Point-of-care ultrasonography in Brazilian intensive care units: a national survey

Point-of-care ultrasonography in Brazilian intensive care units: a national survey Background: Point-of-care ultrasonography (POCUS) has recently become a useful tool that intensivists are incorpo- rating into clinical practice. However, the incorporation of ultrasonography in critical care in developing countries is not straightforward. Methods: Our objective was to investigate current practice and education regarding POCUS among Brazilian inten- sivists. A national survey was administered to Brazilian intensivists using an electronic questionnaire. Questions were selected by the Delphi method and assessed topics included organizational issues, POCUS technique and training patterns, machine availability, and main applications of POCUS in daily practice. Results: Of 1533 intensivists who received the questionnaire, 322 responded from all of Brazil’s regions. Two hundred and five (63.8%) reported having access to an ultrasound machine dedicated to the intensive care unit (ICU); how- ever, this was more likely in university hospitals than in non-university hospitals (80.6 vs. 59.6%; risk ratio [RR] = 1.35 [1.16–1.58], p = 0.002). The main applications of POCUS were ultrasound-guided central vein catheterization (49.4%) and bedside echocardiographic assessment (33.9%). Two hundred and fifty-eight (80.0%) reported having at least one POCUS-trained intensivist in their staff (trained units). Trained units were more likely to perform routine ultrasound- guided jugular vein catheterization than non-trained units (38.6 vs. 16.4%; RR = 2.35 [1.31–4.23], p = 0.001). The proportion of POCUS-trained intensivists and availability of a dedicated ultrasound machine were both independently associated with performing ultrasound-guided jugular vein catheterization (RR = 1.91 [1.32–2.77], p = 0.001) and (RR = 2.20 [1.26–3.29], p = 0.005), respectively. Conclusions: A significant proportion of Brazilian ICUs had at least one intensivist with POCUS capability in their staff. Although ultrasound-guided central vein catheterization constitutes the main application of POCUS, adherence to guideline recommendations is still suboptimal. Keywords: Ultrasonography, Critical care, Survey economic, and structural characteristics in which the Background practitioner is working. POCUS assists physicians to Point-of-care ultrasonography (POCUS) has recently diagnose different causes of clinical deterioration and become a useful and widely disseminated tool that inten- respiratory and/or hemodynamic failure, to tailor medi- sivists are incorporating into clinical practice. Assimi- cal interventions (e.g., fluid therapy and mechanical ven - lation timeframe varies according to the geographic, tilation adjustments), and to guide invasive procedures [1–3]. Despite guidelines that recommend the use of POCUS *Correspondence: rlcordioli@gmail.com Department of Intensive Care Unit, Hospital Israelita Albert Einstein, 627, in different scenarios of critical care [ 3, 4], the incorpo- Albert Einstein St., São Paulo 05652-900, Brazil ration of ultrasonography into clinical practice is not Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Pellegrini et al. Ann. Intensive Care (2018) 8:50 Page 2 of 8 straightforward. For central venous catheterization course encompasses physical principles of ultrasound, (CVC), recent data showed that 18% of French intensiv- knobology, echocardiographic and lung ultrasound basic ists reported that they routinely use ultrasonography [5], techniques, as well as incorporating supervised, practical while 44% and 37% of emergency medicine specialists [6] activities to allow participants to demonstrate expertise and anesthesiologists [7], respectively, reported never acquisition. using ultrasonography for CVC guidance. Questions were selected using the Delphi method. Four Previous studies assessed the implementation of of the authors developed a set of questions of interest, POCUS in critical care [5, 8–10]. Methodologies for which were then subjected to three rounds of apprecia- collecting data were varied: while some authors applied tion. One author served as a facilitator, assessing agree- electronic mailing and waited for spontaneous return, or ment among the other three authors and providing based their findings on self-reported previous experience, feedback between rounds. Rounds were stopped when others adopted cross-sectional epidemiological sampling consensus was reached for all questions in the set. No consisting of punctual observations [9]. Similar studies physical meetings occurred. All of the panel members revealing ultrasonographic patterns of use in intensive are formally certified intensivists and well-known experts care units (ICUs) in developing regions are still lacking. in POCUS techniques and teaching. Three of the panel Brazil’s large territory and policies of public health sys- members are from the board of the ECOTIN group. tem organization lead to challenges in access of health The survey consisted of 32 questions (Additional file  1) care personnel to the population, access to medical edu- assessing the geographic location, type of hospital and cation, and the incorporation of new technologies into type of ICU, availability of an ultrasound (US) machine, clinical practice. Therefore, precise information about training in POCUS techniques, use and daily practice of regionalization, training methods, and preferential appli- US-guided CVC and other applications of POCUS (e.g., cations could help guide national entities in achieving echocardiography, measuring the optic nerve sheath more efficient dissemination of ultrasonography across diameter, lung and abdominal studies), medical resi- Brazilian ICUs, potentially improving the quality of deliv- dents’ education in POCUS, and perceived barriers to ered care. the implementation of ultrasonography. All questions Surveys are standard tools that are increasingly used focused on POCUS performed by intensivists, not on for assessing various aspects of health care, including complementary exams done by other physicians (e.g., educational, technological, and organizational aspects radiologist or cardiologist). Skip logic was used when [11], as well as for investigating translation from scientific appropriate to ease the burden on respondents. research to clinical practice [12]. Consisting of descrip- A web-based platform (S urveyMonkey , www.sur- tive or explanatory questions, surveys can support the veymonkey.com) was used for the survey according to incorporation of medical evidence in current patient recent recommendations [12]. Initially, a group of 12 ICU care. physicians tested the questionnaire. After an interval of Therefore, the purpose of our study was to utilize a sur - 3  weeks, a retest was performed by the same 12 physi- vey to assess current practice and education of POCUS cians to verify reliability. The survey was physician-cen - by Brazilian intensivists, as well as to assess the dissemi- tered and was directly sent to intensivists subscribed to nation of ultrasonography and main applications in ICUs the AMIBnet mailing list. The questionnaire was avail - across Brazil. By evaluating the frequency of use and able for 6 months (from September 2016 to March 2017). barriers of implementing ultrasonography, we can iden- Reminders were sent via e-mail to potential participants