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Background Patients with coronavirus disease 2019 (COVID-19) present with diagnostic challenges because COVID-19 can cause varied end-organ failures that mimic respiratory distress of pulmonary origin. Early identification of concurrent complications can significantly alter patient management and course. Point-of-care ultrasound (POCUS) can be particularly useful in helping to differentiate concomitant complications with COVID-19. While lung POCUS findings related to COVID-19 have been published, little guidance exists on how ultrasound can be incorporated into a more comprehensive evaluation of patients under investigation for COVID-19. Objectives We devised a pathway called COVUS that incorporates POCUS into the initial evaluation of patients under investigation for COVID-19 to guide diagnosis and management. Discussion The pathway was derived based on a review of literature, consensus from the ultrasound faculty, as well as feedback from the entire faculty group at one academic institution with high volumes of patients with COVID-19. The scanning protocol uses a cardiac-first (rather than lung-first) approach to identify potential concomitant organ failure that may immediately alter management. Conclusions COVUS aims to maximize identification of the most immediately life-threatening complications while minimizing time at bedside and provider risk of exposure to COVID-19.

Purpose To explore postanesthesia care unit (PACU) nurses' interactions with technology during the critical Phase I recovery period. Design Interpretive description was used to understand nurses' experiences. Methods Nine PACU nurses were recruited from three mid-sized hospitals within the same health authority in a Western Canadian province. Nurse participants were interviewed using a semistructured interview guide. Findings Nurses' interactions with technology were significantly influenced by PACU culture, as they constantly navigated a level of uncertainly about their patient's respiratory status. Three themes from the study are described. Theme 1 described nurses' confidence and trust in a visual sensory respiratory assessment process and the influence of anesthesia providers. Theme 2 described PACU nurses' guarded trust or rationalized mistrust in technology. Theme 3 highlighted the contextual influences, which sustained nurses' approach to respiratory assessment. Conclusions PACU nurses practiced their intuitive sensory assessments with a projected strong sense of expert practice and minimal dependence on technology. PACU nurses expressed frustrations with current PACU bedside technology, particularly the respiratory module and described some experiences with delayed identification of hypoventilation and hypoxia. Rationalized behaviors with technology and alarm suppression were commonplace. Workplace culture sustained PACU nurses' respiratory assessment practices.

Peripherally inserted central catheter use has increased dramatically over the past decade, parallel to health care costs. Traditional bedside peripherally inserted central catheter placement requires anthropometric measurements of estimated catheter length and confirmation of appropriate tip positioning via chest radiograph. Newer bedside technology, using magnet and electrocardiogram capabilities, seeks to replace the traditional method with equal efficacy but less overall cost. The need for follow-up chest radiograph can been removed, a significant cost savings in direct patient care. In this retrospective case control study, we examine costs related to these 2 tip confirmation methods while assessing overall cost savings to the health care industry.

Bedside technology pressures nurses to integrate and master a variety of new tools, devices, and methods of monitoring patient status. We review opportunities and challenges in the relationship between bedside nursing and technology. The increasing amount of available technology has impacted bedside nurses. The relationship between bedside nursing and technology is largely positive. Big data holds great potential for translating digital patient information into expanded knowledge tools for the bedside nurse, the development of which require nursing involvement. More research is needed to explore the concept of the nurse as advocate in high-technology patient care.

