Main applications of point-of-care ultrasound in palliative care

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The image below shows ascites and metastatic liver lesions in a patient with pancreatic adenocarcinoma." ] ] ] "textoCompleto" => "IntroductionOver the past 20 years, increased use of Point-of-Care Ultrasound (POCUS) has been an influential agent of change in the skills of multiple specialties and has led to Scientific Societies encouraging development in terms of medical care, education, and research. Along these lines, the Clinical Ultrasound Working Groups from the Spanish Society for Internal Medicine (SEMI) and the European Federation of Internal Medicine (EFIM) have drafted guidelines for accrediting POCUS training, this being a framework to guide the implementation of training programs at each centre according to the necessary minimum requirements.<a class="elsevierStyleCrossRefs" href="#bib0005">1,2</a> In addition, the National Commission for Internal Medicine Specialty in Spain has already completed the draft of a new training program structured into skill domains specifying, regarding technical skills, POCUS as a specific training activity.While medical treatment and comfort care for patients in Palliative Care (PC) are highly standardised, the use of POCUS is this field is uncommon. The search strategy used MeSH terms “palliative care”, “palliative medicine”, “home care services”, “home care system”, “hospice care”, “point of care systems”, “ultrasound” and “ultrasonography”. Bibliography contributions from data sources such as PubMed-MEDLINE, Scopus, EMBASE and Cochrane Library were scarce, including some revisions and descriptive studies in PC units.<a class="elsevierStyleCrossRefs" href="#bib0015">3–5</a> It is time to consolidate the use of this modern and appealing technique within PC units by encouraging widespread, structured and high-quality accredited training that is accessible and offers different skill levels.Point-of-care ultrasound conceptThe introduction of the stethoscope by René Laënnec in 1816 revolutionised how clinical examinations were performed.<a class="elsevierStyleCrossRef" href="#bib0030">6</a> Over 200 years passed until the addition of the so-called fifth pillar of physical examination, or “insonation”.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> This term refers to systematic use of ultrasound (US) as an extension to physical examination in the clinical decision-making process in the physical location where the patient is receiving care.<a class="elsevierStyleCrossRefs" href="#bib0040">8,9</a> While it aims to supplement clinical reasoning, the goal is not to replace standard examination by a radiologist or cardiologist, for example. The aim is to find answers to clinical questions (typically dichotomous) via real time studies in circumstances in which US use is cost-effective (high sensitivity and negative predictive value). In addition to minimising diagnostic delays and uncertainty, other advantages include a fast learning curve for specific goals, repeatability (no ionising radiation), and the possibility to direct diagnostic-therapeutic procedures, which is a key aspect in patient safety. In short, it is a cost-effective tool with high satisfaction scores from patients and which promotes professional empowerment.<a class="elsevierStyleCrossRefs" href="#bib0050">10,11</a> Regarding disadvantages, POCUS is an operator-dependent examination. However, this dependency decreases with supervised training by experts on the most common and cost-effective situations as described in this revision.Modernisation and miniaturisation of ultrasound devices has made it possible to create pocket-sized or ultra-portable devices that, when connected to a tablet or smart phone, allow clinicians to obtain good quality imaging that is also affordable. Some ultrasound machines with this user profile have a single multi-frequency transducer, allowing the option to select the settings that best adapt to the examination to be performed. In addition to the standard storage option, it is also possible to “upload” images to a server in real time for remote analysis and feedback from other consultants. Lastly, video tutorials, artificial intelligence programs, and augmented reality programs help optimise images and safely guide invasive procedures.