tify gaps in medical education and incorporate recom- on three occasions, every 2 months. mended clinical practices to critical care. Survey respondents were stratified according to the training status of POCUS: trained versus non-trained. Methods Trained status was dependent on having at least one This study was conducted with the logistic support of intensivist with formal POCUS training working in the AMIBNet (the Brazilian network of research in intensive ICU staff. Additionally, questions gathered data on the care) and Ecografia em Terapia Intensiva (ECOTIN), the proportion of staff that were trained in POCUS. national training program of POCUS for intensivists. No financial support was received from any source. Statistical analysis The ECOTIN program is an initiative of the Brazil - Categorical variables were presented as absolute num- ian Intensivists Medical Association (AMIB), which bers and percentages and compared using the Chi- was conceived in 2010. It consists of a board of POCUS square test with standardized adjusted residuals analysis experts who developed a teaching method and conduct (for tables larger than 2 × 2) and the Fisher exact test short duration courses throughout Brazil. The ECOTIN (for 2 × 2 comparisons). A two-sided p value < 0.05 was Pellegrini et al. Ann. Intensive Care (2018) 8:50 Page 3 of 8 considered statistically significant. Risk ratios (RRs) and Table 1 Baseline characteristics of the study population 95% confidence intervals were calculated for associated Characteristic n (322) measurements. Region within Brazil Multivariate analysis through Poisson linear models Southwest 191 (59.7) with robust estimation were constructed to identify vari- South 58 (18.1) ables that are independently associated with an impor- Northeast 43 (13.4) tant quality-of-care marker: US-guided internal jugular Central-West 19 (5.9) vein (IJV) puncture, in compliance with international North 9 (2.8) guidelines [13–15]. A priori interest factors were those Hospital’s type plausibly associated: the type of institution (university Private 148 (46) vs. non-university), presence of an intensivist on a daily Public 107 (33.2) basis, availability of a dedicated US machine, intensiv- University 67 (20.8) ists’ formal certification in critical care, proportion of ICU type POCUS-trained intensivists (low vs. high level), and Mixed, clinico-surgical 231 (72) payoff. For the construction of the multivariate model, Clinical 43 (13.4) we used forced simultaneous entry—all candidate vari- Pediatrics 22 (6.8) ables remained in the model regardless of statistical sig- Surgical 13 (4.0) nificance. Outputs from this analysis are summarized as Trauma 12 (3.7) RRs. All analyses were performed using Statistical Pack- Number of beds age for Social Science (SPSS), version 21.0 (IBM Corp., < 10 130 (40.5) Armonk, NY, USA). 11–20 107 (33.2) 21–40 47 (14.6) Results > 41 37 (11.5) Characteristics of the study population Attendance of a certified intensivist during daily rounds From September 2016 to March 2017, 1533 intensiv- Full-time (morning and afternoon) 151 (46.9) ists were contacted by electronic mail. Of these, 322 Part time (morning or afternoon) 152 (47.2) responded (20.7% response rate) from all Brazilian None 19 (5.9) regions. Of the units where respondents were working, ICU intensive care unit private hospitals represented 46% while clinical-surgical units represented 72%. Three hundred and three units (94%) had a certified ICU physician attending daily Competence and training of POCUS rounds (Table 1). Two hundred fifty-eight (80.0%) respondents reported to Two hundred and five (63.8%) of the respondents have at least one intensivist with formal POCUS train- stated that they had access to a US machine dedicated to ing working in their staff (Table  3). We designated these the ICU (Table 2). There were disparities throughout Bra - as trained units for the following comparisons. We did zil’s territory in this subject (p = 0.017). Availability of a not identify significant differences across Brazil’s terri - dedicated US machine was more likely in university than tory according to training. The most frequently reported in non-university hospitals (80.6 vs. 59.6%, respectively; training structure was one- to two-day courses (65%). RR = 1.35 [1.16–1.58], p = 0.002). ECOTIN trained 53% of the participants. The imple - US-guided CVC was the main indication of POCUS, mentation of the ECOTIN training method was associ- representing 49.4% of indications, followed by bedside ated with the type of hospital: 67 and 49% of university echocardiography (33.9%). Pleuropulmonary and abdom- and non-university hospital workers reported ECOTIN inal ultrasonographic examinations were infrequently training, respectively (RR = 1.35 [1.1–1.67], p = 0.013). reported (8.5 and 8.2%, respectively). According to 59% ECOTIN training prevalence was heterogeneous among of the respondents, chest x-rays are performed on a daily Brazil’s regions (p = 0.001). basis in more than 50% of the patients. This was nega - Medical residents were present in 69% of the units, tively associated with the frequency of lung ultrasound including critical care medicine residents in 44%. There examination (p =0.028). were no structured training modules for US-guided CVC Sixteen respondents (5.1%) stated that they use a in 54% of cases. Twenty-six respondents (8.1%) said that prespecified form for summarizing data concerning their residents use simulation techniques to learn how to examinations. The exam results images and clips) were perform US-guided CVC. electronically recorded 14.6% of the time. Pellegrini et al. Ann. Intensive Care (2018) 8:50 Page 4 of 8 Table 2 POCUS characteristics Table 3 Medical trainment in POCUS Characteristic n (322) Characteristic n (322) Dedicated ultrasound machine availability Trainment status No 116 (36.1) Yes—ECOTIN 60 (18.7) Yes, without Doppler imaging 35 (10.9) Yes—ECOTIN and other courses 111 (34.6) Yes, with Continuous and Pulsatile Doppler 63 (19.6) Yes—only other courses 87 (27.1) Yes, with Continuous, Pulsatile and Tissue Doppler 107 (33.3) None 63 (19.6) Proportion of patients assessed by POCUS on a regular basis Trainment modality < 10% 124 (39) 1–2 days courses 163 (65.2) 11–25% 100 (31.4) 2 days–1 week 46 (18.4) 26–50% 55 (17.3) 1 week–1 month 8 (3.2) 51–75% 22 (6.9) > 1 month 33 (13.2) > 75% 17 (5.3) Proportion of medical staff trained in POCUS POCUS type < 10% 125 (50) US-guided CVC insertion 156 (49.4) 11–25% 68 (27.2) Cardiac assessment 107 (33.9) 26–50% 38 (15.2) Lung 27 (8.5) 51–75% 11 (4.4) Abdominal 26 (8.2) > 76% 8 (3.2) POCUS recording Medical residents No recording 170 (54.5) Yes—Critical care medicine 138 (44.1) Registered on patient’s records 102 (32.7) Yes—Other specialties 76 (24.3) Electronically stored and registered on patient’s records 47 (14.6) None 99 (31.6) Medical report formally provided 16 (5.1) Medical residents POCUS training modality Payos ff Practice-based only 118 (54.1) None 278 (90.3) Lecture-based trainment available 44 (20.2) Only for the institution 13 (4.2) Simulation-based 26 (11.9) Only for the physician 4 (1.3) No trainment 30 (13.8) For both the institution and the physician 13 (4.2) POCUS point-of-care ultrasound, ECOTIN ecografia em terapia intensiva POCUS point-of-care ultrasound, US ultrasound, CVC central vein catheterization 1000 catheter-days. The two most common approaches As aforementioned, we stratified respondents and their for CVC were the US-guided IJV (36.2%) and landmark- respective units into trained versus non-trained units guided subclavian vein approaches (35.6%). based on self-reporting of training. We observed that the Respondents were questioned about the frequency training status in POCUS affected the pattern of some with which CVC is US-guided in their units. In 22.8% answers (Table  4), such as availability of a dedicated US of cases, IJV catheterization was “always” guided (in line machine, proportion of patients assessed by POCUS and with international guidelines). The most frequent answer the density of certified intensivists. was “only in specific situations” (45%). One hundred The most frequent POCUS applications were distinct thirty-one (40.7%) of the participants classified the rec - according to individual capability (p < 0.001; Fig. 1a): US- ommendations for routine use of ultrasonography when guided CVC and pulmonary ultrasonography was posi- catheterizing the IJV as “weak”. For subclavian access, tively associated with trained individuals. 