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Point-of-Care Ultrasound: Novel Technology to Routine Perioperative Assessment Tool

Ramsingh, Davinder MD; Gudzenko, Vadim MD; Martin, Robert D. MD

doi: 10.1213/ANE.0000000000001529
Editorials: Editorial
Free

Published ahead of print August 22, 2016.

From the *Loma Linda University School of Medicine, Loma Linda, California; and David Geffen School of Medicine at UCLA, Los Angeles, California.

Published ahead of print August 22, 2016.

Accepted for publication July 5, 2016.

Funding: None.

Conflict of Interest: See Disclosures at the end of the article.

Reprints will not be available from the authors.

Address correspondence to Davinder Ramsingh, MD, Department of Anesthesiology, Loma Linda Medical Center, 11234 Anderson St, MC-2532-D, Loma Linda, CA 92354. Address e-mail to dramsingh@llu.edu.

Traditional ultrasound (US) devices were large and often confined to imaging laboratories (cardiology, radiology, and obstetrics). Recently, however, technological advances have made portable US devices more affordable with functionality similar to “high-end” units used in imaging laboratories.1 This advancement has allowed health care providers the ability to perform US examinations at the bedside and use it for procedural, diagnostic, and screening applications, with improvement in patient care.2–5 For anesthesiologists, this is an opportunity to deploy US in the perioperative medicine setting, outside the operating room.

During the past decade, the utility of point of care in the perioperative setting has focused primarily on central venous access and regional anesthesia. Point-of-care ultrasound (POCUS) has proven to significantly lower complication rates for central line placement and was listed as 1 of 12 most highly rated patient safety practices by the Agency for Healthcare Research and Quality.6 As a result, it has rapidly become a standard of care.7,8 Similarly, the use of POCUS has proven to be of benefit for regional anesthesia, and guidelines have indicated its utility toward improving block onset time, reducing number of needle passes, and avoiding vascular puncture.9 As the presence of POCUS in the perioperative setting continues to grow, its utility to improve perioperative care in other areas is beginning to be demonstrated.

In this issue of Anesthesiaand Analgesia, Yao et al10 demonstrated the utility of POCUS to evaluate for patients who are likely to be a difficult laryngoscopy secondary to decreased temporomandibular joint mobility. Specifically, the authors assessed for temporomandibular joint mobility by directly measuring condylar translational distance using a novel US examination. This observational blinded study demonstrated that the direct assessment of a reduced condylar translational distance (defined in the study as <10 mm) had the greatest sensitivity and specificity for predicting a difficult laryngoscopy versus interincisor distance, upper lip bite test, mandibular protrusion, condyle-tragus distance, thyromental distance, and Mallampati classification.10 Overall, this study demonstrates the utility of POCUS to facilitate the routine procedure of airway examination.

Similarly in this issue, Haskins et al11 demonstrate another novel modality for perioperative POCUS by using a well-supported abdominal POCUS examination to detect intra-abdominal fluid extravasation (IAFE) in patients who had undergone hip arthroscopy and subsequently correlating the presence of IAFE to increased pain scores in the postanesthesia care unit. Specifically, this group used probably the most researched POCUS examination, the Focused Assessment with Sonography for Trauma examination, to detect the presence of IAFE.11 Of particular interest is the reported incidence of IAFE found in this study, with a value that was a magnitude greater than what has been reported previously. Overall, this study is one of the first perioperative POCUS studies to demonstrate the utility of perioperative abdominal sonography.

These works are just a few of several recent publications that have demonstrated the utility of POCUS for perioperative care beyond central vascular access and regional anesthesia. Emerging areas of POCUS that have demonstrated to be relevant for the perioperative physician include transthoracic echocardiography, assessment of gastric volume, and location of the endotracheal tube.12–16 Recently, the works of Canty et al12 and Cowie13 have demonstrated that a focused transthoracic echocardiography examination can be performed by an anesthesiologist and, when implemented, can positively impact perioperative patient care by altering management. Others have demonstrated similar results after implementing a comprehensive perioperative POC educational curriculum to anesthesiology residents.5 Perlas et al14,15 reported that the presence of fluid in the antrum, identified by US, correlated with a clinically significant amount of gastric volume. Finally, the utility of POCUS to detect appropriate endotracheal intubation via assessment of tracheal dilation and presence of bilateral pleural lung sliding has been demonstrated to be far superior than traditional auscultation.16

Despite these positive studies supporting perioperative POCUS, there is much more that can be developed. Specialties such as critical care and emergency medicine have demonstrated patient care benefit with the use of POCUS to examine for pulmonary, intracranial, and vascular pathology.3,17 Currently, examination of the utility of these POCUS modalities has not been evaluated in the perioperative setting.

