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Focused Cardiac Ultrasound and the Periresuscitative Period: A Case Series of Resident-Performed Echocardiographic Assessment Using Subcostal-Only View in Advanced Life Support

Bughrara, Nibras MD*; Herrick, Susan L. MD; Leimer, Elizabeth MD, PhD; Sirigaddi, Krishnaveni MBBS; Roberts, Kevin MD; Pustavoitau, Aliaksei MD, MHS

Author Information
doi: 10.1213/XAA.0000000000001278

Abstract

SIGNIFICANCE

Echocardiography is traditionally used in nonemergent settings and often separates the roles of sonographer and interpreter. In high-acuity fields such as anesthesiology, critical care, and emergency medicine, physicians are playing both roles with focused cardiac ultrasound (FOCUS), allowing them to assess and manage acutely ill patients in real time, including during cardiac arrest.1,2

BACKGROUND

While high-quality cardiopulmonary resuscitation (CPR) remains the backbone of resuscitation, the American Heart Association3 and Society of Critical Care Medicine (SCCM)4 suggest that FOCUS can be useful in identifying cardiac motion and potentially reversible causes of cardiac arrest in patients with pulseless electrical activity (PEA). Incorporating FOCUS into advanced life support (ALS) requires a protocol to limit evaluations to the 10-second maximum pause for the pulse/rhythm check.5 In the prehospital setting, FOCUS in ALS proved effective in distinguishing true PEA (without wall motion) from pseudo-PEA (with wall motion) and in identifying treatable conditions such as hypovolemia and pericardial effusion.6 Distinguishing between true and pseudo-PEA may have implications in predicting response to resuscitation and survival after cardiac arrest.7,8

RATIONALE

Unlike prehospital emergency providers in earlier studies, anesthesiologists in the United States primarily work in the hospital. We sought to apply ALS-compliant FOCUS to in-hospital cardiac arrest (IHCA), where anesthesiologists could have the greatest impact. Inspired by earlier work,5,6,9 we developed echocardiographic assessment using subcostal-only view in ALS (EASy-ALS) to be compliant with standard adult CPR.3 We then trained anesthesiology residents in FOCUS and EASy-ALS using a curriculum similar to those previously described9–12 and thus incorporated FOCUS into periresuscitative patient management.

AIMS AND OBJECTIVES

Our purpose was to explore the feasibility of anesthesiology residents performing FOCUS and EASy-ALS in the periresuscitative period after condensed training. We also identified critical system-wide issues that need resolution before transitioning to widespread use of FOCUS and EASy-ALS at our institution. This article adheres to the CAse REport (CARE) Guidelines for case reporting. The Albany Medical Center (AMC) Institutional Review Board approved the study and waived the requirement of informed written consent.

CASE DESCRIPTION

Methods

Patients were enrolled from December 2016 to January 2019 at AMC, an urban academic tertiary care medical center. We included patients evaluated by anesthesiology residents in the periresuscitative period, defined as a period during which a patient experienced hypotension concerning for impending cardiovascular collapse or cardiac arrest requiring CPR.

EASy-ALS evaluations were performed by anesthesiology residents after a formal 4-day course in FOCUS taken during their postgraduate year (PGY)-3 postanesthesia care unit (PACU) rotation. The course includes didactics, hands-on training, and simulation. A licensed web-based video course provided by the SCCM covers ultrasound physics and clinical applications; didactics span 4 hours daily. Hands-on training includes completion of 20 FOCUS studies performed on patients in the PACU or surgical intensive care unit (SICU) to evaluate hypotension or other signs of decompensation. These studies are directly supervised by a FOCUS-credentialed attending anesthesiologist. Each resident then independently performs 10 additional FOCUS studies; the FOCUS-credentialed attending anesthesiologist reviews all studies within 24 hours. Finally, residents complete 4 hours of team-based, high-fidelity simulation encompassing 5 PEA arrest scenarios: hypovolemia, massive myocardial infarction, massive pulmonary embolism, tamponade, and tension pneumothorax.13 Simulation emphasizes teamwork, communication, high-quality CPR, and never pausing chest compressions for >10 seconds. On completion of training, residents can perform EASy-ALS without direct supervision but with mandatory review of each case.

