There ain’t no Hocus in POCUS: Ultrasound is not just for central lines anymore!
Myron Yaster MD, Justin L. Lockman MD MSEd, and Alan Jay Schwartz MD MSEd
Many years ago, a distinguished group of leaders in our nascent subspecialty debated how to define “who is a pediatric anesthesiologist? “and “What differentiated training for the generalist and the pediatric anesthesia subspecialist?” Out of these discussions in the 1980s-early 1990s, came the birth of formal fellowship training and ultimately (in 2013) Board certification in our specialty. I vividly remember the discussions/arguments/debates on curriculum building and formalizing training. One in particular, the management of the difficult airway, raised howls and heckles. Several members of the group from the Children’s Hospital of Philadelphia insisted that light wand intubation be included and be a mandatory element of the curriculum.1 Many of you are thinking: “light wand intubation?” what the heck is that? At the time, light wands were simple alternatives to fiberoptic bronchoscopy. Indeed they were often used successfully when fiberoptic bronchoscopy failed.1 The light wands were originally home made, fiberoptic lighted stylets; when preloaded into an endotracheal tube, they could be used to successfully intubate the trachea blindly. When properly positioned, the skin over the trachea would light up. Forty years later, this “mandatory” technique has nearly entered the dustbin of history. Why do I bring this up? Several new “indispensable” technologies have entered or are entering into our practice, including point of care ultrasound (POCUS) for diagnostic and procedural uses, EEG monitoring to guide the depth of anesthesia, and checklist apps, like the PediCrisis app, to guide therapy during crisis management. These currently “indispensable” technologies may be mandatory today and forgotten tomorrow.
In the May issue of the journal Pediatric Anesthesia, the editors have published several articles on Point of Care Ultrasound (POCUS) in pediatric anesthesia practice and over the course of the next couple of weeks we will review several of them. Starting today we will review the article by O’Brien et al.2 who investigated how, or whether, ultrasound training has entered into the curriculum of U.S. pediatric anesthesiology fellowship training using a survey of the Program Directors of U.S. training programs. Myron Yaster MD
Original article
O'Brien EM, Guris RD, Quarshie W, Lin EE. The state of point-of-care ultrasound training in pediatric anesthesia fellowship programs in the United States: A survey assessment. Paediatr Anaesth. 2024 Jun;34(6):544-550. doi: 10.1111/pan.14851. Epub 2024 Feb 15. PMID: 38358309.
“The role of point-of-care ultrasound (POCUS) has increased in scope and breadth over the past several decades for diagnostic, procedural, and therapeutic purposes. The recognition of POCUS as a vital tool for the modern anesthesiologist has ingratiated POCUS into the forefront of anesthesia practice and training. Proficiency in POCUS is now an independent skillset assessed in the United States by the Accreditation Council for Graduate Medical Education (ACGME) Milestones for Anesthesiology. Transthoracic cardiac evaluation was integrated into the American Board of Anesthesiology's Applied Exam Structured Objective Clinical Examination in 2022, with lung ultrasound following in 2023, and gastric ultrasound to be added in 2024”2
“There is a need for tailored POCUS education specific to pediatric patients within anesthesia. Despite the call to expand POCUS use in the pediatric perioperative setting, there currently is no uniform requirement for POCUS education in this domain, and little is known about anesthesiology trainees' exposure to pediatric-specific POCUS, or what resources are offered in pediatric anesthesia fellowship programs for further POCUS education. We aim[ed] to describe the state of POCUS training and education in pediatric anesthesia fellowship programs within the United States using a voluntary, online survey sent to the program and associate program directors of the 60 pediatric anesthesia fellowship programs in the U.S..”2
“Thirty-three of fifty-eight programs (57%) completed the survey. Of those, 15 programs (45%) reported having a point-of-care ultrasound curriculum. Programs with ≤3 fellows per year were less likely to have an ultrasound curriculum compared to programs with ≥4 fellows per year (30% programs 0–3 fellows/year vs. 69% programs ≥4 fellows/year, odds ratio 0.19 [95% confidence intervals 0.04–0.87]; p = .03). Barriers to use most commonly included lack of experience (64%), lack of oversight/interpretive guidance (58%), and lack of time (45%). Programs without point-of-care ultrasound training had significantly higher odds of listing lack of ultrasound access as a primary barrier (50% programs without vs. 13% programs with, odds ratio 6.5, [95% confidence intervals 1.3–50]; p = .04) “2
Admittedly, we aren’t surprised. This survey underscores the need for more education and hands-on training, in addition to more readily available ultrasound equipment, in what is rapidly emerging as an indispensable component of pediatric anesthesia practice. Eventually, once POCUS training is more formalized, we think that the faculty AND all practitioners in private and academic practices will benefit from working to catch up to our fellows and new graduates with regards to expertise in bedside ultrasonography. Indeed, for those of us at CHOP (JLL) there is already a POCUS credentialing process in place in our department, and this year we implemented a minimum number of ultrasound-guided peripheral IVs placed as a quality metric for faculty. Being able to use POCUS for IV, arterial, and central line placement, peripheral nerve blockade and for cardiac assessment during resuscitation is as indispensable and essential in modern practice as laryngeal intubation. How do we bring both new and old practitioners up to speed? What are you doing in your practice to ensure you keep up? What should SPA or ASA do differently in workshops in the future to support this professional growth? Send your responses to Myron who will post in a Friday Reader Response.
PS: one of us (JLL) used to insist that all fellows did at least one light wand intubation prior to graduation – if for no other reason than because having many tools in the arsenal is valuable in critical situations. This practice disappeared entirely when our supplier could no longer provide light wands!
References
1. Rehman MA, Schreiner MS. Oral and nasotracheal light wand guided intubation after failed fibreoptic bronchoscopy. Paediatric anaesthesia 1997;7(4):349-51. (In eng). DOI: 10.1046/j.1460-9592.1997.d01-85.x.
2. O'Brien EM, Guris RD, Quarshie W, Lin EE. The state of point-of-care ultrasound training in pediatric anesthesia fellowship programs in the United States: A survey assessment. Paediatric anaesthesia 2024;34(6):544-550. (In eng). DOI: 10.1111/pan.14851.