key: cord-0697784-bu40kpgp
authors: Gibson, Lauren E.; Convissar, David; Berra, Lorenzo; Bittner, Edward A.; Chang, Marvin G.
title: A Surge of FoCUS on COVID-19 POCUS
date: 2020-07-21
journal: Anesth Analg
DOI: 10.1213/ane.0000000000005144
sha: 4d980e9906a798e3928b8e3adc3dd0a4cd06642c
doc_id: 697784
cord_uid: bu40kpgp

nan

2 Dear Editor, In their article, Anile et al. 1 provide a novel and creative framework for the use of ultrasound to evaluate critically ill COVID-19 patients. We agree that ultrasound offers key advantages over other imaging modalities during the current pandemic and may be the preferred method for the routine assessment of these patients 2 . New handheld ultrasound devices may be particularly useful for this proposed application, as they incorporate sophisticated imaging technology while offering portability, affordability, and ease of decontamination 3 to reduce the spread of infection. Some of the latest ultrasound devices offer additional features such as video tutorials and teleguidance, in which a remote expert can guide a novice user in performing an ultrasound exam or procedure 4 . With these advances, ultrasound is becoming increasingly accessible to healthcare providers across all specialties and training levels.

The authors highlight the versatility of ultrasound in evaluating not only the lungs (i.e. presence of B-lines and lung sliding) and heart (i.e. global size and function, pericardial effusion), but also to assess airway anatomy, endotracheal tube placement, end-organ perfusion, intravascular volume status, and peripheral vasculature for evidence of thrombosis. By considering the manifestations of COVID-19 on multiple organ systems, Anile et al. 1 offer a holistic approach to clinical management. We applaud the authors for highlighting several less conventional but very useful applications of critical care ultrasound, all of which can be performed by a single bedside provider, thus limiting infectious exposure to additional staff members. Their clever mnemonic, COVID, will also serve as a useful cognitive aid to the clinician performing these examinations.

In our intensive care units, bedside ultrasound has become a standard tool for assessing and optimizing the management of critically ill COVID-19 patients ( Table 1) . Markers of volume status evaluated by bedside ultrasound, such as IVC collapsibility, stroke volume variation, and evaluation of diastolic dysfunction, can help to avoid over diuresis and consequent renal injury in patients undergoing conservative fluid management. We employ ultrasound to monitor response to interventions, including the titration of PEEP or the administration of pulmonary vasodilators such as nitric oxide, which can have profound hemodynamic effects due to changes in RV afterload. For patients with refractory hypoxemia in whom ventilation management is challenging, our institution has a dedicated team that performs a trifecta of transthoracic echocardiography, esophageal balloon placement, and electrical impedance tomography to provide physiologic data that can be used to optimize ventilation settings 5, 6 . We believe that the ability to monitor cardiac function and titrate ventilatory and hemodynamic parameters using bedside ultrasound may lead to improved outcomes.

We also use focused echocardiography to screen for myocardial injury such as from myocarditis, which may prompt administration of steroids, intracardiac shunting, stress cardiomyopathy, valvulopathies, and the need for mechanical circulatory support such as venoarterial instead of veno-venous extracorporeal membrane oxygenation in severe illness. Diastolic dysfunction may contribute to failure to wean from mechanical ventilation and can be evaluated with ultrasound. All of these assessments can be performed rapidly at the bedside, including in the prone position, thus minimizing disruption and infectious exposures to additional staff members.

The use of ultrasound in airway management is becoming increasingly utilized amongst clinicians, particularly for confirmation of endotracheal tube placement and ventilation by lung sliding. Tracheal ultrasound can rapidly identify esophageal intubation prior to ventilation, thus providing the opportunity to avoid insufflation as required for confirmation by auscultation. We have also found ultrasound to be useful in assessing gastric volume to evaluate the risk of aspiration and the need for rapid sequence induction prior to endotracheal intubation.

In summary, we thank the authors for providing a valuable framework for the use of ultrasound during the current pandemic. These efforts will serve to improve the clinical care of COVID-19 patients worldwide. 

COVID: the new ultrasound alphabet in SARS-CoV-2 era

Application of Lung Ultrasound During the Coronavirus Disease 2019 Pandemic: A Narrative Review

Handheld Ultrasound Devices: An Emerging Technology to Reduce Viral Spread during the Covid-19 Pandemic

Ultrasound Teleguidance to Reduce Healthcare Worker Exposure to Coronavirus Disease 2019. Critical Care Explorations

Development of a lung rescue team to improve care of subjects with refractory acute respiratory failure. Respiratory Care

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