My name is Marylyn Stein and I'm one of the staff and the specialist in main operating. It's my pleasure to welcome our speakers this morning. Dr. Walid, all right, I've seen and Dr. Tony help, who will be speaking on very operative and operatic sites. I'm providing an update on diagnosis and management using polytorocoscis. Dr. All right, I've seen an associate in polyaporosis and sputia Boston to the main hospital and instructor of anesthesia for the manifesto. The computer is not a complete great 고 and an associate professor of the Amsti-Jet-Horid-Ledipi School. To convene and to the actress and speciality, I'm to the editor of clinical chair, Morrison, and current research is the clinical connector of the hospitals for the Boston Children's Hospital of Washington, and is the clinical connector of the CIGF, and the CIGF of the Trans-T. She was awarded a National Public Health Degree from the Harvard Chan School of Public Health in 2017 for the emphasis on quality and safety of the CIGF. On a national level, Dr. Howard serves as one of three key advocacy sciences colleges of the University of New York, the University of New York and College of Surgeons, Children's Surgery, the Education and Quality and Prison Prison. On the elective in 2020, the American Cabinet for the Act for the Directorate, where she represents all of the key ethics research for specialists in the academy. Thank you and welcome Dr. Arbor, Dr. Hock. Thank you, Mary Lynn, for that nice introduction. So we actually are here today to talk to you a little bit about something that spans the entire perioperative program, and something that we actually found to be particular problem, and particular issue for us in our Children's Hospital and the Royal Family and the Royal Family and the Royal Family. So what I want to do is we're going to move fairly quickly through some of the background information. It's not wanting to move. I'm not sure why, but it's not letting me advance my slides. Let me try over here. We'll do it this way, maybe. That's your work, I think. Oh, there we go. I'll do it this way. All right, so unfortunately neither Dr. Al-Rashir or I have any disclosures to make in terms of this particular issue. So what we're going to do today is I'm going to give you a very, a relatively brief overview of perioperative and full access. We're going to start with a case review of an actual case that occurred in Wal-Tam. It's a little bit, for those of you who may have been involved in it, we changed it a little bit so that it wasn't entirely clear and there was some privacy in terms of the actual case. We're going to talk a little bit about the clinical features of anflaxis, some about the etiology and sort of a high-level overview. Talk a little bit about path of physiology and then a little bit about treatment and follow-up. And then the second half of this presentation is going to be much more interesting. Dr. Al-Rashir is going to talk a little bit more about how point-of-care ultrasound in this particular case made a huge difference and actually how it can be used as a general rule to actually improve both diagnosis and treatment of this particular disorder. So this was a case of a 15-year-old athletic, healthy, otherwise ASA-1 patient for an ACL reconstruction with a hamstring graph. After an unadventful induction of anesthesia, Elimate placement and an administration of antibiotics and dexamethasone immediately decreased and tidal violence was noted. A stat was called, Elimate was removed and unfortunately the team was unable to ventilate the amass even with the malairway. Sextonal colon was an epinephrine were given and profound hypotension was noted. She was immediately intubated and over the course of the resuscitation, she actually received a total of 5.5 liters of ibifluids. In addition, she was immediately treated with epinephrine voluses. And in this particular situation, there was such profound hypotension that didn't respond immediately that she also received base of presence. She had profound basic constriction, difficult IV and ALIME placement and central venous access was started with an epinephrine drip was continued in order to maintain her human amass way. She's also given additional adjunctive medications, including famotidine, methylprednisolone and dicenthyzerine. Most importantly, in this particular situation, I believe Dr. Al-Ryashi was actually there that day. He actually pulled out the point of care ultrasound and immediately found that there were minimally filled identical without evidence of right-sided increased pressures. She was eventually stabilized and transferred to the main hospital ICU via the Boston Children's Hospital Critical Care Transport Team. She rapidly improved as you see in these types of situations, excavated that evening. C.V.L. and ALIME were removed and she was transferred to the floor in the morning. She was noted to have a positive triptease later on in the course and allergy testing was planned at four to six weeks. Her surgery had not been started in this particular situation, so she actually was able to be postponed. Just a little reminder that we've been open at Boston Children's at Waltham since 2007. So almost 15 years now. Free standing children's satellite hospital that's 12 miles from the main quadriona hospital. And we have no emergency medicine services on site. There's a lot of really great clinicians. Just a little reminder, and this is just kind of a high-level overview of antifalaxis. So as you call, antifalaxis is a fear rapidly developing allergic reaction. When you look at it on a worldwide basis, there's a lifetime risk of having antifalaxis with somewhere between 0.05 and 2%. So it's not common, but it's actually not even people who've never really had issues with allergies, connect, have actually can develop it over a lifetime. The most common triggers are insect bites or stings. Foods are quite common, especially in children and medications. The average onset of antifalaxis is generally between 50 and 30 minutes after the trigger is encountered. In terms of antifalacias, antifalaxis generally manifests the skin first, but this is not necessarily true with perioperative antifalaxis. In we actually see antifalaxis quite commonly in Walten outside of the operating room, because we give a lot of drugs that cause it, such as