Diagnostic POCUS is Beneficial in the PICU

Source: Baker DR, Glau CL, Himebauch AS, et al. Evolution and impact of a diagnostic point-of-care ultrasound program in a PICU. Pediatr Crit Care Med. Published online ahead of print July 18, 2024; doi: 10.1097/PCC.0000000000003581.Investigators from the Children’s Hospital of Philadelphia and Evelina London Children’s Hospital conducted a retrospective study to evaluate the impact of implementation of a point of care ultrasound (POCUS) program for PICU clinicians at a large non-cardiac PICU. As part of the program, there is a credentialing process for PICU faculty, including completion of educational units and documentation of POCUS studies performed. PICU fellows have POCUS training as part of their curriculum, and educational materials are made available for other trainees and advanced clinicians. Orders for POCUS studies are placed in the electronic medical record (EMR), and area of focus (cardiac, thoracic, abdominal, other) listed. Clinicians also are requested to complete a QA questionnaire about POCUS studies when performed that includes pre- and post-POCUS pathophysiology understanding and, if understanding of pathophysiology changed because of the POCUS results, changes in management. Images in the QA database may be reviewed by a core group of faculty who are POCUS educational leaders.For the study, the program was assessed during the period 2017–2022. Data on the number and type of POCUS studies performed, based on EMR orders, were reviewed. For POCUS studies included in the QA database, changes in understanding of pathophysiology after the POCUS and subsequent changes in management were documented. Studies reviewed by the POCUS educational leaders also were evaluated.During the study period, 7,201 POCUS studies were ordered. The annual number of POCUS orders increased 94.9% between 2017 and 2022. Cardiac POCUS studies were most commonly ordered (81.0%), followed by thoracic (17.8%) and abdominal (2.0%). Information on 1,930 POCUS studies were included in the QA database, with 81.2% being cardiac POCUS. Understanding of pathophysiology was altered as result of the POCUS in 563 cases (29.2%), including 30.1% of cardiac POCUS studies and 21.5% of non-cardiac POCUS (P = 0.06). Among the cases in which understanding of pathophysiology changed, management was altered in 318 (56.5%). Changes in management as result of POCUS findings occurred more frequently with cardiac than non-cardiac POCUS (56.7% vs 45.1%; P = 0.02). POCUS educational leaders reviewed 1,376 POCUS studies in the QA database. A major disagreement with the performing clinician’s interpretation was noted in 4.6% of these studies, with no difference between cardiac and non-cardiac POCUS (P = 0.84).The authors conclude that POCUS studies in the PICU yielded important clinical information that frequently led to changes in management.Dr Miller-Smith has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.POCUS has been shown through multiple research studies to be a beneficial diagnostic tool for an array of pediatric diagnoses.1 This has included shock, pneumonia, pleural effusions, appendicitis, intussusception, and even forearm fractures, among others. (See AAP Grand Rounds. 2013;29[4]:37 and AAP Grand Rounds. 2017;38[2]:17.)2,3 While many studies have been specific to the ED setting, it is increasingly clear that POCUS has diagnostic benefits in multiple inpatient and outpatient clinical settings.1 The PICU, where ultrasound is used for procedural support, has been an early adopter of diagnostic POCUS. The use of POCUS, however, has been limited by a fragmented approach in training programs, as its use in pediatrics and pediatric fellowships is not mandated by the ACGME.4,5 Without these requirements, institutions have adopted its use differently. The Children’s Hospital of Philadelphia (CHOP), the site of the current study, previously reported on the successful development of a bedside ultrasound program within its PICU.6In the current study, the impact of the CHOP curriculum was assessed. Researchers found that POCUS could be performed accurately by PICU clinicians, improved the understanding of patient physiology, and resulted in a change in clinical management for some participants. They demonstrated that, through the development of their diagnostic POCUS curriculum, they improved clinical understanding and perceived care delivery. While the study is limited by subjective measurements and the possibility of self-selection bias, the results demonstrate the importance of diagnostic POCUS in critical care management.With the growing evidence that the diagnosis of multiple pathologies can be improved with POCUS, it is likely that general pediatricians and other pediatric subspecialists would find similar results with adequate training. Lack of resources, absence of standards, and inadequately trained faculty are barriers to the addition of POCUS training into training programs.4 The addition of POCUS to ACGME Common Program Requirements for pediatrics and pediatric subspecialties5 could help support programs overcome these barriers.POCUS is a useful tool for diagnosis and clinical management in the PICU.One wonders how many additional studies are needed before POCUS is a required part of pediatric residency training and documentation of proficiency in use of POCUS is mandated for board certification. Failure to make these changes is a disservice to pediatricians and to the patients they treat.