Original Contribution
Using Critical Care Chest Ultrasonic Examination in Emergency Consultation: A Pilot Study

https://doi.org/10.1016/j.ultrasmedbio.2014.09.010Get rights and content

Abstract

The purpose of this study was to investigate the effects of critical care chest ultrasonic examination (CCUE) by intensivist on the diagnosis and treatment decisions in emergent consultation for patients who may have a problem-need transfer to an intensive care unit (ICU). A total of 130 patients who required emergent consultation in the ordinary wards were included in this study. Patients were randomly divided into conventional group (n = 63) and CCUE group (n = 67, added CCUE). The two groups showed no significant differences in general clinical information or final diagnosis (p > 0.05). The CCUE group had a shorter time to preliminary diagnosis, final diagnosis, treatment response and X-ray/computed tomography examination; a delay in ICU transfer and ICU stay days (3.9 ± 1.2 vs. 5.4 ± 1.9 d, p < 0.05) and a higher diagnostic accuracy than the conventional group (p < 0.001). In conclusion, CCUE could help early diagnosis and therapy for the patient who may need to transfer to the ICU and reduce the ICU stay for in-hospital patients in emergent consultation.

Introduction

Ultrasound was first introduced in the 1950s, then widely used in diagnosis, screening for disease and to aid in treatment of diseases or conditions. It was not until the last 15 y that this imaging facility became the tool for doctors, besides their stethoscope, to cope with the difficulties of routine practice. Critical care ultrasonography is being increasingly applied in the intensive care unit (ICU) for its value in rapid diagnosis and treatment of critically ill patients (Kimura et al., 2011, Breitkreutz et al., 2010). Whole-body ultrasound in the ICU is a new role for an aged technique. Critical care ultrasonography has become an indispensable tool that supplements physical examination in the ICU (Karabinis et al., 2009). Pulmonary and cardiovascular failure is the most important reason for transfer into the ICU department, which suggests that time is a critical factor in saving lives. A rapid and correct diagnosis, minimum delay in ICU transfer, and short time to treatment response are of great importance in critical consultation. We previously demonstrated the good clinical effects of extended focus assessed transthoracic echocardiography (eFATE) in managing circulation and the bedside lung ultrasound examination in emergency (BLUE)-plus protocol in diagnosing apnea for critically ill patients (Wang et al., 2011, Wang et al., 2012). In the eFATE study, 83 septic shock patients were divided into the eFATE and routine groups. In the eFATE group, the 24-h targeting rate was markedly higher than the routine group. The fluid intake volumes at 6 and 24 h and 1 wk were markedly lowered than those of the control group, and the myocardial inhibition occurred earlier versus the control group. There was no difference in mortality rate between two groups, but eFATE plays an meaningful role in the correct assessment of septic shock patients. In BLUE-plus study, the patients whose diagnosis of respiratory failure and need to receive mechanical ventilation for more than 48 h in ICU received BLUE-plus and BLUE lung ultrasound, the bedside chest radiography examination, lung computed tomography (CT) examination at same time. We found that the BLUE-plus lung ultrasound protocol has a better sensitivity (95%), specificity (87%) and diagnostic accuracy for consolidation and atelectasis (94%). Because BLUE-plus lung ultrasound is a bedside non-invasive method allowing immediate assessment of most lung consolidation and atelectasis, it will likely be an alternative to CT and become the key role in assessment of lung consolidation and atelectasis. We speculate that the combination of these two ultrasound protocols might lead to a simple and easy ultrasound protocol that allows for rapid diagnosis and effective treatment of critically ill patients. In this study, the eFATE and BLUE-plus protocols were modified into a critical care ultrasonic examination (CCUE) protocol, which was used in emergent consultation for in-hospital patients with pulmonary or circulation failures.

Section snippets

Materials and Methods

Patients treated at Peking Union Medical College Hospital from February 2013 to July 2013 who required emergent critical consultation for pulmonary or circulation failures were included in this study. All patients were from the medical/surgical units, and include post-surgical patients. The following patients were excluded from this study: patients who refused ICU transfer, patients who had already experienced cardiac arrest and patients who had advanced cancer. The Institutional Research and

Outcome

The following data were collected: general clinical information, final diagnosis and its analysis, time to preliminary diagnosis, time to final diagnosis, diagnostic accuracy, time to treatment response, time to X-ray/CT examination, time to consultation with other specialties, delay in ICU transfer and ICU stay.

Results

The CCUE group and the conventional group did not differ significantly in general information or Acute Physiology and Chronic Health Evaluation II (APACHE II) scores (Kruse et al.,1988) (p > 0.05) (Table 1).

Discussion

The occurrence of critical illness is often unpredictable. Pulmonary and cardiovascular dysfunctions are the most common reasons, and the underlining etiologies are complex. Rapid identification of critically ill patients, correct diagnosis and prompt treatment are of great importance. However, owing to limitations in instruments and laboratory tests, rapid diagnosis is very difficult in an emergent setting. Therefore, the emergent critical consultation must be swiftly and accurately performed

Conclusions

Application of the CCUE protocol in emergent consultation for patients with respiratory and cardiovascular failures can effectively improve the bedside treatment, help to rapidly establish the preliminary diagnosis and suggest treatment regimens. The CCUE protocol can improve the preliminary diagnostic accuracy and significantly reduce the time to final diagnosis, time to X-ray/CT examinations, delay in ICU transfer and ICU stay. We promote that the CCUE protocol needs further investigation.

Acknowledgments

This work was supported by the special fund for health-scientific research in the public interest program (grant number 201202011, the national health and family planning commission the P.R. China).

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