infiximab, etc. We also are close to that. And we're also a place that does food allergy testing. So generally you see a skin rash or eruption hides, or even just so this sort of maculapeth, the red rash that you see here, occurs in 80 and 90% of the cases. Respiratory issues can occur in about 70%. GI issues in 30 to 45%. Heart and vascular issues occur in 10 to 45%. And CNS manifestations occur in somewhere between 10 and 15%. So this is, I actually, I really like infographics, because it helps me remember things. But just to remember, this is a systemic disease that occurs very, very fast. And in the kits that we see outside of the operating room, you'll generally see usually the rash first, generalized hides, or the, you can also see swelling of the lips of face or throat. They'll often start coughing, sensations. I'll have those, I'll say I can't breathe. I feel like my throat is closing. I love shortness of breath. Many of our kits vomit, or just start to feel very nauseated or vomit. And they often have this sense of impending doom. They just know something's wrong. They get very agitated, very upset. And generally they'll faint. But usually the first, often, if you catch this earlier, you see this early, blood pressure is usually not the first sign. Hypertension is not the first sign. There's a whole clinical grading status. And many of the kits that we see outside the operating room often are in the grade one or two level. Just with the continuous signs, very moderate hypotension, maybe a little bit of respiratory issue. But it can rapidly progress into grade three, where you can have a life threatening monon or a multidisceral signs, life threatening hypotension, attack a cardiac or a cardiac with or without cardiac arrhythmias. And some people actually can present actually with cardiac arrhythmias. So, antiflexus without getting into a lot of detail about it is essentially what we see is a very severe reactions, generally an IgE-mediated allergic mechanism. It comes about because mature facels produce specific IgE antibodies to that allergen. And most of the time the initial phase of sensitization, you have no idea. Patients have no idea. And actually the patients that we've seen with these severe reactions have actually no known drug allergies. However, on re exposure, that's when you see issues with cross links of those two specific IgE receptors, creating a bridge. And that leads to rapid re-governulation of the mast cells and the preformed histamine and triptate as well as other mediators such as prostacled and D, like the trines, thromboxane etc. And so this is why it can rapidly develop. And you really have no idea it's going to happen. So what concerns us the most is the cardiac respiratory effects of the kerogenical axis. So you see increased capillary permeability. And that's where you see that anti-abema that we saw in that first picture, and fluid secretation. This also can lead to airway compromise. Broncospason is a feature as well due to the release of the mediators, as well as phase of dilation. They can get increased fast with the pastis and reduced ventricular filling. And this is where we'll talk more about this, but this is where the ultrasound can be exceedingly important in making this diagnosis. They get what happens is you get reduced cardiac contractility, broncospason, reduced ventricular filling, reduced cardiac output, and eventually this leads to this can lead to a shock light state. And so it's fairly very important that you that you're on top of this very quickly. So adult incidence of anaphylaxis has been reported perioperative anaphylaxis has been reported in one to 10,000 versus to one to 20,000 anesthetics with an adult immortality rate of one in about 26 adults. So this is a very serious potentially life through it, that thing problem. The pediatric incidence from the most recent data we have in the wake-up safe registry gives an incidence of one in 37,000. This is information from 2010 to 2017, which is an instance of about 0.003%. So quite low, quite uncommon. And there was one death in the that most recent wake-up safe registry giving the mortality of one in 69. Cardi-pulmonary resuscitation is generally required at least 10% of the time if not if not higher. And escalation of care occurs almost all of the time, 97% of time in pediatric patients. Probably the most concerning aspect of all of this is that it's not particularly preventable. And that's why you really just have to be prepared to deal with it. In the wake-up safe registry, 91% either could not or likely could not have been prevented. So this is something that you need to be just quite aware of and ready to go. In our own institution, Dr. Vlasikosa, Vlasikova actually looked at our stat calls back in the report of this in M.C. Jean-Elegenia in 2018. And what we found interesting to this is that of the stat calls that we had in her database, 1.5% of them were for antiflexus. So it is something that can occur and something that you need to take very, very seriously. Part of what prompted us to really look at this was that we had sort of a rash of antiflexus events in the operating room and periopidative areas. Two of these were actually in the own the best clinic where they actually were kids having teeth extractions under sedation. Both of those kids because they were more awake and we could see the sides very quickly actually ended up having a much less severe course. And both of them actually were able to be kept in all of them. And actually the second one was able to be kept in all of them for a four-hour period and actually discharged home. The OR events, though, were significantly more serious, all of whom required significant resuscitation and were sent via transzo-transport team or medslife rapidly to the ICU in Namb Austin. Just very quickly in terms of etiology of periopidative antiflexus, prior to this earlier wake-up state evaluation, LATX was actually one of the more common reasons why kids would have antiflexus in the operating room. But with our LATX free environments and such, we actually see that the most common causes nowadays are related to medications. Antibiotics, most common followed by our neuromuscular blocking agents and opioid allergies. DeFiX are now the most common reasons why someone could develop antiflexus. So why is periopidative antiflexus