The EASy-ALS protocol was as follows and is outlined in Figure 1 and Table 1 (Supplemental Digital Content, Video 1, http://links.lww.com/AACR/A340, demonstrating EASy-ALS in a simulated setting). The responding resident is alerted to a decompensating patient in the SICU, the operating room, or medical or surgical ward by direct call from the primary service or by overhead Code Blue page. On arrival, the resident prepares to serve as a sonographer and complete an EASy-ALS examination. The ultrasound probe is placed in the subcostal window before the pulse/rhythm check without obstructing chest compressions. The code leader, a senior primary service provider, is responsible for holding and resuming chest compressions. The code leader assigns a rapid response nurse to count down 10 seconds during the pulse/rhythm check; this is standard at our institution. After resumption of chest compressions, the resident interprets recorded images and communicates findings to the code leader. The primary phenotypes (Figure 2) to be identified are cardiac standstill (Supplemental Digital Content, Video 2, http://links.lww.com/AACR/A341, demonstrating cardiac standstill), pericardial effusion (Supplemental Digital Content, Video 3, http://links.lww.com/AACR/A342, demonstrating pericardial effusion), dilated right ventricle (RV) (Supplemental Digital Content, Video 4, http://links.lww.com/AACR/A343, demonstrating dilated RV), dilated left ventricle (LV) (Supplemental Digital Content, Video 5, http://links.lww.com/AACR/A344, demonstrating dilated LV), and underfilled heart (Supplemental Digital Content, Video 6, http://links.lww.com/AACR/A345, demonstrating underfilled heart). The resident can obtain extracardiac views (Supplemental Digital Content, Supplemental Videos 7 and 8, http://links.lww.com/AACR/A346 and http://links.lww.com/AACR/A347, demonstrating the inferior vena cava; and Supplemental Digital Content, Video 9, http://links.lww.com/AACR/A348, demonstrating a pleural effusion) between pulse/rhythm checks. The resident shares images with a FOCUS-credentialed attending anesthesiologist in-person or remotely to confirm interpretation. This attending anesthesiologist assesses for pericardial effusion and function and size of both ventricles. If all features are identified, the examination quality is classified as good; if some or none are identified, the examination is classified as adequate or inadequate, respectively. If the resident cannot obtain adequate images, the same or a different view is attempted during subsequent pulse/rhythm checks. After the event, the resident completes a standardized report (Supplemental Digital Content, Figure 1, http://links.lww.com/AACR/A349, reproducing the standardized report) that includes indication for examination, initial cardiac rhythm, FOCUS findings, interventions made, and immediate patient outcome. Survival to hospital discharge is assessed for each patient.

Table 1. - Sonographer Tasks for Successful Implementation of EASy-ALS Protocola
Timing Tasks
During CPR before pulse/rhythm check 1. Wait until 2 min of chest compressions have been completed.
2. Remove any barriers to ultrasound such as clothing or surgical dressing.
3. Place probe on patient to prepare to obtain subcostal 4-chamber view.
During pulse/rhythm check 4. Perform subcostal 4-chamber view and record images.
 Do not delay resumption of chest compressions
 Remove excessive ultrasound gel from the skin
After pulse/rhythm check 5. Interpret recorded images.
6. Communicate findings to code team leader.
7. Determine if patient would benefit from further FOCUS or lung ultrasound during future pulse/rhythm checks.
Any time during CPR Evaluate
 Inferior vena cava for right-sided filling pressure
 Aorta for aneurysm, dissection, or rupture
 Airway for esophageal intubation
 Chest for pneumothorax and pleural effusion
 Abdomen for intraperitoneal bleeding
 Deep veins for thrombosis
Abbreviations: CPR, cardiopulmonary resuscitation; EASy-ALS, echocardiographic assessment using subcostal-only view in advanced cardiac life support; FOCUS, focused cardiac ultrasound.
aThis protocol was inspired by the earlier work.5,6,9

Figure 1.
Figure 1.:
Algorithm for use of EASy-ALS. This algorithm incorporates FOCUS into the ≤10-s pulse/rhythm check of CPR. A systematic approach allows identification of a shockable rhythm if present and completion of EASy-ALS to search for a cardiac cause of the event without holding chest compressions for >10 s. (Courtesy of N. Bughrara, MD, Albany, NY.) CPR indicates cardiopulmonary resuscitation; EASy-ALS, echocardiographic assessment using subcostal-only view in advanced cardiac life support; FOCUS, focused cardiac ultrasound; PEA, pulseless electrical activity; ROSC, return of spontaneous circulation; RWMA, regional wall motion abnormality; VF, ventricular fibrillation; VT, ventricular tachycardia.
Figure 2.
Figure 2.:
Pseudo-PEA phenotypes identified with EASy-ALS. The primary phenotypes to be identified with EASy-ALS are pericardial effusion, which may result in pericardial tamponade, dilated right heart, which may occur with massive PE, dilated left heart, which may be seen with massive MI, and underfilled heart, which is associated with hypovolemia. Extracardiac views may be obtained as well; these include IVC ultrasound to assess volume status and RV filling pressure and lung ultrasound to assess for pleural effusion or tension pneumothorax. (Courtesy of N. Bughrara, MD, Albany, NY.) EASy-ALS indicates echocardiographic assessment using subcostal-only view in advanced cardiac life support; IVC, inferior vena cava; MI, myocardial infarction; PE, pulmonary embolism; PEA, pulseless electrical activity; RA, right atrium; RV, right ventricular.

