POCUS for Nephrologists - Basic Principles and a General Approach

Fragmentation Of Care

Point of care ultrasonography (POCUS) has evolved as a valuable adjunct to physical examination in the recent past and various medical specialties have embraced it. However, POCUS training and scope of practice remain relatively undefined in nephrology. The utility of diagnostic POCUS beyond kidney and vascular access is under-recognized. Assessment of fluid status is a frequent dilemma faced by nephrologists in day-to-day practice where multi-organ POCUS can enhance the sensitivity of conventional physical examination. POCUS also reduces fragmentation of care, facilitates timely diagnosis, and expedites management. While the need for further imaging studies is obviated in selected cases, POCUS is not meant to serve as an alternative to consultative imaging. In addition, utility of POCUS depends on the skills and experience of the operator, which in turn depends on the quality of training. In this review, we discuss the rationale behind nephrologists performing POCUS, discuss case examples to illustrate the basic principles of focused ultrasonography, and share our experience-based opinion about developing a POCUS training program at the institutional level.

Non-Invasive Intracranial Pressure Evaluation in an Emergency Room – Point-of-Care Ultrasonography

Arquivos Brasileiros de Neurocirurgia Brazilian Neurosurgery ◽

10.1055/s-0036-1594301 ◽

2016 ◽

Vol 38 (04) ◽

pp. 279-283

Author(s):

Daniel Damiani ◽

Durval Damiani

Keyword(s):

Intracranial Pressure ◽

Randomized Trials ◽

Point Of Care ◽

Current Data ◽

Point Of Care Ultrasound ◽

Medical Specialties ◽

Non Invasive ◽

Nerve Sheath ◽

Invasive Method ◽

AbstractPoint-of-care ultrasound is modifying conducts in emergency care. The various medical specialties, in addition to traditional indications in cases of multiple trauma, are using this technique for rapid diagnosis at the bedside without patient mobilization and without radiation. Point-of-care ultrasound in neurocritical patients, through its transorbital window, can estimate the intracranial pressure by a non-invasive method. Through the measurement of the diameter of the optic nerve sheath 3 mm posterior to the retina, the intracranial pressure is estimated if the value of the diameter is > 5 mm, as it has been verified in other studies. The present article describes the most current data on this topic, and it also highlights the need for more multicentric and randomized trials to determine the correct cut-off points that represent the high sensibility and specificity of the method.

Approach to the Patient with Abdominal Pain

10.2310/em.4052 ◽

2020 ◽

Author(s):

Dana Sajed

Keyword(s):

Computed Tomography ◽

Abdominal Pain ◽

Chronic Conditions ◽

Acute Abdominal Pain ◽

Point Of Care ◽

Abdominal Ultrasonography ◽

Pediatric Populations ◽

Ed Visits ◽

Abdominal pain is the most common presenting complaint in the emergency department (ED), accounting for nearly 8% of ED visits. Although many chronic conditions may cause pain in the abdomen, acute abdominal pain, defined as undiagnosed pain present for less than 1 week, is of greatest concern to the emergency practitioner. For many reasons, acute abdominal pain is often diagnostically challenging. Abdominal pain may be due to numerous causes, including gastrointestinal, genitourinary, cardiovascular, pulmonary, and other sources. Symptoms may fluctuate or change in nature, and the quality of pain can be difficult for the patient to describe. Physical examination findings, although important, are variable and can even be misleading. Despite being such a common presenting complaint, misdiagnosis is not uncommon and results in a high percentage of medicolegal actions in both and adult and pediatric populations. This review contains 5 figures, 8 tables, and 92 references Key words: abdominal computed tomography, abdominal pain, abdominal ultrasonography, pain management, point-of-care ultrasonography

Barriers to the implementation of point-of-care ultrasonography by physiotherapists in haemophilia treatment centres in Canada: a modified Delphi approach

The Journal of Haemophilia Practice ◽

10.17225/jhp00146 ◽

2019 ◽

Vol 6 (1) ◽

pp. 29-41

Author(s):

Karen Strike ◽

Anthony Chan ◽

Monica R. Maly ◽

Patricia Solomon

Keyword(s):

