expiration. Do not measure the diameter of the IVC to the side which could underestimate the diameter of the IVC.</li>
	<li>2-D image optimization
	<ol>
		<li>Minimize the depth to only include the IVC. Do not include the spine in the image.</li>
		<li>Adjust the gain to be the same as for the subcostal view.</li>
		<li>Adjust the focus to the depth of the IVC.</li>
		<li>Place the cursor 1-3 cm from the confluence of the IVC and the right atrium, and apply M-mode to evaluate respiratory variation of the IVC.</li>
	</ol>
	</li>
</ol>

<ol>
	<li>Birch, M. S., Marin, J. R., Liu, R. B., Hall, J., Hall, 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=Trends+in+diagnostic+point-of-care+ultrasonography+reimbursement+for+medicare+beneficiaries+among+the+US+emergency+medicine+workforce,+2012+to+2016.">Trends in diagnostic point-of-care ultrasonography reimbursement for medicare beneficiaries among the US emergency medicine workforce, 2012 to 2016.</a> Annals of Emergency Medicine. 76 (5), 609-614 (2020).</li><li>Moore, C. L., Copel, J. A. <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+ultrasonography.">Point-of-care ultrasonography.</a> The New England Journal of Medicine. 364 (8), 749-757 (2011).</li><li>Su, E., Dalesio, N., Pustavoitau, A. <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+in+pediatric+anesthesiology+and+critical+care+medicine.">Point-of-care ultrasound in pediatric anesthesiology and critical care medicine.</a> Canadian Journal of Anaesthesiology. 65 (4), 485-498 (2008).</li><li>Niblock, F., Byun, H., Jabbarpour, Y. <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+use+by+primary+care+physicians.">Point-of-care ultrasound use by primary care physicians.</a> The Journal of the American Board of Family Medicine. 34 (4), 859-860 (2021).</li><li>Coritsidis, G. 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=Point-of-care+ultrasound+for+assessing+arteriovenous+fistula+maturity+in+outpatient+hemodialysis.">Point-of-care ultrasound for assessing arteriovenous fistula maturity in outpatient hemodialysis.</a> The Journal of Vascular Access. 21 (6), 923-930 (2020).</li><li>Gundersen, G. H., 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=Adding+point+of+care+ultrasound+to+assess+volume+status+in+heart+failure+patients+in+a+nurse-led+outpatient+clinic.+A+randomised+study.">Adding point of care ultrasound to assess volume status in heart failure patients in a nurse-led outpatient clinic. A randomised study.</a> Heart. 102 (1), 29-34 (2016).</li><li>Kirkpatrick, J. 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=Recommendations+for+echocardiography+laboratories+participating+in+cardiac+point+of+care+cardiac+ultrasound+(POCUS)+and+critical+care+echocardiography+training:+report+from+the+American+Society+of+Echocardiography.">Recommendations for echocardiography laboratories participating in cardiac point of care cardiac ultrasound (POCUS) and critical care echocardiography training: report from the American Society of Echocardiography.</a> Journal of the American Society of Echocardiography. 33 (4), 409-422 (2020).</li><li>Annals of Emergency Medicine. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasound+Guidelines:+Emergency,+point-of-care+and+clinical+ultrasound+guidelines+in+medicine.">Ultrasound Guidelines: Emergency, point-of-care and clinical ultrasound guidelines in medicine.</a> Annals of Emergency Medicine. 69 (5), 27-54 (2017).</li><li>Levitov, 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=Guidelines+for+the+appropriate+use+of+bedside+general+and+cardiac+ultrasonography+in+the+evaluation+of+critically+ill+patients-part+II:+cardiac+ultrasonography.">Guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients-part II: cardiac ultrasonography.</a> Critical Care Medicine. 44 (6), 1206-1227 (2016).</li><li>Neskovic, A. 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=Focus+cardiac+ultrasound+core+curriculum+and+core+syllabus+of+the+European+Association+of+Cardiovascular+Imaging.">Focus cardiac ultrasound core curriculum and core syllabus of the European Association of Cardiovascular Imaging.</a> European Heart Journal. Cardiovascular Imaging. 19 (5), 475-481 (2018).</li><li>Mitchell, 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=Guidelines+for+Performing+a+Comprehensive+Transthoracic+Echocardiographic+Examination+in+Adults:+Recommendations+from+the+American+Society+of+Echocardiography.">Guidelines for Performing a Comprehensive Transthoracic Echocardiographic Examination in Adults: Recommendations from the American Society of Echocardiography.</a> Journal of the American Society of Echocardiography. 32 (1), 1-64 (2019).</li><li>Dinh, V. 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=Measuring+cardiac+index+with+a+focused+cardiac+ultrasound+examination+in+the+ED.">Measuring cardiac index with a focused cardiac ultrasound examination in the ED.</a> The American Journal of Emergency Medicine. 30 (9), 1845-1851 (2012).</li><li>Expert Round Table on Echocardiography in ICU. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=International+consensus+statement+on+training+standards+for+advanced+critical+care+echocardiography.">International consensus statement on training standards for advanced critical care echocardiography.</a> Intensive Care Medicine. 40 (5), 654-666 (2014).</li><li>Expert Round Table on Echocardiography in ICU. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=International+expert+statement+on+training+standards+for+critical+care+ultrasonography.">International expert statement on training standards for critical care ultrasonography.</a> Intensive Care Medicine. 37 (7), 1077-1083 (2011).</li><li>Spencer, K. T., 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=Focused+cardiac+ultrasound:+recommendations+from+the+American+Society+of+Echocardiography.">Focused cardiac ultrasound: recommendations from the American Society of Echocardiography.</a> Journal of the American Society of Echocardiography. 26 (6), 567-581 (2013).</li><li>Nelson, B. P., Sanghvi, A. <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+cardiac+ultrasound:+feasibility+of+performance+by+noncardiologists.">Point-of-care cardiac ultrasound: feasibility of performance by noncardiologists.</a> Global Heart. 8 (4), 293-297 (2013).</li></ol>

