The PIEPEAR Workflow: A Critical Care Ultrasound Based 7-Step Approach as a Standard Procedure to Manage Patients with Acute Cardiorespiratory Compromise, with Two Example Cases Presented

Abstract

Critical care ultrasound (CCUS) has been widely used as a useful tool to assist clinical judgement. The utilization should be integrated into clinical scenario and interact with other tests. No publication has reported this. We present a CCUS based “7-step approach” workflow—the PIEPEAR Workflow—which we had summarized and integrated our experience in CCUS and clinical practice into, and then we present two cases which we have applied the workflow into as examples. Step one is “problems emerged?” classifying the signs of the deterioration into two aspects: acute circulatory compromise and acute respiratory compromise. Step two is “information clear?” quickly summarizing the patient's medical history by three aspects. Step three is “focused exam launched”: (1) focused exam of the heart by five views: the assessment includes (1) fast and global assessment of the heart (heart glance) to identify cases that need immediate life-saving intervention and (2) assessing the inferior vena cava, right heart, diastolic and systolic function of left heart, and systematic vascular resistance to clarify the hemodynamics. (2) Lung ultrasound exam is performed to clarify the predominant pattern of the lung. Step four is “pathophysiologic changes reported.” The results of the focused ultrasound exam were integrated to conclude the pathophysiologic changes. Step five is “etiology explored” diagnosing the etiology by integrating Step two and Step four and searching for the source of infection, according to the clues extracted from the focused ultrasound exam; additional ultrasound exams or other tests should be applied if needed. Step six is “action” supporting the circulation and respiration sticking to Step four. Treat the etiologies according step five. Step seven is “recheck to adjust.” Repeat focused ultrasound and other tests to assess the response to treatment, adjust the treatment if needed, and confirm or correct the final diagnosis. With two cases as examples presented, we insist that applying CCUS with 7-step approach workflow is easy to follow and has theoretical advantages. The coming research on its value is expected.

Application of Critical Care Ultrasound in Patients With COVID-19: Our Experience and Perspective

“…Central venous pressure (CVP), pulse-indicated continuous cardiac output, which aims to monitor the pressure of the right atrium, pulmonary edema, and cardiac output, and other invasive monitoring methods were limited in the isolation units. Echocardiography based on five standard views could rapidly assess the cardiac structure, volume status, cardiac function, and peripheral resistance, which can help to identify the type of shock and to guide clinical treatment precisely [16] , [35] . Prior to the COVID-19 outbreak, our research group has published a critical care chest ultrasonic examination protocol (CCUE protocol) as a simple assessment workflow to rapidly and accurately assess the etiologies of pulmonary and cardiovascular failures at the bedside [16] .…”

Point-of-care ultrasound for critically-ill patients: A mini-review of key diagnostic features and protocols

“…The PIEPEAR[ 13 ] protocol is a 7-step protocol used in the setting of acute clinical deterioration of a critically ill patient. It describes a thought process, and incorporates POCUS assessments: (1) Identifying deranged physiological systems; (2) Screening for causes; (3) Focused ultrasound exam; (4) Making a presumptive diagnosis; (5) Exploring an etiology, including other investigations; (6) Initiating treatment; and (7) Repeating the focused ultrasound to assess the response to treatment, and titrating the treatment accordingly.…”