Physical Examination ◽

Point Of Care ◽

Healthcare Organisation ◽

Knowledge To Action ◽

Modified Delphi ◽

Delphi Approach ◽

Treatment Centre ◽

Diagnostic Modalities ◽

Inner Setting

Abstract Background: In patients with haemophilia, evidence suggests that the physical examination alone is not sensitive enough to detect small amounts of blood within a joint. Attention has shifted to methods of improving the sensitivity of the physical examination through adding diagnostic modalities such as point-of-care ultrasonography (POC-US). Proficiency with the physical examination and understanding of the role of POC-US are important competencies for physiotherapists. Despite training, implementation of POC-US by physiotherapists in haemophilia treatment centres in Canada has been mixed. Aim: Using a theory-based approach, the aim of the current study is to achieve expert consensus regarding the barriers to physiotherapy performed POC-US in haemophilia treatment centres in Canada using a modified Delphi approach. Materials and Methods: Using the Knowledge-to-Action Framework and the Consolidated Framework for Implementation Research (CFIR), a modified Delphi approach was completed using the Modified BARRIERS Scale (MBS). Participants were blinded and consensus was reached over three rounds at the Canadian Hemophilia Society’s annual three-day conference. Results: Twenty-two physiotherapists participated; 20 participants completed Round 1, and 21 completed Rounds 2 and 3. Four items of the MBS reached consensus: 1) The physiotherapist does not have time to read research related to POC-US; 2) The physiotherapist is isolated from knowledgeable colleagues with whom to discuss POC-US; 3) Administration will not allow POC-US implementation; 4) There is insufficient time on the job to implement new ideas. All four consensus items can be mapped to one domain of the CFIR: the inner setting. Conclusion: The haemophilia treatment centre within a healthcare organisation appears to be an important target for addressing barriers to the implementation of physiotherapy performed POC-US.

Point-of-care ultrasonography (POCUS) in hemophilia A: a commentary on current status and its potential role for improving prophylaxis management in severe hemophilia A

Therapeutic Advances in Hematology ◽

10.1177/2040620717690316 ◽

2017 ◽

Vol 8 (4) ◽

pp. 153-156 ◽

Cited By ~ 7

Author(s):

Suchitra S. Acharya ◽

Brittny Rule ◽

Omar McMillan ◽

Thomas J. Humphries

Keyword(s):

Hemophilia A ◽

Point Of Care ◽

Scoring Systems ◽

Current Status ◽

Recurrent Bleeding ◽

Severe Hemophilia ◽

Transitional Age ◽

User Friendly

In patients with severe hemophilia A, recurrent bleeding into joints results in increased morbidity and reduced quality of life. Prophylaxis using replacement factor products, especially when initiated early, has established benefits in terms of reducing joint bleeds and preserving joint function. Poor adherence to prophylactic regimens is a common cause for breakthrough bleeds and resultant arthropathy. Improving prophylaxis management, especially in the transitional age group, is a challenge. Here, we discuss the current status of ultrasonography (US) in hemophilia A, challenges in its wider implementation, and the potential for use of point-of-care US (POCUS) as an adjunct in the routine management of patients with hemophilia following prophylaxis regimens. Using POCUS, in which US is performed by trained hematologists and nonphysician operators (rather than comprehensive US performed by imaging specialists), specific clinical questions can be addressed in a time-efficient, user-friendly manner to promote adherence to prophylaxis and guide or modify treatment approaches. This review also discusses barriers to acceptance of POCUS as a part of routine management of patients with hemophilia, including questions related to its diagnostic accuracy, dependence on trained operators, agreement on appropriate scoring systems, and potential usefulness in patient management.

Comprehensive Assessment of Fluid Status by Point-of-Care Ultrasonography

Kidney360 ◽

10.34067/kid.0006482020 ◽

2021 ◽

pp. 10.34067/KID.0006482020

Author(s):

Eduardo R Argaiz ◽

Abhilash Koratala ◽

Nathaniel Reisinger

Keyword(s):

Clinical Decision Making ◽

Point Of Care ◽

Relevant Literature ◽

Laboratory Data ◽

Quantitative Information ◽

Right Atrial ◽

Electrolyte Disorders ◽

Fluid Status ◽

Hemodynamic Assessment ◽

The management of complex fluid and electrolyte disorders is central to the practice of nephrologists. The sensitivity of physical examination alone to determine fluid status is limited, precluding accurate clinical decision making. Point-of-Care Ultrasonography (POCUS) is emerging as a valuable non-invasive bedside diagnostic tool for objective evaluation of physiological and hemodynamic parameters related to fluid status, tolerance, and responsiveness. Rapid bedside sonographic evaluation can obtain qualitative data on cardiac function as well as quantitative data on pulmonary congestion. Advanced POCUS, including goal-directed Doppler echocardiography provides additional quantitative information including flow velocities and pressures across the cardiac structures. Recently, abnormal Doppler flow patterns in abdominal organs secondary to increased right atrial pressure have been linked to congestive organ damage adding another component to the hemodynamic assessment. Integrating POCUS findings with clinical and laboratory data can further elucidate a patient's hemodynamic status. This drives decisions regarding crystalloid administration or, conversely, diuresis or ultrafiltration and allows tailored therapy for individual patients. In this article, we provide an overview of the focused assessment of cardiovascular function, pulmonary and venous congestion using POCUS and review relevant literature.

