Multi-organ point-of-care ultrasound for detection of pulmonary embolism in critically ill COVID-19 patients – A diagnostic accuracy study

Abstract

Purpose Critically ill COVID-19 patients have an increased risk of developing pulmonary embolism (PE). Diagnosis of PE by point-of-care ultrasound (POCUS) might reduce the need for computed tomography pulmonary angiography (CTPA), while decreasing time-to-diagnosis. Materials & methods This prospective, observational study included adult ICU patients with COVID-19. Multi-organ (lungs, deep vein, cardiac) POCUS was performed within 24 h of CTPA, looking for subpleural consolidations, deep venous thrombosis (DVT), and right ventricular strain (RVS). We reported the scan time, and calculated diagnostic accuracy measures for these signs separately and in combination. Results 70 consecutive patients were included. 23 patients (32.8%) had a PE. Median scan time was 14 min (IQR 11–17). Subpleural consolidations' diagnostic accuracy was: 42.9% (95%CI [34.1–52.0]). DVT's and RVS' diagnostic accuracy was: 75.6% (95%CI [67.1–82.9]) and 74.4% (95%CI [65.8–81.8]). Their sensitivity was: 24.0% (95%CI [9.4–45.1]), and 40.0% (95%CI [21.3–61.3]), while their specificity was: 88.8% (95%CI [80.8–94.3]), and: 83.0% (95%CI [74.2–89.8]), respectively. Multi-organ POCUS sensitivity was: 87.5% (95%CI [67.6–97.3]), and specificity was: 25% (95%CI [16.9–34.7]). Conclusions Multi-organ rather than single-organ POCUS can be of aid in ruling out PE in critically ill COVID-19 and help select patients for CTPA. In addition, finding RVS can make PE more likely, while a DVT would preclude the need for a CTPA. Registration: www.trialregister.nl : NL8540.

Pocus No Manejo De Tromboembolismo Pulmonar

“…Poucos artigos nos trazem a prevalência de trombo em VD, pelo fato de ser geralmente apresentado em relatos de casos, justamente por ser pouco frequente. Nessa lista, Fields et al (2017), mostra uma sensibilidade de aproximadamente 5% de sensibilidade, porém, quando esse achado é visualizado pela ecocardiografia, associado a uma clínica de TEP, o diagnóstico é praticamente conclusivo com uma especifici-dade de 99% (FIELDS et al, 2017;LIEVELD et al, 2022).…”

“…Esse achado pode ser encontrado até no TEP subsegmentar (presente em 90% dos pacientes com TEP), apresentando uma sensibilidade muito alta, porém, a especificidade é o que limita a conclusão desse achado, tendo em vista que várias outras patologias promovem consolidação subpleural, o que pode ser estratificado diante a dimensão da extensão da consolidação e o número de focos com alteração na US, tendo em vista que a literatura mostra que as consolidações subpleurais (CSP) com dimensão maior que 1 cm mostraram ser mais especifica para TEP do que para as outras patologias (ZOTZ-MANN et al, 2021). Lieveld et al (2022), demonstrou exatamente essa relação sendo, 1 apresentação focal de consolidação pleural (>1cm) apresentava uma sensibilidade e especificidade de 8,7% e 78,6% para TEP; 2 apresentações, uma sensbilidade de 70,8% e 36,3% de especificidade; e um ponto de corte ideal quando apresentava 4 consolidações subpleurais, o que passava a apresentar valores de 60,9% e 66% de sensibilidade e especificidade (LIEVELD et al, 2022).…”

“…Sobre a acurácia desse método, mesmo para aqueles médicos com pouca formação na técnica do POCUS, apresentaram uma sensibilidade e especificidade de 96% e 97% respectivamente, havendo ganhos diante a acurácia do examinador, alcançando até 100% de especificidade (ALBRICKER et al, 2022;ARNOLD & JONAS, 2020;BARROSSE-ANTLE et al, 2021;FISCHER et al, 2019;LIEVELD et al, 2022).…”

Diagnosing Pulmonary Embolism Using Point-of-Care Ultrasound in a Patient With Malingering and Coccidioidomycosis Infection

“…In such cases, point-ofcare ultrasound (POCUS) performed at the bedside can be useful diagnostically [5]. It might reveal signs of right ventricular (RV) strain, which can raise clinical suspicion for the diagnosis of PE and prompt appropriate diagnostic tests, including computed tomography pulmonary angiography (CTPA) [6]. Coccidioidomycosis (also known as Valley Fever) is prevalent in Central and South America.…”

Prevalence of pulmonary embolism and deep venous thrombosis during the COVID-19 pandemic in an intensive care unit cohort: a service evaluation

“…Another uncertainty regards the frequency and distribution of PE within the pulmonary circulation in patients with COVID-19 as well as its association with co-existing DVT. 7 , 8 If peripherally located clot burden within the pulmonary circulation reflects in situ thrombosis, would less likely be associated with DVT. Conversely, embolisation of clot via the deep veins might be associated with a more centrally located clot burden.…”