We would like to thank all members of the SICS-Study group that have been involved within the SICS-I and have participated in brainstorm sessions about the current protocol. We would also like to thank the research bureau of our Critical Care department and its coordinators for their support; dr. W. Dieperink and M. Onrust. Furthermore, we would like to thank the ICU Studentsteam and the student-researchers who have structurally included patients into SICS-II so far; J. A. de Bruin, B. E. Keuning, drs. K. Selles.

<ol><li>Hiemstra, B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Clinical+examination%2C+critical+care+ultrasonography+and+outcomes+in+the+critically+ill%3A+cohort+profile+of+the+Simple+Intensive+Care+Studies-I%5BTitle%5D)+AND+%22BMJ+open%22%5BJournal%5D)">Clinical examination, critical care ultrasonography and outcomes in the critically ill: cohort profile of the Simple Intensive Care Studies-I.</a> BMJ open. 7 (9), 017170(2017).</li>
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<li>Perner, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Fluid+management+in+acute+kidney+injury%5BTitle%5D)+AND+%22Intensive+Care+Medicine%22%5BJournal%5D)">Fluid management in acute kidney injury.</a> Intensive Care Medicine. 43 (6), 807-815 (2017).</li>
<li>Balakumar, V., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Both+Positive+and+Negative+Fluid+Balance+May+Be+Associated+With+Reduced+Long-Term+Survival+in+the+Critically+Ill%5BTitle%5D)+AND+%22Critical+care+medicine%22%5BJournal%5D)">Both Positive and Negative Fluid Balance May Be Associated With Reduced Long-Term Survival in the Critically Ill.</a> Critical care medicine. 45 (8), 749-757 (2017).</li>
<li>Hjortrup, P. B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Restricting+volumes+of+resuscitation+fluid+in+adults+with+septic+shock+after+initial+management%3A+the+CLASSIC+randomised%2C+parallel-group%2C+multicentre+feasibility+trial%5BTitle%5D)+AND+%22Intensive+Care+Medicine%22%5BJournal%5D)">Restricting volumes of resuscitation fluid in adults with septic shock after initial management: the CLASSIC randomised, parallel-group, multicentre feasibility trial.</a> Intensive Care Medicine. 42 (11), 1695-1705 (2016).</li>
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<li>Gambardella, I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Congestive+kidney+failure+in+cardiac+surgery%3A+the+relationship+between+central+venous+pressure+and+acute+kidney+injury%5BTitle%5D)+AND+%22Interactive+CardioVascular+and+Thoracic+Surgery%22%5BJournal%5D)">Congestive kidney failure in cardiac surgery: the relationship between central venous pressure and acute kidney injury.</a> Interactive CardioVascular and Thoracic Surgery. 23 (5), 800-805 (2016).</li>
<li>Chen, K. P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Peripheral+Edema%2C+Central+Venous+Pressure%2C+and+Risk+of+AKI+in+Critical+Illness%5BTitle%5D)+AND+%22Clinical+journal+of+the+American+Society+of+Nephrology+%3A+CJASN%22%5BJournal%5D)">Peripheral Edema, Central Venous Pressure, and Risk of AKI in Critical Illness.</a> Clinical journal of the American Society of Nephrology : CJASN. 11 (4), 602-608 (2016).</li>
<li>Song, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Value+of+the+combination+of+renal+resistance+index+and+central+venous+pressure+in+the+early+prediction+of+sepsis-induced+acute+kidney+injury%5BTitle%5D)+AND+%22Journal+of+critical+care%22%5BJournal%5D)">Value of the combination of renal resistance index and central venous pressure in the early prediction of sepsis-induced acute kidney injury.</a> Journal of critical care. 45, 204-208 (2018).</li>
<li>Zhang, L., Chen, Z., Diao, Y., Yang, Y., Fu, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Associations+of+fluid+overload+with+mortality+and+kidney+recovery+in+patients+with+acute+kidney+injury%3A+A+systematic+review+and+meta-analysis%5BTitle%5D)+AND+%22Journal+of+Critical+Care%22%5BJournal%5D)">Associations of fluid overload with mortality and kidney recovery in patients with acute kidney injury: A systematic review and meta-analysis.</a> Journal of Critical Care. 30 (4), (2015).</li>
<li>Simple Intensive Care Studies II - Full Text View. ClinicalTrials.gov. , Available from: 
 <a target="_blank" href="https://clinicaltrials.gov/ct2/show/NCT03577405? term=simple+intensive+care+studies">https://clinicaltrials.gov/ct2/show/NCT03577405? term=simple+intensive+care+studies</a> (2018).</li>
<li>Wetterslev, J. Statistical analysis plan Simple Intensive Care Studies-I DETAILED STATISTICAL ANALYSIS PLAN (SAP) 1. Administrative information 1.1. Title, registration, versions and revisions. ClinicalTrials.gov. , Available from: 
 <a target="_blank" href="https://clinicaltrials.gov/ProvidedDocs/24/NCT02912624/SAP_000.pdf">https://clinicaltrials.gov/ProvidedDocs/24/NCT02912624/SAP_000.pdf</a> (2018).</li>
<li>van der Horst, I. C. C. Simple Observational Critical Care Studies - Full Text View - ClinicalTrials.gov. ClinicalTrials.gov. , Available from: 
 <a target="_blank" href="https://clinicaltrials.gov/ct2/show/NCT03553069">https://clinicaltrials.gov/ct2/show/NCT03553069</a> (2018).</li>
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<li>Teasdale, G., Jennett, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Assessment+of+Coma+and+Impaired+Consciousness%3A+A+Practical+Scale%5BTitle%5D)+AND+%22The+Lancet%22%5BJournal%5D)">Assessment of Coma and Impaired Consciousness: A Practical Scale.</a> The Lancet. 304 (7872), 81-84 (1974).</li>
<li>Detsky, M. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Discriminative+Accuracy+of+Physician+and+Nurse+Predictions+for+Survival+and+Functional+Outcomes+6+Months+After+an+ICU+Admission%5BTitle%5D)+AND+%22JAMA%22%5BJournal%5D)">Discriminative Accuracy of Physician and Nurse Predictions for Survival and Functional Outcomes 6 Months After an ICU Admission.</a> JAMA. 317 (21), 2187(2017).</li>
<li>Lipson, A. R., Miano, S. J., Daly, B. J., Douglas, S. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((The+Accuracy+of+Nurses%27+Predictions+for+Clinical+Outcomes+in+the+Chronically+Critically+Ill%5BTitle%5D)+AND+%22Research+%26+reviews.+Journal+of+nursing+and+health+sciences%22%5BJournal%5D)">The Accuracy of Nurses' Predictions for Clinical Outcomes in the Chronically Critically Ill.</a> Research & reviews. Journal of nursing and health sciences. 3 (2), 35-38 (2017).</li>
<li>Lichtenstein, D. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((BLUE-protocol+and+FALLS-protocol%3A+two+applications+of+lung+ultrasound+in+the+critically+ill%5BTitle%5D)+AND+%22Chest%22%5BJournal%5D)">BLUE-protocol and FALLS-protocol: two applications of lung ultrasound in the critically ill.</a> Chest. 147 (6), 1659-1670 (2015).</li>
<li>Tang, W. H. W., Kitai, T. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Intrarenal+Venous+Flow%3A+A+Window+Into+the+Congestive+Kidney+Failure+Phenotype+of+Heart+Failure%5BTitle%5D)+AND+%22JACC%3A+Heart+Failure%22%5BJournal%5D)">Intrarenal Venous Flow: A Window Into the Congestive Kidney Failure Phenotype of Heart Failure.</a> JACC: Heart Failure. 4 (8), 683-686 (2016).</li>
<li>Jeong, S. H., Jung, D. C., Kim, S. H., Kim, S. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Renal+venous+doppler+ultrasonography+in+normal+subjects+and+patients+with+diabetic+nephropathy%3A+Value+of+venous+impedance+index+measurements%5BTitle%5D)+AND+%22Journal+of+Clinical+Ultrasound%22%5BJournal%5D)">Renal venous doppler ultrasonography in normal subjects and patients with diabetic nephropathy: Value of venous impedance index measurements.</a> Journal of Clinical Ultrasound. 39 (9), 512-518 (2011).</li>
<li>Iida, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Clinical+Implications+of+Intrarenal+Hemodynamic+Evaluation+by+Doppler+Ultrasonography+in+Heart+Failure%5BTitle%5D)+AND+%22JACC%3A+Heart+Failure%22%5BJournal%5D)">Clinical Implications of Intrarenal Hemodynamic Evaluation by Doppler Ultrasonography in Heart Failure.</a> JACC: Heart Failure. 4 (8), 674-682 (2016).</li>
<li>Lang, R. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Recommendations+for+Cardiac+Chamber+Quantification+by+Echocardiography+in+Adults%3A+An+Update+from+the+American+Society+of+Echocardiography+and+the+European+Association+of+Cardiovascular+Imaging%5BTitle%5D)+AND+%22European+Heart+Journal+-+Cardiovascular+Imaging%22%5BJournal%5D)">Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.</a> European Heart Journal - Cardiovascular Imaging. 16 (3), 233-271 (2015).</li>
<li>Hiemstra, B., Eck, R. J., Keus, F., van der Horst, I. C. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Clinical+examination+for+diagnosing+circulatory+shock%5BTitle%5D)+AND+%22Current+opinion+in+critical+care%22%5BJournal%5D)">Clinical examination for diagnosing circulatory shock.</a> Current opinion in critical care. 23 (4), 293-301 (2017).</li>
<li>Vignon, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Basic+critical+care+echocardiography%3A+validation+of+a+curriculum+dedicated+to+noncardiologist+residents%5BTitle%5D)+AND+%22Critical+care+medicine%22%5BJournal%5D)">Basic critical care echocardiography: validation of a curriculum dedicated to noncardiologist residents.</a> Critical care medicine. 39 (4), 636-642 (2011).</li>
<li>Jensen, M. B., Sloth, E., Larsen, K. M., Schmidt, M. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Transthoracic+echocardiography+for+cardiopulmonary+monitoring+in+intensive+care%5BTitle%5D)+AND+%22European+journal+of+anaesthesiology%22%5BJournal%5D)">Transthoracic echocardiography for cardiopulmonary monitoring in intensive care.</a> European journal of anaesthesiology. 21 (9), 700-707 (2004).</li>
<li>Koster, G., van der Horst, I. C. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Critical+care+ultrasonography+in+circulatory+shock%5BTitle%5D)+AND+%22Current+opinion+in+critical+care%22%5BJournal%5D)">Critical care ultrasonography in circulatory shock.</a> Current opinion in critical care. 23 (4), 326-333 (2017).</li>
<li>Haitsma Mulier, J. L. G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Renal+resistive+index+as+an+early+predictor+and+discriminator+of+acute+kidney+injury+in+critically+ill+patients%3B+A+prospective+observational+cohort+study%5BTitle%5D)+AND+%22PloS+one%22%5BJournal%5D)">Renal resistive index as an early predictor and discriminator of acute kidney injury in critically ill patients; A prospective observational cohort study.</a> PloS one. 13 (6), 0197967(2018).</li>
<li>Micek, S. T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Fluid+balance+and+cardiac+function+in+septic+shock+as+predictors+of+hospital+mortality%5BTitle%5D)+AND+%22Critical+care%22%5BJournal%5D)">Fluid balance and cardiac function in septic shock as predictors of hospital mortality.</a> Critical care. 17 (5), London, England. 246(2013).</li>
</ol>