To assess the correlation between total serum bilirubin (TSB) and transcutaneous bilirubin (TcB) values in Malawian newborn infants, and to investigate whether TcB can be used safely to guide phototherapy treatment in the absence of TSB results.128 newborn jaundiced infants were studied in the neonatal nursery at Queen Elizabeth Central Hospital, Blantyre. Paired TSB and TcB measurements (from forehead and sternum) were compared using the linear regression and Bland-Altman methods. Clinical decisions based on TcB results were compared with those based on 'gold standard' TSB results.For infants not under phototherapy, the lowest TcB reading (from forehead or sternum) gave the strongest correlation with TSB: r = 0·83 for term infants and r = 0·71 for premature infants. For infants undergoing phototherapy, the highest TcB reading gave the strongest correlation with TSB: r = 0·66 for term infants and r = 0·71 for premature infants. TcB values overestimated the degree of jaundice. For infants not under phototherapy, the mean (SD) bias and imprecision of TcB was 25 (72) μmol/L for term infants and 37 (73) μmol/L for premature infants. For infants under phototherapy, the mean bias and imprecision was 30 (79) μmol/L for term infants and 44 (77) μmol/L for premature infants. For infants not under phototherapy, using the lowest TcB reading to guide treatment decisions (n = 167) had good sensitivity (91%) and specificity (90%). For infants undergoing phototherapy, using the highest TcB reading to guide treatment decisions (n = 129) had good sensitivity (94%), but lower specificity (36%).TcB can be used to safely guide phototherapy treatment in a resource-poor setting.

The prevalence of heart failure (HF) is increasing as the population ages, but its rapid diagnosis and phenotype identification remain challenging. We sought to determine whether acoustic cardiography can accurately identify HF and its phenotypes.Three cohorts of patients were studied [94 with hypertension, 109 with HF and normal ejection fraction (HFNEF, EF ≥ 50%) and 89 with HF and reduced ejection fraction (HFREF, EF50%)]. All participants received acoustic cardiography and echocardiography examinations. Acoustic cardiographic parameters included S3 score (probability that the third heart sound exists), electromechanical activation time (EMAT, interval from Q wave to the first heart sound; EMAT/RR is EMAT normalized by heart rate), and systolic dysfunction index (SDI, a combination of EMAT/RR, S3 score, QRS duration and QR interval). Receiver operative characteristic curves were used to determine diagnostic utility of acoustic cardiography.EMAT/RR significantly differentiated HFNEF from hypertension (area under curve [AUC], 0.83; 95% confidence interval [CI], 0.77-0.89) with an EMAT/RR11.54% yielded 55% sensitivity and 90% specificity. Similarly, an echo-measured E/e'15 yielded 55% sensitivity, 90% specificity and 0.84 AUC in detecting HFNEF. Whereas SDI out-performed the other acoustic cardiographic parameters in differentiating HFREF from HFNEF (AUC, 0.81; 95% CI, 0.75-0.87), and an SDI5.43 yielded 53% sensitivity and 91% specificity. The E/e' ratio had a similar diagnostic performance.Our study demonstrates that this bedside technology may be helpful in identifying HF and its phenotypes, especially when echocardiography is not immediately available.

Hypothermia has long been recognized as an effective therapy for acute neurologic injury. Recent advances in bedside technology and greater understanding of thermoregulatory mechanisms have made this therapy readily available at the bedside. Critical care management of the hypothermic patient can be divided into 3 phases: induction, maintenance, and rewarming. Each phase has known complications that require careful monitoring. At present, hypothermia has only been shown to be an effective neuroprotective therapy in cardiac arrest survivors. The primary use of hypothermia in the neurocritical care unit is to treat increased intracranial pressure.

The use of ventilatory assistance can be traced back to biblical times. However, mechanical ventilators, in the form of negative-pressure ventilation, first appeared in the early 1800s. Positive-pressure devices started to become available around 1900 and today9s typical intensive care unit (ICU) ventilator did not begin to be developed until the 1940s. From the original 1940s ventilators until today, 4 distinct generations of ICU ventilators have existed, each with features different from that of the previous generation. All of the advancements in ICU ventilator design over these generations provide the basis for speculation on the future. ICU ventilators of the future will be able to integrate electronically with other bedside technology; they will be able to effectively ventilate all patients in all settings, invasively and noninvasively; ventilator management protocols will be incorporated into the basic operation of the ventilator; organized information will be presented instead of rows of unrelated data; alarm systems will be smart; closed-loop control will be present on most aspects of ventilatory support; and decision support will be available. The key term that will be used to identify these future ventilators will be smart!