<a class="elsevierStyleCrossRef" href="#bib0060">12</a> All these aspects take on greater importance in the field of PC as most patients are at a stage in their illness that they want to receive care at home, provided they can receive an adequate level of care. Medical care provided with the support of this technology includes, among others, diagnosis of intercurrent processes or the performance of invasive procedures without the need to, in most situations, transfer the patient to a hospital setting with the physical and emotional impact that such a move could involve.Main applications of point-of-care ultrasound in palliative carePOCUS has been shown to improve the cost effectiveness of physical examination in multiple syndromes, with the development of specific protocols for diverse situations such as acute dyspnoea or shock, which are typical examples of the cost effectiveness of multi-organ point-of-care ultrasound. This approach is also applicable to various PC scenarios as these days it is considered that POCUS, like traditional physical examination, should be performed in a standardised manner in patients with various syndromes including fever, dyspnoea, chest pain, abdominal pain, musculoskeletal pain, etc. The contribution of this tool to the diagnosis of conditions such as pneumonia, pneumothorax, pulmonary embolism, or acute heart failure, among other processes, is no longer a controversial topic.Without losing sight of this concept, this manuscript aims to concisely detail the utility of POCUS in specific situations that could arise during the provision of medical care to patients receiving oncological palliative care (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>In its positioning statement on the addition of POCUS to Internal Medicine services, the SEMI established an approach towards the components and educational time frame for basic ultrasound training, with 3 different successive levels.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> For the goals proposed for PC, even in Level 1, clinicians must perform at least 20 supervised examinations.Malignant ascitesAscites is common in patients with peritoneal carcinomatosis. The cost effectiveness of physical examination in terms of detection is low, particularly if volume is low or patients are obese or have significant meteorism. When the traditional signs are examined, such as flank dullness and bulging flanks, sensitivity and specificity are 75% and 57%, respectively.<a class="elsevierStyleCrossRefs" href="#bib0065">13,14</a> In addition, at least 1,500 mL fluid volume is needed for such findings to be detected.<a class="elsevierStyleCrossRef" href="#bib0075">15</a>Ultrasound is the exam of choice to confirm the presence of ascites and its volume, and also enables paracentesis to be performed at the care site. This latter is a safe technique that can be performed in the patient’s own home.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> Complications resulting from the procedure are significantly reduced when ultrasound is used (4.7 vs 1.4%).<a class="elsevierStyleCrossRef" href="#bib0085">17</a> Likewise, it enables guided insertion of permanent tunnelled catheters. Ascites is identified as a homogeneous anechoic collection. However, in neoplastic ascites, altered echogenicity of the fluid, septa or loculations, peritoneal implants, and in the mesentery, can be observed, in addition to increased vascularisation of the parietal peritoneum.<a class="elsevierStyleCrossRef" href="#bib0090">18</a>The ultrasound findings from a patient with malignant ascites can be seen in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> and Video 1.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Intestinal obstructionThis is a fairly common condition in advanced stages of gastrointestinal or pelvic neoplasm. POCUS enables the identification of small bowel obstruction with a sensitivity of up to 90% and specificity of 97%, meaning it is the superior technique compared to conventional radiological exams.<a class="elsevierStyleCrossRef" href="#bib0095">19</a> Due to the accessibility, lack of ionising radiation, and rapid implementation, POCUS has been established as the first-line diagnostic technique for this condition, used to select patients who could benefit from undergoing abdominal computed tomography (CT) or, depending on the circumstances of the disease, more conservative management without the need for this imaging test.<a class="elsevierStyleCrossRef" href="#bib0100">20</a>Many different ultrasound signs may be seen<a class="elsevierStyleCrossRefs" href="#bib0100">20,21</a>: bowel loops dilated and filled with fluid, with a small bowel diameter greater than 25 mm measured between the external walls. Peristalsis is absent and the intestinal content has a whirling movement, also called ‘to-and-fro peristalsis’. In more advanced cases, thickening of the intestinal wall (>3 mm) and the valvulae conniventes (>2 mm; keyboard sign) can be observed, together with the presence of free fluid interspersed between bowel loops (tanga sign). The prominence of the valvulae conniventes tends to point to the obstruction having a jejunal location. Lastly, the colon lumen, identifiable by the presence of haustras, is collapsed.A case of small bowl obstruction can be observed in Video 2.Pleural effusionPleural effusion (PE) is a common clinical problem in PC and can affect between 15 and 20% of cancer patients (particularly lung and breast).