78% of the respondents reported “rarely” using US, while The status of POCUS training was negatively associ - 5% reported routinely using it; two hundred twenty- ated with exam payoff: fourteen (5.6%) of the trained seven (70.5%) physicians classified the recommendation units reported payoffs, compared to 27.6% of the non- supporting US for subclavian puncture as “weak”. trained units (RR = 0.20 [0.11–0.39], p < 0.001). Patterns of preferences for CVC according to train- ing status are represented in Fig.  1b. US-guided IJV was US‑guided CVC the first choice for trained individuals (41%), in contrast According to the study participants, 58.5% of the units to the landmark-guided subclavian approach (48.4%) for dealt with a monthly incidence density of less than 200 those not trained. Overall, eighty-five percent of non- catheter-days and, in 54.5% of the cases, a catheter- trained individuals preferred landmark-guided CVC. related bloodstream infection of less than 2 events per Pellegrini et al. Ann. Intensive Care (2018) 8:50 Page 5 of 8 Table 4 Competence and POCUS Characteristic Trained (258) Not trained (63) Risk Ratio (95% CI) p value Dedicated ultrasound machine 184 (71.3) 22 (34.9) 2.04 (1.44–2.89) < 0.001 High intensity of certified intensivists 160 (62) 21 (33.3) 1.86 (1.29–2.67) < 0.001 > 10% of patients assessed by POCUS on daily basis 165 (64.7) 29 (46.8) 1.38 (1.04–1.83) 0.013 Routine US-guided IJV catheterization 96 (38.6) 10 (16.4) 2.35 (1.31–4.23) 0.001 Payoff 14 (5.6) 16 (27.6) 0.20 (0.11–0.39) < 0.001 POCUS point-of-care ultrasound, CI confidence interval, US ultrasound, IJV internal jugular vein Fig. 1 Black bars represent trained units; gray bars represent non-trained units. a main types of POCUS application; b preferential venous access site; c perceived strength of recommendation for US-guided jugular vein catheterization; and d main barriers for ultrasound dissemination. See text for full explanation. *differences in prevalences with p < 0.05. US ultrasound, CVC central vein catheterization, IJV internal jugular vein, SCV subclavian vein, LM landmark Physicians’ perception about strength of recommen- Routine US‑guided IJV puncture dation for US-guided IJV catheterization appears to be Routine US (defined as more than two-thirds of the time) affected by their training status. While answers of “rou - was used by 38.6% of the trained individuals compared tine use” or “strong recommendation” were associated to 16.4% of the non-trained ones (RR = 2.35 [1.31–4.23], with trained units, “weak recommendation” was asso- p = 0.001). ciated with non-trained units (p < 0.001; Fig.  1c). For Most of the factors plausibly associated with routine the subclavian route, the same pattern was identified US-guided IJV puncture (as defined above) were sta - (p < 0.001). tistically associated in univariate analysis (all factors Other invasive procedures that were reported to be except payoff). Considering multivariate analysis, two “usually” US-guided included thoracentesis (49%), para- factors maintained independent association: dedicated centesis (31.5%), and arterial line insertion (27%). ultrasound machine availability (RR = 2.20 [1.26–3.29], Pellegrini et al. Ann. Intensive Care (2018) 8:50 Page 6 of 8 p =0.005) and proportion of POCUS-trained intensiv- of ultrasonography of the critically ill. Additionally, we ists (RR = 1.91 [1.32 - 2.77], p = 0.001) (Additional file  2: aimed to directly assess the intensivists and their self- Table S1). perception of training, in contrast to previous studies [9] that designed questionnaires for ICU coordinators Barriers for nationwide dissemination of POCUS regarding their medical staff’s capability. Medical resi - One hundred thirty-three (41.3%) of the respondents dents in Brazil are beginning to learn ultrasonography in answered that physicians’ training was the greatest bar- their education, although this is done in an unstructured rier in the dissemination of ultrasonography across the and potentially heterogeneous way. Brazilian territory. When comparing the types of institu- POCUS training issues are one of the major challenges tions, private hospitals responded differently (p = 0.012); of ultrasound dissemination in Brazil and other low- and in these institutions, limited intensivist time when con- middle-income countries. When heterogeneous training sidering other tasks was more relevant than medical modalities coexist, it is difficult to ensure that all kinds capability or other limitations. of training provide comparable efficacy and competence Main barriers to the dissemination of ultrasonography acquisition. Standardization of training structures, both according to the training status are represented in Fig. 1d. for medical residents and for those already working as Non-trained respondents were more likely to classify the intensivists, is needed, as those training structures influ - availability of a dedicated US machine as the most rele- ence intensivists’ perceptions and use of evidence-based vant barrier (not training itself ) (p = 0.021). practices. Reaching a balance between uniform accessibility to US Discussion machines and achieving minimum requirements of qual- The main findings of this survey can be summarized as ity in care delivery remains an important future objective follows: (1) availability of a dedicated US machine in for Brazil. Realistic simulation should be provided in a Brazilian ICUs is still suboptimal; (2) US-guided CVC method that is scalable and replicable. Medical associa- insertion is the main application of POCUS, followed tions of developing countries should contextualize inter- by echocardiography, and lung ultrasonography is rarely national recommendations on POCUS training [17, 18] performed; (3) a large proportion of assessed intensivists for specific guidelines in Brazilian (and other developing are trained in POCUS, but as there is a predominance country) contexts. of courses with a short duration and workshop struc- Zielezkiewicz et al. [9] demonstrated in a 1-day preva- ture, medical residents are being trained in POCUS in lence study in Europe that 13% of the POCUS examina- an unstructured fashion); and 4) training is associated tions performed were for central venous puncture, and with several aspects of POCUS application, including that nearly half