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

https://doi.org/10.1016/j.jcrc.2022.153992Get rights and content
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Highlights

  • Multi-organ POCUS may help rule out pulmonary embolism in ICU COVID-19 patients.

  • Multi-organ POCUS may thus reduce the need for CTPA.

  • Separately, lung, heart, or deep vein POCUS are not useful in ruling out PE.

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.

Keywords

Point-of-care ultrasound
POCUS
COVID-19
ICU
Pulmonary embolism
Diagnostics

Abbreviations

APACHE II
Acute Physiology and chronic Health Evaluation II
aPTT
activated prothrombin time
ARDS
acute respiratory distress syndrome
BMI
Body Mass Index
CI
confidence interval
COVID-19
coronavirus Disease 2019
CRP
C-reactive protein
CT
computed tomography
CTPA
computed tomography pulmonary angiography
CON1
1 subpleural consolidation of ≥1 cm (probable criterium)
CON2
≥2 subpleural consolidations of ≥1 cm (high likelihood criterium)
CVC
central venous catheter
DVT
deep venous thrombosis
EtCO2
end-tidal carbon dioxide
FiO2
Fraction of inspired oxygen
Hs
high sensitivity
ICU
intensive care unit
IQR
inter-quartile range
IU
international units
kPa
kilopascal
L
liter
LDH
lactate dehydrogenase
LV
left ventricle
NLR
negative likelihood ratio
NT-pro BNP
N-terminal pro b-type natriuretic peptide
NPV
negative predictive value
PaO2
partial pressure of arterial oxygen
PaO2/FiO2 (P/F) ratio
ratio of arterial oxygen partial pressure to fractional inspired oxygen)
PE
pulmonary embolism
PEEP
positive end-expiratory pressure
PLR
positive likelihood ratio
POCUS
point-of-care ultrasound
PPV
positive predictive value
SD
standard deviation
SOFA
Sequential Organ Failure Assessment
RV
right ventricle
RVS
right ventricular strain
US-
ultrasound negative
US+
ultrasound positive

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1

Both authors contributed equally to this manuscript