ResUS in the Literature: Serial FEEL and Termination of Resuscitation

Journal: Resuscitation

Date:April 2016

Format: Prospective Observational Study

Method: A prospective observational study of non-consecutive non-trauma adult patients with out of hospital cardiac arrest (OHCA) using the ResUS FEEL protocol. ResUS was performed every two minutes during pulse check for <10s throughout resuscitation and findings were recorded as video clips.

Results: 

• 48 patients enrolled
• ROSC patients had standstill for 2.86 ± 2.07min
• Non-ROSC patients had standstill for 20.30 ± 8.42min
• Standstill ≥10min predicts non-ROSC with a sensitivity of 90.0% and specificity of 100%.
• The presence of cardiac activity on initial FEEL was not identified in 40 patients, but 21 had ROSC. 

Figure: A receiver operating characteristic (ROC) curve determining the accuracy of serial echocardiographic cardiac standstill duration for predicting non-return of spontaneous circulation. The area under the receiver operating characteristic curve is 0.991 (p < 0.001).


Commentary: We have seen previously that loss of cardiac activity on ResUS is a strong negative predictor of ROSC. Current study authors note cardiac standstill on initial ResUS could not predict non-ROSC and cannot be used as a TOR rule, arguing that serial ResUS can better determine ROSC.

Of note in this study:
-clinicians were not blinded to the echocardiography findings (bias). 
-patients were committed to the same 30 min duration of resuscitation
-efforts were terminated early in no patients.
-unlike other studies, videos were recorded and reviewed

Question:
What was the duration of cardiopulmonary resuscitation prior to ED arrival?

References:

Kim HB, Suh JY, Choi JH, Cho YS. Can serial focussed echocardiographic evaluation in life support (FEEL) predict resuscitation outcome or termination of resuscitation (TOR)? A pilot study. Resuscitation. 2016 Apr;101:21-6.

ResUS in the Literature: Finally!! A Fluid ResUS Protocol

Journal: Journal of Critical Care

Date: Feb 2016

Format: Review 

The authors review and present an "evidence-informed protocol" of fluid resuscitation strategies using ResUS. 

In particular:

• The role of IVC  ResUS for estimating fluid responsiveness, with particular attention to:
• IVC distensibility
• IVC diameter
• IVC collapsability
• Lung ResUS guided fluid resuscitation with particular attention to
• Identifying pulmonary edema
• Step-wise approach to performing their IVC + Lung integrated ResUSprotocol for fluid resuscitation, fluid testing, and fluid restriction. 

Commentary: Its about time someone has suggested a clean, simple, and elegant method for integrating ResUS into the fluid resuscitationstrategy beyond looking at the IVC. Most impressive is that cardiac ResUS not included in this protocol, opening the possibility of non-expert (and even non-MD) use in patient care. The proposed protocol has not been validated. Looking forward to the prospective trails.

Reference:  
Lee CW, Kory PD, Arntfield RT. Development of a fluid resuscitation protocol using inferior vena cava and lung ultrasound.J Crit Care. 2016 Feb;31(1):96-100. 

ResUS in the Literature: Technological Requirements

Journal: Anesthesiology Intensive Therapy

Date: November 2015

Format: Review

The authors put forth technological and machine requirements needed to perform ResUS using the SESAME protocol. 

In the article, the authors review:

• The role of ResUS in cardiac arrest
• Ideal equipment specifications including: 
• size
• "boot up" time 
• transducer selection(s)
• imaging filters
• presets 
• keyboard specs, 
• gain, depth and B-Mode functionality.
• Step-wise approach to performing the SESAME protocol along with regionally specific technical considerations
• Common sense strategies to fine-tune the SESAME protocol, such as have an AED or percardiocentesis kit integrated onto the machine cart.

Commentary: Technical innovation has occurred rapidly in the field of point of care ultrasound, and yet there are few studies on the minimum requirements of ultrasound equipment in the setting of cardiac arrest. The authors suggest some minimum machine requirements for performing the SESAME protocol, although there is little empiric data to support their recommendations. A discussion regarding the pros and cons of the various machine functions and technical requisites seems long overdue.The SESAME protocol itself has not been validated.

Reference:
Lichtenstein D, Malbrain ML.Critical care ultrasound in cardiac arrest. Technological requirements for performing the SESAME-protocol - a holistic approach. Anaesthesiol Intensive Ther. 2015;47(5):471-81.

Posted by: A Adedipe, MD