so much more severe? And why do we really need to have better methods or consider better methods to be able to look at this? Well, actually, definitely recognition of antiflexus is challenging and delayed. And this is something, as I said, for somebody who spent a lot of my time dealing with kids with antiflexus, we actually had an antiflexus event in the infusion unit just last weekend. This periopidative antiflexus is no question of very different animals. And this is because the effects of genal anesthesia are generally masked by the masked early signs of antiflexus. So all of those things we showed earlier, you don't see any of them. Basically, also visual inspection of the skin is actually limited. You can see the skin because of the greats. So even though those are often the first manifestations of things, you don't see it. On top of it, it's been shown that periopidative antiflexus specifically, the skin manifestations also seem to be a little less common. So this is actually makes it even much more complicated to figure this out. And so basically, we just basically, in the OR, blast past all of everything. And the first, our first indication is that they are having any kind of antiflexus reaction is when they get hypotension or perhaps lungestabins. So just to remind you just to look at this inographic again, we basically blast past everything. We don't see any of these signs under anesthesia. And they go right to hypotension, which in our algorithm, he's dropped all the way down to grade three right there. So just to give you a little bit of data about this, this is from the national audit from the Royal College of and NISTASIS in the UK. The hypotension is the first medical feature in most patients that have grade three or greater periopidative antiflexus, followed by bronchospasm and high airway pressures. So unfortunately, we're pretty far down the line when we figure out that we've got a problem. The timing of the event, too, it doesn't usually occur right at induction. It's generally a little bit more interoperative, often before the incision. So so fairly quickly, it occurs, but it's generally after receiving the intravenous medications. Or if it does happen to be related to a topical agent like a life core hexadene, or it may occur a little bit later after the patient's being prepped. So just to kind of throw that out a little bit more quickly, you can see that once the drugs have been administered and that there's a suspected trigger of agent, usually the this rapidly comes together and often you can pick this up within five, 10 minutes at the most. So by that time though, a lot of the mediators have definitely made their way around your circulatory system. So in terms of treatment, we actually follow an algorithmic pattern here and I'll show you the critical of that checklist in just a moment. But as soon as you think that something like this might be going on, you need to quickly deal with the airway breathing circulation, put them on 100% O2 and show that their ventilation is adequate. And then if you do think there could possibly be a triggering agent that is either in the line or something that is on the skin, you need to immediately remove that by cleaning off any core hexadene or anything like that. And if they become hypotencity, you should consider turning off your anesthetic agents. So treatment is primarily at the influence. Those are the main two things you need to remember. Epi, you need to restore your cardiovascular volume as quickly as possible. And often this can be difficult because putting ID lines and such as we saw in the case can often be difficult because they can get quite once your father down the line. And they're quite hypotencity actually, even though they had initial days of dilation, they can become quite days of constricted father down the line and peri-operative anaphylaxis. Also, you need to do something to get rid of the mediators and increase the blood pressure. So that's where your epinephrine comes in. And bronchospasm is also going to be treated quite effectively with epinephrine and ovular. And in addition, you can try to once you're a little farther along and you fully resuscitate the patient, you should think about some of the adjuncted agents that can decrease mediator release. Metal prednisolence, good for both the cardiovascular and the respiratory effects. And then you can decrease the histamine effects with scythin hydrogenine and famoididine. So epinephrine is the primary treatment. V is alpha-1 adjunctic receptor. It increases phase of constriction, increases blood pressure, and decreases in coastal adema. V is beta-1 adjunctic receptor. It increases cardiac contraction force and increases the heart rate. And V is beta-2 adjunctic receptor, increases bronchidilation, and decreases mediator release. So all the things that you're trying to accomplish can generally be accomplished quite well with epinephrine. In this particular situation that we described, there was actually vasopressin given. This is a little bit more controversial and its role in anvilaxis is still unclear. But the vasoconstrictive effects of vasopressin are mediated by non-enternergic bascular B1 receptors. So it's something to consider if you do have a situation of refractory hypotension. So one thing I just wanted to quickly mention because it is something that perhaps ultrasound could be helpful. Sometimes in a situation of very high levels of cataclysmines, both either endogenous or exogenous, you can see this to coat the subo syndrome or TTS syndrome, which is a cute ventricular left ventricular systolic dysfunction. We're going to have high gluconegia, aconegia, and dyskonegia. And you can, this can actually be a very rapid onset with apical or basal localization of this hypokinetic effects. So it's something to think about in the back of your mind if you do have some refractory hypotension or you're particularly concerned, it's something that we can can actually get at least a little bit of a look at with ultrasound. So just quickly, everyone knows that we have cognitive aids on our OR carts. This, my recommendation is just pick up the cognitive aid and open it up because this is a quite a critical event and you need to be ready for this. We have made this a little bit more related to childrens and it will run you through all the