Authors have nothing to disclose.

All examinations need to be performed according to the protocol. Physical examination only has value if performed according to pre-specified definitions23. Laboratory values should be collected according protocol to obtain all values. Clear, interpretable CCUS images are key to answer the research question of this study, as described in Step 3.3. If poor quality images are obtained, the measurements and analyses described in Step 5 cannot be performed, and the purpose of repeated measurements expires. Three important measures are taken to minimize the risk of obtaining low quality images. First, student-researchers who perform CCUS in our study are trained by an experienced cardiologist-intensivist. Literature shows that a short training program is well suited to obtain basic competence in CCUS24. Second, the student researchers are supervised by a senior student-researcher during their first 20 exams so they may receive hands on feedback. Last, all acquired cardiac and kidney images will be reassessed and validated by an independent expert of a Cardiac Imaging Core Laboratory and an experienced abdominal radiologist, respectively to ensure that data is reliable.
To ensure image quality, researchers also need to pay attention to other aspects. Re-applying ultrasound gel or repositioning the probe so that it makes better contact with the skin of the patient is sometimes required to ensure optimal image quality. It is also important to take enough time to acquire the most optimal image and if there are doubts a senior researcher, i.e., a supervising cardiologist-intensivist or core laboratory technician, should be consulted before the clinical examination is completed. Continuous evaluation and validation of all ultrasonographic images is ensured by enforcing the protocolized steps displayed in Figure 1. In addition, student-researchers and experts frequently exchange feedback, making it easy to quickly implement protocol changes to further increase the quality of images and measurements. This frequent verification makes systematic errors easy to detect so that the CCUS training for future student-researchers can be adapted accordingly. Furthermore, monthly meetings open to all team members allows thorough evaluation and (if necessary) modifications of the protocol.
Round the clock availability for patient screening and inclusion is another key element for the successful implementation of this study. This can only be achieved by having a dedicated team of student-researchers, a large team of students to provide support, and good coordination with the ICU caregivers. This coordination takes place by regular low stake contact between caregivers and researchers about possible improvements to optimize collaboration with standard care.
A limitation of this protocol is that successfully conducting CCUS is dependent on the accessibility of the pre-specified positions where the probe is placed. During the SICS-I, it was already shown that cardiac CCUS cannot be performed when patients require drains, gauzes or wound dressings which obstruct the theoretically optimal echocardiographic window1. Additionally, the possibility to obtain a proper subcostal window via transthoracic echocardiography, which is required for the IVC measurements, has previously been shown to be potentially limited in a general ICU population25. The 24/7 availability required by this protocol to carry out the different examinations at different time points is also a potential limitation, as some centers may lack the capacity to do so. Even in a large academic hospital such as the UMCG, ensuring this has led to delays in the start of the study. Another limitation intrinsic to ultrasonographic measurements is the inter-observer variability of the measurements. For patient inclusion to be guaranteed 24/7, it is impossible for one researcher to conduct all clinical examinations in all included patients. This study aims to have the same researcher carry out all ultrasound measurement in one same patient to minimize variability at the individual level, but for the entire cohort, inter-observer variability remains an issue.
Ultrasonographic imaging of multiple organs can be a fast, safe, and effective structure for visualizing organ perfusion and function. It is a convenient tool that all medical professionals should be able to use, and for which few measurements based on a simple, standardized protocol should generally provide reliable measurements.
Furthermore, most observational studies evaluating the use of ultrasonography, and particularly of echocardiography, are retrospective in nature or include only a small number of patients.26 This protocol allows a structural 24/7 screening of an unselected cohort of critically ill patients, of which subpopulations of interest can be defined, thus allowing for the simultaneous investigation of multiple research questions.
Moreover, despite it being known that clinical variables in critical care are highly dynamic and reciprocally influence each other, most studies have only investigated the additive value of singular ultrasound measurements of specific organs27,28. This is the first protocol to focus on repeated measures, whole body ultrasound and venous congestion. We expect that the SICS-II will provide a more accurate reflection of patients&#39; hemodynamic status during ICU admission.
The current structure used in SICS can be applied to a large number of settings, and the addition of other elements is currently being studied. Its strength lies in the combination of a basic research line and an adaptive line in which new variables can easily be added to the CRFs so that new research questions can be investigated. An example of this adaptability is the addition of extensive ventricular wall assessment by deformation imaging, i.e., strain on short term, to the regular protocol in a specific subset of patients.
Moreover, patient inclusion is currently exclusively taking place in the ICU and part of the patients&#39; care trajectory is now missed. ICU patients are often first admitted to the emergency department (ED), and stay in the regular hospital ward after ICU discharge. Therefore, the SICS aims to include patients at an earlier stage by including patients upon ED arrival and register interventions and hemodynamic function from initial hospital admission onwards. Furthermore, plans to conduct CCUS after ICU-discharge to regular wards are also ongoing so that all patients can be measured at each predefined study time. Another important aspect is the expandability of the protocol to other centers: its simplicity allows easy adaptation by centers which can start inclusion themselves.
Lastly, the development and successful implementation of a structured CCUS protocol may also have clinical ramifications. Despite being used for research purposes only, it could be implemented for clinical CCUS by medical doctors after the proposed short training period. It would then be interesting to assess if facilitating CCUS training to (inexperienced) physicians would decrease additional diagnostic testing.

Patients admitted to the Intensive Care Unit (ICU) are the most critically ill with high rates of co- and multi-morbidities, independent of their admission diagnosis. Therefore, the ICU is the setting to investigate co- and multi-morbidity, their negative impact on patient outcomes, and how critical illness may lead to complications that contribute to additional multi-morbidities. To gain insight in this heterogeneous patient group detailed examination of each individual patient is of utmost interest.
The Simple Intensive Care Studies (SICS) research line is designed with the goal of evaluating the prognostic and diagnostic value of a comprehensive selection of clinical, hemodynamic and biochemical variables in ICU patients collected by a dedicated team of student-researchers coordinated by medical experts. One of the primary objectives of the SICS-I is to investigate the combination of clinical examination findings best associated with shock defined by cardiac output (CO) measured by critical care ultrasonography (CCUS)1. The SICS-II uses the structure of the SICS-I but adds repeated clinical examination, biochemical analysis and CCUS. The primary focus of SICS-II is to quantify venous congestion and identify variables that may contribute to its development. Repeated measurements provide dynamic information on the course of a patient&#39;s illness. Studies show that fluid overload is present in critically ill patients and fluid overload is associated with new morbidities. We thus focus on venous congestion in these patients. Moreover, several studies have suggested the possible negative effects of excessive fluid administration2,3,4,5,6. Fluid overload can be perceived as venous congestion or venous fluid overload, which may be observed by an increased central venous pressure (CVP) or peripheral edema. Elevated pressure in the central venous system may contribute to reduced organ perfusion followed by organ failure, but no exact definition of venous congestion exists.
Previous studies that suggested negative effects associated with excessive fluid administration used single surrogate measurements of venous congestion such as CVP, IVC collapsibility, fluid balance and/or peripheral edema7,8,9,10. To the best of our knowledge, the SICS-II is the first study to perform repeated CCUS of multiple organs combined with findings from clinical examination to assess the hemodynamic status of ICU patients. The focus on this multi-organ ultrasonography technique is important as organ failure or diminished organ function always influences the entire hemodynamic system. We expect that data from repeated examinations in SICS-II will help to unravel the pathophysiology and consequences of venous congestion. Consequently, this may help to improve earlier identification of critically ill patients at risk of venous congestion and guide the optimization of fluid administration. Additionally, the association between venous congestion and short- and long-term organ failure can be explored. Finally, the successful implementation of the SICS-II protocol would make evident that carrying out a large prospective study with a dedicated team of student-researchers is feasible and can yield quality data to investigate clinical problems.
Here, the procedure to perform comprehensive clinical examination of ICU patients with the goal of measuring venous congestion is demonstrated. A concise protocol of SICS-II was published on clinicaltrials.gov11. After the first initial clinical examination, a maximum of three additional clinical examinations, biochemical analyses and CCUS are conducted. Physical examination comprises of variables which reflect peripheral perfusion/microcirculation such as capillary refill time (CRT) or mottling as well as variables of the macrocirculation such as blood pressure, heart rate and urine output. Also, standard care laboratory values are registered (e.g., lactate, pH). Subsequently, CCUS of the heart, lungs, IVC and kidney is performed to obtain information on perfusion. Further methods will be elaborated within our statistical analysis plan, as was done in the SICS-I12.
Based on 138 patients included between 14-05-2018 and 15-08-2018, repeated measurements of a broad array of clinical variables within this structure seem feasible. We also show that independent validation is feasible. The SICS-II exemplifies a valuable methodology for enabling researchers to accurately register changes in variables of interest and can thus act as a guide to conducting research that reflects the progression in patients&#39; condition as seen in daily practice. The SICS-II study is carried out daily by a team of 2-3 student-researchers at all times, with a senior supervisor available on call. These student-researchers are trained in performing the physical examination and CCUS. They execute all the steps of the following protocol and are responsible for patient inclusion both during working hours and in the weekends. In addition, a larger ICU student team of around 30 students participate in evening and night shifts, to conduct the initial clinical examination (within 3 h of admittance) of new patients. Figure 1 presents a schematic summary of the study protocol, and Figure 2 and 3 display the Case Report Forms (CRF) used to register data upon collection.

