Advertisement

Journal of Thrombosis and Thrombolysis

, Volume 37, Issue 3, pp 298–302 | Cite as

Resident performed two-point compression ultrasound is inadequate for diagnosis of deep vein thrombosis in the critically III

  • Jonathan CaroniaEmail author
  • Adrian Sarzynski
  • Babak Tofighi
  • Ramyar Mahdavi
  • Charles Allred
  • Georgia Panagopoulos
  • Bushra Mina
Article

Abstract

Doppler ultrasonography is a standard in diagnosis of deep vein thrombosis (DVT) but is often delayed. Clinician-performed focused vascular sonography (FVS) has proven to accurately diagnose DVT in the ambulatory and emergency room settings. Whether trained medical residents can perform quality FVS in the critically ill is unknown. Medical residents were trained in a 2-hour module in FVS assessing for complete compressibility of common femoral and popliteal veins. Residents imaged consecutive medical ICU and intermediate care patients awaiting comprehensive, sonographer-performed and radiologist-interpreted examinations. Sensitivity, specificity, positive and negative predictive values of the focused examination were calculated against the comprehensive study. Fleiss Kappa (κ), the degree of agreement between resident and radiologist, was calculated. Time savings was measured. Nineteen residents performed 143 studies on 75 patients. Twelve patients had above-the-knee DVTs, a prevalence of 16 %. All 6 common femoral and 7 of 9 popliteal vein DVTs were identified. None of 6 isolated superficial femoral DVTs were identified. Sensitivity for above-the-knee DVT was 63 %, specificity 97 %. Sensitivity for common femoral and popliteal DVT was 86 %, specificity 97 %. Residents showed substantial agreement with radiologists for diagnosis of DVT (κ = 0.70, SE 0.114, p < 0.001).Time from order of a formal ultrasound to a radiologist’s read averaged 14.7 h. The two-point compression ultrasound method demonstrated insufficient sensitivity in a cohort of critically ill medical patients due to a high-incidence of superficial femoral DVT. However, residents demonstrated substantial agreement with radiologists for the diagnosis of clinically relevant DVT after a 2-hour course. FVS should include the superficial femoral vein and is associated with a significant time savings.

Keywords

Focused vascular sonography Residents Imaging 

Notes

Acknowledgments

This work was supported by an educational grant from the New York State Department of Health, ECRIP, Empire Clinical Research Investigator Program.

Conflict of interest

No authors have any other relevant conflicts of interest.

