Surgeon-performed ultrasound: endorectal ultrasound

Endorectal (ERUS) and endoanal (EAUS) ultrasound imaging is increasingly being performed by surgeons in the office and outpatient setting for the assessment of both benign and malignant disease.Multiple studies have demonstrated the accuracy of these modalities in identifying pertinent anatomy and anatomic abnormalities.The ultrasound is easily tolerated by most patients, and is easily performed with minimal preparation on the patient's part. The ability of the surgeon to perform and interpret this straight forward diagnostic procedure allows for the simplification of the diagnostic process and a more rapid determination of treatment options for the patient.     

Surgeon-performed ultrasound in the ICU setting

Evaluation of critically ill patients is often challenging due to altered sensorium, underlying disease, and the presence of multiple drains or monitoring devices. In such circumstances, the ability of physicians to perform ultrasound examinations in the intensive care unit provides a useful diagnostic and therapeutic adjunct. In this article,we review the application of surgeon-performed ultrasonography in the evaluation and management of critically ill patients.     

Surgeon-performed ultrasound in the critical care setting: its use as an extension of the physical examination to detect pleural effusion

BACKGROUND: Critically ill surgical patients are often difficult to assess for complications because of their altered sensorium, multiple monitoring devices, and immobility. Surgeon-performed ultrasound may enhance the physical examination of these patients and provide for an early detection of select complications. We hypothesized that a focused thoracic ultrasound examination could reliably detect a pleural effusion and the results could be used in the decision matrix for patient care. METHODS: Serial focused thoracic ultrasound examinations were performed by a surgeon and a medical student on critically ill patients. The medical student learned select facets of the physical examination and then demonstrated how ultrasound imaging could enhance these findings. Ultrasound images were recorded on hard copy and videotape, with the results available to the surgical intensive care unit and surgery teams. The images were reviewed and compared with the chest radiograph readings. RESULTS: Forty-seven patients underwent 140 ultrasound examinations. There were 85 true-negative, 46 true-positive, 9 false-negative, and zero false-positive examination results, yielding an 83.6% sensitivity, 100% specificity, and 94% accuracy. Of the 46 true-positive results, thoracentesis was performed or a thoracostomy tube was placed in 5 patients. Nine false-negative ultrasound examinations occurred in six patients, five of whom had their effusions detected on computed tomographic scans. CONCLUSION: A focused thoracic ultrasound examination reliably detects pleural effusions in critically ill patients, and the results can be used successfully in the decision matrix for patient care.     

Surgeon-performed ultrasound imaging in acute surgical disorders

As the role of the general surgeon continues to evolve, the surgeon's use of ultrasound imaging will surely influence practice patterns, particularly for the evaluation of patients in the acute setting. With the use of real-time imaging, the surgeon receives "instantaneous" information to augment the physical examination, to narrow the differential diagnosis, or to initiate an intervention. With select ultrasound examinations, the surgeon can rapidly evaluate adult and pediatric patients with an acute abdomen, especially those patients who are hypotensive. In the hands of the surgeon, this noninvasive, bedside tool can assess more accurately the presence, depth, and extent of an abscess, confirm complete aspiration, or diagnose wound dehiscence before it is apparent on physical examination. Ultrasound imaging is so accurate for the diagnosis of pyloric stenosis that it has essentially replaced the upper gastrointestinal series in most institutions. The surgeon's use of ultrasound imaging to detect a pleural effusion has virtually supplanted the lateral decubitus radiograph. Furthermore, an ultrasound-guided thoracentesis not only facilitates the procedure but improves its safety. As surgeons become more facile with ultrasound imaging, it is anticipated that other uses will develop to further enhance its value for the assessment of patients in the acute setting.     

Surgeon-performed ultrasound in the management of thyroid malignancy

Surgeon-controlled real-time ultrasound (US) is a new adjunct in the management of patients with thyroid malignancy. The introduction of US as a routine evaluation tool has increased the recognition of nonpalpable thyroid cancers and cervical lymph node metastases. We report our experience and the change in management of patients with thyroid cancer due to the use of US. We reviewed the records of all patients undergoing neck operations for thyroid cancer since 2002. US was performed by a surgeon preoperatively in all patients and intraoperatively when non-palpable cervical lymph nodes were present. Suspicious nonpalpable thyroid nodules underwent US-guided fine-needle aspiration (FNA) for cytology. Seventy-two patients underwent operations for thyroid cancer. US influenced the management in 57 per cent (41/72) of patients. US was useful in 1) identification and guidance for the FNA of nonpalpable cancers in 28 per cent (20/72), 2) identification of nonpalpable nodules in the contralateral lobe in 38 per cent (27/72), 3) preoperative diagnosis of nonpalpable metastatic lymph nodes in 24 per cent (17/72), and intraoperative guidance for their excision. Surgeon-performed US changed and enhanced the pre- and intraoperative management in more than half the patients with thyroid cancer.     

