SonoStudy: Meta-analysis of 9 trials – ultrasound use for peripheral IVs in kids and adults #FOAMed

Not that we didnt already know this, but at least we have more data to say it is so – in a recent study in Annals of Emergency medicine – a meta analysis reviewed 9 trials – both kids and adults.

This concept has been getting a lot of press, and many of my ultrasound enthusiast friends have passed this around. It’s good to know the concept – and use it when you are in a conversation with someone who thinks the blind technique it still the way to go.

“Pediatric trials yielded conflicting data, the authors reported February 18 online in Annals of Emergency Medicine, but there appeared to be significantly fewer attempts and shorter procedure times when ultrasound guidance was used in the emergency department, as well as significantly decreased risk of first-attempt failure, reduced attempts, and shorter procedure time when ultrasound guidance was used in the operating room…..”Ultrasonographically guided peripheral intravenous cannulation may perform better in the pediatric population because failure rates with the traditional method are much higher in children than adults,” the researchers note. “Ultrasonography may not be as beneficial in adults, in whom target vessels are easier to locate.” – Now, these trials were from operating room patients, where the setting is a bit more controlled, the patients may be a bit different in their difficult IV access spectrum – but the authors still suggest that if faced with a difficult IV – use ultrasound.

Below is the abstract:

Study objective

Peripheral intravenous cannulation is procedurally challenging and painful. We perform a systematic review to evaluate ultrasonographic guidance as an aid to peripheral intravenous cannulation.

Methods

We searched MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, ClinicalTrials.gov, and Google.ca. We included randomized trials evaluating ultrasonographically guided peripheral intravenous cannulation and reporting risk of peripheral intravenous cannulation failure, number of attempts, procedure time, or time from randomization to peripheral intravenous cannulation. We separately analyzed pediatric and adult data and emergency department (ED), ICU, and operating room data. Quality assessment used the Cochrane Risk of Bias Tool.

Results

We identified 4,664 citations, assessed 403 full texts for eligibility, and included 9 trials. Five had low risk, 1 high risk, and 3 unclear risk of bias. A pediatric ED trial found that ultrasonography decreased mean difference (MD) in the number of attempts (MD −2.00; 95% confidence interval [CI] −2.73 to −1.27) and procedure time (MD −8.10 minutes; 95% CI −12.48 to −3.72 minutes). In an operating room pediatric trial, ultrasonography decreased risk of first-attempt failure (risk ratio 0.23; 95% CI 0.08 to 0.69), number of attempts (MD −1.50; 95% CI −2.52 to −0.48), and procedure time (MD −5.95; 95% CI −10.21 to −1.69). Meta-analysis of adult ED trials suggests that ultrasonography decreases the number of attempts (MD −0.43; 95% CI −0.81 to −0.05). Ultrasonography decreased risk of failure (risk ratio 0.47; 95% CI 0.26 to 0.87) in an adult ICU trial.

Conclusion

Ultrasonography may decrease peripheral intravenous cannulation attempts and procedure time in children in ED and operating room settings. Few outcomes reached statistical significance. Larger well-controlled trials are needed.

For more info and a how-to for ultrasound guided procedures, including ultrasound-guided peripheral IV and central IV acces – go here.

SonoStudy: >12,000 kids – Identifying factors putting kids at low risk, not needing CT after trauma

There has been quite a bit of press lately on this –  Here and Here – And for good reason. With the ALARA principle, and being a pediatric population which has been studied so many times with regard to trauma and the need for CT, a recent study by Holmes et al published in Annals of Emergency Medicine did a multi-site study enrolling >12,000 kids and identified 7 factors that places children at very low risk for injury not requiring abdominal CT. A prior post discusses a study done by the same author and my thoughts of pediatric US in trauma. BTW – Dr. Holmes also discusses low risk factors for adult patients in a prior study too.

The prediction rule for pediatric patients consisted of (in descending order of importance):

No evidence of abdominal wall trauma or seat belt sign,

Glasgow Coma Scale score greater than 13,

No abdominal tenderness,

No evidence of thoracic wall trauma,

No complaints of abdominal pain,

No decreased breath sounds, and

No vomiting.

Now, I dont know about you, but to me it is quite obvious – we just now have a nicely powered study that we can use for all the doctors who want to CT despite all of the above being negative. The authors say that if any one of the above exist then a decision by the physician should be made as to what the next best management step would be – observation period with serial exams, ultrasound (holla!), CT – are all options depending on clinical judgement. Below is the abstract:

Study objective: We derive a prediction rule to identify children at very low risk for intra-abdominal injuries undergoing acute intervention and for whom computed tomography (CT) could be obviated.

Methods: We prospectively enrolled children with blunt torso trauma in 20 emergency departments. We used binary recursive partitioning to create a prediction rule to identify children at very low risk of intra-abdominal injuries undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion for abdominal hemorrhage, or intravenous fluid for ≥2 nights for pancreatic/gastrointestinal injuries). We considered only historical and physical examination variables with acceptable interrater reliability.