The authors whose names are listed immediately below certify that they have NO affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers' bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge, or beliefs) in the subject matter or materials discussed in this manuscript.

The aim of this publication is to provide practical recommendations and best practices to achieve optimal FoCUS images in challenging clinical environments. Formal ultrasound seminars, clinical experience, and observations of learners during hands-on teaching have given insight into pitfalls and less optimal tendencies. As a result, many factors that influence the stereotactic and psychomotor skills have become apparent. Although this material is described in relation to FoCUS exams, many of the principles can be applied...

Focused cardiac ultrasound (FoCUS) is a limited, clinician-performed application of echocardiography that provides immediate anatomic, physiologic, and functional information to patient care. These exams, consisting of five classic views, are problem oriented, performed in real time at the bedside, and do not replace comprehensive echocardiography exams1,2. Given the focused nature of these exams, they are often repeatedly performed when clinical status changes or serial monitoring is required. It is important to have standardized training and obtain adequate images of all five views, when possible, as some views may provide limited information depending on the individual patient and pathology.
The use of FoCUS is rapidly expanding. Many clinical landscapes, such as perioperative anesthesiology, critical care and emergency medicine1,2,3, now routinely employ FoCUS. Inpatient medical wards and outpatient clinical care settings are also adopting this tool to enhance clinical practice4,5,6. As a result, several societal bodies, such as the American Society of Echocardiography, the Society of Critical Care Medicine, and the American College of Emergency Physicians, have published guidelines and recommendations for FoCUS competency and scope of practice7,8,9. While these guidelines and recommendations are not codified, much of the content is consistent and influences FoCUS training curricula10.
Beyond didactics and image interpretation, competency in FoCUS includes mastery of stereotactic and psychomotor skill sets. Stereotactic skill refers to the accurate positioning of ultrasound transducers on the body, based on three-dimensional anatomic features. Psychomotor skill describes the relationship between cognitive function and physical movement that influences coordination, dexterity, and manipulation. Expanding knowledge and awareness about these skills supports FoCUS trainee development.
This article presents concepts for high-quality image acquisition in FoCUS, with both pragmatic considerations and attention to stereotactic and psychomotor skill sets. Specifically, it discusses optimal patient positioning, transducer manipulation, and suggests tips to optimize phased array transducer use. Finally, it examines image optimization for 2-dimensional (B-mode or 2-D mode) and motion modes (M-mode).