things we just discussed in case your oxygen to 100 percent, removing the triggers, making sure your ventilation is appropriate, and then it runs through all the treatments, including dosages for each of these things. Generally, you need to give a little smaller dose of epinephrine, then you might, if it was a true cardiac arrest, so again, you're going to need to decide this should help restore the blood pressure and decrease the media media release. But what we find is that people, it's the best thing is just have somebody pull out that checklist and start running you through this as quickly as possible. A lot of folks also have this feed crisis app on their phones, which will also, which also will allow you to do this if for some reason you're cognitive aid is nowhere to be found. Lastly, I'm just going to say a little bit about triptates and just because it is very important that you do encounter a case of periopera-debataphylaxis, there's going to be a time, especially if surgery never got done, that you're going to need to think about bringing this kid back to the OR. So, triptates is not something that you're going to get right away, but it has very specific time range in it. You need, if you want to be able to look at whether there's been an activated mast cell reaction, then you need to think about in every situation of pursuing periopera-debataphylaxis, you should be getting triptase. So, generally measurements should be obtained between 30 minutes and two hours. So, I actually often find people are running through the algorithm and they're like, okay, let's do the triptase. And then we're usually saying, wait, wait, wait, wait, not going to really get much unless you wait at least 30 minutes to be able to pick this up. And if it goes beyond two hours, it's not going to be something that's going to be particularly helpful for you. So, this is why something that we want to make sure that people who respond to the event are ready to get this, because once you need to have it in that time frame, or it's really not going to be a particularly helpful piece of information. Serum levels normally are less than 11.5 mg per mil. So, if you do see an elevated triptase level, this is really going to help in terms of making the diagnosis of anaphylaxis. Just running through very quickly, this is an algorithm that was put together recently by some of the allergy folks. Again, getting, encouraging you to get your triptase level between 30 minutes to two hours after clinical onset. And then they'll actually do a baseline. You can do a baseline either later while they're in the hospital, generally at least 24 hours after the event, or it actually can be done at the time of allergy evaluation. And definitely all of these kids need a consult from allergy. And many of them, if the surgery is not emergent, will come back for allergy testing to try to figure out what's the cause was for the later surgery. We actually, and while them have a triptase kit, to make it easy so that you can just pull that out, you've got the right, you've got a syringe, you've got the right tube that you need. And we will get that sent off downtown so that as we're resuscitating the patient, we can get the kid ready to go and have that triptase level sent downtown as with them as well. Obviously, most of these kids require some sort of escalation of care. And I found it really interesting that most of the patients ended up in the ICU in the wake-up safe database. So what I want to do at this point is I want to turn this over to Wally, because one of the things that we all felt was really important in all of this was having the availability of point-of-care ultrasound. And now with all of our patients being in Wally, we actually have a separate person who is assigned to be the regional attending. And we also would have that downtown as well. The thought is you should, anytime you're concerned about an antiflexus of this, you should consider having them bring the ultrasound machine in. And Wally is going to spend the rest of the time talking a little bit about how this can be done to actually improve both diagnosis and ultimate care. So I am going to stop sharing and Wally, you're on. All right, thank you, Connie. Really appreciate it. I'm just going to set my screen share here. All right, so thank you all for being present. It is a very impressive 178 people that are alive right now. So it's amazing where we've come from and how we used to do things in the past. So I will say, and I will challenge folks here and say that we have embraced change and innovation in this format. So I'm going to begin now and give you my talk. Before we begin, I'd like to do an exercise together. First, close your eyes. Please, don't close your eyes if you are driving or in any kind of motion. Now, think about your surroundings and your hot cup of coffee on your desk. You kind of know where it is, but not 100% sure. So what do you do? You use your other senses to navigate. You feel your way around your desk or even try to smell the scent of it. And based on your careful, slow search, you now are down and find that cup of coffee. What you would do is it aggressively thrust out your arm. Otherwise, you were spilling it everywhere and potentially burn yourself. Now, open your eyes. Everything is right in front of you. You have full confidence in grabbing that cup of coffee, right? Why? Because you can see everything. Now, let's do the same exercise, except now you are driving a car, going 100 miles an hour on a busy highway with blindfolds on. Clearly, no one would ever do that. So why do we do it during a cute medical event? Well, today, I hope to share with you how we can see just a little bit more during these emergencies. We currently use monitors that give us bits of information that we then put together to reach differential diagnosis. For example, a blood pressure gives us a surrogate measure of perfusion. The pulse oxymeter provides a general idea of oxygenation, but doesn't tell you the whole picture of the patient's complete respiratory physiology. From there, we begin to rule in or rule out diagnoses by ordering more tests like an echo or chest x-ray or last. Unfortunately, during a crisis, things can happen extremely quickly and we don't always have the luxury of ordering other studies. This is where Pocus comes in as