Effect of bedside ultrasonography on the certainty of physician clinical decisionmaking for septic patients in the emergency department

Abstract

Study objective: Sepsis protocols promote aggressive patient management, including invasive procedures. After the provision of point-of-care ultrasonographic markers of volume status and cardiac function, we seek to evaluate changes in emergency physician clinical decisionmaking and physician assessments about the clinical utility of the point-of-care ultrasonographic data when caring for adult sepsis patients.

Methods: For this prospective before-and-after study, patients with suspected sepsis received point-of-care ultrasonography to determine cardiac contractility, inferior vena cava diameter, and inferior vena cava collapsibility. Physician reports of treatment plans, presumed causes of observed vital sign abnormalities, and degree of certainty were compared before and after knowledge of point-of-care ultrasonographic findings. The clinical utility of point-of-care ultrasonographic data was also evaluated.

Results: Seventy-four adult sepsis patients were enrolled: 27 (37%) sepsis, 30 (40%) severe sepsis, 16 (22%) septic shock, and 1 (1%) systemic inflammatory response syndrome. After receipt of point-of-care ultrasonographic data, physicians altered the presumed primary cause of vital sign abnormalities in 12 cases (17% [95% confidence interval {CI} 8% to 25%]) and procedural intervention plans in 20 cases (27% [95% CI 17% to 37%]). Overall treatment plans were changed in 39 cases (53% [95% CI 41% to 64%]). Certainty increased in 47 (71%) cases and decreased in 19 (29%). Measured on a 100-mm visual analog scale, the mean clinical utility score was 65 mm (SD 29; 95% CI 58 to 72), with usefulness reported in all cases.

Conclusion: Emergency physicians found point-of-care ultrasonographic data about cardiac contractility, inferior vena cava diameter, and inferior vena cava collapsibility to be clinically useful in treating adult patients with sepsis. Increased certainty followed acquisition of point-of-care ultrasonographic data in most instances. Point-of-care ultrasonography appears to be a useful modality in evaluating and treating adult sepsis patients.