Longjohn Mindy, Wan Jim, Joshi Vijay, Pershad Jay
Division of Emergency Services, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA.
Pediatr Emerg Care. 2011 Aug;27(8):693-6. doi: 10.1097/PEC.0b013e318226c7c7.
Currently, pediatric emergency medicine (PEM) physicians have limited data on point-of-care echocardiography (POCE). Our goals were to (1) determine the overall accuracy of POCE by PEMs in assessing left ventricular (LV) systolic function visually, presence or absence of pericardial effusion, and cardiac preload by estimating inferior vena cava (IVC) collapsibility, in acutely ill children in the pediatric emergency department; and (2) assess interobserver agreement between the PEM physician and pediatric cardiologist.
This is a prospective, observational study conducted in an urban, tertiary pediatric facility with an annual census of 67,000 emergency department visits. Patients between the ages of 0 and 18 years meeting 1 or more of the following inclusion criteria were recruited: (1) cardiopulmonary arrest, (2) fluid refractory shock requiring vasoactive infusions, (3) undifferentiated cardiomegaly on chest radiography, and (4) receiving emergent formal echocardiography. All eligible patients underwent POCE by 1 of 2 trained PEM physicians. Dynamic video clips were recorded and reviewed by a pediatric cardiologist who was unaware of the clinical condition of the study patients.
For a period of 18 months, we recruited 70 patients. Diminished LV function was noted in 17, pericardial effusion in 16, and abnormal IVC collapsibility in 35 patients. The κ statistics of agreement between the PEM and the cardiologist for detection of LV function, IVC collapsibility, and effusion were 0.87 (95% confidence interval [CI], 0.73-1.00), 0.73 (95% CI, 0.59-0.88), and 0.77 (95% CI, 0.58-0.95), respectively. The overall sensitivity and specificity of POCE compared with a formal echocardiogram was 95% (95% CI, 82%-99%) and 83% (95% CI, 64%-93%), respectively.
With goal-directed training, PEM physicians may be able to perform POCE and accurately assess for significant LV systolic dysfunction, vascular filling, and the presence of pericardial effusion. The model may be expanded to train physicians to use POCE.
目前，儿科急诊医学（PEM）医生在床旁超声心动图（POCE）方面的数据有限。我们的目标是：（1）确定PEM医生在儿科急诊科对急性病患儿进行床旁超声心动图检查时，通过目测评估左心室（LV）收缩功能、心包积液的有无以及通过估计下腔静脉（IVC）塌陷程度来评估心脏前负荷的总体准确性；（2）评估PEM医生与儿科心脏病专家之间的观察者间一致性。
这是一项前瞻性观察性研究，在一家城市三级儿科机构进行，该机构每年急诊科就诊人数为67000人。招募年龄在0至18岁之间符合以下一项或多项纳入标准的患者：（1）心肺骤停；（2）需要血管活性药物输注的液体难治性休克；（3）胸部X线片显示不明原因的心脏增大；（4）接受紧急正式超声心动图检查。所有符合条件的患者均由两名经过培训的PEM医生中的一名进行床旁超声心动图检查。动态视频片段由一名不了解研究患者临床情况的儿科心脏病专家记录并审查。
在18个月的时间里，我们招募了70名患者。17例患者左心室功能减退，16例有心包积液，35例患者下腔静脉塌陷异常。PEM医生与心脏病专家在检测左心室功能、下腔静脉塌陷程度和积液方面的一致性κ统计量分别为0.87（95%置信区间[CI]，0.73 - 1.00）、0.73（95%CI，0.59 - 0.88）和0.77（95%CI，0.58 - 0.95）。与正式超声心动图相比，床旁超声心动图的总体敏感性和特异性分别为95%（95%CI，82% - 99%）和83%（95%CI，64% - 93%）。
通过目标导向培训，PEM医生或许能够进行床旁超声心动图检查，并准确评估显著的左心室收缩功能障碍、血管充盈情况以及心包积液的存在。该模式可扩展用于培训医生使用床旁超声心动图。