a tool that can provide direct visual information of what is happening. Thereby, allowing one of the abilities and now the differential down quickly and treat at the same time. So here's what I'll do. I'll first talk about what point of prayer ultrasound therapy is and why it matters. Then we'll discuss how it has been used with a focus on acute events and reviews in case examples. Lastly, we'll conclude with a look at the future. So point of care ultrasound therapy or focus ultrasound therapy is the use of ultrasound technology at the patient's best site to facilitate rapid diagnostic and therapeutic management. Ultrasound has been available for a long time. Why is it now emerging as an essential addition to our practice? Because technology has improved so dramatically with better image resolution and portability. In fact, there are now ultrasounds that you can carry in your pocket and plug into your phone. Additionally, the cost of these devices is dramatically decreased over time with some of these devices costing less than $3,000. Another major reason is the expansion of education in this area. A lot of work has been spearheaded by emergency medicine. Many of us are familiar with the fast exam during trauma, which exam is discrete areas of the abdomen, paracardium, and pelvis to look for bleeding. However, now with the proliferation of that experience, focus is being corporate to other specialties, including pediatric critical care and neonatology and anesthesiology. Thanks for looking at the application. There are many ways focus can be used, including the heart and lungs which we'll dive into later. The brain, where one can check for cerebral hemorrhages or elevated ICP as indicated by the image on the bottom right here, where there's a germinal matrix bleed. The abdomen for ruling out a cult bleeding or even simply a gastric examiner evaluate for context of the energy to placement, such as the one on the bottom left here highlighted in red. The juicist and prohydrogenic process bleeding for even simply confirming fully catheter placement. The spine for pathology, this is incredibly helpful to anesthesiologists who perform hautles fine oblong, especially if there's a benign sacrobitral or when searching for blood vessels to perform lines or rule out our form, our promise. But to take a brevity into focus presentation, we will discuss focus used during acute event. Starting with cardiac, we can qualitatively determine if the contractility appears to be normal, what the volume status looks and ruling or out tamponod elevated right-sided pressures from things like pulmonary hypertension or PE. Naturally, the follow-up question would be, is this something we should be doing since we aren't cardiologists or radiologists? Turns out the answer is actually yes, if a well-designed training and credentialing program is in place, many studies are left. I actually looked at this and demonstrated that interpretation by trainees, i.e. medical students, residents and fellows, will consider it acceptable by cardiologists blinded to the reviewer. When it comes to examining the lungs, there are numerous uses including the detection of pneumonia, evaluating lung aeration in patients with ARDS, and accurately detecting no authorities and amsoil effusion. In the case of pneumonia, two studies found that focus was non-inferiority chest acryl, with a 96% sensitivity and a 93% specificity. In fact, one RTP looked at the use of lung ultrasound for children with suspected pneumonia in place of a chest acryl, and found a 38.8% reduction in radiation exposure. That's pretty sizable. What is interesting about the lung ultrasound is that it is mostly artifact interpretation because ultrasound doesn't transmit through air. It is the artifact's created one's mythology habit. For example, assume what their actions virtually diagnostic when the above three findings are present. No lung sliding, no b-lines, and a positive lung point. The video on the top here demonstrates what a lung point is, which is basically where the tip of lung actually enters into the screen where the air pocket is. Pomanary fluid or edema can be seriously checked over time by looking at artifacts for a b-line. So if you have a patient with ARDS, you can actually trend to see how many b-lines they have with the treatment that you're giving them. So if you're giving lasex, you can actually see how well they do over time. The bottom video here demonstrates a lot of b-line, and usually if you see more than three between two ribs in an area that is not anticipated to have that many b-lines, you suspect increased consolidation or pulmonary density. As an extension of the pulmonary exam, the use of ultrasound for airway management. Airway ultrasound can be used to check endotracheal tube position, conduct lung isolation, measure endotracheal tube size, and identify anatomical landmarks in case of one of the neck approaches needed for an emergency airway. The reason this matters is that it is actually challenging for little children's anatomy to be identified without patient. In fact, the success rate of identifying the criteria to remember my anesthesiologist will look at. And the success was found to be between 0 and 40 percent compared with 60 to 100 percent when ultrasound leaves. So we will shift gears now and talk about some of the acute events where these can be employed together. In undifferentiated shock, ultrasound can help narrow down the differential quickly based on the characteristic findings. So for example, in cardiogenic shock, you'll often see a dilated left ventricle. Potentially, you will see wall motion abnormalities, a large IVC, and diffuse beyond. In obstructive shock, you'll see tamponaut, hemothorax, and pneumothorax, pulmonary hypertension, hypoboleumic shock. You might see colapse ventricles and free fluid under the thorax or in the abdomen. This is a busy slide, but a helpful graph is showing all of the various ultrasound findings in each category of shock. Basically, providing you with another tool to narrow down and hone in on your differential here. Now, when it comes to cardiac arrest, several organizations have advocated for the use of poukas. In fact, it is now part of the ACLS. As an example, the American Society of Eccocardiography, American College of Emergency Physicians, European