In training emergency physicians the carotid artery Doppler with passive leg raise, does previous sonographic experience influence scan time and competency?
Open accessAbstract
Background: Determination of fluid responsiveness (FR) associated with intravascular fluid resuscitation in hypotensive patients poses a challenge, with current best evidence methods fraught with poor retest reliability and difficulty in image acquisition (Osman, Crit Care Med 2007; 35: 64; Marik, Crit Care Med 2009; 37: 2642). Doppler carotid blood flow with passive leg raise (PLR) is a recent modality for determining FR (Marik, Chest 2013; 143: 364). Purpose: This study aimed to determine whether emergency physicians with limited ultrasound experience can reliably acquire this skill. Method: This prospective study recruited 60 emergency physicians with varying experience, who underwent a 3‐step learning programme. Participants performed carotid velocity time integral (VTi) Doppler on healthy subjects, followed by repeat measurements in the PLR position. A 16‐point checklist and time recorded were assessed for each sonographer, with each participant completing a post‐study questionnaire to evaluate perceived competence and ease of skill acquisition. Results: Of the 60 emergency physicians recruited, 37 (61.6%) were inexperienced and 23 (38.4%) were experienced. Against the 16‐point assessment, 61% completed assessment without any errors. Fifty‐six out of 60 (94.3%) completed the assessment to acceptable standard with errors recognised and corrected, and four participants (6.7%) made critical errors without correction (Figure 1). Average (±SEM) total scan time was 4:52 ± 0:19, with no significant difference found between inexperienced and experienced groups. Conclusions: This study demonstrated feasibility to train emergency physicians, demonstrating that average FR assessment was obtained within 5 min, with no difference between prior experience in scan quality/time taken. 94% completed the scan to acceptable standards, demonstrating ease of carotid Doppler flow with PLR to provide critical information in management of the hypotensive patient.
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Operator experience may impact the reliability of carotid flow measurements.
“obtaining and maintaining this mid-axis parallel view is difficult and literature describes that operator experience may impact the reliability of carotid flow measurements [2].”
From ESICM LIVES 2023 (2023) · cites this paper as [2]
The Reliability Parameter section (page unavailable) says differences in participants’ prior scanning experience may have altered their performance. But it also states that the study did not assess the reliability of their measurements against a gold standard; the Discussion reports no correlation between prior experience and scan quality. The paper therefore supports a possible effect on performance, not the claimed effect on measurement reliability. (LLM, conf=0.78)
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Research works printed but not linked: 17
- Osman D, Ridel C, Ray P, Monnet X, Anguel N, Richard C, et al. Cardiac filling pressures are not appropriate to predict hemody- namic response to volume challenge. Crit Care Med 2007; 35: 64-8.
- Marik PE, Cavallazzi R, Vasu T, Hirani A. Dynamic changes in arterial waveform derived variables and fluid responsiveness in mechanically ventilated patients: a systematic review of the litera- ture. Crit Care Med 2009; 37: 2642-7.
- Marik PE, Levitov A, Young A, Andrews L. The use of bioreactance and carotid doppler to determine volume responsiveness and blood flow redistribution following passive leg raising in haemodynami- cally unstable patients. Chest 2013; 143(2): 364-70.
- Mackenzie DC, Noble VE. Assessing volume status and fluid responsiveness in the emergency department. Clin Exp Emerg Med 2014; 1(2): 67-77.
- Wang CH, Hsieh WH, Chou HC, Huang YS, Shen JH, Yeo YH, et al. Liberal versus restricted fluid resuscitation strategies in trauma patients: a systematic review and meta-analysis of random- ized controlled trials and observational studies. Crit Care Med 2014; 42: 954-61.
- Marik PE. Iatrogenic salt water drowning and the hazards of a high central venous pressure. Ann Intensive Care 2014; 4: 21.
