Does point-of-care ultrasonography improve diagnostic accuracy in emergency department patients with undifferentiated hypotension? An international randomized controlled trial from the SHOC-ED investigators
Purpose Point-of-care ultrasonography (POCUS) is an established tool in the management of hypotensive patients in the emergency department (ED). We compared the diagnostic accuracy of a POCUS protocol versus standard assessment without POCUS in patients with undifferentiated hypotension. Methods Thi...
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| Veröffentlicht in: | Canadian journal of emergency medicine 2023, Vol.25 (1), p.48-56 |
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| creator | Peach, M. Milne, J. Diegelmann, L. Lamprecht, H. Stander, M. Lussier, D. Pham, C. Henneberry, R. Fraser, J. Chandra, K. Howlett, M. Mekwan, J. Ramrattan, B. Middleton, J. van Hoving, N. Taylor, L. Dahn, T. Hurley, S. MacSween, K. Richardson, L. Stoica, G. Hunter, Samuel Olszynski, P. Lewis, D. Atkinson, P. |
| description | Purpose
Point-of-care ultrasonography (POCUS) is an established tool in the management of hypotensive patients in the emergency department (ED). We compared the diagnostic accuracy of a POCUS protocol versus standard assessment without POCUS in patients with undifferentiated hypotension.
Methods
This was an international, multicenter randomized controlled trial included three EDs in North America and three in South Africa from September 2012 to December 2016. Hypotensive patients were randomized to early POCUS protocol plus standard care (POCUS group) or standard care without POCUS (control group). Initial and secondary diagnoses were recorded at 0 and 60 min. The main outcome was measures of diagnostic accuracy of a POCUS protocol in differentiating between cardiogenic and non-cardiogenic shock. Secondary outcomes were diagnostic performance for shock sub-types, as well as changes in perceived category of shock and overall diagnosis.
Results
Follow-up was completed for 270 of 273 patients. For cardiogenic shock, the POCUS-based diagnostic approach (POCUS) performed similarly to the non-POCUS approach (control) for specificity [95.5% (89.9–98.5) vs.93.8% (87.7–97.5)]; positive likelihood ratio (17.92 vs 14.80); negative likelihood ratio (0.21 vs 0.09) and diagnostic odds ratio (85.6 vs 166.57), with a similar overall diagnostic accuracy between the two approaches [93.7% (88–97.2) vs 93.6% (87.8–97.2)]. Diagnostic performance measures were similar across sub-categories of shock.
Conclusion
This is the first randomized controlled trial to compare diagnostic performance of a POCUS protocol to standard care without POCUS in undifferentiated hypotensive ED patients. POCUS performed well diagnostically in undifferentiated hypotensive patients, especially as a rule-in test; however, performance did not differ meaningfully from standard assessment. |
| doi_str_mv | 10.1007/s43678-022-00431-9 |
| format | Article |
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Point-of-care ultrasonography (POCUS) is an established tool in the management of hypotensive patients in the emergency department (ED). We compared the diagnostic accuracy of a POCUS protocol versus standard assessment without POCUS in patients with undifferentiated hypotension.
Methods
This was an international, multicenter randomized controlled trial included three EDs in North America and three in South Africa from September 2012 to December 2016. Hypotensive patients were randomized to early POCUS protocol plus standard care (POCUS group) or standard care without POCUS (control group). Initial and secondary diagnoses were recorded at 0 and 60 min. The main outcome was measures of diagnostic accuracy of a POCUS protocol in differentiating between cardiogenic and non-cardiogenic shock. Secondary outcomes were diagnostic performance for shock sub-types, as well as changes in perceived category of shock and overall diagnosis.
Results
Follow-up was completed for 270 of 273 patients. For cardiogenic shock, the POCUS-based diagnostic approach (POCUS) performed similarly to the non-POCUS approach (control) for specificity [95.5% (89.9–98.5) vs.93.8% (87.7–97.5)]; positive likelihood ratio (17.92 vs 14.80); negative likelihood ratio (0.21 vs 0.09) and diagnostic odds ratio (85.6 vs 166.57), with a similar overall diagnostic accuracy between the two approaches [93.7% (88–97.2) vs 93.6% (87.8–97.2)]. Diagnostic performance measures were similar across sub-categories of shock.