<table><tbody><tr><td>Ultrasound machine</td><td>GE Healthcare</td><td>0144VS6</td><td>Ultrasound machine, GE Vivid S6</td></tr><tr><td>Ultrasound machine</td><td>GE Healthcare</td><td>3507VS6</td><td>Ultrasound machine, GE Vivid S6</td></tr><tr><td>Ultrasound machine</td><td>GE Healthcare</td><td>0630VS6</td><td>Ultrasound machine, GE Vivid S6</td></tr><tr><td>Ultrasound gel</td><td>Parker</td><td>01-08</td><td>Aquasonic 100 ultrasound transmission gel</td></tr><tr><td>Temperature probe</td><td>DeRoyal</td><td>81-010400EU</td><td>Skin Temperature Sensor&amp;nbsp;</td></tr></tbody></table>

observational study protocol for repeated clinical examination and critical care ultrasonography within the simple intensive care studies

Longitudinal evaluations of critically ill patients by combinations of clinical examination, biochemical analysis and critical care ultrasonography (CCUS) may detect adverse events of interventions such as fluid overload at an early stage. The Simple Intensive Care Studies (SICS) is a research line that focuses on the prognostic and diagnostic value of combinations of clinical variables.
The SICS-I specifically focused on the use of clinical variables obtained within 24 h of acute admission for prediction of cardiac output (CO) and mortality. Its sequel, SICS-II, focuses on repeated evaluations during ICU admission. The first clinical examination by trained researchers is performed within 3 h after admission consisting of physical examination and educated guessing. The second clinical examination is performed within 24 h after admission and includes physical examination and educated guessing, biochemical analysis and CCUS assessments of heart, lungs, inferior vena cava (IVC) and kidney. This evaluation is repeated at days 3 and 5 after admission. CCUS images are validated by an independent expert, and all data is registered in an online secured database. Follow-up at 90 days includes registration of complications and survival status according to patient&#39;s medical charts and the municipal person registry. The primary focus of SICS-II is the association between venous congestion and organ dysfunction.
The purpose of publishing this protocol is to provide details on the structure and methods of this on-going prospective observational cohort study allowing answering multiple research questions. The design of the data collection of combined clinical examination and CCUS assessments in critically ill patients are explicated. The SICS-II is open for other centers to participate and is open for other research questions that can be answered with our data.