Recephalitation, Countful, and American Heart Association have all advocated for. Speaking of VA, what is it? Technically, it is an organized rhythm with neither palpable post-nord detectable cardiac contractility on ultrasound. While it turns out, 10 to 35 percent of patients who have thought to be an acystalline actually had cardiac contractility on ultrasound, what's interesting is that there's such a thing called pseudo VA, which is when there is an organized rhythm, no pulse, but they have preserved contractility. When this happens, it is believed to be associated with a higher likelihood of return of circulation. However, the only way to really distinguish this is to look at the heart directly within ultrasound. What about another thing we assume we do well during code or the post-check? How accurate do we think we are in checking a post in children during a crisis event, especially if they're hyperpropuse, and not much is traveling to their distal vessel? Turns out we're actually a bismill addict. In fact, a study that looked at this found that the rate of misdiagnosis of a pulse was 22 percent with experienced providers, and that 36 percent of the patients received chest compression when they didn't need it. Furthermore, chest compressors were inappropriately withheld in 14 percent of the patient. One suggested approach is to actually use the ultrasound on the carotid and look for a pulse there with the ultrasound while also checking for blood flow. Now, I want to provide a couple of examples of how focus has been utilized in the parryoperative environment, specifically here at BCH. To start, I want to go back to the original antifilitis case that Connie brought up when the patient had severe hypertension with modeled extremities and still receiving epinephrine and fluid boluses. During that period, the distal extremity pulse could not be palpated consistently. There were reports that I could feel it other people would say I didn't feel it, and so there was this back and forth, and no one was quite sure whether there was a pulse or there wasn't a pulse. So the question of whether this was a PEA was entertained, and whether we would start chest impressions. Simultaneously, though, a focused ultrasound stand of the heart was being conducted. Needless to say, this changed the whole course of the case. So when this pulse looks electrical activity, let's take a look. Here, you have a short axis view of the left ventricle. You can see the donut line contracting and squeezing. So no, we had contractility, so we did not proceed with chest impression. Was there paracardiophluid? In this image and in other images that we've acquired, no, there wasn't any. And we can take a look at the long axis view on the right here. You can see that the ventricles are touching each other. Was there air in the heart? No, was there concern for PE or signs of elevated RV pressures? No. So you can see we were quickly narrowing down that differential, honing in on what needed to be done without wasting time, still trying to figure out these other things. What was visibly obvious, and you can see in the video again here, was a hyper dynamic heart with hypobelania as evidenced by the complete obliteration of the endocardial lumen in both the long and the short axis view. But the use of ultrasound didn't stop there in this case. We then used it to place an arterial line and CDL. What's interesting is that the radial artery was barely pulsed tile, and so still we're able to do it in that situation, in that hyper perfused situation. After we got all our line, we initiated aggressive food administration and continued to use the ultrasound to monitor our IV hydration and pressure use, as can be seen on the right video. You can see now that the ventricle is still. Here are a paristerinal long and short axis views of the heart after food or septitation. As you can see, at some point, at some point, we had a well filled, maybe even overfilled, left ventricle. That's when we began to reduce fluid administration and high-neutropic support. Here are better images here. What's interesting is on the image on the right, the short axis view, is a slightly reduced heart rate. That's actually when we began to titrate down our epinephrine. Therefore, the patient was no longer tachycardally. Tachycardic. Needless to say, we were no longer driving blind here. We had goal-oriented management where we can directly see the impact of our intervention. And of course, the job is needed. Another case involved a 16-month-old boy who was undergoing hit surgery. He had a smooth IV induction, airway, and carto block. But then 15 minutes later, he developed hypotension, cardiac, and a loss of entitle. It was really bizarre, and we were entertaining in a way of possibility, including local anesthetic toxicity. Was it the carto that we placed? A mucus plug or other mechanical issue with the breathing tube? Could it have been a new work that our experts have some strange reason? Fortunately, an ultrasound was employed, and here's what we saw. This is a subcustom view of the heart where you can see on the left. You can actually see a massive amount of air in the right ventricle. Turns out, the patient line was not de-aired in primal fluid. So, 20 CCs of air was delivered directly to the patient's vein. Fortunately, we were able to put the patient in turn delimber, provide ionotropic and supportive care fluid, and watch the air dissipate live on ultrasound. The little boy recovered without any issues. The video on the right shows the resolution of air. So, where are we going in the future? Well, it's an exciting area with a lot of rapid development. First, we hope to educate ourselves in point of care, I'll just not go see, and determine how we can effectively integrate it into our practice. As you know, the perioperative environment is a very unique one. And so, being able to do the same things that are done in the ICU or in the emergency medicine arena, it doesn't quite apply. There are unique challenges to the OR that we have to consider when doing so. This would also involve developing a training pathway with credentialing, certification, maintenance of skills, quality of strength, and on and on and on. Nonetheless, we're excited and hopefully looking forward to doing that. Another example that we are doing here at the Department of