References

  1. 1.
    Marik PE, Andrews L, Maini B (1997) The incidence of deep venous thrombosis in ICU patients. Chest 111:661–664PubMedCrossRefGoogle Scholar
  2. 2.
    Qaseem A, Snow V, Barry P et al (2007) Current diagnosis of venous thromboembolism in primary care: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Ann Intern Med 146:454–459PubMedCrossRefGoogle Scholar
  3. 3.
    Mayo PH, Beaulieu Y, Doelken P et al (2009) American college of chest physicians/la société de réanimation de langue française statement on competence in critical care ultrasonography. Chest 135:1050–1060PubMedCrossRefGoogle Scholar
  4. 4.
    Rios M, Lewis R, Saul T (2009) Focus on: emergency ultrasound for deep vein thrombosis. www.acep.org. Accessed 5 Jan 2012
  5. 5.
    Akhtar S, Theodoro D, Gaspari R, Tayal V, Sierzenski P, Lamantia J, Stahmer S, Raio C (2009) Resident training in emergency ultrasound: consensus recommendations from the 2008 council of emergency medicine residency director’s conference. Acad Emerg Med 16(Suppl 2):32–36CrossRefGoogle Scholar
  6. 6.
    Bernardi E, Camporese G, Büller HR et al (2008) Serial 2-point ultrasonography plus D-dimer vs. whole-leg color-coded Doppler ultrasonography for diagnosing suspected symptomatic deep vein thrombosis: a randomized controlled trial. JAMA 300:1653–1659PubMedCrossRefGoogle Scholar
  7. 7.
    Cogo A, Lensig AW, Koopman MM et al (1998) Compression ultrasonography for diagnostic management of patients with clinically suspected deep vein thrombosis: prospective cohort study. BMJ 316:17–20PubMedCentralPubMedCrossRefGoogle Scholar
  8. 8.
    Lensing AW, Prandoni P, Brandjes D et al (1989) Detection of deep-vein thrombosis by real-time B-mode ultrasonography. N Engl J Med 320:342–345PubMedCrossRefGoogle Scholar
  9. 9.
    Frazee BW, Snoey ER, Levitt A (2001) Emergency department compression ultrasound to diagnose proximal deep vein thrombosis. J Emerg Med 20:107–112PubMedCrossRefGoogle Scholar
  10. 10.
    Crisp JG, Lovato LM, Jang TB (2010) Compression ultrasonography of the lower extremity with portable vascular ultrasonography can accurately detect deep venous thrombosis in the emergency department. Ann Emerg Med 56:601–610PubMedCrossRefGoogle Scholar
  11. 11.
    Blaivas M, Lambert MJ, Harwood RA, Wood JP, Konicki J (2000) Lower-extremity Doppler for deep venous thrombosis–can emergency physicians be accurate and fast? Acad Emerg Med 7:120–126PubMedCrossRefGoogle Scholar
  12. 12.
    Heijboer H, Büller HR, Lensing AW, Turpie AG, Colly LP, Ten Cate JW (1993) A comparison of real-time compression ultrasonography with impedance plethysmography for the diagnosis of deep vein thrombosis in symptomatic outpatients. N Engl J Med 329:1365–1369PubMedCrossRefGoogle Scholar
  13. 13.
    Cogo A, Lensing AW, Prandoni P, Hirsh J (1993) Distribution of thrombosis in patients with symptomatic deep vein thrombosis. Implications for simplifying the diagnostic process with compression ultrasound. Arch Intern Med 153:2777–2780PubMedCrossRefGoogle Scholar
  14. 14.
    Fox JC, Bertoglio KC (2011) Emergency physician performed ultrasound for DVT evaluation. Thrombosis. doi: 10.1155/2011/938709 PubMedCentralPubMedGoogle Scholar
  15. 15.
    Trottier SJ, Todi S, Veremakis C (1996) Validation of an inexpensive B-mode ultrasound device for detection of deep vein thrombosis. Chest 110:1547–1550PubMedCrossRefGoogle Scholar
  16. 16.
    Magazzini S, Vanni S, Toccafondi S et al (2007) Duplex ultrasound in the emergency department for the diagnostic management of clinically suspected deep vein thrombosis. Acad Emerg Med 14:216–220PubMedCrossRefGoogle Scholar
  17. 17.
    Bailey BP, Ault M, Greengold NL, Rosendahl T, Cossman D (2001) Ultrasonography performed by primary care residents for abdominal aortic aneurysm screening. J Gen Int Med 16:845–849CrossRefGoogle Scholar
  18. 18.
    Vignon P, Dugard A, Abraham J et al (2007) Focused training for goal-oriented hand-held echocardiography performed by non cardiologist residents in the intensive care unit. Intensive Care Med 33:1795–1799PubMedCrossRefGoogle Scholar
  19. 19.
    Croft LB, Duvall WL, Goldman ME (2006) A pilot study of the clinical impact of hand-carried cardiac ultrasound unit in the medical clinic. Echocardiography 23:439–446PubMedCrossRefGoogle Scholar
  20. 20.
    Hellman DB, Whiting-O’Keefe Q, Shapiro EP, Martin LD, Martire C, Ziegelstein RC (2005) The rate at which residents learn to use hand-held echocardiography at the bedside. Am J Med 118:1010–1018CrossRefGoogle Scholar
  21. 21.
    Chalumeau-Lemoine L, Baudel JL, Das V, Arrivé L et al (2009) Results of short-term training of naïve physicians in focused general ultrasonography in an intensive-care unit. Intensive Care Med 35:1767–1771PubMedCrossRefGoogle Scholar
  22. 22.
    Zytaruk N, Heels-Ansdell D, McDonald J et al (2011) Venous segments affected in critically ill patients with deep vein thrombosis. Am J Respir Crit Care Med 183:A2382Google Scholar
  23. 23.
    Maki DD, Kumar N, Nguyen B, Langer JE, Miller WT Jr, Gefter WB (2000) Distribution of thrombi in acute lower extremity deep venous thrombosis: implications for sonography and CT and MR venography. Am J Radiol 175:1299–1301Google Scholar
  24. 24.
    Frederick MG, Hertzberg BS, Kliewer MA, Paulson EK, Bowie JD, Lalouche KJ, DeLong DM, Carroll BA (1996) Can the US examination for lower extremity deep venous thrombosis be abbreviated? A prospective study of 755 examinations. Radiology 199:45–47PubMedGoogle Scholar
  25. 25.
    Kory PD, Pellecchia CM, Shiloh AL, Mayo PH, DiBello C, Koenig S (2011) Accuracy of ultrasonography performed by critical care physicians for the diagnosis of DVT. Chest 139:538–542PubMedCrossRefGoogle Scholar
  26. 26.
    American College of Emergency Physicians (2006) Emergency ultrasound imaging criteria compendium. Ann Emerg Med. 48:487–510CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Jonathan Caronia
    • 1
    Email author
  • Adrian Sarzynski
    • 1
  • Babak Tofighi
    • 1
  • Ramyar Mahdavi
    • 1
  • Charles Allred
    • 1
  • Georgia Panagopoulos
    • 2
  • Bushra Mina
    • 1
  1. 1.Division of Pulmonary and Critical Care MedicineLenox Hill HospitalNew YorkUSA
  2. 2.Department of Bio-statisticsLenox Hill HospitalNew YorkUSA

Personalised recommendations