The purpose of these representative results is to illustrate the feasibility of the protocol.
Patients 
In total, 663 patients were admitted to the ICU between 14-05-2018 and 15-08-2018. Of these, 208 patients were eligible for inclusion (reasons for exclusion are displayed in Figure 4). A number of 49 patients were excluded as there was no possibility to perform the CCUS due to ongoing resuscitation efforts. Seven patients refused to participate (no informed consent) and in four patients CCUS was impossible, e.g., due to prone positioning for mechanical ventilation or vacuum assisted closure of large wounds, resulting in 138 included patients with data for analysis.
CCUS validation and image quality 
Extensive validation of cardiac imaging is planned. Renal ultrasonography validation has been initiated. So far, images of 21 patients (15%) were validated. In 18 patients (86%) images appeared of sufficient quality. All reasons for disapproval of images were listed and returned for feedback to the researcher who performed the ultrasonography. The name of the researcher who performed the ultrasonography is recorded to be able to asses inter- and intra-observer variability using the Intraclass Correlation Coefficient (ICC). Exact statistical methods will be described in our statistical analysis plan, as was done in the SICS-I12.
Example case: Patient X, middle aged female 
Patient X was admitted after she was found with impaired consciousness and low blood pressure. All obtained measurements are shown in Table 1. All variables were obtained within the required time set without missing data, illustrating the possible feasibility of this protocol. Within 3 hours after admission the first clinical examination was performed. During this examination the patient was sedated, intubated and needed vasopressor treatment. The second clinical examination was performed ten hours later and showed stable vitals after 700 mL of fluid infusion. Vasopressors were reduced. CCUS and biochemical analysis showed normal cardiac, IVC and renal function (Figure 5, Figure 6 and Figure 7). At T3, two days later, the vasopressors were stopped but cumulative positive fluid balance had risen to 6 liters, accompanied by an increased CO, wider IVC and diminished renal perfusion and function reflected by increased serum creatinine. At T4, 5 days after admission, fluid balance and serum creatinine had risen even further, where the patient developed stage 3 AKI. The patient died 2 days later due to multi organ failure with unclear origin, at 7 days after admission.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/58802/58802fig1.jpg" /> 
Figure 1: SICS-II study overview.&#160;Timeline of the SICS-II study from patient admission to Intensive Care to the final step of data registration. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/58802/58802fig1large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/58802/58802fig2.jpg" /> 
Figure 2: Case Report Form (CRF) for clinical examination 1.&#160;CRF to be filled by the ICU team students or student-researchers when conducting the first clinical examination. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/58802/58802fig2large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/58802/58802fig3.jpg" /> 
Figure 3:&#160;Case Report Form (CRF) for clinical examinations 2, 3 and 4.&#160;CRF to be filled by the ICU team students or student-researchers when conducting the second, third and fourth clinical examinations. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/58802/58802fig3large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/58802/58802fig4.jpg" /> 
Figure 4:&#160;SICS-II patient inclusion and exclusion chart.&#160;Flowchart describing the criteria for patient inclusion and exclusion in the SICS-II study until 15-08-2018. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/58802/58802fig4large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/58802/58802fig5.jpg" /> 
Figure 5: Apical views showing change in cardiac function.&#160;(A) Image of the heart on an AP4CH view during CCUS conducted during clinical examination 2 (T=2); (B) Image of the heart VTI pulse wave signal on T=2, showing a CO of 5.6 L/min; (C) Image of the heart on an AP5CH view during CCUS conducted during clinical examination 3 (T=3); (D) Image of the heart VTI pulse wave signal on T=3, showing a CO of 8.3 L/min. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/58802/58802fig5large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 6" class="xfigimg" src="/files/ftp_upload/58802/58802fig6.jpg" /> 
Figure 6: M-mode image of the inferior vena cava (IVC) for diameter measurements.&#160;Image showing, on top, the IVC in real-time, and, below, the M-mode image representing the IVC diameter changes, from which the collapsibility can be calculated. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/58802/58802fig6large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 7" class="xfigimg" src="/files/ftp_upload/58802/58802fig7.jpg" /> 
Figure 7: The various elements of renal ultrasonography.&#160;(A) Image of the right kidney during CCUS; (B) Image showing, on top, the Doppler flow in the renal arteries, and, below, the flow wave from which the renal resistive index is calculated; (C) Image showing, on top, the Doppler flow in the renal veins, and, below, the flow wave from which the venous impedance index is calculated; (D) Image illustrating the measurement of renal length. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/58802/58802fig7large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table fo:keep-together.within-page="1">
	<tbody>
		<tr>
			<td>Variable</td>
			<td>T1 
			Day 1, at 00:38</td>
			<td>T2 
			Day 1, at 10:53</td>
			<td>T3 
			Day 3, at 10:14</td>
			<td>T4 
			Day 5, at 10:20</td>
		</tr>
		<tr>
			<td>Heart rate (bpm)</td>
			<td>110</td>
			<td>124</td>
			<td>122</td>
			<td>98</td>
		</tr>
		<tr>
			<td>Respiratory rate (breaths per min)</td>
			<td>24</td>
			<td>15</td>
			<td>26</td>
			<td>12</td>
		</tr>
		<tr>
			<td>Systolic blood pressure (mmhg)</td>
			<td>100</td>
			<td>115</td>
			<td>130</td>
			<td>118</td>
		</tr>
		<tr>
			<td>Diastolic blood pressure (mmhg)</td>
			<td>61</td>
			<td>69</td>
			<td>66</td>