Surgeon-performed ultrasound for pneumothorax in the trauma suite

BACKGROUND: Surgeon-performed ultrasound has become ubiquitous in the trauma suite. Initial reports suggest that sonography may be used for the detection of pneumothorax. The purpose of this study was to evaluate the efficacy of sonography to rule out the presence of a pneumothorax in the trauma population. METHODS: A prospective analysis of 328 consecutive trauma patients at an American College of Surgeons-verified Level I trauma center was undertaken. Thoracic ultrasound was performed before chest radiography. The presence or absence of a "sliding-lung" sign or "comet-tail" artifact was recorded. RESULTS: Of 328 evaluations, there were 312 true-negatives, 12 true-positives, 1 false-negative, 1 false-positive, and 2 exclusions. Specificity, negative predictive value, and accuracy were 99.7%, 99.7%, and 99.4%, respectively. CONCLUSION: Ultrasound is a reliable modality for the diagnosis of pneumothorax in the injured patient. This modality may serve as an adjunct or precursor to routine chest radiography in the evaluation of injured patients.     

Surgeon-performed ultrasound as a diagnostic tool in appendicitis

Purpose

Diagnosing appendicitis may require adjunct studies such as computed tomography or ultrasound (US). Combining a clinical examination with surgeon-performed US (SPUS) may increase diagnostic accuracy and decrease radiation exposure and costs.

Methods

A prospective study was conducted including children with a potential diagnosis of appendicitis. A surgery resident performed a clinical examination and US to make a diagnosis. Final diagnosis of appendicitis was confirmed by operative findings and pathology. Results were compared with radiology department US (RDUS) and a large randomized trial. Analysis was performed using Fisher exact test.

Results

Fifty-four patients were evaluated and underwent SPUS. Twenty-nine patients (54%) had appendicitis. Overall accuracy was 89%, with accuracy increasing from 85% to 93% between the 2 halves of the study. Radiology department US was performed on 21 patients before surgical evaluation, yielding an accuracy of 81%. Surgeon-performed US on those 21 patients yielded an accuracy of 90%. No statistical differences were found between any groups (P > .05).

Conclusion

Accuracy of SPUS was similar to RDUS and that of a large prospective randomized trial performed by radiologists. Furthermore, when the same clinician performs the clinical examination and US, a high level of accuracy can be achieved. With this degree of accuracy, SPUS may be used as a primary diagnostic tool and computed tomography reserved for challenging cases, limiting costs, and radiation exposure.     

Surgeon-performed ultrasound improves localization of abnormal parathyroid glands

With a secure diagnosis of hyperparathyroidism, preoperative localization of abnormal glands is the initial step toward limited parathyroidectomy (LPX). We investigated whether ultrasonography in the hands of the surgeon (SUS) could improve the localization of abnormal parathyroids when sestamibi scans (MIBI) were negative or equivocal. One hundred eighty patients with sporadic primary hyperparathyroidism (SPHPT) underwent preoperative SUS and MIBI scans before LPX guided by intraoperative parathormone assay. When the sestamibi scans were negative, SUS was used to localize the parathyroid, distinguish parathyroid from thyroid tissue, and to guide the intraoperative jugular venous sampling for differential elevation of parathyroid hormone (PTH). Operative findings, intraoperative hormone dynamics, and postoperative calcium levels determined successful localization. MIBI was negative or equivocal in 36/180 (20%) patients: (1) showed no parathyroid gland in 22 patients, (2) suggested an incorrect location for the abnormal gland in 9, and (3) was insufficient in recognizing multiglandular disease in 5. In these 36 patients, the addition of SUS led to the successful identification of the abnormal tissue in 19/36 (53%). In the remaining 17 patients with negative/equivocal scans, the parathyroid could not be clearly visualized by SUS. In these patients, SUS facilitated LPX by aiding preoperative transcutaneous jugular venous sampling for differentially elevated PTH (n=3) and identifying questionable thyroid nodule versus parathyroid tissue (n=1). Overall, SUS was useful in 23/36 (67%) patients with nonlocalizing MIBI scans, thus improving the rate of localization from 80 per cent to 93 per cent (P < 0.01). Surgeon-performed cervical ultrasonography improved the localization of abnormal parathyroids by MIBI scan, adding to the success of limited parathyroidectomy.     

Surgeon-performed ultrasound for the assessment of truncal injuries: lessons learned from 1540 patients.