Results: We enrolled 12,044 children with a median age of 11.1 years (interquartile range 5.8, 15.1 years). Of the 761 (6.3%) children with intra-abdominal injuries, 203 (26.7%) received acute interventions. The prediction rule consisted of (in descending order of importance) no evidence of abdominal wall trauma or seat belt sign, Glasgow Coma Scale score greater than 13, no abdominal tenderness, no evidence of thoracic wall trauma, no complaints of abdominal pain, no decreased breath sounds, and no vomiting. The rule had a negative predictive value of 5,028 of 5,034 (99.9%; 95% confidence interval [CI] 99.7% to 100%), sensitivity of 197 of 203 (97%; 95% CI 94% to 99%), specificity of 5,028 of 11,841 (42.5%; 95% CI 41.6% to 43.4%), and negative likelihood ratio of 0.07 (95% CI 0.03 to 0.15).

Conclusion: A prediction rule consisting of 7 patient history and physical examination findings, and without laboratory or ultrasonographic information, identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention. These findings require external validation before implementation.

SonoStudy: Ultrasound can diagnose pediatric pneumonia! – Quite a lot of press on this topic!

Not that thoracic bedside ultrasound is only good for children’s pneumonia – as we know there have been recent articles ….and posts here on SonoSpot summarizing the recent hot topic (including one from Blaivas from the Journal of US in Medicine, and another highlighted in our bi-annual Northern CA Journal Club) …that it can help in diagnosing adult pneumonia too – but this topic is getting quite a bit of press lately due to the affect of it with our kids in another study recently published – decreasing radiation? decreasing length of stay? decreasing cost? increasing satisfaction? yes, please.

The actual pediatric study (abstract) can be found here.  It states: just after 1 hour of clinicians learning how to do it, they were able to diagnose pneumonia with ultrasound (chest Xray used as a reference standard). 200 patients (!!) were studied with the prevalence of pneumonia by chest XRay was 18%. “Ultrasonography had an overall sensitivity of 86% (95% CI, 71%-94%), specificity of 89% (95% CI, 83%-93%), positive LR of 7.8 (95% CI, 5.0-12.4), and negative LR of 0.2 (95% CI, 0.1-0.4) for diagnosing pneumonia by visualizing lung consolidation with sonographic air bronchograms. In subgroup analysis of 187 patients having lung consolidation exceeding 1 cm, ultrasonography had a sensitivity of 86% (95% CI, 71%-94%), specificity of 97% (95% CI, 93%-99%), positive LR of 28.2 (95% CI, 11.8-67.6) and negative LR of 0.1 (95% CI, 0.1-0.3) for diagnosing pneumonia.” To view another study from 2009 (!!) where they compared ultrasound to CT, go here. Or one from 2009 from the Italians (because they do everything better) go here.

Medwire from ACEP News has spread the word recently too: “Point-of-care ultrasound scanning can be used to diagnose pneumonia accurately in children and young people, show study findings. Researchers led by James Tsung, from Mount Sinai School of Medicine in New York, USA, hope that their findings could help diagnose children with pneumonia in developing countries, where deaths from the disease are particularly high. “The World Health Organization has estimated as many as three-quarters of the world’s population, especially in the developing world, does not have access to any diagnostic imaging, such as chest X-ray, to detect pneumonia,” said Tsung in a press statement. “Many children treated with antibiotics may only have a viral infection – not pneumonia. Portable ultrasound machines can provide a more accurate diagnosis of pneumonia than a stethoscope.” Tsung and colleagues enrolled 200 patients under the age of 21 years to take part in their study. All patients had suspected community-acquired pneumonia and all diagnoses were checked using chest radiography. The clinicians involved in the study had 1 hour of focused training in ultrasonography to diagnose pneumonia in children and young people. As reported in the Archives of Pediatric and Adolescent Medicine, the patients were aged a median of 3 years and chest radiography diagnosed pneumonia in 18% of the group. Ultrasonography, involving visualization of lung consolidation with sonographic air bronchograms, accurately diagnosed pneumonia in the majority of cases, with a sensitivity of 86%, a specificity of 89%, a positive likelihood ratio (LR) of 7.8, and a negative LR of 0.2. In patients with lung consolidation of over 1 cm, point-of-care ultrasound was even more accurate, with a sensitivity of 86%, specificity of 97%, positive LR of 28.2, and negative LR of 0.1 for diagnosing pneumonia. Kassa Darge and Aaron Chen (The Children’s Hospital of Philadelphia, Pennsylvania, USA), the authors of an accompanying editorial, say that further studies are needed to confirm these results. However, they conclude: “In the future, wherever the institutional infrastructure permits, in the diagnostic imaging algorithm for suspected pneumonia in children, ultrasonography may need to precede, augment, or even replace chest radiography.”

Oh yeah…..let the ultrasoundin’ begin!

For a very fun and funny podcast by the Ultrasound Podcast guys, go here.

For a great and complete pdf lecture on Lung ultrasound by the Critical Care Ultrasound God – aka Lichtenstein – go here.

What it can look like: look for the bright white (hyperechoic) areas within lung:

From AJR: a 2 yr old with Pneumonia – the Arrow showing pleural line; the * showing consolidation

From Ultrasound in Med and Bio:

SonoStudy: “US equivocal for appy” To scan or not to scan? THAT is the question…

Interesting topic of discussion and I wonder what the usual plan is at your facilities with regard to US “equivocal and cannot see the appendix”. Apparently, we order too many CTs after that result, and might want to think about an alternative to radiation: observation period. According to one of our Radiology colleagues who is a guru with US, Dr Brooke Jeffrey, and studied this extensively with a goal to minimize radiation: 400 pediatric and adult patients had US to evaluate for appendicitis.