<a class="elsevierStyleCrossRef" href="#bib0110">22</a>The sensitivity of physical examination in detecting PE is directly proportional to its size, with diagnosis highly unlikely when fluid volume is less than 300 mL.<a class="elsevierStyleCrossRef" href="#bib0115">23</a> Standard chest x-ray with anteroposterior images is useful when fluid volume is greater than 200 mL. Ultrasound has a 100% sensitivity for pleural fluid volumes greater than 100 mL and can even detect volumes less than 20 mL.<a class="elsevierStyleCrossRefs" href="#bib0115">23,24</a> In addition to observing the details (septa, loculations, echogenicity of the fluid, etc.), this technique allows for characterisation of the lung parenchyma (atelectasis, condensation and masses) and the chest wall (masses, costal lytic lesions, pleural thickening or nodularity), though this aspect is not the focus of this review.Pleural fluid accumulates in the most dependent areas of the chest, particularly in the posterolateral costophrenic recess when patients are seated or semi-recumbent. Five structures can be identified in the coronal plane: liver/spleen, diaphragm, pleural fluid (anechoic or of variable echogenicity), lung (typically collapsed) and the chest wall (Video 3).Some of the ultrasound signs associated with PE are mentioned in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>While there are different formulas for calculating pleural fluid volume,<a class="elsevierStyleCrossRef" href="#bib0135">27</a> we suggest a qualitative evaluation. In small or loculated PE, it is recommended that thoracentesis be performed under ultrasound guidance in real time.<a class="elsevierStyleCrossRef" href="#bib0140">28</a> This helps the technician locate the best puncture site, ensuring the needle is visible throughout the entire procedure. With this approach, complications (pneumothorax, haemothorax, and failed punctures) are very rare (<1%). Nevertheless, within the context of PC, if the fluid chamber is large, the technique can be performed statically in real time, with the operator measuring the distance between the skin and the effusion and marking the puncture site without visualising the needle during the procedure.While the traditional recommendation is to not drain more than 1500 mL, there is no firm evidence restricting the amount of drained fluid. The limiting factor is symptom onset during the procedure, such as chest pressure, dyspnoea, or persistent cough. Once completed, normal pleural sliding can be confirmed, indicating the absence of iatrogenic pneumothorax. Routine chest x-ray is not indicated after thoracentesis.<a class="elsevierStyleCrossRef" href="#bib0145">29</a> This technique can be safely performed in the homes of PC patients.<a class="elsevierStyleCrossRef" href="#bib0150">30</a> Lastly, POCUS is useful for guiding the insertion of tunnelled catheters and other procedures indicated in cases of recurrent pleural effusion.<a class="elsevierStyleCrossRef" href="#bib0155">31</a>Pericardial effusion and cardiac tamponadeLung, breast, oesophagus, and lymphoma neoplasm often cause pericardial metastasis. Drug toxicity (chemotherapy and immunotherapy) and radiation therapy are other aetiologies that can be considered in PC.<a class="elsevierStyleCrossRef" href="#bib0160">32</a> The sensitivity of the classic Beck’s triad (low blood pressure, distension of the jugular veins, and muffled heart sounds) in tamponade diagnosis is low.<a class="elsevierStyleCrossRef" href="#bib0165">33</a> Unless pulsus paradoxus occurs (drop in systolic blood pressure > 10 mmHg upon inhalation, sensitive but not specific finding), neither classic physical examination nor ECG or chest x-ray findings can predict the presence of tamponade.<a class="elsevierStyleCrossRef" href="#bib0165">33</a> Ultrasound has a sensitivity and specificity of over 90% in detecting effusion, even when performed by physicians with little experience. It therefore reduces pericardiocentesis delays whenever this is clinically indicated.<a class="elsevierStyleCrossRef" href="#bib0170">34</a>Any pericardial effusion should be classified according to its hemodynamic impact, size, distribution, composition and form of presentation (acute, subacute, or chronic). When the diameter between the parietal and visceral pericardium at end-diastole is greater than 2 cm (20 mm), this is considered severe and is correlated with a fluid volume greater than 700 mL.