of the CVCs were US-guided. In the US-guided IJV catheterization, an important marker of present survey, we assessed physicians’ self-reporting quality of care regarding ultrasonography in critical care practice, not real procedures; nevertheless, US-guided medicine. CVC insertion was identified as the major indication for Availability of a dedicated US machine is obviously a POCUS by Brazilian intensivists. This behavior was also fundamental aspect for the dissemination of POCUS. more pronounced in environments with a high level of While two-thirds of the respondents in this study training: the proportion of trained staff was identified as reported having this machine in their units, authors in independently associated with adherence to US-guided other countries [8, 16] have reported higher rates. Some IJV puncture. Overall adherence to routine US-guided specific regions in Brazil and non-university hospitals IJV catheterization recommendations was relatively were less likely to have a dedicated US machine. Our low (22.8%), compared to other critical care scenarios results indicated that a dedicated US machine is inde- [19–21]. pendently associated with adherence to US-guided IJV Lung ultrasonography, although infrequently reported, catheterization. also showed a positive association with educational sta- Similar rates of training in POCUS were reported tus. Lung ultrasound prevalence was negatively associ- from 70 to 81% in Europe and the United States [6, 8, ated with routine chest x-ray, indicating a potential role 9], although precise information concerning the train- of POCUS in reducing radiation exposure. This finding, ing structure and specific curriculum is scarce. Other however, is exploratory due to low adherence to lung authors [5] have reported even higher rates. Our results ultrasound examination in this study. Other authors have on this subject, however, are unique: although previous previously reported similar data [22, 23]. studies [5, 6, 8] have focused on specific areas within Our results contrast with other studies, as US-guided POCUS education (e.g., US-guided venous catheteriza- CVC insertion represents the major indication for tion or echocardiography), we assessed general aspects POCUS in Brazil. This could be explained by several Pellegrini et al. Ann. Intensive Care (2018) 8:50 Page 7 of 8 Abbreviations reasons: the evidence concerning CVC guidance is solid, CVC: central venous catheterization; ECOTIN: Ecografia em Terapia Intensiva reducing adverse event rates and improving procedural (ultrasonography in intensive care); ICU: intensive care unit; IJV: internal jugular success; the learning curve for US-guided IJV catheteri- vein; POCUS: point-of-care ultrasonography; RR: risk ratio; US: ultrasound. zation appears to be smoother than, for example, cardiac Authors’ contributions assessment and hemodynamic monitoring; some of the Drs. JASP and LUT had full access to all data and take responsibility for the US machines available in Brazilian ICUs are relatively writing of the manuscript, the integrity of the data and the accuracy of the final analysis. Dr. Ziegelmann was responsible for biostatistical consultation basic technology, and do not offer Doppler techniques or and data interpretation. Dr. Cordioli and Grumann contributed substantially cardiac assessment software. to the study design, data acquisition, and analysis and interpretation of the Our study has several limitations. First, inherent self- results. All authors read and approved the final manuscript. selection bias can influence our results. Physicians who Author details already use ultrasonography were more likely to complete Department of Critical Care Medicine, Hospital de Clínicas de Porto Alegre, the survey; however, we obtained answers from a wide Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil. Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil. range of respondents from all Brazilian regions, repre- Department of Critical Care Medicine, Alemão Oswaldo Cruz Hospital, São senting private and public institutions, as well as clinical, Paulo, Brazil. Department of Critical Care Medicine, Nereu Ramos Hospital, surgical, and mixed units. Second, self-reporting, while Florianópolis, Brazil. Statistics Department and Post-Graduation Program in Epidemiology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Bra- providing direct answers from the practitioner, risks data zil. Department of Critical Care Medicine, Hospital das Clínicas de São Paulo, precision. Instead of obtaining objective real-time meas- FMUSP, São Paulo, Brazil. Department of Intensive Care Unit, Hospital Israelita ures, our study was based on physicians’ impressions, Albert Einstein, 627, Albert Einstein St., São Paulo 05652-900, Brazil. which could be a distorted representation of actual prac- Acknowledgements tices. This limitation has been previously recognized [24]. The authors would like to thank the FIPE-HCPA (Fundo de Incentivo à Pesquisa Third, as we obtained direct responses from the intensiv - of Hospital de Clínicas de Porto Alegre) for their support in manuscript publication. ists, large ICUs could be redundantly represented, which could also bias our results. Nevertheless, our sample Competing interests consisted of intensivists working in small units (40.5% The authors declare that they have no competing interests. had less than 10 beds) with part time intensivist presence Availability of data and materials (47.2%), indicating that although some degree of redun- The datasets used and/or analyzed during the current study are available from dancy may have occurred, it was likely of minor influ - the corresponding author on reasonable request. ence to our results. Finally, we aimed to construct direct, Consent for publication objective questions that could reduce misunderstanding Not applicable. as much as possible. Our intention was to minimize the Ethics approval and consent to participate survey burden effect [25] that could potentially minimize The study was approved by the Ethics and Research Committee of Hospital our return rate. Nevertheless, our questionnaire was vali- de Clínicas de Porto Alegre (Registration Number 17-0110). Since the answers dated in a standard way, as previously described [12]. were provided anonymously, informed consent was waived. Conclusions Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in pub- The rate of dissemination of POCUS in Brazilian ICUs is lished maps and institutional affiliations. nearing rates reported in other countries. Although US- guided CVC insertion constitutes the main application Received: 16 January 2018 Accepted: 12 April 2018 of POCUS, adherence to international recommendations remains suboptimal. 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Comput Rev. 2001;19:146–62. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Annals of Intensive Care Springer Journals

Point-of-care ultrasonography in Brazilian intensive care units: a national survey

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Medicine & Public Health; Intensive / Critical Care Medicine; Emergency Medicine; Anesthesiology
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Abstract