Antichesiology is the development of a miniature probe that can be fixed on the patient's chest to provide continuous visual monitoring. Whether it's figuring out if the patient's high-volume may do a two-blood loss, has reduced contractility for some other region, or some other issue, we can take a look directly and determine the best course of action. Here in pain A, you can see the probe on the side view in pain B is the probe from the top. And on pain C, you can actually see it sort of with an arm fixed to the bed holding the probe against the patient's chest and being able to deliver a orthogonal view of the heart. So, who knows, maybe in the future we'll be able to adapt this to direct patient care. There are also other wearable ultrasound devices that are being developed in the market and they come with automatic image acquisition, artificial intelligence, and data transmission. So, who knows, maybe your cardiologist can remotely look at your echo as you go about your day. That would certainly be something interesting. Speaking of looking, let's take the blindfolds off and get a better look at all of the medical emergencies we handle every day. Join me. Thank you so much for your time. I look forward to taking any questions. Thanks, Holly. That was wonderful. And I'm hoping that we can have a few questions specifically about maybe not so much about pariopic and antiflexus, but probably a little more about the use of point of care ultrasound in emergencies like this and what a huge difference it can make. Can you have any questions? Comey and Holly, thank you so much. I guess one thing that might be interesting to go over a little bit is, while it's I think a great advance, there would be questions about how do we understand that people have a competency and how do they maintain competencies to make these diagnoses over time. I think we've talked about this in the department, but for this larger group, it might be helpful for people to understand what the plan is to try to make sure that when people are trying to make these diagnoses, that there's consistency, that there's some assuridence that what folks are seeing and calling is actually accurate. Holly, thank you. Thank you. Yeah, absolutely. This is a big topic of discussion and it's sort of spanned all of the other specialties as well, where defining the scope of practice has to be done in a very conscientious way and usually in a multidisciplinary way, where what we call and what we don't call is defined and discrete. The way Pocos is designed is to have very specific questions at the outset that you are trying to answer and that can be answered in which you are trained to do. So things like being able to qualitatively say the ventricle is empty, the ventricle is full and simple things like there is tamponade, there is no tamponade, basic, basic findings like that. There has been pretty good inter-rater validation with cardiologists who were blinded to trainees that were trained in being able to make these adjustments and a lot of the times after a decent amount of training and maintaining that training of anywhere, different studies of quote, a different things where they'll say 15 stands, some will say 25 stands and on. But once you have that degree of competency, there are these discrete questions and binary questions that you would answer. Yes, no. And there is a quality improvement, quality assurance process whereby the images that are acquired are considered adequate enough to make the call and they're validated by another person. So there's a long lengthy process before anyone can just kind of put the probe on and make a call where that has to be sort of determined early on in advance. So it's not and sort of going on here, but there are several studies that have been done with various sort of learners as well as various stages of their learning where they have been validated. But there's actually pretty good inter-rater reliability and accuracy when it comes to other users and once they're trained. This is Steve Fishman. That's a great talk. And I think I would add to at least comment about what happens in other specialties. It used to be that radiologists would not allow anybody, eventually cardiologists, but other specialists, we weren't allowed to hold an old probe. That was their purview, that was their their their Bayley Whip. Or time that has changed. The technology has improved to make it simpler. The visualization has improved so that you don't necessarily have to be radiologists to interpret at least basic images. And what we've seen in surgery and in the emergency medicine world is a gradual expectation that our trainees and young faculty members around the country are fastened with an ophthalm probe for limited applications. So in our trauma bay routine, the uncertainty in adult hospitals around around the country, any of the most outside the United States, emergency physicians and surgeons are quite comfortable doing fast exams to look for the basics of tamponon and pneumothorics and free blood in the abdominal cavity, et cetera. And I suspect that with your demonstrating, although you're quite fastened with this, you will see this happen in a generational fashion. So there's a few of us on this screen, myself included, who feel like I have a blindfold on when I quit the ultrasound probe in my hand. But we have on a departmental basis started teaching ourselves or having the younger people teach the old dog how to hold on some code, how to use it for for example, central line placement. For several years, I have for every central line asked the residents, would you like to teach me how to do this with an ultrasound or would you like me to teach you how to do this without because I've done many thousands by landmark and have never held on some probe. And of course, the trainees say, well, I've never seen one done with that ultrasound. And so they always chose for me to teach them to do it by landmark. Now we've reversed that. And I said, no, I'm actually not going to give you that choice. I want you to teach me. And what has really helped with us is a development of a simulation program. And given our Sim program capacity, I suspect that you could accelerate the learning for the people who don't have experience with the technique. Not to the point where it was going to develop your facility with