Authors: Bret S. Stetka, MD et al
Editor’s Note: Medscape recently interviewed Stephen Caleb Haskins, MD, a clinical assistant professor of anesthesiology at Hospital for Special Surgery (HSS) in New York City, about the emerging role that point-of-care ultrasound is playing in his field.
Medscape: To start, what is point-of-care ultrasound?
Dr Haskins: Point-of-care ultrasound is utilizing ultrasound at the bedside. We’re encouraging clinicians to both obtain as well as interpret images of potential pathologies—in many cases, life-threatening pathologies—to improve patient care. We like to think of it as the 21st-century version of the stethoscope.
We’re now in a position where this technology is ubiquitous and incredibly portable. There are handheld ultrasound devices that literally fit in your pocket and allow you to walk bedside to bedside and use ultrasound to look inside your patient. This is a very effective tool for rapidly diagnosing certain pathologies that can be severe and life-threatening, while more effectively managing the patient.
Medscape: What sorts of conditions and patients are you using this with?
Dr Haskins: We use it in a variety of scenarios. I currently help plan a course through the American Society of Regional Anesthesia and Pain Medicine (ASRA) that will be teaching doctors how to use a comprehensive point-of-care ultrasound exam to evaluate the airway, lung, and heart, and to also look at gastric contents and assess for intraperitoneal fluid via the focused assessment with sonography for trauma (FAST) exam. We will teach how to identify pathology like pneumothorax, hemothorax, and pleural effusions. We will also teach how to assess the heart for cardiac pathology such as pericardial effusions and signs of pulmonary embolism, as well as obvious valvular disease such as severe aortic stenosis.
There is also a gastric element that allows us to determine whether patients scheduled for emergent or urgent surgery have a full stomach, which increases their risk for aspiration upon induction of anesthesia. We will also teach trauma assessment via the FAST exam. This is something that has recently been shown to be somewhat helpful to the anesthesiologist.
I recently had a publication in Anesthesia and Analgesia that looked at the use of the FAST exam to identify patients who have fluid extravasation from their hip into their peritoneum following hip arthroscopy. At our institution, we’ve had patients present with symptoms ranging from increased pain after surgery to something as severe as abdominal compartment syndrome as a result of the fluid extravasation.
Medscape: Is it mostly surgical patients you’re looking at?
Dr Haskins: We teach this to be a truly perioperative skill set. For the anesthesiologist, we primarily work in a presurgical, intraoperative, and postoperative environment. That’s where we’re teaching how to use this skill and where we feel it’s going to be most effective for anesthesiologists. But point-of-care ultrasound is something that’s also used by emergency medicine physicians on a regular basis for trauma assessment.
There’s even been a movement by cardiologists to do a prescreening in the office with a point-of-care machine. They use the findings to determine whether a patient needs a full echocardiogram to look for signs and symptoms that are suggestive of heart or valvular disease. Its implications are quite broad, and I truly believe that it is the future standard of care for most medical fields. Because I’m an anesthesiologist, my focus is on creating awareness and educating within our community first.
Dr Haskins: Yes. The course that we have been teaching at HSS—which is the focus assessed transthoracic echocardiography, or FATE, protocol—emerged in Denmark about 25 years ago. When it comes to the echocardiography aspect of point-of-care, to be somewhat diplomatic, in Europe they are not quite as territorial as we are when it comes to billing and things of that nature. As ultrasound became more widely available, the benefit of having critical care clinicians, anesthesiologists, and emergency medicine physicians looking at the heart to identify these types of obvious and life-threatening pathologies became clear. The cardiologists embraced it earlier because they realized they can’t be at every code or assess every patient who is hemodynamically unstable.
Now the momentum has shifted and we’re starting to see that there’s a real benefit for it in the United States as well. I think the tipping point came when we embraced ultrasound for things like vascular access, such as central- and arterial-line placement, and also for nerve blocks. We started to say, “These machines are ubiquitous in most anesthesia practices. Why don’t we start finding other ways to use them to help improve patient care?”
Medscape: Who have been the FATE course participants at HSS?
Dr Haskins: The FATE courses at the hospital have been a combination of CME-accredited courses with clinicians from all over the country—and in some cases, the world—who come to learn this point-of-care exam. The vast majority of them have been anesthesiologists because this is a well-known entity in the anesthesia world.
We’ve also taught our residents and fellows through non-CME-accredited courses. Although the vast majority are anesthesiologists, I think the demand for this skill is going to extend well beyond anesthesia in the not-so-distant future.
Medscape: Is this something our Medscape clinician readers can enroll in?
Dr Haskins: Yes. And to clarify, there are two courses when it comes to FATE. There’s a basic FATE course and there’s an advanced FATE course. The basic FATE course teaches fundamental skills—essentially, where to put a probe on a patient’s chest and how to obtain basic views to evaluate for obvious pathology and assess cardiac function. This skillset is the most important one that the vast majority of general practitioners need, and that is what we’ve been teaching primarily.
Now that we’ve trained almost 200 clinicians at HSS and I’m now leading courses at other institutions around the country, not as many people need to come to HSS to get this basic FATE training. So we’ve decided to provide an opportunity to get more advanced training. The advanced FATE course teaches how to use echocardiography in more nuanced ways that aren’t necessary for the general practitioner but which will advance their ability to assess cardiac pathology in a perioperative setting.
The advanced FATE course is open to all-comers, but we highly recommend that anyone taking the course already have some form of basic focused cardiac ultrasound training before showing up, in order to get the most out of the course. The expectation is that they know how to obtain all of the fundamental views and do all of the basic calculations; this course is going to build on those skills.
Medscape: To close, what is the primary reason that point-of-care ultrasound skills are beneficial to anesthesiologists?
Dr Haskins: When it comes to point-of-care ultrasound for the anesthesiologist, specifically cardiac ultrasound, it’s helpful to put it in the clinical context. For example, imagine a weekend call without a lot of ancillary support, and an urgent case comes in—maybe a hip fracture on an older patient without a recent medical assessment. It is difficult to determine whether a patient like this should be taken to the OR for urgent surgery or whether surgery should be postponed for another day so that a complete cardiac evaluation can be ordered. Focused cardiac ultrasound becomes an additional tool, beyond the ECG, chest x-ray, and physical exam, to determine appropriate management by looking inside the patient to determine whether he or she has a fairly normal-looking heart and lungs, or whether there are signs of obvious pathology that could be missed on physical exam or by our standard imaging modalities, but which might put them at increased operative risk.
That makes a huge difference in terms of clinical decision-making. Is it safe to take this patient to the OR should surgery be postponed? Will I change my management intraoperatively on the basis of the findings? Should this patient be sent for standard postoperative care or do they need to be stepped up to an ICU-type setting? Additionally, for patients who are hemodynamically unstable, this can guide therapy. It can give insight into whether the patient is hypovolemic and will therefore be volume responsive. Or, alternatively, it can point out a new cardiomyopathy, pulmonary embolism, or large fluid collection around the heart or the lungs that is causing the instability. To be able to rapidly narrow down your differential diagnosis and change management makes a massive difference in the postoperative setting.
With our courses, we put this skill in the context of a patient with a large differential diagnosis requiring rapid intervention. Being able to looking inside does provide a great deal of clarity.