Get On Board the BUS

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Ultrasound in the emergency medicine field has rapidly advanced over the last few years, and its use has become standard practice for many centers. Unfortunately, the pediatric emergency medicine world is lagging in the advancement of ultrasound use in children.  

Educational Objectives:

After evaluating this article participants will be able to:

1. Understand the benefits of ultrasound-guided intravenous line placement and incorporate this strategy into practice.
2. Recognize the value of ultrasound-guided urinary catheterization and incorporate this concept into practice.
3. Implement improved safer strategies for G-tube replacement in the emergency department.



Ultrasound in the emergency medicine field has rapidly advanced over the last few years, and its use has become standard practice for many centers. Unfortunately, the pediatric emergency medicine world is lagging in the advancement of ultrasound use in children.  This journal club will focus on the benefits of ultrasound use in children in the hopes that we can encourage an increased focus on incorporating ultrasound into our pediatric emergency medicine training programs.

Q. Can the use of ultrasound guidance improve the success rate of peripheral intravenous catheter placement in pediatric patients with difficult access in a pediatric emergency department (ED)? Secondarily, can ultrasound guidance reduce the number of attempts, the number of needle redirections and the overall time to catheter placement?


A. In a sample of pediatric ED patients with difficult access, ultrasound-guided intravenous cannulation required less overall time, fewer attempts and fewer needle redirections than traditional approaches.

Citation: Doniger SJ; Ishimine P; Fox JC; Kanegaye JT Randomized controlled trial of ultrasound-guided peripheral intravenous catheter placement versus traditional techniques in difficult-access pediatric patients. Pediatr Emerg Care.  2009; 25(3):154-9 (ISSN: 1535-1815)

Methodology: This was a prospective, randomized study of pediatric ED patients younger than 10 years old requiring intravenous access, presenting between August 2006 and May 2007. Inclusion criteria were 2 unsuccessful traditional attempts at peripheral intravenous access or history of difficult access. Exclusion was critical illness or instability. Patients were randomized to undergo peripheral intravenous catheter placement using continued traditional approaches or real-time, dual-operator ultrasound-guided technique. Measured outcomes were success of cannulation, number of attempts, number of needle redirections and overall time to catheter placement.

Findings: Fifty patients were enrolled, with 25 patients randomized to each group. The overall success rates for the ultrasound-guided group were 80% and for the traditional-attempts group, 64%, with a difference in proportions of 16% (95% confidence interval, -9% to 38%, P = 0.208). The ultrasound-guided group required less overall time (6.3 vs 14.4 minutes, difference of -8.1 minutes [95% confidence interval, -12.5 to -3.6], P = 0.001), fewer attempts (median, 1 vs 3; P = 0.004), and fewer needle redirections (median, 2 vs 10; P G 0.0001) than traditional approaches.



Q. How useful is bedside ultrasonography during G-tube replacements in the ED?

A.Verifying appropriate placement through aspirate evaluation can be misleading, and post-procedure radiographs increase radiation exposure and ED wait times. Bedside ultrasonography can be used to guide catheter insertion while providing a safe and quick adjunct to confirm proper G-tube placement.

Citation: Wu TS; Leech SJ; Rosenberg M; Huggins C; Papa L Ultrasound can accurately guide gastrostomy tube replacement and confirm proper tube placement at the bedside.J Emerg Med.  2009; 36(3):280-4 (ISSN: 1090-1280)

Background: Malfunctioning or dislodged gastrostomy tubes (G-tubes) often require urgent replacement and reinsertion in the Emergency Department (ED). Few data exist regarding the best technique for bedside catheter replacement and verification, and individual operator preferences vary. Although a few reports have described the use of ultrasound guidance during the initial percutaneous insertion, no data are available concerning its role during subsequent G-tube replacements.

Methodology: This was a prospective pilot study conducted at a Level 1 Trauma Center with an annual census of 90,000 patients. Seven adults and three children with malfunctioning G-tubes were enrolled. Three tubes were cracked and leaking, and seven tubes had been dislodged. Under ultrasound guidance, a new G-tube was inserted through the previously fashioned tract. After insertion, color Doppler was applied over the catheter tip to enhance visualization during gentle tube oscillation.

Findings: Ultrasound successfully visualized G-tube replacement in all 10 patients. Application of color Doppler over the G-tube tip during catheter oscillation enhanced placement confirmation. Sonographic findings were corroborated with gastric content aspiration, contrast-enhanced radiographs, and successful use of the new G-tubes. No false tracts were identified during ultrasound-guided insertion, post-procedure sonographic confirmation, or subsequent radiographs.


Q. How useful is bedside ultrasound of the bladder, performed by pediatric emergency medicine physicians before catheterization, in reducing the number of unsuccessful attempts?

A. A rapid bedside ultrasound of the bladder performed by pediatric emergency physicians led to an increased success rate of urethral catheterization in children who were younger than 2 years. We were able to avoid repeated invasive testing with a simple non-invasive procedure

Citation: Lei Chen, MD*, Allen L. Hsiao, MD*, Christopher L. Moore, MD , James D. Dziura, PhD , Karen A. Santucci, MD. Utility of Bedside Bladder Ultrasound Before Urethral Catheterization in Young Children. PEDIATRICS Vol. 115 No. 1 January 2005, pp. 108-111 (doi:10.1542/peds.2004-0738)

Background: Urethral catheterization is the method of choice for obtaining samples for urine culture and urine analysis in infants. Before the procedure, there is little certainty of the presence or amount of urine in the bladder. Consequently, this relatively invasive and uncomfortable procedure often needs to be repeated. The newly available technology of portable ultrasound may be useful in reducing the number of unsuccessful procedures.