			<td>65</td>
		</tr>
		<tr>
			<td>Mean arterial pressure (mmhg)</td>
			<td>73</td>
			<td>80</td>
			<td>84</td>
			<td>81</td>
		</tr>
		<tr>
			<td>Cumulative fluid balance (mL)</td>
			<td>0</td>
			<td>704</td>
			<td>7272</td>
			<td>12338</td>
		</tr>
		<tr>
			<td>Mechanical ventilation</td>
			<td>PEEP 5, FiO2 40%</td>
			<td>PEEP 5, FiO2 40%</td>
			<td>PEEP 5, FiO2 30%</td>
			<td>PEEP 5, FiO2 30%</td>
		</tr>
		<tr>
			<td>CRT sternum (seconds)</td>
			<td>1.5</td>
			<td>2</td>
			<td>4</td>
			<td>3</td>
		</tr>
		<tr>
			<td>Central temperature (&#9702; C)</td>
			<td>37.6</td>
			<td>37.5</td>
			<td>38.0</td>
			<td>37.4</td>
		</tr>
		<tr>
			<td>Urinary output previous hour (mL)</td>
			<td>117</td>
			<td>60</td>
			<td>0</td>
			<td>10</td>
		</tr>
		<tr>
			<td>Administered inotropic agents</td>
			<td>Noradrenaline 
			0.1 mg/ml 
			3.0 ml/h</td>
			<td>Noradrenaline 
			0.1 mg/ml 
			1.0 ml/h</td>
			<td>none</td>
			<td>none</td>
		</tr>
		<tr>
			<td>Administered sedative agents</td>
			<td>Propofol 
			20 mg/ml 
			5.0 ml/h</td>
			<td>none</td>
			<td>none</td>
			<td>none</td>
		</tr>
		<tr>
			<td>APACHE IV score</td>
			<td>92</td>
			<td>88</td>
			<td>87</td>
			<td>90</td>
		</tr>
		<tr>
			<td>SOFA score</td>
			<td>8</td>
			<td>8</td>
			<td>5</td>
			<td>8</td>
		</tr>
		<tr>
			<td>LVOT (cm)</td>
			<td>N.A.</td>
			<td>2.4</td>
			<td>2.4</td>
			<td>2.4</td>
		</tr>
		<tr>
			<td>Cardiac output (L/min)</td>
			<td>N.A.</td>
			<td>5.6</td>
			<td>8.34</td>
			<td>9.89</td>
		</tr>
		<tr>
			<td>TAPSE (mm)</td>
			<td>N.A.</td>
			<td>25</td>
			<td>26</td>
			<td>21</td>
		</tr>
		<tr>
			<td>RV S&#8217; (cm/s)</td>
			<td>N.A.</td>
			<td>14</td>
			<td>15</td>
			<td>12</td>
		</tr>
		<tr>
			<td>IVC inspiratory diameter (cm)</td>
			<td>N.A.</td>
			<td>1.14</td>
			<td>1.24</td>
			<td>1.10</td>
		</tr>
		<tr>
			<td>IVC expiratory diameter (cm)</td>
			<td>N.A.</td>
			<td>1.27</td>
			<td>1.38</td>
			<td>1.50</td>
		</tr>
		<tr>
			<td>Kerley B lines (total)</td>
			<td>N.A.</td>
			<td>6</td>
			<td>2</td>
			<td>4</td>
		</tr>
		<tr>
			<td>Renal length (cm)</td>
			<td>N.A.</td>
			<td>10.59</td>
			<td>N.A.</td>
			<td>N.A.</td>
		</tr>
		<tr>
			<td>Intrarenal venous flow pattern</td>
			<td>N.A.</td>
			<td>Continuous</td>
			<td>Continuous</td>
			<td>Continuous</td>
		</tr>
		<tr>
			<td>Doppler Renal RI</td>
			<td>N.A.</td>
			<td>0.61</td>
			<td>0.75</td>
			<td>0.70</td>
		</tr>
		<tr>
			<td>VII</td>
			<td>N.A.</td>
			<td>0.33</td>
			<td>0.56</td>
			<td>0.68</td>
		</tr>
	</tbody>
</table>
Table 1: A random SICS-II patient.&#160;Patient X, middle aged female admitted to the ICU after being found with impaired consciousness. Abbreviations: bpm = beats per minute, CRT = capillary refill time, LVOT = left ventricular outflow tract, TAPSE = tricuspid annular plane systolic excursion, RV S&#39; = right ventricular systolic excursion, IVC = inferior vena cava, RRI = Renal resistive index, VII = venous impedance index, N.A. = not applicable.
<table fo:keep-together.within-page="1">
	<tbody>
		<tr>
			<td>Variable</td>
			<td>Unit</td>
			<td>Source</td>
			<td>Obtained at</td>
		</tr>
		<tr>
			<td>Lactate</td>
			<td>mmol/L</td>
			<td>Arterial blood gas analysis</td>
			<td>From standard care, as close as possible too each clinical examination, max 12 h difference</td>
		</tr>
		<tr>
			<td>Chloride</td>
			<td>mmol/L</td>
			<td>Arterial blood gas analysis</td>
			<td>From standard care, as close as possible too each clinical examination, max 12 h difference</td>
		</tr>
		<tr>
			<td>pH</td>
			<td></td>
			<td>Arterial blood gas analysis</td>
			<td>From standard care, as close as possible too each clinical examination, max 12 ho difference</td>
		</tr>
		<tr>
			<td>PCO2</td>
			<td>kPa</td>
			<td>Arterial blood gas analysis</td>
			<td>From standard care, as close as possible too each clinical examination, max 12 h difference</td>
		</tr>
		<tr>
			<td>PaO2</td>
			<td>kPa</td>
			<td>Arterial blood gas analysis</td>
			<td>From standard care, as close as possible too each clinical examination, max 12 h difference</td>
		</tr>
		<tr>
			<td>HCO3-</td>
			<td>mmol/L</td>
			<td>Arterial blood gas analysis</td>
			<td>From standard care, as close as possible too each clinical examination, max 12 h difference</td>
		</tr>
		<tr>
			<td>Hemoglobin</td>
			<td>mmol/L</td>
			<td>Arterial blood gas analysis</td>
			<td>From standard care, as close as possible too each clinical examination, max 12 h difference</td>
		</tr>
		<tr>
			<td>Leukocytes</td>
			<td>10 x 10-9/L</td>
			<td>Serum analysis</td>
			<td>From standard care, as close as possible too each clinical examination, max 12 h difference</td>
		</tr>
		<tr>
			<td>Trombocytes</td>
			<td>10 x 10-9/L</td>
			<td>Serum analysis</td>
			<td>From standard care, as close as possible too each clinical examination, max 12 h difference</td>
		</tr>
		<tr>
			<td>HS Troponine</td>
			<td>ng/L</td>
			<td>Serum analysis</td>
			<td>From standard care, as close as possible too each clinical examination, max 12 h difference</td>
		</tr>
		<tr>
			<td>ASAT</td>
			<td>U/L</td>
			<td>Serum analysis</td>
			<td>From standard care, as close as possible too each clinical examination, max 12 h difference</td>
		</tr>
		<tr>
			<td>ALAT</td>
			<td>U/L</td>
			<td>Serum analysis</td>
			<td>From standard care, as close as possible too each clinical examination, max 12 h difference</td>
		</tr>
		<tr>
			<td>Total bilirubin</td>
			<td>uoml/L</td>
			<td>Serum analysis</td>
			<td>From standard care, as close as possible too each clinical examination, max 12 h difference</td>
		</tr>
		<tr>
			<td>Creatinine</td>
			<td>umol/L</td>
			<td>Serum analysis</td>
			<td>All measurements from start of ICU admission</td>
		</tr>
		<tr>
			<td>Urine volume</td>
			<td>ml</td>
			<td>Urine collection of 24 h</td>
			<td>All measurements from start of ICU admission</td>
		</tr>
		<tr>
			<td>Creatinine</td>
			<td>mmol/24 h</td>
			<td>Urine analysis</td>
			<td>All measurements from start of ICU admission</td>
		</tr>
	</tbody>
</table>
Table 2: List of biochemical variables obtained.&#160;All patient biochemical variables collected during the study are listed here.

