Multi-organ Point-of-Care Ultrasound for COVID-19 (PoCUS4COVID)

International Expert Consensus

Arif Hussain; Gabriele Via; Lawrence Melniker; Alberto Goffi; Guido Tavazzi; Luca Neri; Tomas Villen; Richard Hoppmann; Francesco Mojoli; Vicki Noble; Laurent Zieleskiewicz; Pablo Blanco; Irene W. Y. Ma; Mahathar Abd. Wahab; Abdulmohsen Alsaawi; Majid Al Salamah; Martin Balik; Diego Barca; Karim Bendjelid; Belaid Bouhemad; Pablo Bravo-Figueroa; Raoul Breitkreutz; Juan Calderon; Jim Connolly; Roberto Copetti; Francesco Corradi; Anthony J. Dean; Andre Denault; Deepak Govil; Carmela Graci; Young-Rock Ha; Laura Hurtado; Toru Kameda; Michael Lanspa; Christian B. Laursen; Francis Lee; Rachel Liu; Massimiliano Meineri; Miguel Montorfano; Peiman Nazerian; Bret P. Nelson; Aleksandar N. Neskovic; Ramon Nogue; Adi Osman; Jose Pazeli; Elmo Pereira-Junior; Tomislav Petrovic; Emanuele Pivetta; Jan Poelaert; Susanna Price; Gregor Prosen; Shalim Rodriguez; Philippe Rola; Colin Royse; Yale Tung Chen; Mike Wells; Adrian Wong; Wang Xiaoting; Wang Zhen; Yaseen Arabi

Disclosures

Crit Care. 2020;24(702)

Abstract and Introduction

Abstract

COVID-19 has caused great devastation in the past year. Multi-organ point-of-care ultrasound (PoCUS) including lung ultrasound (LUS) and focused cardiac ultrasound (FoCUS) as a clinical adjunct has played a significant role in triaging, diagnosis and medical management of COVID-19 patients. The expert panel from 27 countries and 6 continents with considerable experience of direct application of PoCUS on COVID-19 patients presents evidence-based consensus using GRADE methodology for the quality of evidence and an expedited, modified-Delphi process for the strength of expert consensus. The use of ultrasound is suggested in many clinical situations related to respiratory, cardiovascular and thromboembolic aspects of COVID-19, comparing well with other imaging modalities. The limitations due to insufficient data are highlighted as opportunities for future research.

Introduction

Since the first reports from China,^[1] SARS-CoV-2 has caused considerable morbidity and mortality from COVID-19 globally.^[1] Although respiratory signs and symptoms are the most common manifestations, other systems may be involved.^[2] Clinical presentations range from mild (80%) to life-threatening (5%), usually as acute respiratory distress syndrome (ARDS). Paucity of evidence, and urgency to adjust to evolving clinical scenarios have prompted adoption of approaches based on institutional experience,^[3] limited evidence, or extrapolation from other conditions.^[4,5]

Point-of-care ultrasound (PoCUS) is a rapid, bedside, goal-oriented, diagnostic test that is used to answer specific clinical questions.^[6] These distinctive features are appealing and address concerns of environmental contamination and disinfection of larger devices such as chest X-ray (CXR) and computed tomography (CT). Thus, multi-organ PoCUS could enhance the management of COVID-19 (Figure 1).

(Enlarge Image)

Figure 1.

Graphical synopsis of potentially useful applications of point-of-care ultrasound (PoCUS) in COVID-19 patients. ABD, abdominal ultrasound; ACP, acute cor pulmonale; AKI, acute kidney injury; DUS, diaphragmatic ultrasound; DVT, ultrasound for deep venous thrombosis screening; ECHO, echocardiography; FoCUS, focused cardiac ultrasound; LUS, lung ultrasound; MUS, parasternal intercostal muscles ultrasound; ONSD, optic nerve sheath diameter; PEEP, positive end expiratory pressure; PoCUS, point-of-care ultrasound; TCD, transcranial Doppler; VASC, ultrasound for venous and arterial access

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Crit Care. 2020;24(702) © 2020 BioMed Central, Ltd.
Copyright to this article is held by the author(s), licensee BioMed Central Ltd. This is an Open Access article: verbatim copying and redistribution of this article are permitted in all media for any purpose, provided this notice is preserved along with the article's original citation.