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Aquasonic ultrasound gel</td>
			<td>Parker</td>
			<td>30592052</td>
			<td>https://dr.graphiccontrols.com/en/catalog/ultrasound-gel/parker-laboratories-01-50-aquasonic-100-gel-5l-1332e66e/</td>
		</tr>
		<tr>
			<td>Philips Sparq ultrasound machine</td>
			<td>Phillips</td>
			<td></td>
			<td>https://www.usa.philips.com/healthcare/product/HC795090CC/sparq-ultrasound-system#documents</td>
		</tr>
	</tbody>
</table>

troubleshooting focus image acquisition: patient positioning, transducer manipulation, and image optimization

Focused cardiac ultrasound (FoCUS) is a limited, clinician-performed application of echocardiography to add real-time information to patient care. These bedside exams are problem oriented, rapidly and repeatedly performed, and largely qualitative in nature. Competency in FoCUS includes mastery of the stereotactic and psychomotor skills required for transducer manipulation and image acquisition. Competency also requires the ability to optimize the setup, troubleshoot image acquisition, and understand the sonographic limitations because of complex clinical environments and patient pathology. This article presents concepts for successful, high-quality two-dimensional (B-mode) image acquisition in FoCUS.
Concepts of high-quality image acquisition can be applied to all established sonographic windows of the FoCUS exam: the parasternal long-axis (PLAX), parasternal short-axis (PSAX), apical four chamber (A4C), subcostal fourchamber (SC4C), and the inferior vena cava (IVC). The apical five-chamber (A5C) and subcostal short-axis (SCSA) views are mentioned, but are not discussed in-depth. A pragmatic figure illustrating the movements of the phased array transducer is also provided to serve as a cognitive aid during FoCUS image acquisition.

Representative images obtained from the focused cardiac ultrasound protocol presented above are presented in Figure 2, Figure 3, Figure 4, Figure 5, and Figure 6, demonstrating the feasibility of the technique described. These images were captured with the phased array 5-1 MHz transducer. The parasternal long axis (PLAX) image obtained from protocol se...

Watch this Scientific Journal Video about Troubleshooting FoCUS Image Acquisition: Patient Positioning, Transducer Manipulation, and Image Optimization at JoVE.com

Troubleshooting FoCUS Image Acquisition: Patient Positioning, Transducer Manipulation, and Image Optimization

Here, we present a protocol to allow providers to perform focused cardiac ultrasound (FoCUS) in the clinical environment. We describe methods of transducer manipulation, review common pitfalls of transducer movements, and suggest tips to optimize phased array transducer use.

Focused cardiac ultrasound (FoCUS) is a limited, clinician-performed application of echocardiography to add real-time information to patient care. These ...

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1.3K Views.  University of Michigan, Ann Arbor. Here, we present a protocol to allow providers to perform focused cardiac ultrasound (FoCUS) in the clinical environment. We describe methods of transducer manipulation, review common pitfalls of transducer movements, and suggest tips to optimize phased array transducer use. 

Video: Troubleshooting FoCUS Image Acquisition: Patient Positioning, Transducer Manipulation, and Image Optimization

Shrinkage of Dental Composite in Simulated Cavity Measured with Digital Image Correlation

Polymerization shrinkage of dental resin composites can lead to restoration debonding or cracked tooth tissues in composite-restored teeth. In order to understand where and how shrinkage strain and stress develop in such restored teeth, Digital Image Correlation (DIC) was used to provide a comprehensive view of the displacement and strain distributions within model restorations that had undergone polymerization shrinkage.
Specimens with model cavities were made of cylindrical glass rods with both diameter and length being 10 mm. The dimensions of the mesial-occlusal-distal (MOD) cavity prepared in each specimen measured 3 mm and 2 mm in width and depth, respectively. After filling the cavity with resin composite, the surface under observation was sprayed with first a thin layer of white paint and then fine black charcoal powder to create high-contrast speckles. Pictures of that surface were then taken before curing and 5 min after. Finally, the two pictures were correlated using DIC software to calculate the displacement and strain distributions.
The resin composite shrunk vertically towards the bottom of the cavity, with the top center portion of the restoration having the largest downward displacement. At the same time, it shrunk horizontally towards its vertical midline. Shrinkage of the composite stretched the material in the vicinity of the &#8220;tooth-restoration&#8221; interface, resulting in cuspal deflections and high tensile strains around the restoration. Material close to the cavity walls or floor had direct strains mostly in the directions perpendicular to the interfaces. Summation of the two direct strain components showed a relatively uniform distribution around the restoration and its magnitude equaled approximately to the volumetric shrinkage strain of the material.