Watch this Scientific Journal Video about Observational Study Protocol for Repeated Clinical Examination and Critical Care Ultrasonography Within the Simple Intensive Care Studies at JoVE.com

Observational Study Protocol for Repeated Clinical Examination and Critical Care Ultrasonography Within the Simple Intensive Care Studies

Structured protocols are necessary to provide answers on research questions in critically ill patients. The Simple Intensive Care Studies (SICS) provides an infrastructure for repeated measurements in critically ill patients including clinical examination, biochemical analysis and ultrasonography. SICS projects have specific focus but the structure is flexible to other investigations.

Longitudinal evaluations of critically ill patients by combinations of clinical examination, biochemical analysis and critical care ultrasonography (CCUS) ...

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20.1K Views.  University Medical Center Groningen. Gestructureerde protocollen zijn nodig om antwoorden te geven op onderzoeksvragen bij ernstig zieke patiënten. De Simple Intensive Care Studies (SICS) biedt een infrastructuur voor herhaalde metingen bij ernstig zieke patiënten, waaronder klinisch onderzoek, biochemische analyse en echografie. SICS-projecten hebben een specifieke focus, maar de structuur is flexibel voor andere onderzoeken. 

Video: Observationeel studieprotocol voor herhaald klinisch onderzoek en echografie op kritieke zorg binnen de eenvoudige intensive care-onderzoeken

A Detailed Protocol for Physiological Parameters Acquisition and Analysis in Neurosurgical Critical Patients

Intracranial pressure (ICP) monitoring is now widely used in neurosurgical critical patients. Besides mean ICP value, the ICP derived parameters such as ICP waveform, amplitude of pulse (AMP), the correlation of ICP amplitude and ICP mean (RAP), pressure reactivity index (PRx), ICP and arterial blood pressure (ABP) wave amplitude correlation (IAAC), and so on, can reflect intracranial status, predict prognosis, and can also be used as guidance of proper treatment. However, most of the clinicians focus only on the mean ICP value while ignoring these parameters because of the limitations of the current devices. We have recently developed a multimodality monitoring system to address these drawbacks. This portable, user-friendly system will use a data collecting and storing device to continuously acquire patients&#39; physiological parameters first, i.e., ABP, ICP, and oxygen saturation, and then analyze these physiological parameters. We hope that the multimodality monitoring system will be accepted as a key measure to monitor physiological parameters, to analyze the current clinical status, and to predict the prognosis of the neurosurgical critical patients.

Recently, we have developed a portable multimodality monitoring system for the monitoring of various physiological parameters in neurosurgical critical patients. Detailed protocols on how to use this multimodality monitoring system are presented here.

Intracranial pressure (ICP) monitoring is now widely used in neurosurgical critical patients. Besides mean ICP value, the ICP derived parameters such as ...

Ultrasonographic Assessment During Cardiopulmonary Resuscitation

The US-CAB (Ultrasound, Circulation/Airway/Breathing) protocol integrates several sonographic techniques into a structured assessment of the circulation, airway, and breathing status of a patient during cardiopulmonary resuscitation (CPR) in an advanced life support-compliant manner. US-C provides a subxiphoid view of the heart, to look for potentially reversible causes of disease, such as pericardial effusion, pulmonary embolism, hypovolemia, and acute coronary thrombosis. Sonographic cardiac activity during CPR not only helps differentiate pseudo-pulseless electrical activity (PEA) from true PEA but also represents a higher chance of the return of spontaneous circulation (ROSC) and survival. Evaluation of the inferior vena cava (IVC) shows the fluid status of the patient and indicates the best methods to use for fluid resuscitation. If aortic dissection is suspected, a subxiphoid view of the aorta is suggested for identifying an intimal flap. Once intubation is done, tracheal ultrasound (US-A) at the suprasternal notch helps differentiate endotracheal intubation (one air-mucosal interface with one comet-tail) from esophageal intubation (double tract sign). Immediately following US-A, bilateral lung US (US-B) should be done to confirm proper bilateral ventilation using the lung sliding sign. In addition, US-C can be serially followed to see the dynamic changes in the cardiac chambers and IVC, or any cardiac contraction suggestive of ROSC. US-B can also detect coexisting lung or pleural pathologies without interfering with the performance of CPR. The main concern when implementing this method is maintaining high-quality CPR without delays in chest compressions when performing US-CAB. Rigorous training and continued practice are key to minimize any interruptions during resuscitation.

Here, we present a US-CAB (Ultrasound, Circulation/Airway/Breathing) protocol for use during cardiopulmonary resuscitation (CPR). US-C evaluates the subxiphoid view of the heart and inferior vena cava. After intubation, tracheal US (US-A) and lung US (US-B) help confirm endotracheal intubation and proper ventilation.

The US-CAB (Ultrasound, Circulation/Airway/Breathing) protocol integrates several sonographic techniques into a structured assessment of the circulation, ...