Point-of-Care Ultrasound in Undergraduate Medical Education: a Probe into its Feasibility

University of Ottawa Journal of Medicine ◽

10.18192/uojm.v8i2.3837 ◽

2018 ◽

Vol 8 (2) ◽

pp. 23-24

Author(s):

John MacIsaac

Keyword(s):

Medical Education ◽

Residency Training ◽

Undergraduate Medical Education ◽

Training Programs ◽

Point Of Care ◽

Point Of Care Ultrasound ◽

Medical Specialties ◽

Undergraduate Level ◽

Medical Undergraduate ◽

Point of care ultrasonography (POCUS) has had its applications expand rapidly over recent years and across several medical specialties. Enough so that is has become an essential skill in most residency training programs across Canada. Despite this, there is little to no structured POCUS training at the medical undergraduate level. The goal of this commentary is to briefly introduce the value of POCUS in medical education; the feasibility of its integration; current barriers to its introduction; and the potential for students to be a possible solution until faculty can introduce a formal undergraduate POCUS curriculum.

Albumin Infusion in Patients with Cirrhosis: Time for POCUS-Enhanced Physical Examination

Cardiorenal Medicine ◽

10.1159/000517363 ◽

2021 ◽

pp. 1-5

Author(s):

Abhilash Koratala ◽

Claudio Ronco ◽

Amir Kazory

Keyword(s):

Physical Examination ◽

Hepatorenal Syndrome ◽

Point Of Care ◽

Objective Assessment ◽

Objective Evaluation ◽

Pulmonary Complications ◽

Complex Disorders ◽

The Impact

Objective assessment of fluid status is of utmost significance in the management of patients with complex disorders involving hemodynamics and multi-organ crosstalk such as cardiorenal or hepatorenal syndrome. The role of volume expansion using intravenous albumin in the setting of hepatorenal syndrome has been an everlasting debate among clinicians. With the accumulating evidence on the deleterious consequences of iatrogenic fluid overload, empiric albumin administration in these patients has been the focus of much attention, and the findings of recent studies suggest a higher incidence of pulmonary complications with albumin. Poor sensitivity of conventional physical examination has led to an interest in the utility of novel noninvasive bedside tools such as point-of-care ultrasonography (POCUS) to evaluate hemodynamics more precisely. Once confined to specialties such as obstetrics and emergency medicine, the scope of diagnostic POCUS is rapidly expanding in other fields including internal medicine and nephrology. Herein, we offer our perspective on the emerging role of POCUS for objective evaluation of patients with suspected hepatorenal physiology based on our experience. We propose that future clinical trials consider incorporating this strategy and explore the impact of POCUS-guided therapy on the outcomes.

Point-of-Care Ultrasonography for Objective Volume Management in End-Stage Renal Disease

Blood Purification ◽

10.1159/000503000 ◽

2019 ◽

Vol 49 (1-2) ◽

pp. 132-136 ◽

Cited By ~ 1

Author(s):

Abhilash Koratala ◽

Gajapathiraju Chamarthi ◽

Amir Kazory

Keyword(s):

Renal Disease ◽

Physical Examination ◽

End Stage Renal Disease ◽

Point Of Care ◽

Esrd Patient ◽

Vena Cava ◽

Volume Status ◽

Stage Renal Disease ◽

End Stage

Focused ultrasonography or point-of-care ultrasonography (POCUS) is increasingly considered as an essential bedside diagnostic tool. In patients with end-stage renal disease (ESRD) treated with hemodialysis, it can be used as an adjunct to physical examination to objectively assess the volume status and guide the rate and amount of ultrafiltration. Herein, we describe the case of an ESRD patient presenting with hypertensive urgency where POCUS disclosed the presence of hypervolemia despite unremarkable physical examination. The sonographic findings of the inferior vena cava, heart, and lungs guided fluid extraction during hemodialysis therapy, and the actual ultrafiltration volume was significantly higher than what was anticipated based on clinical findings. This case highlights the importance of using POCUS as a tool for objective and precise assessment of volume status in patients with ESRD.