<a class="elsevierStyleCrossRef" href="#bib0175">35</a>While comprehensive echocardiogram should examine of all the planes, the approach of choice is subcostal or subxiphoid in PC. Pericardial effusion is identified as an anechoic structure of variable distribution around the chambers of the heart. In neoplasm involvement, echogenicity may be altered, and it is possible to observe septa and a pericardium that is thickened or looks nodular. Collapse of the right cavities at end-diastole is the finding that implies haemodynamic compromise. In these cases, the inferior vena cava (IVC) may have plethora (>20 mm) with no respiratory variations.<a class="elsevierStyleCrossRef" href="#bib0180">36</a> Swinging heart refers to the pendular motion of the heart in cases of severe effusion and tamponade.<a class="elsevierStyleCrossRef" href="#bib0185">37</a> Obviously, there are other echocardiogram signs that suggest haemodynamic compromise and whose development is not a basic aim of PC. To diagnose tamponade, POCUS findings must correlate with the presence of arterial hypertension, tachycardia, and signs of low cardiac output. These patients require emergency pericardiocentesis in hospital.Video 7 shows severe pericardial effusion with compromise of the right cavities (right ventricle collapse).Hydronephrosis and acute urinary retentionFor patients who present with acute impairment of renal function or who are experiencing anuria, the main aim of POCUS is to identify an obstructive uropathy, in some cases enabling immediate intervention such as urinary diversion via placement of a urinary catheter in the event of acute urinary retention (AUR).Hydronephrosis translates into dilation of the pelvis and renal calyces due to obstructed urine flow due to intrinsic (i.e., lithiasis, urothelial tumour) or extrinsic causes (i.e., adenopathies, pelvic or retroperitoneal tumour). The most distal obstructions produce bilateral hydronephrosis (i.e., acute urinary retention, pelvic tumour, prostate enlargement). While computed tomography (CT) is the imaging test of choice for the diagnosis and aetiology of hydronephrosis, POCUS, with close to 90% sensitivity and specificity, represents the initial diagnostic method.<a class="elsevierStyleCrossRef" href="#bib0190">38</a>Hydronephrosis can be classified as mild, moderate, or severe.<a class="elsevierStyleCrossRef" href="#bib0195">39</a> In the initial phases of obstruction, the renal pelvis appears anechoic. If this progresses, the calyces dilate, though the pyelocaliceal architecture remains preserved. In severe and prolonged obstruction, the renal pyramids narrow, the pelvis and calyces appear anechoic, and the cortical narrows (Videos 8 and 9). Hydronephrosis can be confused with the presence of parapyelic cysts. Unlike proximal dilation, cysts are not connected to the excretory route.<a class="elsevierStyleCrossRef" href="#bib0200">40</a>Another useful application of POCUS is in calculating the volume of intravesical urine, which facilitates sure-fire AUR diagnosis,<a class="elsevierStyleCrossRef" href="#bib0205">41</a> as described in <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>. There are ultra-portable devices that can automatically calculate this. What’s more, POCUS is useful for confirming correct placement of a urinary catheter.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Deep vein thrombosis of the lower limbsActive cancer is an independent risk factor for developing venous thromboembolism (VTE). The difficulties involved in clinical diagnosis of deep vein thrombosis (DVT) of the lower limbs in cancer patients, the elevated mortality in untreated patients due to progression to pulmonary thromboembolism (PTE), and the risks of haemorrhage of heparin therapy, make early identification or exclusion of this entity a priority.<a class="elsevierStyleCrossRef" href="#bib0210">42</a> In this sense, compression ultrasound (CUS), when performed by a trained professional, represents a highly cost-effective tool with results comparable to those of a Doppler ultrasound performed by a radiologist. After a rapid learning curve, according to various meta-analyses, the sensitivity of POCUS reaches 100% with a specificity of 91–98%.<a class="elsevierStyleCrossRefs" href="#bib0215">43,44</a>Venous structures collapse easily when compressed, which is the basis of CUS (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The absence of complete venous collapse or the presence of echogenic material inside them (thrombus) determine the diagnosis of DVT. If a colour Doppler is available, the lack of flow on the inside can be confirmed. There are no significant differences between two-point (common femoral vein, popliteal vein) and three-point CUS (common femoral vein, femoral vein, popliteal vein).