Hemodynamic Precision in the Neonatal Intensive Care Unit using Targeted Neonatal Echocardiography

Targeted neonatal echocardiography (TnECHO) refers to the use of comprehensive echocardiographic evaluation and physiologic data to obtain accurate, reliable, and real-time information on developmental hemodynamics in sick newborns. The comprehensive assessment is based on a multiparametric approach that overcomes the reliability issues of individual measurements, allows for earlier recognition of cardiovascular compromise and promotes enhanced diagnostic precision and timely management. TnECHO-driven research has led to an enhanced understanding of the mechanisms of illness and the development of predictive models to identify at-risk populations. This information may then be used to formulate a diagnostic impression and provide individualized guidance for the selection of cardiovascular therapies. TnECHO is based on the expert consultative model in which a neonatologist, with advanced training in neonatal hemodynamics, performs comprehensive and standardized TnECHO assessments. The distinction from point of care ultrasonography (POCUS), which provides limited and brief one-time assessments, is important. Neonatal hemodynamics training is a 1-year structured program designed to optimize image acquisition, measurement analysis, and hemodynamic knowledge (physiology, pharmacotherapy) to support cardiovascular decision-making. Neonatologists with hemodynamic expertise are trained to recognize deviations from normal anatomy and appropriately refer cases of possible structural abnormalities. We provide an outline of neonatal hemodynamics training, the standardized TnECHO imaging protocol, and an example of representative echo findings in a hemodynamically significant patent ductus arteriosus.

Presented here is a protocol to perform comprehensive neonatal echocardiography by trained neonatologists in the neonatal intensive care unit. The trained individuals provide longitudinal assessments of heart function, systemic and pulmonary hemodynamics in a consultative role. The manuscript also describes the requirements to become a fully trained neonatal hemodynamics specialist.

Targeted neonatal echocardiography (TnECHO) refers to the use of comprehensive echocardiographic evaluation and physiologic data to obtain accurate, ...

Troubleshooting FoCUS Image Acquisition: Patient Positioning, Transducer Manipulation, and Image Optimization

Focused cardiac ultrasound (FoCUS) is a limited, clinician-performed application of echocardiography to add real-time information to patient care. These bedside exams are problem oriented, rapidly and repeatedly performed, and largely qualitative in nature. Competency in FoCUS includes mastery of the stereotactic and psychomotor skills required for transducer manipulation and image acquisition. Competency also requires the ability to optimize the setup, troubleshoot image acquisition, and understand the sonographic limitations because of complex clinical environments and patient pathology. This article presents concepts for successful, high-quality two-dimensional (B-mode) image acquisition in FoCUS.
Concepts of high-quality image acquisition can be applied to all established sonographic windows of the FoCUS exam: the parasternal long-axis (PLAX), parasternal short-axis (PSAX), apical four chamber (A4C), subcostal fourchamber (SC4C), and the inferior vena cava (IVC). The apical five-chamber (A5C) and subcostal short-axis (SCSA) views are mentioned, but are not discussed in-depth. A pragmatic figure illustrating the movements of the phased array transducer is also provided to serve as a cognitive aid during FoCUS image acquisition.

Here, we present a protocol to allow providers to perform focused cardiac ultrasound (FoCUS) in the clinical environment. We describe methods of transducer manipulation, review common pitfalls of transducer movements, and suggest tips to optimize phased array transducer use.

Focused cardiac ultrasound (FoCUS) is a limited, clinician-performed application of echocardiography to add real-time information to patient care. These ...

A Modified Sonographic Algorithm for Image Acquisition in Life-Threatening Emergencies in the Critically Ill Newborn

The use of routine point-of-care ultrasound (POCUS) is increasing in neonatal intensive care units (NICUs), with several centers advocating for 24 h equipment availability. In 2018, the sonographic algorithm for life-threatening emergencies (SAFE) protocol was published, which allows the assessment of neonates with sudden decompensation to identify abnormal contractility, tamponade, pneumothorax, and pleural effusion. In the study unit (with a consulting neonatal hemodynamics and POCUS service), the algorithm was adapted by including consolidated core steps to support at-risk newborns, aiding clinicians in managing cardiac arrest, and adding views to verify correct intubation. This paper presents a protocol that can be applied in the NICU and the delivery room (DR) in relation to three scenarios: cardiac arrest, hemodynamic deterioration, or respiratory decompensation. 
This protocol can be performed with a state-of-the-art ultrasound machine or an affordable handheld device; the image acquisition protocol is carefully detailed. This method was designed to be learned as a general competence to obtain the timely diagnosis of life-threatening scenarios; the method aims to save time but does not represent a substitute for comprehensive and standardized hemodynamic and radiological analyses by a multidisciplinary team, which might not universally be on call but needs to be involved in the process. From January 2019 to July 2022, in our center, 1,045 hemodynamic consultation/POCUS consults were performed with 25 patients requiring the modified SAFE protocol (2.3%), and a total of 19 procedures were performed. In five cases, trained fellows on call resolved life-threatening situations. Clinical examples are provided that show the importance of including this technique in the care of critical newborns.

Here, we present a protocol that can be applied in the neonatal intensive care unit and the delivery room in relation to three scenarios: cardiac arrest, hemodynamic deterioration, or respiratory decompensation. This protocol can be performed with a state-of-the-art ultrasound machine or an affordable handheld device; an image acquisition protocol is carefully detailed.

The use of routine point-of-care ultrasound (POCUS) is increasing in neonatal intensive care units (NICUs), with several centers advocating for 24 h ...

Non-Invasive Monitoring of Microvascular Oxygenation and Reactive Hyperemia using Hybrid, Near-Infrared Diffuse Optical Spectroscopy for Critical Care

The detection of levels of impairment in microvascular oxygen consumption and reactive hyperemia is vital in critical care. However, there are no practical means for a robust and quantitative evaluation. This paper describes a protocol to evaluate these impairments using a hybrid near-infrared diffuse optical device. The device contains modules for near-infrared time-resolved and diffuse correlation spectroscopies and pulse-oximetry. These modules allow the non-invasive, continuous, and real-time measurement of the absolute, microvascular blood/tissue oxygen saturation (StO2) and the blood flow index (BFI) along with the peripheral arterial oxygen saturation (SpO2). This device uses an integrated, computer-controlled tourniquet system to execute a standardized protocol with optical data acquisition from the brachioradialis muscle. The standardized vascular occlusion test (VOT) takes care of the variations in the occlusion duration and pressure reported in the literature, while the automation minimizes inter-operator differences. The protocol we describe focuses on a 3-min occlusion period but the details described in this paper can readily be adapted to other durations and cuff pressures, as well as other muscles. The inclusion of an extended baseline and post-occlusion recovery period measurement allows the quantification of the baseline values for all the parameters and the blood/tissue deoxygenation rate that corresponds to the metabolic rate of oxygen consumption. Once the cuff is released, we characterize the tissue reoxygenation rate, magnitude, and duration of the hyperemic response in BFI and StO2. These latter parameters correspond to the quantification of the reactive hyperemia, which provides information about the endothelial function. Furthermore, the above-mentioned measurements of the absolute concentration of oxygenated and deoxygenated hemoglobin, BFI, the derived metabolic rate of oxygen consumption, StO2, and SpO2 provide a yet-to-be-explored rich data set that can exhibit disease severity, personalized therapeutics, and management interventions.