Conclusion
This is the first randomized controlled trial to compare diagnostic performance of a POCUS protocol to standard care without POCUS in undifferentiated hypotensive ED patients. POCUS performed well diagnostically in undifferentiated hypotensive patients, especially as a rule-in test; however, performance did not differ meaningfully from standard assessment.</description><identifier>ISSN: 1481-8035</identifier><identifier>EISSN: 1481-8043</identifier><identifier>DOI: 10.1007/s43678-022-00431-9</identifier><identifier>PMID: 36577931</identifier><language>eng</language><publisher>Cham: Springer International Publishing</publisher><subject>Accuracy ; Clinical trials ; Emergency medical care ; Emergency Medicine ; Emergency Service, Hospital ; Humans ; Hypotension ; Hypotension - diagnostic imaging ; Medical diagnosis ; Medicine ; Medicine & Public Health ; Original Research ; Point-of-Care Systems ; Public Health ; Shock - diagnostic imaging ; Shock, Cardiogenic ; Ultrasonic imaging ; Ultrasonography - methods</subject><ispartof>Canadian journal of emergency medicine, 2023, Vol.25 (1), p.48-56</ispartof><rights>The Author(s), under exclusive licence to Canadian Association of Emergency Physicians (CAEP)/ Association Canadienne de Médecine d'Urgence (ACMU) 2022. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.</rights><rights>2022. The Author(s), under exclusive licence to Canadian Association of Emergency Physicians (CAEP)/ Association Canadienne de Médecine d'Urgence (ACMU).</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c419t-5242de589ee01f84460c62fa52af7a672ebdc284a93ef61a2262e188e01dbf0a3</citedby><cites>FETCH-LOGICAL-c419t-5242de589ee01f84460c62fa52af7a672ebdc284a93ef61a2262e188e01dbf0a3</cites><orcidid>0000-0001-9900-4594</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://link.springer.com/content/pdf/10.1007/s43678-022-00431-9$$EPDF$$P50$$Gspringer$$H</linktopdf><linktohtml>$$Uhttps://link.springer.com/10.1007/s43678-022-00431-9$$EHTML$$P50$$Gspringer$$H</linktohtml><link.rule.ids>314,776,780,27901,27902,41464,42533,51294</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/36577931$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Peach, M.</creatorcontrib><creatorcontrib>Milne, J.</creatorcontrib><creatorcontrib>Diegelmann, L.</creatorcontrib><creatorcontrib>Lamprecht, H.</creatorcontrib><creatorcontrib>Stander, M.</creatorcontrib><creatorcontrib>Lussier, D.</creatorcontrib><creatorcontrib>Pham, C.</creatorcontrib><creatorcontrib>Henneberry, R.</creatorcontrib><creatorcontrib>Fraser, J.</creatorcontrib><creatorcontrib>Chandra, K.</creatorcontrib><creatorcontrib>Howlett, M.</creatorcontrib><creatorcontrib>Mekwan, J.</creatorcontrib><creatorcontrib>Ramrattan, B.</creatorcontrib><creatorcontrib>Middleton, J.</creatorcontrib><creatorcontrib>van Hoving, N.</creatorcontrib><creatorcontrib>Taylor, L.</creatorcontrib><creatorcontrib>Dahn, T.</creatorcontrib><creatorcontrib>Hurley, S.</creatorcontrib><creatorcontrib>MacSween, K.</creatorcontrib><creatorcontrib>Richardson, L.</creatorcontrib><creatorcontrib>Stoica, G.</creatorcontrib><creatorcontrib>Hunter, Samuel</creatorcontrib><creatorcontrib>Olszynski, P.</creatorcontrib><creatorcontrib>Lewis, D.</creatorcontrib><creatorcontrib>Atkinson, P.</creatorcontrib><title>Does point-of-care ultrasonography improve diagnostic accuracy in emergency department patients with undifferentiated hypotension? An international randomized controlled trial from the SHOC-ED investigators</title><title>Canadian journal of emergency medicine</title><addtitle>Can J Emerg Med</addtitle><addtitle>CJEM</addtitle><description>Purpose
Point-of-care ultrasonography (POCUS) is an established tool in the management of hypotensive patients in the emergency department (ED). We compared the diagnostic accuracy of a POCUS protocol versus standard assessment without POCUS in patients with undifferentiated hypotension.