Background: Point-of-care ultrasonography (POCUS) has recently become a useful tool that intensivists are incorpo- rating into clinical practice. However, the incorporation of ultrasonography in critical care in developing countries is not straightforward. Methods: Our objective was to investigate current practice and education regarding POCUS among Brazilian inten- sivists. A national survey was administered to Brazilian intensivists using an electronic questionnaire. Questions were selected by the Delphi method and assessed topics included organizational issues, POCUS technique and training patterns, machine availability, and main applications of POCUS in daily practice. Results: Of 1533 intensivists who received the questionnaire, 322 responded from all of Brazil’s regions. Two hundred and five (63.8%) reported having access to an ultrasound machine dedicated to the intensive care unit (ICU); how- ever, this was more likely in university hospitals than in non-university hospitals (80.6 vs. 59.6%; risk ratio [RR] = 1.35 [1.16–1.58], p = 0.002). The main applications of POCUS were ultrasound-guided central vein catheterization (49.4%) and bedside echocardiographic assessment (33.9%). Two hundred and fifty-eight (80.0%) reported having at least one POCUS-trained intensivist in their staff (trained units). Trained units were more likely to perform routine ultrasound- guided jugular vein catheterization than non-trained units (38.6 vs. 16.4%; RR = 2.35 [1.31–4.23], p = 0.001). The proportion of POCUS-trained intensivists and availability of a dedicated ultrasound machine were both independently associated with performing ultrasound-guided jugular vein catheterization (RR = 1.91 [1.32–2.77], p = 0.001) and (RR = 2.20 [1.26–3.29], p = 0.005), respectively. Conclusions: A significant proportion of Brazilian ICUs had at least one intensivist with POCUS capability in their staff. Although ultrasound-guided central vein catheterization constitutes the main application of POCUS, adherence to guideline recommendations is still suboptimal. Keywords: Ultrasonography, Critical care, Survey economic, and structural characteristics in which the Background practitioner is working. POCUS assists physicians to Point-of-care ultrasonography (POCUS) has recently diagnose different causes of clinical deterioration and become a useful and widely disseminated tool that inten- respiratory and/or hemodynamic failure, to tailor medi- sivists are incorporating into clinical practice. Assimi- cal interventions (e.g., fluid therapy and mechanical ven - lation timeframe varies according to the geographic, tilation adjustments), and to guide invasive procedures [1–3]. Despite guidelines that recommend the use of POCUS *Correspondence: rlcordioli@gmail.com Department of Intensive Care Unit, Hospital Israelita Albert Einstein, 627, in different scenarios of critical care [ 3, 4], the incorpo- Albert Einstein St., São Paulo 05652-900, Brazil ration of ultrasonography into clinical practice is not Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Pellegrini et al. Ann. Intensive Care (2018) 8:50 Page 2 of 8 straightforward. For central venous catheterization course encompasses physical principles of ultrasound, (CVC), recent data showed that 18% of French intensiv- knobology, echocardiographic and lung ultrasound basic ists reported that they routinely use ultrasonography [5], techniques, as well as incorporating supervised, practical while 44% and 37% of emergency medicine specialists [6] activities to allow participants to demonstrate expertise and anesthesiologists [7], respectively, reported never acquisition. using ultrasonography for CVC guidance. Questions were selected using the Delphi method. Four Previous studies assessed the implementation of of the authors developed a set of questions of interest, POCUS in critical care [5, 8–10]. Methodologies for which were then subjected to three rounds of apprecia- collecting data were varied: while some authors applied tion. One author served as a facilitator, assessing agree- electronic mailing and waited for spontaneous return, or ment among the other three authors and providing based their findings on self-reported previous experience, feedback between rounds. Rounds were stopped when others adopted cross-sectional epidemiological sampling consensus was reached for all questions in the set. No consisting of punctual observations [9]. Similar studies physical meetings occurred. All of the panel members revealing ultrasonographic patterns of use in intensive are formally certified intensivists and well-known experts care units (ICUs) in developing regions are still lacking. in POCUS techniques and teaching. Three of the panel Brazil’s large territory and policies of public health sys- members are from the board of the ECOTIN group. tem organization lead to challenges in access of health The survey consisted of 32 questions (Additional file  1) care personnel to the population, access to medical edu- assessing the geographic location, type of hospital and cation, and the incorporation of new technologies into type of ICU, availability of an ultrasound (US) machine, clinical practice. Therefore, precise information about training in POCUS techniques, use and daily practice of regionalization, training methods, and preferential appli- US-guided CVC and other applications of POCUS (e.g., cations could help guide national entities in achieving echocardiography, measuring the optic nerve sheath more efficient dissemination of ultrasonography across diameter, lung and abdominal studies), medical resi- Brazilian ICUs, potentially improving the quality of deliv- dents’ education in POCUS, and perceived barriers to ered care. the implementation of ultrasonography. All questions Surveys are standard tools that are increasingly used focused on POCUS performed by intensivists, not on for assessing various aspects of health care, including complementary exams done by other physicians (e.g., educational, technological, and organizational aspects radiologist or cardiologist). Skip logic was used when [11], as well as for investigating translation from scientific appropriate to ease the burden on respondents. research to clinical practice [12]. Consisting of descrip- A web-based platform (S urveyMonkey , www.sur- tive or explanatory questions, surveys can support the veymonkey.com) was used for the survey according to incorporation of medical evidence in current patient recent recommendations [12]. Initially, a group of 12 ICU care. physicians tested the questionnaire. After an interval of Therefore, the purpose of our study was to utilize a sur - 3  weeks, a retest was performed by the same 12 physi- vey to assess current practice and education of POCUS cians to verify reliability. The survey was physician-cen - by Brazilian intensivists, as well as to assess the dissemi- tered and was directly sent to intensivists subscribed to nation of ultrasonography and main applications in ICUs the AMIBnet mailing list. The questionnaire was avail - across Brazil. By evaluating the frequency of use and able for 6 months (from September 2016 to March 2017). barriers of implementing ultrasonography, we can iden- Reminders were sent via e-mail to potential participants tify gaps in medical education and incorporate recom- on three occasions, every 2 months. mended clinical practices to critical care. Survey respondents were stratified according to the training status of POCUS: trained versus non-trained. Methods Trained status was dependent on having at least one This study was conducted with the logistic support of intensivist with formal POCUS training