Beruflich Dokumente
Kultur Dokumente
DOI 10.1007/s11239-013-0945-5
123
Introduction
Critically ill patients are at high risk for development of
lower extremity deep vein thrombosis (DVT), with a reported incidence of 12 % [1]. Doppler ultrasonography with
graded compression along contiguous venous segments is
widely accepted as a gold standard in diagnosis [2]. Ultrasound studies are traditionally performed by technologists
and interpreted by board-certified radiologists or vascular
specialists. However, delays in performance and interpretation of the comprehensive study are common. Clinicianperformed focused ultrasound evaluation offers the potential
to reduce this delay. Focused vascular sonography (FVS)
performed and interpreted by intensivists and emergency
physicians is becoming accepted practice. The American
College of Chest Physicians (ACCP) recommends that FVS
be included as part of a basic curriculum in intensivist-performed ultrasound [3]. The American College of Emergency
Physicians (ACEP) also endorses performance of FVS by
Methods
Setting and inclusion/exclusion criteria
We performed a prospective, cohort study at Lenox Hill
Hospital, a 652-bed urban, community teaching hospital in
New York City. IRB approval was obtained and all patients
or next-of-kin gave conformed consent to participate.
Consecutive patients admitted to the medical ICU or
intermediate care unit, who were at least 18 years old, and
299
123
300
J. Caronia et al.
Above the
knee DVT
(Superficial
femoral
included) (%)
Common
femoral
and
popliteal
DVT (%)
Common
femoral
DVT (%)
Sensitivity
63
86
100
78
Specificity
Positive
predictive
value
97
75
97
75
97
67
100
100
Negative
predictive
value
91
97
100
98
Statistical analysis
Sensitivity, specificity, positive predictive value, and negative predictive value of resident exams were calculated using
the formal examination as the reference standard. Fleiss
Kappa, the degree of inter-observer agreement between
residents and radiologists for the diagnosis of DVT, was our
primary outcome. The calculation was performed using
standard software (SPSS version 20.0, IBM software).
Popliteal
DVT (%)
Results
Discussion
Nineteen residents performed 143 studies on 75 patients
from December 2010 to August 2011, with a study defined
as a unilateral sonographic examination. Eight patients
declined to participate. Each resident performed an average
of 8 studies (SD 5). The maximal number of examinations
performed by a resident was 23 and the minimum was 2.
The mode number of examinations was 8.5. Mean patient
age was 70 years old. Thirty-eight female and 37 male
patients participated in the study. Formal studies were read
by one of 7 board-certified radiologists.
Twelve of 75 patients had above-the-knee DVTs on the
formal study, a prevalence of 16 %. Residents correctly
identified 13 of 21 DVTs in the cohort. Anatomical distribution on the formal study of DVTs is shown in Table 1.
All 6 common femoral and 7 of the 9 popliteal vein DVTs
were correctly identified by the residents. None of 6 isolated superficial femoral DVTs were identified by the residents. The sensitivity and specificity of the studies based
on anatomical distribution are listed in Table 2. Residents
showed substantial inter-observer agreement with radiologists for the diagnosis of above-the-knee DVT, demonstrating a Fleiss Kappa = 0.70 (SE 0.114, p \ 0.001).The
average time between the order of a formal study to its read
by a radiologist was 14.7 h. The average unilateral twopoint examination took approximately 5 min.
Number of DVTs
Popliteal vein
123
301
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