Methods
This was an international, multicenter randomized controlled trial included three EDs in North America and three in South Africa from September 2012 to December 2016. Hypotensive patients were randomized to early POCUS protocol plus standard care (POCUS group) or standard care without POCUS (control group). Initial and secondary diagnoses were recorded at 0 and 60 min. The main outcome was measures of diagnostic accuracy of a POCUS protocol in differentiating between cardiogenic and non-cardiogenic shock. Secondary outcomes were diagnostic performance for shock sub-types, as well as changes in perceived category of shock and overall diagnosis.
Results
Follow-up was completed for 270 of 273 patients. For cardiogenic shock, the POCUS-based diagnostic approach (POCUS) performed similarly to the non-POCUS approach (control) for specificity [95.5% (89.9–98.5) vs.93.8% (87.7–97.5)]; positive likelihood ratio (17.92 vs 14.80); negative likelihood ratio (0.21 vs 0.09) and diagnostic odds ratio (85.6 vs 166.57), with a similar overall diagnostic accuracy between the two approaches [93.7% (88–97.2) vs 93.6% (87.8–97.2)]. Diagnostic performance measures were similar across sub-categories of shock.
Conclusion
This is the first randomized controlled trial to compare diagnostic performance of a POCUS protocol to standard care without POCUS in undifferentiated hypotensive ED patients. POCUS performed well diagnostically in undifferentiated hypotensive patients, especially as a rule-in test; however, performance did not differ meaningfully from standard assessment.</description><subject>Accuracy</subject><subject>Clinical trials</subject><subject>Emergency medical care</subject><subject>Emergency Medicine</subject><subject>Emergency Service, Hospital</subject><subject>Humans</subject><subject>Hypotension</subject><subject>Hypotension - diagnostic imaging</subject><subject>Medical diagnosis</subject><subject>Medicine</subject><subject>Medicine & Public Health</subject><subject>Original Research</subject><subject>Point-of-Care Systems</subject><subject>Public Health</subject><subject>Shock - diagnostic imaging</subject><subject>Shock, Cardiogenic</subject><subject>Ultrasonic imaging</subject><subject>Ultrasonography - methods</subject><issn>1481-8035</issn><issn>1481-8043</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2023</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNp9kcFu1DAQhiMEoqXwAhyQJS5cDLaTOMkJVdtCkSr1AJyjWWecdZXYwXaKlofkmZhlS5E4cJoZzzf_2P6L4qUUb6UQzbtUlbppuVCKC1GVknePilNZtZK3VD5-yMv6pHiW0q0QUtWyfVqclLpumq6Up8XPi4CJLcH5zIPlBiKydcoRUvBhjLDs9szNSwx3yAYHow8pO8PAmDWCoZ5nOGMc0VMx4AIxz-gzWyA7iol9d3nHVj84azHSiYOMA9vtl5DRJxf8e3buSSZj9DQTPEwsgh_C7H4QaILPMUwTpTk66tkYZpZ3yD5f3Wz45QWN3iHdaYQcYnpePLEwJXxxH8-Krx8uv2yu-PXNx0-b82tuKtllXqtKDVi3HaKQtq0qLYxWFmoFtgHdKNwORrUVdCVaLUEprVC2LdHD1gooz4o3R136mW8r7e9nlwxOE3gMa-pVU3dKV1IoQl__g96Gld46HSitRVfrqiNKHSkTQ0oRbb9EN0Pc91L0B7f7o9s9ud3_drs_DL26l163Mw4PI3_sJaA8AolafsT4d_d_ZH8BG_27kg</recordid><startdate>2023</startdate><enddate>2023</enddate><creator>Peach, M.</creator><creator>Milne, J.</creator><creator>Diegelmann, L.</creator><creator>Lamprecht, H.</creator><creator>Stander, M.</creator><creator>Lussier, D.</creator><creator>Pham, C.</creator><creator>Henneberry, R.</creator><creator>Fraser, J.</creator><creator>Chandra, K.</creator><creator>Howlett, M.</creator><creator>Mekwan, J.</creator><creator>Ramrattan, B.</creator><creator>Middleton, J.</creator><creator>van Hoving, N.</creator><creator>Taylor, L.</creator><creator>Dahn, T.</creator><creator>Hurley, S.</creator><creator>MacSween, K.</creator><creator>Richardson, L.</creator><creator>Stoica, G.