OBJECTIVE: To determine the accuracy of the Focused Assessment for the Sonographic examination of the Trauma patient (FAST) when performed by trauma team members during a 3-year period, and to determine the clinical conditions in which the FAST is most accurate in the assessment of injured patients. SUMMARY BACKGROUND DATA: The FAST is a rapid test that sequentially surveys the pericardial region for hemopericardium and then the right and left upper quadrants and pelvis for hemoperitoneum in patients with potential truncal injuries. The clinical conditions in which the FAST is most accurate in the assessment of injured patients have yet to be determined. METHODS: FAST examinations were performed on patients with precordial or transthoracic wounds or blunt abdominal trauma. Patients with a positive ultrasound (US) examination for hemopericardium underwent immediate surgery, whereas those with a positive US for hemoperitoneum underwent a computed tomography scan (if they were hemodynamically stable) or immediate celiotomy (if they were hemodynamically unstable- blood pressure < or = 90 mmHg). RESULTS: FAST examinations were performed in 1540 patients (1227 with blunt injuries, 313 with penetrating injuries). There were 1440 true-negative results, 80 true-positive results, 16 false-negative results, and 4 false-positive results; the sensitivity was 83.3%, the specificity 99.7%. US was most sensitive and specific for the evaluation of patients with precordial or transthoracic wounds (sensitivity 100%, specificity 99.3%) and hypotensive patients with blunt abdominal trauma (sensitivity 100%, specificity 100%). CONCLUSIONS: US should be the initial diagnostic modality for the evaluation of patients with precordial wounds and blunt truncal injuries because it is rapid and accurate. Because of the high sensitivity and specificity of US in the evaluation of patients with precordial wounds and hypotensive patients with blunt torso trauma, immediate surgical intervention is justified when those patients have a positive US examination.     

Interpretation and use of FRAX in clinical practice

Summary

The introduction of the WHO FRAX? algorithms has facilitated the assessment of fracture risk on the basis of fracture probability. Its use in fracture risk prediction has strengths, but also limitations of which the clinician should be aware and are the focus of this review

Introduction

The International Osteoporosis Foundation (IOF) and the International Society for Clinical Densitometry (ISCD) appointed a joint Task Force to develop resource documents in order to make recommendations on how to improve FRAX and better inform clinicians who use FRAX. The Task Force met in November 2010 for 3?days to discuss these topics which form the focus of this review.

Methods

This study reviews the resource documents and joint position statements of ISCD and IOF.

Results

Details on the clinical risk factors currently used in FRAX are provided, and the reasons for the exclusion of others are provided. Recommendations are made for the development of surrogate models where country-specific FRAX models are not available.

Conclusions

The wish list of clinicians for the modulation of FRAX is large, but in many instances, these wishes cannot presently be fulfilled; however, an explanation and understanding of the reasons may be helpful in translating the information provided by FRAX into clinical practice.     

The use of propofol for its antiemetic effect: a survey of clinical practice in the United States

STUDY OBJECTIVES: To investigate the use of propofol by anesthesiologists for its antiemetic effect and to compare our findings with published evidence. DESIGN: Anonymous survey of U.S. anesthesiologists. SETTING: American Society of Anesthesiologists' annual meeting. MEASUREMENTS AND MAIN RESULTS: One hundred fifty anesthesiologists were surveyed on how they use propofol to achieve an antiemetic effect. A large majority (84%) of the anesthesiologists surveyed stated they used propofol for its antiemetic effect: 63% of those used propofol for induction only for cases lasting <1 h to achieve an antiemetic effect. In addition 37% used a "sandwich" technique, using propofol at the beginning and end of a case for a similar purpose. There is evidence that the antiemetic effect of propofol is associated with a defined plasma concentration range; mean, 343 ng/mL (10-90% confidence intervals [CI] 200-600 ng/mL). Simulation data demonstrated that after propofol 2 mg/kg, its concentration will drop below 350 ng/mL at 32 min. After 2 mg/kg and 20 mg within 10 min of the end of surgery, its concentration will drop below 350 ng/mL by 7 min after the 20 mg bolus dose. This finding suggests that the plasma concentrations of propofol, when used in these cases, will be below the effective range of antiemetic effect. CONCLUSIONS: Many anesthesiologists used propofol for its antiemetic effect. There is strong evidence for its antiemetic efficacy after anesthesia maintained by a propofol infusion and also for its use in the postanesthesia care unit (PACU). However, there is little evidence to support its use purely at induction of anesthesia or as part of a "sandwich" technique in an attempt to reduce postoperative nausea and vomiting. This is especially true in cases lasting longer than a few minutes.