Methodology: A prospective, 2-phase study was performed in the setting of an urban pediatric emergency department from August 2003 to February 2004. Children who were between the ages of 0 and 24 months were enrolled. During the observation phase, the amount of urine obtained during the first catheterization was recorded for each patient. During the intervention period, a rapid bedside ultrasound of the bladder was performed by a pediatric emergency medicine physician immediately before urethral catheterization. When a sufficient amount of urine was seen, catheterization was conducted as usual. Otherwise, catheterization was deferred and repeated ultrasound was performed at 30-minute intervals until sufficient urine was identified. The amount of urine obtained was recorded.

Findings: During the observation phase, 136 infants underwent urethral catheterization. Overall, the rate of success during the first attempt, defined as obtaining >2 mL of urine, sufficient for culture and other routine studies, was 72% (95% confidence interval: 66%–78%). A total of 112 subjects were
enrolled during the intervention phase. Sufficient urine was identified on the first ultrasound in 76% (n = 85) of the patients. Among these, 98% (n = 83) underwent successful urethral catheterization during the first attempt. Among those in whom insufficient urine was identified initially (n = 27; 24%), subsequent ultrasound revealed sufficient amounts in all patients within 90 minutes. Among these, 93% (n = 25) underwent successful urethral catheterization during the first attempt. Overall rate of success of initial urethral catheterization during the intervention phase was 96% (95% confidence interval: 93%–99%). Compared with the success rate during the observation phase, the differences were statistically significant. The results were consistent after being adjusted for gender.

Q. Can the use of volumetric ultrasound by trained pediatric emergency department (ED) nurses improve first-attempt urine collection success rates?

 A.Although there is a time delay, urine collection in the ultrasound arm generated a significant improvement over conventional catheterization in obtaining an adequate urine sample.

Citation: Baumann BM; McCans K; Stahmer SA; Leonard MB; Shults J; Holmes WC Volumetric bladder ultrasound performed by trained nurses increases catheterization success in pediatric patients.Am J Emerg Med.  2008; 26(1):18-23 (ISSN: 1532-8171)

Methodology: This randomized controlled trial was conducted in children aged < or = 36 months requiring diagnostic urine samples. Children were randomized to either the conventional (nonimaged) or the ultrasound arm. Demographics, number of catheterizations required for success, postponements, and collection times were recorded.

Findings: Forty-five children were assigned to the conventional and 48 to the ultrasound arm (n = 93). First-attempt success rates were higher in the ultrasound arm: 67% (conventional) vs 92% (ultrasound) (P = .003). Both urinalysis and culture were less likely to be completed on conventional group specimens (91% vs 100%; P = .04). However, mean conventional group urine collection time was less than the ultrasound group’s collection time (12 vs 28 minutes; P < .001).

Q. To what extent do pediatric emergency medicine fellowship programs train fellows in the use of bedside ultrasound?

 A.Despite literature supporting the benefits of BUS in the ED, many PEM fellowship programs do not incorporate BUS training for their PEM fellows. Most PEM fellows who receive training in BUS are instructed by physicians trained in EM, not PEM.

Citation: Ramirez-Schrempp D; Dorfman DH; Tien I; Liteplo AS Bedside ultrasound in pediatric emergency medicine fellowship programs in the United States: little formal training. Pediatr Emerg Care.  2008; 24(10):664-7 (ISSN: 1535-1815)

Background: Bedside ultrasound (BUS) can provide critical information in a rapid and noninvasive manner to the emergency physician. It is widely used in emergency departments (ED) throughout the nation. Literature shows that BUS shortens patient stay and increases patient satisfaction. General emergency medicine (EM) residencies incorporate BUS training in their curricula. However, there are limited data about the training that pediatric emergency medicine (PEM) fellows receive.

Methodology: A 29-question survey was mailed to all (57) PEM fellowship program directors in the spring of 2006.

Findings: The response rate was 81% (46/57). Fifty-seven percent (26/46) of the responding PEM fellowship program directors reported that their faculty used BUS in their departments. At 50% (23/46) of programs, fellows perform BUS studies. Sixty-five percent (30/46) of PEM fellowships reported that their fellows receive some BUS training, but only 15 of these programs included BUS training in the curriculum as a 2- to 4-week ultrasound rotation.Sixty-five percent (30/46) of PEM fellowship programs had access to an ultrasound machine, but only 28% (13/46) of programs had their own machine. The main reason not to own an ultrasound machine was a lack of ultrasound expertise in their department (67%, 22/33). Bedside ultrasound training was provided by general EM physicians in 57% (17/30) of programs. Eighty-seven percent of the directors agree that BUS training would benefit their practice.The 2 factors significantly associated with the likelihood of having formal BUS training were access to an ultrasound machine (87% vs 55% P=0.04) and presence of an adult ED with an EM residency at the program (80% vs 42% P=0.03). Pediatric emergency medicine fellowship programs at children’s hospitals were significantly less likely to have formal training (33.3% vs 74.2%; P=0.01).

Ghazala sharieff, MD Division Director San Diego Rady Children’s Hospital Emergency Care Center


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