Statistical Analysis

We used descriptive statistics to summarize findings during the periresuscitative period and survival to hospital discharge. We calculated the proportion of cases in which diagnostic quality (good or adequate) images were obtained.

RESULTS

Data were collected for 22 patients; examinations were performed by 10 residents (1–4 examinations per each resident) (Table 2). Indications for EASy-ALS included PEA (n = 9; 41%), post–return of spontaneous circulation (ROSC; n = 7; 32%), prearrest (n = 3; 14%), asystole (n = 2; 9%), and pulseless ventricular tachycardia (n = 1; 5%). Image quality was good in 16 cases (73%) and adequate in 6 cases (27%). Major findings were absence of cardiac causes of event (n = 10; 45%), RV dilation with underfilled LV (n = 3; 14%), cardiac standstill (n = 2; 9%), dilated LV with regional wall motion abnormality (RWMA) (n = 1; 5%), biventricular dilation and dysfunction (n = 1; 5%), pericardial effusion (n = 1; 5%), severe hypovolemia (n = 3; 15%), and systolic anterior motion (SAM) of the mitral valve (n = 1; 5%). A cofinding of pleural effusion was identified in 2 cases (9%), with 1 occurring in a patient with hypovolemia and the other in a patient with RV dilation. In all patients, ultrasound findings supported targeted intervention. Overall, 11 (50%) survived to hospital discharge. Of the 12 patients evaluated during cardiac arrest, 9 achieved ROSC (75%) and 5 (42%) survived to hospital discharge, with 3 having favorable neurologic outcome. Both patients with cardiac standstill (100%) and 1 patient (10%) with cardiac motion on EASy-ALS during cardiac arrest failed to achieve ROSC.

Table 2. - Results of Resident-Obtained FOCUS Evaluations
Case Number Indication Image Qualitya Cardiac Motion Assessmentb Intervention ROSC Achieved Survival to Hospital Discharge
1 PEA Adequate Yes Hypovolemia, pleural effusion Rapid IVF bolus Yes No
2 PEA Adequate Yes Ruled-out cardiac causes of event Management of aspiration pneumonitis Yes Yes
3 PEA Good Yes Ruled-out cardiac causes of event Management of anesthetic-induced cardiac arrest Yes Yes
4 Asystole Good No Cardiac standstill Helped in decision of stopping CPR after 16 min No No
5 Post-ROSC Good Yes Ruled-out cardiac causes of event Focused on noncardiac etiology Yes No
6 Post-ROSC Adequate Yes Biventricular dysfunction Inotropes choice post-ROSC Yes No
7 Post-ROSC Adequate Yes Ruled-out cardiac causes of event Focused on noncardiac causes Yes Yes
8 Post-ROSC Good Yes RV dilation with underfilled LV, pleural effusion Given thrombolytics for suspected massive PE Yes No
9 Asystole Good Yes Hypovolemia, small pericardial effusion, flat IVC IVF bolus, external compression device to control internal bleeding followed by surgical repair of femoral artery injury Yes Yes
10 PEA Good Yes Noncardiac etiology Focused on noncardiac causes Yes No
11 PEA Good Yes Ruled-out cardiac causes of event Focused on noncardiac causes No No
12 PEA Good Yes Hypovolemia IVF bolus, initiating massive blood transfusion protocol and returned to OR Yes No
13 Post-ROSC Good Yes Pericardial effusion Drained and placed pericardial window Yes Yes
14 Post-ROSC Adequate Yes Ruled-out cardiac causes of event Focused on noncardiac causes Yes Yes
15 Post-ROSC Good Yes Ruled-out cardiac causes of event Focused on noncardiac causes Yes No
16 PEA Good No Cardiac standstill Helped in decision of stopping CPR after 20 min of CPR No No
17 Prearrestc Good Yes RV dilation with underfilled LV Stopped IVF,
started on vasopressin and milrinone and optimized mechanical ventilation
Not Applicable Yes
18 PEA Good Yes RV dilation with underfilled LV Stopped IVF, started on vasopressin and epinephrine and optimized mechanical ventilation Yes Yes
19 Prearrest Good Yes SAM Stopped inotropes, started IVF and phenylephrine Not applicable Yes
20 Pulseless ventricular tachycardia Good Yes LV dysfunction Defibrillation performed Yes Yes
21 Prearrest Adequate Yes Ruled-out cardiac causes of event Distributive shock was diagnosed and started on norepinephrine Not applicable Yes
22 PEA Good Yes Ruled-out cardiac causes of event Focused on noncardiac causes Yes No
Abbreviations: CPR, cardiopulmonary resuscitation; FOCUS, focused cardiac ultrasound; IVF, intravenous fluid; LV, left ventricular; OR, operating room; PE, pulmonary embolism; PEA, pulseless electrical activity; ROSC, return of spontaneous circulation; RV, right ventricular; SAM, systolic anterior motion.
aDetermined by FOCUS-credentialed anesthesiologist. Good images were those in which presence or absence of pericardial effusion and function and size of right and left ventricles could be confidently identified. Adequate images were those in which some but not all of the aforementioned features could be confidently identified or those in which further images were indicated to confirm findings. Inadequate images were those in which none of the aforementioned features could be identified.
bThe primary findings for which providers evaluated were pericardial effusion, RV syndrome, LV dysfunction, and hypovolemia. If none of these were observed and no other finding (such as SAM) was identified, it was determined that the study was able to rule-out cardiac causes of the event.
cDefined as systemic hypotension with sustained systolic blood pressure ≤50 mm Hg. None of the patients with prearrest progressed toward cardiac arrest.