BACKGROUND: Vibration response imaging (VRI) is a bedside technology to monitor ventilation by detecting lung sound vibrations. It is currently unknown whether VRI is able to accurately monitor the local distribution of ventilation within the lungs. We therefore compared VRI to electrical impedance tomography (EIT), an established technique used for the assessment of regional ventilation. METHODOLOGY/PRINCIPAL FINDINGS: Simultaneous EIT and VRI measurements were performed in the healthy and injured lungs (ALI; induced by saline lavage) at different PEEP levels (0, 5, 10, 15 mbar) in nine piglets. Vibration energy amplitude (VEA) by VRI, and amplitudes of relative impedance changes (rel.ΔZ) by EIT, were evaluated in seven regions of interest (ROIs). To assess the distribution of tidal volume (VT) by VRI and EIT, absolute values were normalized to the VT obtained by simultaneous spirometry measurements. Redistribution of ventilation by ALI and PEEP was detected by VRI and EIT. The linear correlation between pooled VT by VEA and rel.ΔZ was R(2) = 0.96. Bland-Altman analysis showed a bias of -1.07±24.71 ml and limits of agreement of -49.05 to +47.36 ml. Within the different ROIs, correlations of VT-distribution by EIT and VRI ranged between R(2) values of 0.29 and 0.96. ALI and PEEP did not alter the agreement of VT between VRI and EIT. CONCLUSIONS/SIGNIFICANCE: Measurements of regional ventilation distribution by VRI are comparable to those obtained by EIT.

Numerous bedside diagnostic modalities are appropriate for the practice of emergency medicine. The proliferation of sophisticated technology is likely to increase both the availability and accuracy of commercial testing products. If health care reform in the United States results in a relaxation of the CLIA regulations, there will be a rapid expansion of research and development aimed at the biotechnology market. How much this would pertain to hospital-based emergency practice remains to be seen. Cost containment pressures may act in both directions on the utilization of available bedside technology. Although these tests are often less expensive than centralized laboratory determinations, the ready availability of near-patient testing may result in an increase in use that negates the lower cost. As with other diagnostic modalities, a thoughtful, considered approach based on scientific evidence will be necessary to formulate the appropriate use of bedside testing in individual emergency practice settings.

Low left ventricular ejection fraction (LVEF) and the presence of restrictive LV filling pattern are poor prognosticators in heart failure patients with reduced EF (HFREF). We sought to investigate whether acoustic cardiography can identify these high-risk HFREF subgroups.A total of 127 HFREF patients (EF50%) were enrolled into our study. All patients underwent acoustic cardiographic and echocardiographic examinations. Acoustic cardiographic parameters included S3 score (probability that the third heart sound exists), electromechanical activation time (EMAT, interval from Q wave to the first heart sound; %EMAT is the proportion of cardiac cycle that EMAT occupies), and systolic dysfunction index (SDI, a derived variable from the combination of %EMAT, S3 score, QRS duration and QR interval). Receiver operating characteristic curves were used to determine diagnostic utility of acoustic cardiography.SDI discriminated (area under curve [AUC], 0.79; 95% confidence interval [CI], 0.71-0.87) patients with severely impaired EF (EF ≤ 35%) from those with moderately impaired EF (35%EF50%) with an SDI5 that yielded 87% sensitivity and 60% specificity. An S3 score4 identified patients with restrictive LV filling pattern with 0.76 AUC (95% CI, 0.67-0.84), 81% sensitivity and 55% specificity.SDI and S3 score obtained by acoustic cardiography identified HFREF patients with severely impaired systolic and diastolic function, respectively. This simple, bedside technology may be used as a screening tool to identify the sickest HFREF patients for more intensive therapy.

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