- Lamia B, Ochagavia A, Monnet X, Chemla D, Richard C, Teboul JL. Echocardiographic prediction of volume responsiveness in criti- cally ill patients with spontaneously breathing activity. Intensive Care Med 2007; 33: 1125-32.
- Stolz LA, Jarrod MM, Gross AM, Douglas MJ, Blaivas M, Adhikari S. Can emergency physicians perform common carotid doppler flow measurements to assess volume responsiveness? West J Emerg Med 2015; 16(2): 255-9.
- Mandeville JC, Colebourn CL. Can transthoracic echocardiography be used to predict fluid responsiveness in the critically ill patient? A systematic review. Crit Care Res Pract 2012; 2012: 513480.
- Mohan S, John L, Stirling E, Stirling S. Can Emergency Physicians reliably use Carotid Artery Doppler Ultrasound combined with Passive Leg Raise to predict fluid responsiveness in healthy sub- jects? Conference presentation: A Pilot study Emergency Depart- ment Logan Hospital, Metro South Health, Qld Government, Australia.
- Dinh VA, Ko HS, Rao R, Bansal RC, Smith DD, Kim TE, et al. Measuring cardiac index with a focused cardiac ultrasound exami- nation in the ED. Am J Emerg Med 2012; 30: 1845-51.
- Peachy T, Tang A, Baker EC, Pott J, Freund Y, Harris T. The assessment of circulating volume using inferior vena cava collapse index and carotid Doppler velocity time integral in healthy volun- teers: a pilot study. Scand J Trauma Resusc Emerg Med 2016; 24: 108-16.
- Corl K, Napoli AM, Gardiner F. Bedside sonographic regime of the inferior vena caval index is a poor predictor of fluid responsiveness in emergency department patients. Emerg Med Australas. 2012; 24 (5): 534-9.
- Marik PE, Cavallazzi R. Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med 2013; 41(7): 1774-81.
- Monnet X, Rienzo M, Osman D, Anguel N, Richard C, Pinsky MR, et al. Passive leg raising predicts fluid responsiveness in the criti- cally ill. Crit Care Med 2006; 34(5): 1402-7.
- Torres-Macho J, Anton-Santos JM, Garcia-Gutierrez I, de Castro- Garcia M, Gamez-Diez S, de la Torre PG, et al. Initial accuracy of bedside ultrasound performed by emergency physicians for multi- ple indications after a short training period. Am J Emerg Med 2012; 30(9): 1943-9.
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(2023) · Intensive Care Medicine Experimental · doi:10.1186/s40635-023-00546-y · Cited by 14 · see citing works
- Authors
- Osgood, R., Mohan, S., John, L., Stirling, E., & Stirling, S.
- Affiliations
- Logan Hospital (AU)
- Launceston General Hospital (AU)
- The Royal Melbourne Hospital (AU)
- Corresponding author
- Osgood, Robert
- ORCID
- Osgood, Robert
- Venue
- Australasian Journal of Ultrasound in Medicine
- Publisher
- Wiley
- Published
- 2020-04-16
- Volume
- 24
- Issue
- 1
- Pages
- 20-26
- ISSN
- 1836-6864 (ISSN-L)
- 2205-0140
- PMC
- PMC8412025
- OpenAlex
- W3017384015
- Cited by
- 8
- References
- 0
- Citations by year
- 2026: 2 · 2025: 2 · 2024: 2 · 2023: 1 · 2022: 1
- FWCI
- 0.32
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Australasian Journal of Ultrasound in Medicine (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Emergency Medicine Foundation (EMTR‐207R26‐2016)
- Topics
- Health Sciences › Medicine › Critical Care and Intensive Care Medicine › Ultrasound in Clinical Applications
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Innovations in Medical Education
- Health Sciences › Medicine › Emergency Medicine › Emergency Medicine Education and Research
- Keywords
- fluid responsiveness, passive leg raising, carotid Doppler ultrasound, velocity time integral, emergency physician training, ultrasound competency, scan time, fluid resuscitation, sonographer experience
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