it, but where you can, you know, push things faster because it's obvious this is a good way. So great talk. Yeah, thank you. Yes, absolutely. I think I think there's a lot of resources that we have, namely the simulation center and the support of multiple programs and providers where we can leverage those to really kind of fast track that education. But really with sort of flip-cost models and the simulation center, when you start to combine those things and then to have one-on-one sort of training, you really can move ahead pretty quickly. So I think, yes, it's going to come over time. I think it's this wave that's coming no matter what. So it's a question of, you know, how much of it do we embrace and how do we do it in an effective manner to make sure that we do it and do it appropriately when it's appropriate and not sort of venture into areas that might hurt us rather than help because I think there's always a risk in either way depending on how you use it. And the literature does have some interesting places where folks have used ultrasound and it's actually sort of inhibited rather than help. For example, when there is a cardiac arrest, they did a study looking at the application of focus during the arrest and found that actually during the period when there was the 10-second pause to look at the rhythm, that's when they wanted to do the ultrasound. But because of how it was applied and there was no sort of plan to doing it, it actually took longer and delayed that period of time. So it extended the 10 seconds to to an average, you know, much higher than that. And so that was problematic. But when it's more thoughtful and integrated in a more sort of planned way, such as they'll have the probe on the chest during compressions ready to go so that when it's stopped, you already have an image ready to go and you have a countdown to minimize that amount of time where you're doing the echo and you have the most skilled person doing it and so on and so forth. When that's taken into account, it's actually been shown that it's actually helpful rather than hurting. So totally agree. I think with all the resources we have putting them together, we can really kind of bring this in and hone it. And you know, in pediatrics is such a very operative, a pediatric perioperative care. This is still sort of a burgeoning field. And since we have the opportunity, we ought to be sort of moving that ahead. Well, thanks, Rick. I talked it's shown here. I wondered if we have currently any credentialing process for any of these exams or your thoughts are about that in the future. And also what you're thought about setting minimum standards for competencies. So you have to do X number of scans every year to maintain your credentialing. This is something that I've thought about a lot with airway management that we've implemented some things where we put in some standards. I'm just wondering what you thought about that for this. Yeah, excellent question. And this sort of goes back to the question that Joe brought up, which is how do we make those standards? We don't have any formal ones in the perioperative arena. I know that the emergency medicine physicians do have a protocol where I believe it's 50 scans or so or somewhere between 20 and 30 is what the literature has shown. And I think that's where we would shoot for on any specific module. So say, you know, we were going to do, you know, vascular access or we were going to do the basic gastro scan or cardiac scan, then we would shoot for that. And then, you know, obviously we want to have a platform in a place where we can actually store all of those images. And more importantly than anything else is that we maintain this over time. Because what has been shown is that after two years, it isn't practice or it isn't utilized, there's a rapid decline in people's skill in image acquisition and interpretation. So however we do it, we have to ensure that there is not only a minimum requirement and a process by which people are credentialed officially, but that we actually maintain that credentialing. Wally, could you comment on what the formal training programs and focus are for the critical care fellows and the anesthesia fellows on how far has that come along? Yep. So I think other folks in the ICU can probably speak to the ICU setup a little bit more than I can, but I do know that, you know, there is some, there was some training where we held courses just to introduce people to the idea over the last couple of years for staff members. And then up in the ICU, I believe that there are, there we are building up the programs there so that folks can actually begin to certify. We just have where we have a platform that has been worked on by a few folks like Dave Cantor and Raleigh and a few others, which is called QPath, where we now have a place where we can store images. We're also evaluating other things, other platforms to see if they might be more applicable or not. So that's where we are. We're basically at the early planning stages of determining where and when we're going to do that. Thoughts being around, you know, utilizing areas like the pre-op space using coaches one-on-one coaching, using a flip-class from model where there are online platforms that folks can do their education and then layering on top of that simulation. So it's all really in the early planning phases. We're not quite there in terms of actually rolling out something formal other than having sort of beginning to raise awareness to folks and having them begin to feel and see and touch and see how this may apply in clinical practice. I'm going to, it's actually after eight so I'm going to close us out, but I just wanted to thank Steve for what he said and I, part of the reason that we're presenting this today in this format is just to make sure that everyone's aware that this is a very much of an all-hands-on-deck situation and if you've got situations where you've got surgeons who are also very fast-style in this particular situation, this might be an indication for, you know, getting basically all-hands-on-deck to help out in this acute situation. Anyway, thank you all for your attention and I guess it's off to, off to work. All right, thank you. Thank you. Feel free to email with any questions or discussion points.
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