</creator><creator>Hunter, Samuel</creator><creator>Olszynski, P.</creator><creator>Lewis, D.</creator><creator>Atkinson, P.</creator><general>Springer International Publishing</general><general>Springer Nature B.V</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>4T-</scope><scope>4U-</scope><scope>K9.</scope><scope>NAPCQ</scope><scope>7X8</scope><orcidid>https://orcid.org/0000-0001-9900-4594</orcidid></search><sort><creationdate>2023</creationdate><title>Does point-of-care ultrasonography improve diagnostic accuracy in emergency department patients with undifferentiated hypotension? An international randomized controlled trial from the SHOC-ED investigators</title><author>Peach, M. ; Milne, J. ; Diegelmann, L. ; Lamprecht, H. ; Stander, M. ; Lussier, D. ; Pham, C. ; Henneberry, R. ; Fraser, J. ; Chandra, K. ; Howlett, M. ; Mekwan, J. ; Ramrattan, B. ; Middleton, J. ; van Hoving, N. ; Taylor, L. ; Dahn, T. ; Hurley, S. ; MacSween, K. ; Richardson, L. ; Stoica, G. ; Hunter, Samuel ; Olszynski, P. ; Lewis, D. ; Atkinson, P.</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c419t-5242de589ee01f84460c62fa52af7a672ebdc284a93ef61a2262e188e01dbf0a3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2023</creationdate><topic>Accuracy</topic><topic>Clinical trials</topic><topic>Emergency medical care</topic><topic>Emergency Medicine</topic><topic>Emergency Service, Hospital</topic><topic>Humans</topic><topic>Hypotension</topic><topic>Hypotension - diagnostic imaging</topic><topic>Medical diagnosis</topic><topic>Medicine</topic><topic>Medicine & Public Health</topic><topic>Original Research</topic><topic>Point-of-Care Systems</topic><topic>Public Health</topic><topic>Shock - diagnostic imaging</topic><topic>Shock, Cardiogenic</topic><topic>Ultrasonic imaging</topic><topic>Ultrasonography - methods</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Peach, M.</creatorcontrib><creatorcontrib>Milne, J.</creatorcontrib><creatorcontrib>Diegelmann, L.</creatorcontrib><creatorcontrib>Lamprecht, H.</creatorcontrib><creatorcontrib>Stander, M.</creatorcontrib><creatorcontrib>Lussier, D.</creatorcontrib><creatorcontrib>Pham, C.</creatorcontrib><creatorcontrib>Henneberry, R.</creatorcontrib><creatorcontrib>Fraser, J.</creatorcontrib><creatorcontrib>Chandra, K.</creatorcontrib><creatorcontrib>Howlett, M.</creatorcontrib><creatorcontrib>Mekwan, J.</creatorcontrib><creatorcontrib>Ramrattan, B.</creatorcontrib><creatorcontrib>Middleton, J.</creatorcontrib><creatorcontrib>van Hoving, N.</creatorcontrib><creatorcontrib>Taylor, L.</creatorcontrib><creatorcontrib>Dahn, T.</creatorcontrib><creatorcontrib>Hurley, S.</creatorcontrib><creatorcontrib>MacSween, K.</creatorcontrib><creatorcontrib>Richardson, L.</creatorcontrib><creatorcontrib>Stoica, G.</creatorcontrib><creatorcontrib>Hunter, Samuel</creatorcontrib><creatorcontrib>Olszynski, P.</creatorcontrib><creatorcontrib>Lewis, D.</creatorcontrib><creatorcontrib>Atkinson, P.</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>Docstoc</collection><collection>University Readers</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Nursing & Allied Health Premium</collection><collection>MEDLINE - Academic</collection><jtitle>Canadian journal of emergency medicine</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Peach, M.</au><au>Milne, J.</au><au>Diegelmann, L.</au><au>Lamprecht, H.</au><au>Stander, M.</au><au>Lussier, D.</au><au>Pham, C.</au><au>Henneberry, R.</au><au>Fraser, J.</au><au>Chandra, K.</au><au>Howlett, M.</au><au>Mekwan, J.</au><au>Ramrattan, B.</au><au>Middleton, J.</au><au>van Hoving, N.</au><au>Taylor, L.</au><au>Dahn, T.</au><au>Hurley, S.</au><au>MacSween, K.</au><au>Richardson, L.</au><au>Stoica, G.