Table 1. PoCUS domains considered for consensus recommendations
Domain 1	PoCUS for Sars-Cov-2 infection diagnosis
Domain 2	PoCUS as a tool for triage/disposition
Domain 3	PoCUS for diagnosis of COVID-19 pneumonia
Domain 4	PoCUS for cardiovascular diagnosis
Domain 5	PoCUS for screening and diagnosis of thromboembolic disease
Domain 6	PoCUS and respiratory support strategies
Domain 7	PoCUS for management of fluid administration
Domain 8	PoCUS for monitoring of COVID-19 patients
Domain 9	POCUS and infection control, techniques, technology and protocols

Authors and Disclosures

Arif Hussain^1*†, Gabriele Via^2†, Lawrence Melniker³, Alberto Goffi⁴, Guido Tavazzi^5,6, Luca Neri⁷, Tomas Villen⁸, Richard Hoppmann⁹, Francesco Mojoli¹⁰, Vicki Noble¹¹, Laurent Zieleskiewicz¹², Pablo Blanco¹³, Irene W. Y. Ma¹⁴, Mahathar Abd. Wahab¹⁵, Abdulmohsen Alsaawi¹⁶, Majid Al Salamah¹⁷, Martin Balik¹⁸, Diego Barca¹⁹, Karim Bendjelid²⁰, Belaid Bouhemad²¹, Pablo Bravo-Figueroa²², Raoul Breitkreutz²³, Juan Calderon²⁴, Jim Connolly²⁵, Roberto Copetti²⁶, Francesco Corradi²⁷, Anthony J. Dean⁸, Andre Denault²⁹, Deepak Govil³⁰, Carmela Graci³¹, Young-Rock Ha³², Laura Hurtado³³, Toru Kameda³⁴, Michael Lanspa³⁵, Christian B. Laursen³⁶, Francis Lee³⁷, Rachel Liu³⁸, Massimiliano Meineri³⁹, Miguel Montorfano⁴⁰, Peiman Nazerian⁴¹, Bret P. Nelson⁴², Aleksandar N. Neskovic⁴³, Ramon Nogue⁴⁴, Adi Osman⁴⁵, Jose Pazeli⁴⁶, Elmo Pereira-Junior⁴⁷, Tomislav Petrovic⁴⁸, Emanuele Pivetta⁴⁹, Jan Poelaert⁵⁰, Susanna Price⁵¹, Gregor Prosen⁵², Shalim Rodriguez⁵³, Philippe Rola⁵⁴, Colin Royse^55,56, Yale Tung Chen⁵⁷, Mike Wells⁵⁸, Adrian Wong⁵⁹, Wang Xiaoting⁶⁰, Wang Zhen⁶¹ and Yaseen Arabi⁶²