In order to understand the spatial development of polymerization shrinkage stress in dental resin-composite restorations, Digital Image Correlation was used to provide full-field displacement/strain measurement of restored model glass cavities by correlating images of the restoration taken before and after polymerization.

Polymerization shrinkage of dental resin composites can lead to restoration debonding or cracked tooth tissues in composite-restored teeth. In order to ...

A Pipeline for 3D Multimodality Image Integration and Computer-assisted Planning in Epilepsy Surgery

Epilepsy surgery is challenging and the use of 3D multimodality image integration (3DMMI) to aid presurgical planning is well-established. Multimodality image integration can be technically demanding, and is underutilised in clinical practice. We have developed a single software platform for image integration, 3D visualization and surgical planning. Here, our pipeline is described in step-by-step fashion, starting with image acquisition, proceeding through image co-registration, manual segmentation, brain and vessel extraction, 3D visualization and manual planning of stereoEEG (SEEG) implantations. With dissemination of the software this pipeline can be reproduced in other centres, allowing other groups to benefit from 3DMMI. We also describe the use of an automated, multi-trajectory planner to generate stereoEEG implantation plans. Preliminary studies suggest this is a rapid, safe and efficacious adjunct for planning SEEG implantations. Finally, a simple solution for the export of plans and models to commercial neuronavigation systems for implementation of plans in the operating theater is described. This software is a valuable tool that can support clinical decision making throughout the epilepsy surgery pathway.

We describe the steps to use our custom designed software for image integration, visualization and planning in epilepsy surgery.

Epilepsy surgery is challenging and the use of 3D multimodality image integration (3DMMI) to aid presurgical planning is well-established. Multimodality ...

Visualization of Vascular and Parenchymal Regeneration after 70% Partial Hepatectomy in Normal Mice

A modified silicone injection procedure was used for visualization of the hepatic vascular tree. This procedure consisted of in-vivo injection of the silicone compound, via a 26 G catheter, into the portal or hepatic vein. After silicone injection, organs were explanted and prepared for ex-vivo micro-CT (&#181;CT) scanning. The silicone injection procedure is technically challenging. Achieving a successful outcome requires extensive microsurgical experience from the surgeon. One of the challenges of this procedure involves determining the adequate perfusion rate for the silicone compound. The perfusion rate for the silicone compound needs to be defined based on the hemodynamic of the vascular system of interest. Inappropriate perfusion rate can lead to an incomplete perfusion, artificial dilation and rupturing of vascular trees.
The 3D reconstruction of the vascular system was based on CT scans and was achieved using preclinical software such as HepaVision. The quality of the reconstructed vascular tree was directly related to the quality of silicone perfusion. Subsequently computed vascular parameters indicative of vascular growth, such as total vascular volume, were calculated based on the vascular reconstructions. Contrasting the vascular tree with silicone allowed for subsequent histological work-up of the specimen after &#181;CT scanning. The specimen can be subjected to serial sectioning, histological analysis and whole slide scanning, and thereafter to 3D reconstruction of the vascular trees based on histological images. This is the prerequisite for the detection of molecular events and their distribution with respect to the vascular tree. This modified silicone injection procedure can also be used to visualize and reconstruct the vascular systems of other organs. This technique has the potential to be extensively applied to studies concerning vascular anatomy and growth in various animal and disease models.

Tools used for visualizing vascular regeneration require methods for contrasting the vascular trees. This film demonstrated a delicate injection technique used to achieve optimal contrasting of the vascular trees and illustrate the potential benefits resulting from a detailed analysis of the resulting specimen using &#181;CT and histological serial sections.

A modified silicone injection procedure was used for visualization of the hepatic vascular tree. This procedure consisted of in-vivo injection of the ...