working in the AMIBNet (the Brazilian network of research in intensive ICU staff. Additionally, questions gathered data on the care) and Ecografia em Terapia Intensiva (ECOTIN), the proportion of staff that were trained in POCUS. national training program of POCUS for intensivists. No financial support was received from any source. Statistical analysis The ECOTIN program is an initiative of the Brazil - Categorical variables were presented as absolute num- ian Intensivists Medical Association (AMIB), which bers and percentages and compared using the Chi- was conceived in 2010. It consists of a board of POCUS square test with standardized adjusted residuals analysis experts who developed a teaching method and conduct (for tables larger than 2 × 2) and the Fisher exact test short duration courses throughout Brazil. The ECOTIN (for 2 × 2 comparisons). A two-sided p value < 0.05 was Pellegrini et al. Ann. Intensive Care (2018) 8:50 Page 3 of 8 considered statistically significant. Risk ratios (RRs) and Table 1 Baseline characteristics of the study population 95% confidence intervals were calculated for associated Characteristic n (322) measurements. Region within Brazil Multivariate analysis through Poisson linear models Southwest 191 (59.7) with robust estimation were constructed to identify vari- South 58 (18.1) ables that are independently associated with an impor- Northeast 43 (13.4) tant quality-of-care marker: US-guided internal jugular Central-West 19 (5.9) vein (IJV) puncture, in compliance with international North 9 (2.8) guidelines [13–15]. A priori interest factors were those Hospital’s type plausibly associated: the type of institution (university Private 148 (46) vs. non-university), presence of an intensivist on a daily Public 107 (33.2) basis, availability of a dedicated US machine, intensiv- University 67 (20.8) ists’ formal certification in critical care, proportion of ICU type POCUS-trained intensivists (low vs. high level), and Mixed, clinico-surgical 231 (72) payoff. For the construction of the multivariate model, Clinical 43 (13.4) we used forced simultaneous entry—all candidate vari- Pediatrics 22 (6.8) ables remained in the model regardless of statistical sig- Surgical 13 (4.0) nificance. Outputs from this analysis are summarized as Trauma 12 (3.7) RRs. All analyses were performed using Statistical Pack- Number of beds age for Social Science (SPSS), version 21.0 (IBM Corp., < 10 130 (40.5) Armonk, NY, USA). 11–20 107 (33.2) 21–40 47 (14.6) Results > 41 37 (11.5) Characteristics of the study population Attendance of a certified intensivist during daily rounds From September 2016 to March 2017, 1533 intensiv- Full-time (morning and afternoon) 151 (46.9) ists were contacted by electronic mail. Of these, 322 Part time (morning or afternoon) 152 (47.2) responded (20.7% response rate) from all Brazilian None 19 (5.9) regions. Of the units where respondents were working, ICU intensive care unit private hospitals represented 46% while clinical-surgical units represented 72%. Three hundred and three units (94%) had a certified ICU physician attending daily Competence and training of POCUS rounds (Table 1). Two hundred fifty-eight (80.0%) respondents reported to Two hundred and five (63.8%) of the respondents have at least one intensivist with formal POCUS train- stated that they had access to a US machine dedicated to ing working in their staff (Table  3). We designated these the ICU (Table 2). There were disparities throughout Bra - as trained units for the following comparisons. We did zil’s territory in this subject (p = 0.017). Availability of a not identify significant differences across Brazil’s terri - dedicated US machine was more likely in university than tory according to training. The most frequently reported in non-university hospitals (80.6 vs. 59.6%, respectively; training structure was one- to two-day courses (65%). RR = 1.35 [1.16–1.58], p = 0.002). ECOTIN trained 53% of the participants. The imple - US-guided CVC was the main indication of POCUS, mentation of the ECOTIN training method was associ- representing 49.4% of indications, followed by bedside ated with the type of hospital: 67 and 49% of university echocardiography (33.9%). Pleuropulmonary and abdom- and non-university hospital workers reported ECOTIN inal ultrasonographic examinations were infrequently training, respectively (RR = 1.35 [1.1–1.67], p = 0.013). reported (8.5 and 8.2%, respectively). According to 59% ECOTIN training prevalence was heterogeneous among of the respondents, chest x-rays are performed on a daily Brazil’s regions (p = 0.001). basis in more than 50% of the patients. This was nega - Medical residents were present in 69% of the units, tively associated with the frequency of lung ultrasound including critical care medicine residents in 44%. There examination (p =0.028). were no structured training modules for US-guided CVC Sixteen respondents (5.1%) stated that they use a in 54% of cases. Twenty-six respondents (8.1%) said that prespecified form for summarizing data concerning their residents use simulation techniques to learn how to examinations. The exam results images and clips) were perform US-guided CVC. electronically recorded 14.6% of the time. Pellegrini et al. Ann. Intensive Care (2018) 8:50 Page 4 of 8 Table 2 POCUS characteristics Table 3 Medical trainment in POCUS Characteristic n (322) Characteristic n (322) Dedicated ultrasound machine availability Trainment status No 116 (36.1) Yes—ECOTIN 60 (18.7) Yes, without Doppler imaging 35 (10.9) Yes—ECOTIN and other courses 111 (34.6) Yes, with Continuous and Pulsatile Doppler 63 (19.6) Yes—only other courses 87 (27.1) Yes, with Continuous, Pulsatile and Tissue Doppler 107 (33.3) None 63 (19.6) Proportion of patients assessed by POCUS on a regular basis Trainment modality < 10% 124 (39) 1–2 days courses 163 (65.2) 11–25% 100 (31.4) 2 days–1 week 46 (18.4) 26–50% 55 (17.3) 1 week–1 month 8 (3.2) 51–75% 22 (6.9) > 1 month 33 (13.2) > 75% 17 (5.3) Proportion of medical staff trained in POCUS POCUS type < 10% 125 (50) US-guided CVC insertion 156 (49.4) 11–25% 68 (27.2) Cardiac assessment 107 (33.9) 26–50% 38 (15.2) Lung 27 (8.5) 51–75% 11 (4.4) Abdominal 26 (8.2) > 76% 8 (3.2) POCUS recording Medical residents No recording 170 (54.5) Yes—Critical care medicine 138 (44.1) Registered on patient’s records 102 (32.7) Yes—Other specialties 76 (24.3) Electronically stored and registered on patient’s records 47 (14.6) None 99 (31.6) Medical report formally provided 16 (5.1) Medical residents POCUS training modality Payos ff Practice-based only 118 (54.1) None 278 (90.3) Lecture-based trainment available 44 (20.2) Only for the institution 13 (4.2) Simulation-based 26 (11.9) Only for the physician 4 (1.3) No trainment 30 (13.8) For both the institution and the physician 13 (4.2) POCUS point-of-care ultrasound, ECOTIN ecografia em terapia intensiva POCUS point-of-care ultrasound, US ultrasound, CVC central vein catheterization 1000 catheter-days. The two most common approaches As aforementioned, we stratified respondents and their for CVC were the US-guided IJV (36.2%) and landmark- respective units into trained versus non-trained units guided subclavian vein approaches (35.6%). based on self-reporting of training. We observed that the Respondents were questioned about the frequency training status in POCUS affected the pattern of some with which CVC is US-guided in their units. In 22.8% answers (Table  4), such as availability of a dedicated US of cases, IJV catheterization was “always” guided (in line machine, proportion of patients assessed by POCUS and with international guidelines). The most frequent answer the density of certified intensivists. was “only in specific situations” (45%). One hundred The most frequent POCUS applications were distinct thirty-one (40.7%) of the participants classified the rec - according to individual capability (p < 0.001; Fig. 1a): US- ommendations for routine use of ultrasonography when guided CVC and pulmonary ultrasonography was posi- catheterizing the IJV as “weak”. For subclavian access, tively associated with trained individuals. 