Faculty Bibliography

Aggressive fluid resuscitation has become standard of care for hypotensive patients with sepsis. However, sepsis is a syndrome that occurs in patients with diverse underlying physiology and a one-size-fits-all approach to fluid administration seems misguided. To individualize fluid management, several methods to assess fluid responsiveness have been validated, but even in fluid responsive patients, fluid administration may still be harmful and lead to pulmonary edema. Hence, to individualize fluid management, in addition to fluid responsiveness, fluid tolerance needs to be assessed. This article examines whether lung ultrasound can be useful to detect excess extravascular lung water (EVLW) and thus assess fluid tolerance. The physiology of EVLW and the principles of lung ultrasound are briefly described. Articles examining the correlation between EVLW and lung ultrasound findings in various clinical settings are carefully reviewed. Overall, lung ultrasound has been found to be an excellent tool to detect EVLW, but large outcome studies investigating lung ultrasound-guided fluid management are still lacking.

Needs and Objectives: Point-of-care ultrasound (POCUS), when integrated with a physical examination, increases accuracy of diagnosis and decreases procedural complications. However, most hospitalists have not been trained to use this new technology. We developed a year-long curriculum, the Integrated Sonographic Competency at NYU (I-ScaN), to train hospitalists in POCUS. Setting and Participants: Twenty-three hospitalists from across the 4 hospitals affiliated with NYU Langone Health participated. Sixteen of the participants (72%) reported prior ultrasound training, with a range of 2-80 hours (median = 4 hours); 3 reported more than 5 hours of prior training. Three reported active clinical use of POCUS though none of them had more than 5 hours of prior training. The group averaged 4.5 years of clinical practice (range = 1-13 years). Description: The program began with an intensive 2-day course consisting of lectures and hands-on training on human models covering views of the heart, lungs/pleura, abdomen, and leg vasculature. We developed the remainder of the year-long program with the goal of helping participants retain and improve upon the skills acquired during the initial course. Our program included hands-on teaching sessions held at each institution by local experts, presentations at monthly conferences with the course director (HS), and online feedback on uploaded ultrasound images. To facilitate this final item, each participant was given access to portable ultrasound devices with the ability to upload ultrasound clips to a HIPAA-compliant website. Participants provided a clinical interpretation and assessment of image quality for each of their clips. The clips were then reviewed by an expert who provided feedback on both of these domains. Participants could then use these clips to create personal portfolios in accordance with national standards set by the Society of Hospital Medicine. Evaluation: Participants rated the 2-day intensive program as very useful and satisfaction with the individual components of the program ranged from useful to very useful. Participants reported statistically significant increases in their confidence in acquiring images, interpreting images, and performing a clinical evaluation using POCUS for all domains except in performing paracentesis. Knowledge scores increased from a baseline of 58% to 83%; p< 0.001. At 6 months into the program, 2 hospitalists had uploaded > 400 clips each and 7 had uploaded fewer than 20 clips each. Discussion/Reflection/Lessons Learned: I-ScaN is a highly rated and effective program to train hospitalists in core POCUS competencies. The 2-day intensive program significantly improves confidence and knowledge. Monitoring of progress and scanning activity was difficult because few hospitalists uploaded clips regularly. Our focus now is on identifying barriers to using POCUS for new trainees. Future analysis will include frequency of scanning, retention of knowledge and skill, and generation of learning curves for each view

A diagnosis of acute pancreatitis requires two of three diagnostic criteria to be present: elevated serum lipase, characteristic epigastric abdominal pain radiating to the back and/or abdominal tenderness, or CT evidence of pancreatitis. Here we describe a case of necrotizing pancreatitis in a patient with only mild abdominal pain and a normal serum lipase. A 55 year-old male presented with abdominal pain and subjective fevers for 5 days. 6 weeks prior, the patient was diagnosed with non-small cell lung cancer and CT scans for staging purposes showed no evidence of abdominal pathology. He had yet to undergo treatment for his malignancy. The patient then presented to the hospital two weeks prior to his current presentation with acute abdominal pain and inability to tolerate po. Labs revealed a normal lipase but CT abdomen and pelvis revealed acute pancreatitis. The patient was treated supportively and was subsequently discharged home. He felt well for the next 5 days but then presented to an outside hospital with subjective fevers and chills. He was treated with IV antibiotics for pneumonia but left against medical advice after 4 days and presented to our ER that evening with abdominal pain, nausea/vomiting. Physical exam revealed an afebrile man, non-toxic, with a soft abdomen and normoactive bowel sounds. He was mildly tender in all four abdominal quadrants. Labs revealed a serum glucose of 344. Urine toxicology was positive for cocaine. Serum lipase and amylase were 12.3 and 36, respectively. Urinalysis revealed 3+ ketones. CXR was stable with the patient's prior. The patient was initially treated with fluids and insulin for possible diabetic ketoacidosis, but by morning his condition worsened with development of a distended abdomen and guarding. Urgent CT revealed necrotizing pancreatitis with possible abscesses in the pancreatic head and tail. The patient was taken for laparoscopic debridement, which confirmed the diagnosis. The pancreatitis was thought to be due to alcohol-use. He eventually stabilized, and was discharged to rehab. Literature on acute pancreatitis with normal serum lipase is limited. Anecdotally, lipase-negative pancreatitis is thought to be mechanistically related to a "burnt-out pancreas" that is unable to synthesize the enzyme. However, our patient had a normal CT abdomen 6 weeks prior. We highlight this case for its challenging and unusual presentation of a common diagnosis