Image-Guided Resection of Glioblastoma and Intracranial Implantation of Therapeutic Stem Cell-seeded Scaffolds

Glioblastoma (GBM), the most common and aggressive primary brain cancer, carries a life expectancy of 12-15 months. The short life expectancy is due in part to the inability of the current treatment, consisting of surgical resection followed by radiation and chemotherapy, to eliminate invasive tumor foci. Treatment of these foci may be improved with tumoricidal human mesenchymal stem cells (MSCs). MSCs exhibit potent tumor tropism and can be engineered to express therapeutic proteins that kill tumor cells. Advancements in preclinical models indicate that surgical resection induces premature MSC loss and reduces therapeutic efficacy. Efficacy of MSC treatment can be improved by seeding MSCs on a biodegradable poly(lactic acid) (PLA) scaffold. MSC delivery into the surgical resection cavity on a PLA scaffold restores cell retention, persistence, and tumor killing. To study the effects of MSC-seeded PLA implantation on GBM, an accurate preclinical model is needed. Here we provide a preclinical surgical protocol for image-guided tumor resection of GBM in immune-deficient mice followed by MSC-seeded scaffold implantation. MSCs are engineered with lentiviral constructs to constitutively express and secrete therapeutic TNF&#945;-related apoptosis-inducing ligand (TRAIL) as well as green fluorescent protein (GFP) to allow fluorescent tracking. Similarly, the U87 tumor cells are engineered to express mCherry and firefly luciferase, providing dual fluorescent/luminescent tracking. While currently used for investigating stem cell mediated delivery of therapeutics, this protocol could be modified to investigate the impact of surgical resection on other GBM interventions.

Tumor-seeking therapeutic mesenchymal stem cells (MSCs) show promise as a treatment for invasive glioblastoma. Optimal transplantation involves delivery of MSCs into the tumor resection cavity on scaffolds. Here, preclinical techniques to study MSC treatment of glioblastoma are provided including: image-guided tumor resection; implantation of MSC-seeded scaffolds; and postoperative therapy tracking.

Glioblastoma (GBM), the most common and aggressive primary brain cancer, carries a life expectancy of 12-15 months. The short life expectancy is due in ...

A Whole Body Dosimetry Protocol for Peptide-Receptor Radionuclide Therapy (PRRT): 2D Planar Image and Hybrid 2D+3D SPECT/CT Image Methods

Peptide-receptor-radionuclide-therapy (PPRT) is a targeted therapy that combines a short-range energy radionuclide with a substrate with high specificity for cancer cell receptors. After injection, the radiotracer is distributed throughout the entire body, with a higher uptake in tissues where targeted receptors are overexpressed. The use of beta/gamma radionuclide emitters enables therapy imaging (beta-emission) and post-therapy imaging (gamma-emission) to be performed at the same time. Post-treatment sequential images permit absorbed dose calculation based on local uptake and wash-in/wash-out kinetics. We implemented a hybrid method that combines information derived from both 2D and 3D images. Serial whole-body images and blood samples are acquired to estimate the absorbed dose to different organs at risk and to lesions disseminated throughout the body. A single 3D-SPECT/CT image, limited to the abdominal region, overcomes projection overlap on planar images of different structures such as the intestines and kidneys. The hybrid 2D+3D-SPECT/CT method combines the effective half-life information derived from 2D planar images with the local uptake distribution derived from 3D images. We implemented this methodology to estimate the absorbed dose for patients undergoing PRRT with 177Lu-PSMA-617. The methodology could, however, be implemented with other beta-gamma radiotracers. To date, 10 patients have been enrolled into the dosimetry study with 177Lu-PSMA-617 combined with drug protectors for kidneys and salivary glands (mannitol and glutamate tablets, respectively). The median ratio between kidney uptake at 24 h evaluated on planar images and 3D-SPECT/CT is 0.45 (range:0.32-1.23). The comparison between hybrid and full 3D approach has been tested on one patient, resulting in a 1.6% underestimation with respect to full 3D (2D: 0.829 mGy/MBq, hybrid: 0.315 mGy/MBq, 3D: 0.320 mGy/MBq). Treatment safety has been confirmed, with a mean absorbed dose of 0.73 mGy/MBq (range:0.26-1.07) for kidneys, 0.56 mGy/MBq (0.33-2.63) for the parotid glands and 0.63 mGy/MBq (0.23-1.20) for submandibular glands, values in accordance with previously published data.

