藉由在病床边使用超音波 研究医师可以指出肺栓塞位置


  【24drs.com】根据一篇单一中心研究的结果,对于怀疑患有肺栓塞的患者,肺部与重症照护研究医师与专责主治医师可以使用具有可接受之精准度的快速照护现场超音波。
  
  领衔研究者、纽约市西奈山贝斯以色列医院的Jason Filopei医师表示,坦白地说,透过最少的培训,研究医师就可以做得相当不错。
  
  同样来自西奈山贝斯以色列医院的资深研究者Samuel Acquah医师表示,通常,是由心脏科医师完成这项检查,但是不一定找得到心脏科医师执行;那么,你要如何能够安全、快速地执行它,且随时都可以操作呢?这就是需要训练精于这些操作的学员之处。
  
  他报告指出,藉由一些基本训练,研究医师可以准确地执行检测。
  
  但是,并非所有人都同意。意大利Varese Insubria大学血栓栓塞性疾病和抗栓塞治疗研究中心的Alessandro Squizzato博士表示,我不同意这些结论;在这篇研究中,充分训练之肺部与重症照护研究医师的准确度仍未臻理想。
  
  研究结果以墙报方式发表于「CHEST 2016:美国胸腔科医师学院年会」。
  
  在这篇研究中,由完成3天现场超音波介绍课程的肺部与重症照护研究医师进行病床边超音波。
  
  Filopei医师解释,研究医师在病床边评估了60名患者的右心室大小与功能。
  
  为了比较,所有患者也进行了经胸壁心超—由超音波专家执行,并由委员会认证的心脏科医师分析。
  
  另外,44例病床边超音波检查由有5年以上超音波经验的肺部与重症照护主治医师进行。
  
  与由超音波专家进行的经胸壁心超进行准确度比较时,Filopei医师报告指出,肺部与重症照护研究医师的诊断准确度是可接受的,合并敏感度与专一度时,他们的整体正确诊断率约为80%。
  
  他指出,专责主治医师做得更好,在许多案例,准确度大于90%。
  
  但是,根据Squizzato医师指出—参与了最近一篇照护现场超音波用于肺栓塞之研究(Crit Ultrasound J. 2015;7:7) —敏感度93%意谓著7%的伪阴性比率,专一度86%意谓著14%的伪阳性比率。
  
  他表示,这是过高的伪阳性与伪阴性,就我的观点,对于肺栓塞这个潜在致命的疾病,这是不可接受的。
  
  Filopei医师指出,但是,时机是其中一个重要的考虑因素。
  
  他解释,对于急性肺栓塞患者,最初24小时的死亡风险最高;平均而言,现场超音波可以比经胸壁心超提早一天进行,平均时间差达25小时31分钟。
  
  Filopei医师表示,这是一个可行的选择,当你周遭没有超音波专家可以适当地进行风险分类,但是你现场有受过充分训练、足以执行的一些人力时,专责主治医师与肺部研究医师可以安全地执行它且有高度准确度。
  
  资料来源:http://www.24drs.com/
  
  Native link:With Bedside Ultrasound, Fellows Can Spot Pulmonary Embolism

With Bedside Ultrasound, Fellows Can Spot Pulmonary Embolism

By Kate Johnson
Medscape Medical News

LOS ANGELES — For patients suspected of having pulmonary embolism, pulmonary and critical care fellows and intensivists can use rapid point-of-care ultrasound with acceptable accuracy, according to results from a single-center study.

"In all honesty, with minimal training, fellows can do a pretty good job," said lead investigator Jason Filopei, MD, from Mount Sinai Beth Israel Hospital in New York City.

"Normally, the exam is done by cardiologists, who are not routinely available. So how can you do it safely and quickly and have it available all the time? That's where having trainees who are adept at doing the procedure comes in," said senior investigator Samuel Acquah, MD, also from Mount Sinai Beth Israel Hospital.

"With some basic training, fellows are able to perform the test appropriately," he reported.

But not everyone agrees. "I would definitely downgrade these conclusions," said Alessandro Squizzato, MD, PhD, from the Research Center on Thromboembolic Disorders and Antithrombotic Therapies at the University of Insubria in Varese, Italy.

"The accuracy of well-trained pulmonary and critical care fellows in this study is still suboptimal," he told Medscape Medical News.

The findings were presented as a poster here at CHEST 2016: American College of Chest Physicians Annual Meeting.

In the study, bedside ultrasound was performed by pulmonary and critical care fellows who had attended a 3-day introductory course on point-of-care ultrasound.

The fellows evaluated right ventricular size and function at the bedsides of 60 patients, explained Dr Filopei.

For comparison, all patients also underwent a transthoracic echocardiogram performed by an expert sonographer, which was analyzed by a board-certified cardiologist.

In addition, 44 of the bedside ultrasound examinations were available for overread by a pulmonary and critical care attending physician who had more than 5 years of ultrasound experience.

In comparison with the accuracy of transthoracic echocardiography performed by an expert sonographer, "the diagnostic accuracy of pulmonary and critical care fellows was acceptable," Dr Filopei reported. "They're hitting diagnostic accuracies of about 80% overall, when you combine sensitivity and specificity."

"And intensivists did much better," he added, with accuracies of "greater than 90% in many cases."

For pulmonary embolism, a potentially fatal disease, this is not acceptable. Dr Alessandro Squizzato

But according to Dr Squizzato — who was involved in a recent study of point-of-care ultrasound for the diagnosis of pulmonary embolism (Crit Ultrasound J. 2015;7:7) — "a sensitivity of 93% means a 7% false-negative rate, and a specificity of 86% means a 14% false-positive rate."

That is "too many false positives and false negatives," he said. "For pulmonary embolism, a potentially fatal disease, this is not acceptable from my point of view."

But timing is an important consideration in the equation, Dr Filopei pointed out.

"For acute pulmonary embolism patients, risk of death is greatest in the first 24 hours. On average, point-of-care ultrasound was performed 1 day earlier than transthoracic echocardiogram, with an average time difference of 25 hours and 31 minutes," he explained.

This is a viable option "when you don't have a sonographer accessible to appropriately risk-stratify but you do have boots on the ground that are capable of doing it with some level of training," Dr Filopei said. "Intensivists and pulmonary fellows can do it safely with a high degree of accuracy."

Dr Filopei, Dr Acquah, and Dr Squizzato have disclosed no relevant financial relationships.

CHEST 2016: American College of Chest Physicians Annual Meeting. Presented October 26, 2016.

    
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