DISCUSSION

We demonstrated that it is feasible for trained anesthesiology residents to perform EASy-ALS, expanding the role of anesthesiologists in acute patient care. As in previous reports using FOCUS in out-of-hospital cardiac arrest,3,4 we established that providers consistently obtained diagnostic images and identified cardiac motion and potentially reversible cardiac causes of instability in the hospital setting.

Examining the limitations of our study uncovered several system-wide issues requiring attention before implementing routine use of EASy-ALS. Our institution has approximately 20 IHCA events monthly, but only a small number were captured in our case series. At present, an attending anesthesiologist and nurse anesthetist respond to Code Blue events, and their primary responsibility is airway management. Residents can only perform FOCUS after training and if not occupied with staffing an operating room. Furthermore, our small size residency program has only 6 residents per class, all residents receive their training at the second half of their PGY-3 training year, so only a small proportion have been trained at any one time. Expanded use of EASy-ALS is also limited by a lack of ultrasound machines in each clinical unit and a paucity of FOCUS-adept attending anesthesiologists. We are considering purchase of handheld ultrasound devices and expanding FOCUS training to PGY-2 residents and attending anesthesiologists to address these issues.

While EASy-ALS supported clinical decision-making in patients, our study design as case series does not allow us to make conclusions whether use of EASy-ALS resulted in management adjustments and effected outcomes. Another limitation is the lack of data on the duration of pulse/rhythm check pauses during EASy-ALS. Evidence has shown that training reduces the proportion of pauses lasting >10 seconds, but every pause is not always shorter than 10 seconds.13,14 While we have not recorded duration of pauses, code leaders assign a nurse to count down 10 seconds during pauses to limit the amount of time compressions are held. Rapid response nurses responding to code events attend simulation training and are instructed to intervene and stop the resident if 10 seconds have elapsed. Future steps may include acquisition of defibrillators with automated recording functionality and ongoing review of all code events by hospital committee.

In conclusion, EASy-ALS performed by anesthesiology residents in in-hospital periresuscitation is feasible, but routine clinical implementation of EASy-ALS will require system-wide changes in code management.

DISCLOSURES

Name: Nibras Bughrara, MD.

Contribution: This author is the principal investigator. He developed the idea for the study, implemented the training program for residents, participated in data collection and analysis, helped in writing of the manuscript, and reviewed the final product.

Name: Susan L. Herrick, MD.

Contribution: This author is a coinvestigator. She wrote the institutional review board proposal that gained approval for the study and assisted with data collection, analysis, and writing of the manuscript.

Name: Elizabeth Leimer, MD, PhD.

Contribution: This author is a coinvestigator. She assisted with data organization and writing of the manuscript.

Name: Krishnaveni Sirigaddi, MBBS.

Contribution: This author is a coinvestigator. She assisted with documentation of findings, compilation of images, and review of the final manuscript.

Name: Kevin Roberts, MD.

Contribution: This author is a coinvestigator. He assisted with review of the final manuscript.

Name: Aliaksei Pustavoitau, MD, MHS.

Contribution: This author is a coinvestigator. He assisted with writing of the manuscript, developing simulation scenarios, statistical analysis, and review of the final manuscript.

This manuscript was handled by: Kent H. Rehfeldt, MD.

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