Novice Physician Ultrasound Evaluation of Pediatric Tricuspid Regurgitant Jet Velocity

Abstract

Introduction Pulmonary hypertension, associated with high mortality in pediatric patients, is traditionally screened for by trained professionals by measuring a tricuspid regurgitant jet velocity (TRJV). Our objective was to test the feasibility of novice physician sonographers (NPS) to perform echocardiograms of adequate quality to exclude pathology (defined as TRJV > 2.5 meters per second). Methods We conducted a cross-sectional study of NPS to assess TRJV by echocardiogram in an urban pediatric emergency department. NPS completed an educational course consisting of a didactic curriculum and hands-on workshop. NPS enrolled a convenience sample of patients aged 7–21 years. Our primary outcome was the proportion of echocardiograms with images of adequate quality to exclude pathology. Our secondary outcome was NPS performance on four image elements. We present descriptive statistics, binomial proportions, kappa coefficients, and logistic regression analysis. Results Eight NPS completed 80 echocardiograms. We found 82.5% (95% confidence interval [CI], 74.2–90.8) of echocardiograms had images of adequate quality to exclude pathology. Among image elements, NPS obtained a satisfactory, apical 4-chamber view in 85% (95% CI, 77.1–92.9); positioned the color box accurately 65% (95% CI, 54.5–75.5); optimized TRJV color signal 78.7% (95% CI, 69.8–87.7); and optimized continuous-wave Doppler in 55% (95% CI, 44.1–66.0) of echocardiograms. Conclusion NPS obtained images of adequate quality to exclude pathology in a majority of studies; however, optimized acquisition of specific image elements varied. This work establishes the basis for future study of NPS assessment of TRJV pathology when elevated pulmonary pressures are of clinical concern.

Tricuspid Regurgitant Jet Velocity Point-of-Care Ultrasound Curriculum Development and Validation

“…During that study novice physician sonographers were graded by the study's primary cardiologist using the same grading rubric as this educational intervention (Document S5). In that study novice sonographers obtained a satisfactory apical 4-chamber view in 85% (95% CI 77.1-92.9), positioned the color box accurately 65% (95% CI 54.5-75.5), optimized TRJV color signal 78.7% (95% CI 69.8-87.7), and optimized continuous-wave Doppler in 55% (95% CI 44.1-66.0) of echocardiograms [13]. Future research into the implementation of this curriculum could compare novice performance to the gold standard of sonographer performed comprehensive echocardiogram to provide further validation of skill acquisition.…”

“…A previously published prospective research study by Binder et al tested sonographer's ability to physically perform TRJV scans (second stage) [13]. During that study novice physician sonographers were graded by the study's primary cardiologist using the same grading rubric as this educational intervention (Document S5).…”

“…We assessed an educational intervention as part of a larger prospective cross-sectional study. The prospective study tested the feasibility of novice physician sonographers to perform echocardiograms of adequate quality to exclude TRJV pathology in Emergency Department patients [13]. The educational intervention was performed in an urban tertiary care level 1 trauma center with an accredited Emergency Medicine residency and Pediatric Emergency Medicine (PEM) fellowship.…”

“…Each sonographer completed a minimum of 5 practice scans during the workshop followed by one graded scan. The instructors used a developed image grading rubric to grade scans (Document S5) [13]. Scans received a maximum score of 4 with each element receiving a complete (1), incomplete (0) or not performed (0).…”

The 2023 Core Content of advanced emergency medicine ultrasonography

“…Recent studies have shown the utility of estimating the tricuspid regurgitant jet to detect acute right ventricular strain in evaluating patients with pulmonary embolism in the emergency department. [56][57][58][59] The existing literature extensively supports the use of ultrasound in cardiac arrest. It has been proven to enhance the detection of reversible causes, assess compression quality during CPR, guide resuscitation efforts, and aid in determining survival prognosis based on specific findings.…”