In addition, these specialties have developed formalized educational and certification pathways. In fact, emergency medicine has adopted POCUS training as a “core competency” for residency training and provide a year of fellowship training in clinical ultrasonography.18 Although there has been some development in formalizing a comprehensive perioperative POCUS educational curriculum,5 this has not gained widespread adoption. This is despite the interest of POCUS education reported by anesthesiology residents.19,20

As acute care physicians of the perioperative arena, along with a growing presence in the pre- and postoperative period, anesthesiologists more frequently will encounter patient care scenarios that have proven to be aided by POCUS. Because anesthesiologists were one of the first adopters of US, it seems intuitive that we would embrace this technology for all the relevant approaches it may provide to improve perioperative care.21 Currently, however, POCUS technology is improving at a far faster rate than what our specialty is doing to incorporate all of its utility. Truly, we have gone from pioneers in the development of POCUS to a specialty that is behind when compared with some medical specialties.

The works of Yao et al10 and Haskins et al11 emphasize the important value of POCUS for anesthesiology. Both studies have shown that using US in the perioperative setting is not just convenient and safe, but it also changes management and potential outcomes. As research continues to be developed on the clinical utility of perioperative POCUS, our specialty will need to embrace a more comprehensive endorsement of this technology. Recently, a multisubspecialty group reviewed the current applications of perioperative US and its training.22 This group reported a “call to action” on this topic and emphasized the importance of our specialty’s societies to develop standards of training such that proficiency in perioperative US is expected on completion of accredited residency training.22

Regarding education, there has been some development in formalizing a comprehensive perioperative POCUS educational curriculum (FORESIGHT: Focused Perioperative Risk Evaluation Sonography Involving Gastro-abdominal Hemodynamic and Transthoracic Ultrasound), which is now available free online at www.foresightultrasound.com.5 Similarly, the Society of Critical Care Medicine has online educational tools at http://www.sccm.org/Education-Center/Ultrasound/Pages/default.aspx. Finally, the American Institute of Ultrasound (http://www.aium.org) also has many online educational resources.

It is important to note that the American Medical Association passed a resolution (#802) stating that all medical specialties have the right to use US in accordance with specialty-specific practice standards.23 Therefore, the impetus is on our specialty to develop: structured guidelines, endorsed educational pathways, and certified credentialing processes to incorporate this new assessment tool into everyday practice. The significance of this development cannot be overstated as the limitations and potential harm of POCUS without these processes have been suggested.24 Once in place, anesthesiologists can evaluate the widespread clinical impact of incorporating this technology.

Adjustment of current patient care standards from advancing technology has always been strongly intertwined with anesthesiology. From advances such as pulse oximetry, capnography, and cardiac output assessment devices, anesthesiologists have constantly changed the standards of care using technology to advance patient safety. It is now time for our specialty to do the same with POCUS.

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DISCLOSURES

Name: Davinder Ramsingh, MD.

Contribution: This author helped design the study, write the manuscript, and review the literature.

Conflicts of Interest: Davinder Ramsingh is a recipient of a Foundation for Anesthesia Education and Research Grant for Research in Education on the topic of Point of Care Ultrasound.

Name: Vadim Gudzenko, MD.

Contribution: This author helped design the study, write the manuscript, and review the literature.

Conflicts of Interest: None.

Name: Robert D. Martin, MD.

Contribution: This author helped design the study, write the manuscript, and review the literature.

Conflicts of Interest: None.

This manuscript was handled by: Maxime Cannesson, MD, PhD.

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