Hi, everyone. Thank you for coming. I'm excited to discuss the use of point-of-care ultrasound and change in clinical management in the ICU. I have no conflicts of interest to disclose. So the objective of my talk today are to discuss the application of POCUS in dyspnea, shock, and sepsis. I'll discuss the use of POCUS in deresuscitation, or what we call the later phase of ICU management. I'll explain how POCUS can be used in the entire health system. So I think POCUS is very similar to music. They both are precise. In music, a single note played with precision and intention can create a beautiful melody. Similarly, POCUS allows us to gather great information about a single organ system. The first organ system that proves benefit with POCUS is the blue protocol by Dr. Lichtenstein, who's considered the father of lung ultrasound. In blue protocol, lung ultrasound is combined with DVT ultrasound to diagnose patients with shortness of breath in the ICU. So by using several profiles of lung, patients can be diagnosed to have pneumonia, PE, pneumothorax, or COPD. So as a quick background, the A profile on the left is when you see mostly the horizontal lines, less lung sliding. This is commonly seen in patients with COPD or normal situation. The B profile in the middle is when you see B lines, which are vertical flashlights extending from the pleura. This is most commonly seen in cardiogenic pulmonary edema. The AB profile on the right is when you see B lines on the left of the chest, but the other chest is normal. So it can mean an isolated disease in left chest, chest pneumonia. So blue protocol was published in 2008. It was a single center, two operator study. And it has a 90% accuracy of being able to tell the pathology found on chest CT. Since the publication of blue protocol, there has been several studies combining lung ultrasound with ECHOs. So this study by Dr. Silver in 2013 combined ECHO with lung to diagnose dyspnea in ICU. It found that multi-organ POCUS led to an improvement in diagnostic accuracy by 20% compared to standard method without use of POCUS. Another scenario that POCUS has been studied, it's a nantraumatic shock in the ICU. This study by Kanji wants to evaluate the outcomes of clinical management guided by POCUS to standard management without POCUS. The study is done in patients with nantraumatic undifferentiated vasopressor-dependent shock, the common question we often have in the ICU. So the limited ECHO in the study includes standard personal lung, short apical full, and subcostal abuse with color flow Doppler. So Dr. Kanji found that patients managed with POCUS had a higher 28 days survival. The patients received less fluid in 24 hours and less stage 3 kidney disease. And they have less need for renal replacement therapy. So ICU management guided by POCUS resulted in less fluid prescription and more inotropic support. So another scenario very applicable to us is evaluating fluid tolerance among patients with sepsis. So this study by Dr. Provasco want to evaluate whether we can identify fluid tolerance among patients with severe sepsis and septic shock. And if we do find these patients, are they more likely to be compliant with sepsis bundle, which is 30 cc per kilo of fluid bolus within three hours of sepsis identification. So for all of us working with Medicare and sepsis committee, we all know how much we like to be compliant with those bundles. So fluid tolerance in the study is defined as an absence of decreased left ventricular ejection fraction, dilated IVC, and decreased IVC respiratory variation. So the study found that patients found to be fluid tolerant by POCUS were more likely to receive the recommended bolus when compared to those who were found to be poorly fluid tolerant or those who did not receive any ultrasound at all. So there was no difference in clinical outcomes between the three groups in 28-day mortality, vasopressor requirement, or need for mechanical ventilation, even among the subgroups of patients with heart failure or chronic kidney disease. So POCUS was not only beneficial in making us compliant with sepsis bundle, but also helping us guide fluid management in septic shock. So we can combine POCUS of heart, lung, DVT, and IVC to make an impact on diagnosis and resuscitate. So in a symphony, music can be created by combining or subtracting the notes. Similarly, can we use ultrasound to subtract or dial down our resuscitation, so-called de-resuscitation? So there has been a lot of focus lately on importance of venous circulation. And POCUS can be used to examine the venous congestion. So this ultrasound protocol is known as VAXESS. It was published in 2020. It evaluates the Doppler flow of hepatic vein, portal vein, and intrarenal vein to examine venous congestion. To make it simple, the vein Doppler in a normal situation should be venous flow, or like mostly in one direction. But once it gets congested, it starts to have bidirectional flow or positile flow without going into details of S and D wave. So the VAXESS protocol was evaluated among patients who underwent cardiac surgery in a single-center cardiothoracic ICU. So patients got POCUS with measurements of venous congestion daily for three days from the day of surgery. And severe venous congestion is graded as VAXESS grade 3 when patients have IVC greater than 2 centimeter. And there are signs of severe congestion in two veins, such as hepatic and portal vein, like I discussed in the previous slide. So the leaf plot from the study displayed the relationship between pretest probability of VAXESS grade 3, which is severe congestion, and the probability of acute kidney injury within one week. So VAXESS grade 3 predicts the risk of AKI within one week from cardiac surgery with the likelihood ratio of 6. In fact, it even outperforms CVP in predicting AKI. So that was in cardiac surgery ICU. So what about in general ICU? So in 2020, Dr. Spiegel's study evaluated venous congestion in general ICU population using POCUS. This study found that hepatic vein abnormality is associated with an increase in major adverse kidney events at 30 days with an odds ratio of 4. So here's a shout out to our nephrology colleagues. We've got to protect that kidney. So we have started with creating music from a single note, but we can combine several notes of music and song into an orchestra. Similarly, we can combine and apply POCUS in our health system. So we saw a glimpse of POCUS potential and predicted ability during the pandemic. This study in France found that COVID lung ultrasound model predicts patients' outcomes better than the standard clinical practice in COVID-19 pneumonia. So this holds the promise of determining which patients shall be prioritized coming to the ICU, especially because our ICU beds are becoming so limited. We may be able to apply POCUS in predictive modeling in the case of future pandemics. Hopefully not for all of us who got burned out. So what about in resource-limited settings? As we are all sitting in a perfectly air-conditioned conference room in a desert metropolis, I'm sure it's hard to imagine how POCUS is beneficial in resource-limited setting. But several studies have been done in India, Nepal, and Rwanda to see if POCUS can be used in the workup of dyspnea. So POCUS led to the diagnostic accuracy of 88%, change in diagnosis of 44%, and change in management of 53%. So even if we are privileged and practice in a resource-rich settings, we can still use POCUS in resource-limited situations. One situation is in war emergency, like rapid response and code blue situations before patients arrive to the ICU. So POCUS led to an improvement in immediate diagnosis during these emergency, 94% compared to 80% in control group. Time to first treatment or intervention was shorter in the POCUS group, 15 minutes versus 34 minutes. So POCUS can be applied in the entire hospital system. And we can use POCUS to rapidly triage those who need the ICU. So in summary, I have discussed so far about POCUS in early and late management of ICU care for patients with dyspnea, shock, or sepsis. POCUS can be used in resuscitation or de-resuscitation. POCUS has many applications in the health system, from ICU triage, predictive modeling situations, to applying in resource-limited setting. So what's the future of POCUS? Is portability and adaptability has emerged into applying it beyond more than stethoscope. I'll even argue that POCUS applications can extend to health system management and triaging patients to ICU. We can be the conductor of our own orchestra and determine how much we will allow POCUS to make changes in our health system. Thank you.

POCUS

ICU management

diagnostic accuracy

BLUE protocol

VExUS protocol