A Whole Body Dosimetry Protocol for Peptide-Receptor Radionuclide Therapy PRRT: 2D Planar Image and Hybrid 2D+3D SPECT/CT Image Methods

This method estimates the absorbed dose of different structures for peptide-receptor-radionuclide-therapy (PRRT) with the possibility of avoiding organ overlap on 2D-projections. Serial whole-body planar images permit estimation of mean absorbed doses along the whole body, while the hybrid approach, combining planar images and 3D-SPECT/CT image, overcomes the limitations of structure overlapping.

Peptide-receptor-radionuclide-therapy (PPRT) is a targeted therapy that combines a short-range energy radionuclide with a substrate with high specificity ...

Image Acquisition using Portable Sonography for Emergency Airway Management

With its increasing popularity and accessibility, portable ultrasonography has been rapidly adapted not only to improve the perioperative care of patients, but also to address the potential benefits of employing ultrasound in airway management. The benefits of point of care ultrasound (POCUS) include its portability, the speed at which it can be utilized, and its lack of invasiveness or exposure of the patient to radiation of other imaging modalities.
Two primary indications for airway POCUS include confirmation of endotracheal intubation and identification of the cricothyroid membrane in the event a surgical airway is required. In this article, the technique of using ultrasound to confirm endotracheal intubation and the relevant anatomy is described, along with the associated ultrasonographic images. In addition, identification of the anatomy of the cricothyroid membrane and the ultrasonographic acquisition of appropriate images to perform this procedure are reviewed.
Future advances include utilizing airway POCUS to identify patient characteristics that might indicate difficult airway management. Traditional bedside clinical exams have, at best, fair predictive values. The addition of ultrasonographic airway assessment has the potential to improve this predictive accuracy. This article describes the use of POCUS for airway management, and initial evidence suggests that this has improved the diagnostic accuracy of predicting a difficult airway. Given that one of the limitations of airway POCUS is that it requires a skilled sonographer, and image analysis can be operator dependent, this paper will provide recommendations to standardize the technical aspects of airway ultrasonography and promote further research utilizing sonography in airway management. The goal of this protocol is to educate researchers and medical health professionals and to advance the research in the field of airway POCUS.

Point of care ultrasound (POCUS) is increasingly being utilized in airway management. Presented here are some clinical utilities of POCUS, including differentiating endotracheal and esophageal intubation, identification of the cricothyroid membrane in the event a surgical airway is required, and measuring anterior neck soft tissue to predict difficult airway management.

With its increasing popularity and accessibility, portable ultrasonography has been rapidly adapted not only to improve the perioperative care of ...

Image Acquisition Method for the Sonographic Assessment of the Inferior Vena Cava

Over the past several decades, clinicians have incorporated several applications of diagnostic point-of-care ultrasound (POCUS) into medical decision-making. Among the applications of POCUS, imaging the inferior vena cava (IVC) is practiced by a wide variety of specialties, such as nephrology, emergency medicine, internal medicine, critical care, anesthesiology, pulmonology, and cardiology. Although each specialty uses IVC data in slightly different ways, most medical specialties, at minimum, attempt to use IVC data to make predictions about intravascular volume status. While the relationship between IVC sonographic data and intravascular volume status is complex and highly context-dependent, all clinicians should collect the sonographic data in standardized ways to ensure repeatability. This paper describes standardized IVC image acquisition including patient positioning, transducer selection, probe placement, image optimization, and the pitfalls and limitations of IVC sonographic imaging.&#160;This paper also describes the commonly performed anterior IVC long-axis view and three other views of the IVC that can each provide helpful diagnostic information when the anterior long-axis view is difficult to obtain or interpret.

Point-of-care ultrasound evaluation of the inferior vena cava (IVC) is commonly utilized to identify, among other things, the volume status. Imaging should be performed systematically to ensure repeatability. This manuscript reviews the methods and pitfalls of sonographic IVC examination.

Over the past several decades, clinicians have incorporated several applications of diagnostic point-of-care ultrasound (POCUS) into medical ...

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 ...

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 ...

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 ...