78% of the respondents reported “rarely” using US, while The status of POCUS training was negatively associ - 5% reported routinely using it; two hundred twenty- ated with exam payoff: fourteen (5.6%) of the trained seven (70.5%) physicians classified the recommendation units reported payoffs, compared to 27.6% of the non- supporting US for subclavian puncture as “weak”. trained units (RR = 0.20 [0.11–0.39], p < 0.001). Patterns of preferences for CVC according to train- ing status are represented in Fig.  1b. US-guided IJV was US‑guided CVC the first choice for trained individuals (41%), in contrast According to the study participants, 58.5% of the units to the landmark-guided subclavian approach (48.4%) for dealt with a monthly incidence density of less than 200 those not trained. Overall, eighty-five percent of non- catheter-days and, in 54.5% of the cases, a catheter- trained individuals preferred landmark-guided CVC. related bloodstream infection of less than 2 events per Pellegrini et al. Ann. Intensive Care (2018) 8:50 Page 5 of 8 Table 4 Competence and POCUS Characteristic Trained (258) Not trained (63) Risk Ratio (95% CI) p value Dedicated ultrasound machine 184 (71.3) 22 (34.9) 2.04 (1.44–2.89) < 0.001 High intensity of certified intensivists 160 (62) 21 (33.3) 1.86 (1.29–2.67) < 0.001 > 10% of patients assessed by POCUS on daily basis 165 (64.7) 29 (46.8) 1.38 (1.04–1.83) 0.013 Routine US-guided IJV catheterization 96 (38.6) 10 (16.4) 2.35 (1.31–4.23) 0.001 Payoff 14 (5.6) 16 (27.6) 0.20 (0.11–0.39) < 0.001 POCUS point-of-care ultrasound, CI confidence interval, US ultrasound, IJV internal jugular vein Fig. 1 Black bars represent trained units; gray bars represent non-trained units. a main types of POCUS application; b preferential venous access site; c perceived strength of recommendation for US-guided jugular vein catheterization; and d main barriers for ultrasound dissemination. See text for full explanation. *differences in prevalences with p < 0.05. US ultrasound, CVC central vein catheterization, IJV internal jugular vein, SCV subclavian vein, LM landmark Physicians’ perception about strength of recommen- Routine US‑guided IJV puncture dation for US-guided IJV catheterization appears to be Routine US (defined as more than two-thirds of the time) affected by their training status. While answers of “rou - was used by 38.6% of the trained individuals compared tine use” or “strong recommendation” were associated to 16.4% of the non-trained ones (RR = 2.35 [1.31–4.23], with trained units, “weak recommendation” was asso- p = 0.001). ciated with non-trained units (p < 0.001; Fig.  1c). For Most of the factors plausibly associated with routine the subclavian route, the same pattern was identified US-guided IJV puncture (as defined above) were sta - (p < 0.001). tistically associated in univariate analysis (all factors Other invasive procedures that were reported to be except payoff). Considering multivariate analysis, two “usually” US-guided included thoracentesis (49%), para- factors maintained independent association: dedicated centesis (31.5%), and arterial line insertion (27%). ultrasound machine availability (RR = 2.20 [1.26–3.29], Pellegrini et al. Ann. Intensive Care (2018) 8:50 Page 6 of 8 p =0.005) and proportion of POCUS-trained intensiv- of ultrasonography of the critically ill. Additionally, we ists (RR = 1.91 [1.32 - 2.77], p = 0.001) (Additional file  2: aimed to directly assess the intensivists and their self- Table S1). perception of training, in contrast to previous studies [9] that designed questionnaires for ICU coordinators Barriers for nationwide dissemination of POCUS regarding their medical staff’s capability. Medical resi - One hundred thirty-three (41.3%) of the respondents dents in Brazil are beginning to learn ultrasonography in answered that physicians’ training was the greatest bar- their education, although this is done in an unstructured rier in the dissemination of ultrasonography across the and potentially heterogeneous way. Brazilian territory. When comparing the types of institu- POCUS training issues are one of the major challenges tions, private hospitals responded differently (p = 0.012); of ultrasound dissemination in Brazil and other low- and in these institutions, limited intensivist time when con- middle-income countries. When heterogeneous training sidering other tasks was more relevant than medical modalities coexist, it is difficult to ensure that all kinds capability or other limitations. of training provide comparable efficacy and competence Main barriers to the dissemination of ultrasonography acquisition. Standardization of training structures, both according to the training status are represented in Fig. 1d. for medical residents and for those already working as Non-trained respondents were more likely to classify the intensivists, is needed, as those training structures influ - availability of a dedicated US machine as the most rele- ence intensivists’ perceptions and use of evidence-based vant barrier (not training itself ) (p = 0.021). practices. Reaching a balance between uniform accessibility to US Discussion machines and achieving minimum requirements of qual- The main findings of this survey can be summarized as ity in care delivery remains an important future objective follows: (1) availability of a dedicated US machine in for Brazil. Realistic simulation should be provided in a Brazilian ICUs is still suboptimal; (2) US-guided CVC method that is scalable and replicable. Medical associa- insertion is the main application of POCUS, followed tions of developing countries should contextualize inter- by echocardiography, and lung ultrasonography is rarely national recommendations on POCUS training [17, 18] performed; (3) a large proportion of assessed intensivists for specific guidelines in Brazilian (and other developing are trained in POCUS, but as there is a predominance country) contexts. of courses with a short duration and workshop struc- Zielezkiewicz et al. [9] demonstrated in a 1-day preva- ture, medical residents are being trained in POCUS in lence study in Europe that 13% of the POCUS examina- an unstructured fashion); and 4) training is associated tions performed were for central venous puncture, and with several aspects of POCUS application, including that nearly half of the CVCs were US-guided. In the US-guided IJV catheterization, an important marker of present survey, we assessed physicians’ self-reporting quality of care regarding ultrasonography in critical care practice, not real procedures; nevertheless, US-guided medicine. CVC insertion was identified as the major indication for Availability of a dedicated US machine is obviously a POCUS by Brazilian