</au><au>Hunter, Samuel</au><au>Olszynski, P.</au><au>Lewis, D.</au><au>Atkinson, P.</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Does point-of-care ultrasonography improve diagnostic accuracy in emergency department patients with undifferentiated hypotension? An international randomized controlled trial from the SHOC-ED investigators</atitle><jtitle>Canadian journal of emergency medicine</jtitle><stitle>Can J Emerg Med</stitle><addtitle>CJEM</addtitle><date>2023</date><risdate>2023</risdate><volume>25</volume><issue>1</issue><spage>48</spage><epage>56</epage><pages>48-56</pages><issn>1481-8035</issn><eissn>1481-8043</eissn><abstract>Purpose
Point-of-care ultrasonography (POCUS) is an established tool in the management of hypotensive patients in the emergency department (ED). We compared the diagnostic accuracy of a POCUS protocol versus standard assessment without POCUS in patients with undifferentiated hypotension.
Methods
This was an international, multicenter randomized controlled trial included three EDs in North America and three in South Africa from September 2012 to December 2016. Hypotensive patients were randomized to early POCUS protocol plus standard care (POCUS group) or standard care without POCUS (control group). Initial and secondary diagnoses were recorded at 0 and 60 min. The main outcome was measures of diagnostic accuracy of a POCUS protocol in differentiating between cardiogenic and non-cardiogenic shock. Secondary outcomes were diagnostic performance for shock sub-types, as well as changes in perceived category of shock and overall diagnosis.
Results
Follow-up was completed for 270 of 273 patients. For cardiogenic shock, the POCUS-based diagnostic approach (POCUS) performed similarly to the non-POCUS approach (control) for specificity [95.5% (89.9–98.5) vs.93.8% (87.7–97.5)]; positive likelihood ratio (17.92 vs 14.80); negative likelihood ratio (0.21 vs 0.09) and diagnostic odds ratio (85.6 vs 166.57), with a similar overall diagnostic accuracy between the two approaches [93.7% (88–97.2) vs 93.6% (87.8–97.2)]. Diagnostic performance measures were similar across sub-categories of shock.
Conclusion
This is the first randomized controlled trial to compare diagnostic performance of a POCUS protocol to standard care without POCUS in undifferentiated hypotensive ED patients. POCUS performed well diagnostically in undifferentiated hypotensive patients, especially as a rule-in test; however, performance did not differ meaningfully from standard assessment.</abstract><cop>Cham</cop><pub>Springer International Publishing</pub><pmid>36577931</pmid><doi>10.1007/s43678-022-00431-9</doi><tpages>9</tpages><orcidid>https://orcid.org/0000-0001-9900-4594</orcidid><oa>free_for_read</oa></addata></record> |
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| ispartof | Canadian journal of emergency medicine, 2023, Vol.25 (1), p.48-56 |
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| source | MEDLINE; EZB-FREE-00999 freely available EZB journals; SpringerLink Journals - AutoHoldings |
| subjects | Accuracy Clinical trials Emergency medical care Emergency Medicine Emergency Service, Hospital Humans Hypotension Hypotension - diagnostic imaging Medical diagnosis Medicine Medicine & Public Health Original Research Point-of-Care Systems Public Health Shock - diagnostic imaging Shock, Cardiogenic Ultrasonic imaging Ultrasonography - methods |
| title | Does point-of-care ultrasonography improve diagnostic accuracy in emergency department patients with undifferentiated hypotension? An international randomized controlled trial from the SHOC-ED investigators |
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