¹Department of Cardiac Sciences, King Abdulaziz Medical City and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia. ²Cardiac Anesthesia and Intensive Care, Cardiocentro Ticino, Lugano, Switzerland. ³New York Presbyterian Brooklyn Methodist Hospital, New York, NY, USA. ⁴Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada. ⁵Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, Unit of Anaesthesia and Intensive Care, University of Pavia, Pavia, Italy. ⁶Anaesthesia and Intensive Care, Fondazione Istituto Di Ricovero E Cura a Carattere Scientifico, Policlinico San Matteo Foundation, Pavia, Italy. ⁷Emergency Medicine and Critical Care Consultant, King Fahad Specialist Hospital –Dammam, Dammam, Saudi Arabia. ⁸School of Medicine, Francisco de Vitoria University, Madrid, Spain. ⁹University of South Carolina School of Medicine, Columbia, SC, USA. ¹⁰Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Università Degli Studi Di Pavia, Pavia, Italy. ¹¹University Hospitals Cleveland Medical Center, Cleveland, OH, USA. ¹²Service D'Anesthésie Réanimation Hôpital Nord, APHM, Chemin des Bourrely, 13015 Marseille, France. ¹³Department of Teaching and Research, Hospital "Dr. Emilio Ferreyra", Necochea, Argentina. ¹⁴Division of General Internal Medicine, Department of Medicine, University of Calgary, Calgary, Canada. ¹⁵Emergency and Trauma Department, Hospital Kuala Lumpur, 50586 Kuala Lumpur, Malaysia. ¹⁶King Abdulaziz Medical City, King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia. ¹⁷College of Public Health and Health Informatics, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia. ¹⁸Dept of Anaesthesiology and Intensive Care, First Medical Faculty, Charles University, Prague, Czechia. ¹⁹Médico Ecografista IADT, Buenos Aires, Argentina. ²⁰Intensive Care Division, Geneva University Hospitals, Geneva, Switzerland. ²¹Department of Anaesthesiology and Intensive Care, C.H.U. Dijon and Université Bourgogne Franche-Comté, LNC UMR866, 21000 Dijon, France. ²²PICU Hospital San Juan de Dios, Santiago, Chile. ²³FOM University of Economy & Management, Frankfurt Campus, Frankfurt, Germany. ²⁴Hospital General, Instituto Mexicano del Seguro Social, De Zona 4 Monterrey, Nuevo Leon, Mexico. ²⁵Great North Trauma and Emergency Care Newcastle, Newcastle upon Tyne, UK. ²⁶Emergency Department, Latisana General Hospital, Latisana, Italy. ²⁷Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy. ²⁸University of Pennsylvania, Philadelphia, PA, USA. ²⁹Montreal Heart Institute, Montreal, Canada. ³⁰Medanta, The Medicity, Gurgaon, India. ³¹Ospedale Niguarda C' Grande, Milan, Italy. ³²Dept. of Emergency Medicine, Bundang Jesaeng Hospital, Seoul, Korea. ³³WINFOCUS Argentina BOD, Rosario, Argentina. ³⁴Department of Clinical Laboratory Medicine and Department of Emergency Medicine, Jichi Medical University, Tokyo, Japan. ³⁵Oregon Health and Science University, Portland, OR, USA. ³⁶Department of Respiratory Medicine, Department of Clinical Research, Odense University Hospital, University of Southern Denmark, Odense, Denmark. ³⁷Khoo Teck Puat Hospital, Singapore, Singapore. ³⁸Dept. of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA. ³⁹Herzzentrum Leipzig, Leipzig, Germany. ⁴⁰Department of Ultrasound & Doppler Hospital de Emergencias "Dr. Clemente Alvarez", Rosario, Santa Fe, Argentina. ⁴¹Department of Emergency Medicine, Careggi University Hospital, Firenze, Italia. ⁴²Department of Emergency Medicine, Icahn School of Medicine At Mount Sinai, New York, NY, USA. ⁴³Clinical Hospital Zemun, Faculty of Medicine, University of Belgrade, Belgrade, Serbia. ⁴⁴Faculty of Medecine, University of Lleida, Lleida, Spain. ⁴⁵Hospital Raja Permaisuri Bainun, Ipoh, Perak, Malaysia. ⁴⁶FAME - Medicine School of Barbacena - MG-Brasil, Barbacena, Brazil. ⁴⁷Arbo Education, Rio de Janeiro, Brazil. ⁴⁸SAMU 93 - Hopital Avicenne, Paris, France. ⁴⁹Citta Della Salute E Della Scienza Di Torino Hospital, University of Turin, Turin, Italy. ⁵⁰Faculty of Medicine and Pharmacy VUB, Univ Hospital Brussels, Brussels, Belgium. ⁵¹Royal Brompton Hospital, London, UK. ⁵²Emergency Department, University Clinical Centre Maribor, Maribor, Slovenia. ⁵³Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru. ⁵⁴Santa Cabrini Hospital, Montreal, Canada. ⁵⁵Department of Surgery, The University of Melbourne, Melbourne, VIC, Australia. ⁵⁶Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH, USA. ⁵⁷Department of Emergency Medicine, Hospital Universitario La Paz, Madrid, Spain. ⁵⁸Division of Emergency Medicine, University of the Witwatersrand, Johannesburg, South Africa. ⁵⁹King's College Hospital, London, UK. ⁶⁰Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China. ⁶¹The Fourth Military Medical University, Xi'an 710032, China. ⁶²King Abdulaziz Medical City, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.

*Correspondence
hussain_pscc@hotmail.com

^†Arif Hussain and Gabriele Via have contributed equally to this work

Authors' contributions
AH and GV contributed equally as authors in conceiving the contents, gathering the relevant material, preparing the manuscript and chairing the steering committee of the process, LM GRADEd the evidence and supervised the Delphi consensus process as methodologist and reviewed the manuscript, AG conceived the evidence presentation and edited, GT contributed to the cardiovascular and hematological sections, LN contributed to concepts of triaging, TV contributed to LUS, FC and FM contributed to the ventilation section, RH and VN contributed to the manuscript, and YA conceived the idea of this work, provided guidance and edited the manuscript. All the authors participated in the Delphi process, provided input for drafting recommendations and reviewed the manuscript.