intensivists. This behavior was also fundamental aspect for the dissemination of POCUS. more pronounced in environments with a high level of While two-thirds of the respondents in this study training: the proportion of trained staff was identified as reported having this machine in their units, authors in independently associated with adherence to US-guided other countries [8, 16] have reported higher rates. Some IJV puncture. Overall adherence to routine US-guided specific regions in Brazil and non-university hospitals IJV catheterization recommendations was relatively were less likely to have a dedicated US machine. Our low (22.8%), compared to other critical care scenarios results indicated that a dedicated US machine is inde- [19–21]. pendently associated with adherence to US-guided IJV Lung ultrasonography, although infrequently reported, catheterization. also showed a positive association with educational sta- Similar rates of training in POCUS were reported tus. Lung ultrasound prevalence was negatively associ- from 70 to 81% in Europe and the United States [6, 8, ated with routine chest x-ray, indicating a potential role 9], although precise information concerning the train- of POCUS in reducing radiation exposure. This finding, ing structure and specific curriculum is scarce. Other however, is exploratory due to low adherence to lung authors [5] have reported even higher rates. Our results ultrasound examination in this study. Other authors have on this subject, however, are unique: although previous previously reported similar data [22, 23]. studies [5, 6, 8] have focused on specific areas within Our results contrast with other studies, as US-guided POCUS education (e.g., US-guided venous catheteriza- CVC insertion represents the major indication for tion or echocardiography), we assessed general aspects POCUS in Brazil. This could be explained by several Pellegrini et al. Ann. Intensive Care (2018) 8:50 Page 7 of 8 Abbreviations reasons: the evidence concerning CVC guidance is solid, CVC: central venous catheterization; ECOTIN: Ecografia em Terapia Intensiva reducing adverse event rates and improving procedural (ultrasonography in intensive care); ICU: intensive care unit; IJV: internal jugular success; the learning curve for US-guided IJV catheteri- vein; POCUS: point-of-care ultrasonography; RR: risk ratio; US: ultrasound. zation appears to be smoother than, for example, cardiac Authors’ contributions assessment and hemodynamic monitoring; some of the Drs. JASP and LUT had full access to all data and take responsibility for the US machines available in Brazilian ICUs are relatively writing of the manuscript, the integrity of the data and the accuracy of the final analysis. Dr. Ziegelmann was responsible for biostatistical consultation basic technology, and do not offer Doppler techniques or and data interpretation. Dr. Cordioli and Grumann contributed substantially cardiac assessment software. to the study design, data acquisition, and analysis and interpretation of the Our study has several limitations. First, inherent self- results. All authors read and approved the final manuscript. selection bias can influence our results. Physicians who Author details already use ultrasonography were more likely to complete Department of Critical Care Medicine, Hospital de Clínicas de Porto Alegre, the survey; however, we obtained answers from a wide Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil. Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil. range of respondents from all Brazilian regions, repre- Department of Critical Care Medicine, Alemão Oswaldo Cruz Hospital, São senting private and public institutions, as well as clinical, Paulo, Brazil. Department of Critical Care Medicine, Nereu Ramos Hospital, surgical, and mixed units. Second, self-reporting, while Florianópolis, Brazil. Statistics Department and Post-Graduation Program in Epidemiology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Bra- providing direct answers from the practitioner, risks data zil. Department of Critical Care Medicine, Hospital das Clínicas de São Paulo, precision. Instead of obtaining objective real-time meas- FMUSP, São Paulo, Brazil. Department of Intensive Care Unit, Hospital Israelita ures, our study was based on physicians’ impressions, Albert Einstein, 627, Albert Einstein St., São Paulo 05652-900, Brazil. which could be a distorted representation of actual prac- Acknowledgements tices. This limitation has been previously recognized [24]. The authors would like to thank the FIPE-HCPA (Fundo de Incentivo à Pesquisa Third, as we obtained direct responses from the intensiv - of Hospital de Clínicas de Porto Alegre) for their support in manuscript publication. ists, large ICUs could be redundantly represented, which could also bias our results. Nevertheless, our sample Competing interests consisted of intensivists working in small units (40.5% The authors declare that they have no competing interests. had less than 10 beds) with part time intensivist presence Availability of data and materials (47.2%), indicating that although some degree of redun- The datasets used and/or analyzed during the current study are available from dancy may have occurred, it was likely of minor influ - the corresponding author on reasonable request. ence to our results. Finally, we aimed to construct direct, Consent for publication objective questions that could reduce misunderstanding Not applicable. as much as possible. Our intention was to minimize the Ethics approval and consent to participate survey burden effect [25] that could potentially minimize The study was approved by the Ethics and Research Committee of Hospital our return rate. Nevertheless, our questionnaire was vali- de Clínicas de Porto Alegre (Registration Number 17-0110). Since the answers dated in a standard way, as previously described [12]. were provided anonymously, informed consent was waived. Conclusions Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in pub- The rate of dissemination of POCUS in Brazilian ICUs is lished maps and institutional affiliations. nearing rates reported in other countries. Although US- guided CVC insertion constitutes the main application Received: 16 January 2018 Accepted: 12 April 2018 of POCUS, adherence to international recommendations remains suboptimal. POCUS training, although includ- ing various relevant aspects of care, is heterogeneous, as is medical resident education regarding POCUS. Future References research could address these gaps and help to better 1. Lichtenstein D, van Hooland S, Elbers P, Malbrain ML. Ten good reasons achieve POCUS dissemination in developing countries. to practice ultrasound in critical care. Anaesthesiol Intensive Ther. 2014;46(5):323–35. 2. Cardenas-Garcia J, Mayo PH. Bedside ultrasonography for the intensivist. Additional files Crit Care Clin. 2015;31(1):43–66. 3. Frankel HL, Kirkpatrick AW, Elbarbary M, Blaivas M, Desai H, Evans D, Additional file 1. Survey’s set of questions. et al. Guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients—part I: general Additional file 2: Table S1. Poisson regression model for routine* US- ultrasonography. Crit Care Med. 2015;43(11):2479–502. guided IJV catheterization. 4. 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Journal

Annals of Intensive CareSpringer Journals

Published: Apr 20, 2018

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