We describe a protocol to non-invasively and continuously measure absolute microvascular blood flow index and blood oxygen saturation using a multi-modal device based on near-infrared diffuse optics. We then evaluate the metabolic rate of oxygen consumption and reactive hyperemia utilizing a vascular occlusion test.

The detection of levels of impairment in microvascular oxygen consumption and reactive hyperemia is vital in critical care. However, there are no ...

POCUS Protocol for IVC Assessment in Management of Heart Failure

Workflow and Framework for Collecting and Implementing Point-of-Care Ultrasound Data in the Management of Heart Failure Patients

Management and prevention of acute decompensated heart failure remain highly prevalent and challenging medical conditions. Incorporation of Point-of-Care Ultrasound (POCUS) as an adjunctive tool for assessing volume status and treatment response has shown significant promise. POCUS can be used for imaging internal anatomic structures serially and capturing these images for comparison and measurement over time. This protocol describes a scalable and standardized methodology for the serial assessment of the inferior vena cava (IVC). The methodology includes serial image collection, measurement, and presentation in the electronic medical record. A workflow for POCUS-acquired images of the IVC was created to capture the images and measure the diameter in a discrete data field for direct comparison over time and in response to clinical management. The protocol also includes the assessment of the presence or absence of pleural effusion as discrete data in the standardized workflow. By integrating POCUS into heart failure management, clinicians can improve patient outcomes through more precise and timely adjustments in treatment.

Author Spotlight: Workflow for Integrating POCUS Data into EHR for Managing Heart Failure Patients

This protocol presents a scalable workflow for the use of point-of-care ultrasound in the management of hospitalized and outpatient heart failure patients.

Management and prevention of acute decompensated heart failure remain highly prevalent and challenging medical conditions. Incorporation of Point-of-Care ...

Ultrasound Protocol for Perioperative Frailty Assessment

Identifying Frailty Using Point-of-Care Ultrasonography: Image Acquisition and Assessment

Frailty is a significant predictor of a range of adverse outcomes in surgical patients, including increased mechanical ventilation time, longer hospital stays, unplanned readmissions, stroke, delirium, and death. However, accessible tools for screening in clinical settings are limited. Computed tomography of the psoas muscle is the current standard imaging device for measuring frailty, but it is expensive, time-consuming, and exposes the patient to ionizing radiation. Recently, the use of point-of-care ultrasound (POCUS) has emerged as a potential tool to determine the presence of frailty and has been shown to accurately predict frailty and postoperative outcomes. In this article, we will describe the image acquisition of the quadriceps muscles and explain how they can be used to determine frailty and predict postoperative adverse events. We will present information on probe selection, patient positioning, and troubleshooting. Images from a demonstration will be used to present the POCUS technique and example results. The article will culminate in a discussion of the use of these images in medical decision-making and potential limitations.

Author Spotlight: Assessing Surgical Frailty with Point-of-Care Ultrasound of Quadriceps Muscles

Here, we present a protocol to assess frailty in the perioperative setting using point-of-care ultrasound to measure quadriceps thickness. This method offers a practical, non-invasive alternative to traditional assessment methods, potentially enhancing perioperative care by quickly identifying frail patients.

Frailty is a significant predictor of a range of adverse outcomes in surgical patients, including increased mechanical ventilation time, longer hospital ...

Standardizing PoC TCCD Ultrasound Protocols for Critical Care in Adults

Point of Care Transcranial Color-Coded Duplex Ultrasound of the Middle Cerebral Artery

In the assessment and management of many clinical problems, point-of-care (PoC) ultrasound is an emerging bedside tool. Transcranial color-coded duplex (TCCD) ultrasound can be valuable in multiple situations, including for patients who are unconscious or have an equivocal neurologic examination, as it helps rule in specific intracranial pathologies. Despite the known diagnostic value of transcranial ultrasound, its use in critical care medicine remains variable. This variability is partly due to inconsistent training across hospitals, stemming from a lack of standardized education and training. Additionally, the brain has often been overlooked in many critical care protocols, such as RUSH (Rapid Ultrasound for Shock and Hypotension) and FAST (Focused Assessment with Sonography in Trauma) exams. To address these gaps, this article proposes a protocol for PoC TCCD image acquisition in adults, detailing indications, limitations, transducer selection, placement, sequence acquisition, and image optimization. Furthermore, the use of PoC TCCD is discussed as a means of screening for three conditions: vasospasm, raised intracranial pressure, and progression of cerebral circulatory arrest.

Transcranial ultrasound is an essential tool for monitoring patients with various neurological conditions. Although it is commonly used in a protocolized fashion in consultative studies, the brain has been overlooked in many protocols utilizing point-of-care ultrasound (PoCUS). This study proposes a PoCUS image acquisition protocol.

In the assessment and management of many clinical problems, point-of-care (PoC) ultrasound is an emerging bedside tool. Transcranial color-coded duplex ...

Point-of-Care Ultrasound for Peripheral Veno-Arterial Extracorporeal Membrane Oxygenation Without Left Ventricular Venting

Over the past several decades, veno-arterial extracorporeal membrane oxygenation (V-A ECMO) has become a critical tool in the management of patients with severe cardiogenic shock and cardiopulmonary failure. Due to the inherent instability of these patients, their transport away from intensive care units is fraught with risk. As a result, bedside diagnostic tools are essential for their daily care. One such tool is point-of-care ultrasound (POCUS) of the heart, which can non-invasively assess several parameters: left ventricular (LV) performance (size, systolic function, stroke volume, aortic valve opening), right ventricular (RV) performance (size, systolic function), and the presence of intracardiac thrombus. Additionally, POCUS can assist in evaluating readiness for V-A ECMO weaning and eventual decannulation. Despite its potential, the use of POCUS in the context of V-A ECMO remains inconsistent due to variability in provider training. This study aims to address this gap by detailing POCUS image acquisition in V-A ECMO, particularly in the absence of LV venting. It covers key aspects such as patient positioning, transducer selection, probe placement, acquisition sequence, and image optimization.

This protocol outlines the use of point-of-care ultrasound (POCUS) to monitor patients on peripheral veno-arterial extracorporeal membrane oxygenation (V-A ECMO) without left ventricular venting. It evaluates left ventricular distension, intracardiac or aortic root thrombus, and identifies useful cardiac POCUS parameters for weaning from V-A ECMO.

Over the past several decades, veno-arterial extracorporeal membrane oxygenation (V-A ECMO) has become a critical tool in the management of patients with ...

Observational Study Protocol for Repeated Clinical Examination and Critical Care Ultrasonography Within the Simple Intensive Care Studies

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