<a class="elsevierStyleCrossRefs" href="#bib0225">45–47</a><elsevierMultimedia ident="fig0015"></elsevierMultimedia>Videos 10 and 11 show DVT affecting the common femoral vein and the femoral vein.Procedure-oriented POCUSThe previous sections made reference to the advantages of POCUS in performing certain procedures such as paracentesis or thoracentesis, which are highly useful techniques in the PC setting. The bibliography endorses safe execution of these techniques in the patient’s own home, thus avoiding unnecessary hospital transfers (medicine based on efficiency and minimum patient disruption).<a class="elsevierStyleCrossRefs" href="#bib0080">16,30</a>POCUS is a useful tool for hard-to-access peripheral catheter insertion or for placing other intravascular devices such as peripherally inserted central catheters (PICC) or midline catheters. Lastly, ultrasound is used to guide invasive procedures to treat cancer pain (plexus or peripheral nerve block, injections for various musculoskeletal conditions, etc.). These techniques are more complex and require more rigorous training.<a class="elsevierStyleCrossRef" href="#bib0240">48</a> The focus of this revision is not to provide an in-depth description of these uses.Conclusions<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">•Point-of-care ultrasound represents an extension of physical examination (the fifth pillar).</li><li class="elsevierStyleListItem" id="lsti0010">•It does not replace good clinical reasoning nor standard radiological imaging.</li><li class="elsevierStyleListItem" id="lsti0015">•It provides answers to questions, typically dichotomous, at the patient’s bedside (home, health care centre, or nursing home).</li><li class="elsevierStyleListItem" id="lsti0020">•It increases physicians’ problem-solving skills, avoiding diagnostic delays and providing information regarding prognosis and progress.</li><li class="elsevierStyleListItem" id="lsti0025">•It is safe and efficient.</li><li class="elsevierStyleListItem" id="lsti0030">•Using POCUS enhances care quality, avoids useless invasive procedures, and improves comfort and quality of life for patients receiving palliative care.</li><li class="elsevierStyleListItem" id="lsti0035">•It is used in highly cost-effective situations such as DVT, ascites, pleural or pericardial effusion, and more. It can be used to guide procedures without the need to move or transfer the patient.</li><li class="elsevierStyleListItem" id="lsti0040">•It increases both patient and professional satisfaction.</li><li class="elsevierStyleListItem" id="lsti0045">•It is time to implement this tool in Palliative Care units, fostering alliances and partnerships with other scientific societies to create a common, organised educational structure with the goal of guaranteeing quality training and skills accreditation.</li></ul>FundingThis research did not receive any specific funding from agencies from the public sector, commercial sector, or not-for-profit organisations.Conflicts of interestThe authors declare that they do not have any conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:18 [ 0 => array:3 [ "identificador" => "xres2010064" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1721966" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2010065" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1721967" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Point-of-care ultrasound concept" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Main applications of point-of-care ultrasound in palliative care" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Malignant ascites" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Intestinal obstruction" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Pleural effusion" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Pericardial effusion and cardiac tamponade" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Hydronephrosis and acute urinary retention" ] 12 => array:2 [ "identificador" => "sec0045" "titulo" => "Deep vein thrombosis of the lower limbs" ] 13 => array:2 [ "identificador" => "sec0050" "titulo" => "Procedure-oriented POCUS" ] 14 => array:2 [ "identificador" => "sec0055" "titulo" => "Conclusions" ] 15 => array:2 [ "identificador" => "sec0060" "titulo" => "Funding" ] 16 => array:2 [ "identificador" => "sec0065" "titulo" => "Conflicts of interest" ] 17 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-02-10" "fechaAceptado" => "2023-03-24" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1721966" "palabras" => array:5 [ 0 => "Point-of-care ultrasound" 1 => "Ultrasound" 2 => "Palliative care" 3 => "Palliative medicine" 4 => "Home care" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1721967" "palabras" => array:5 [ 0 => "Ecografía clínica" 1 => "Ultrasonidos" 2 => "Cuidados paliativos" 3 => "Medicina paliativa" 4 => "Cuidados domiciliarios" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Combined with a physical examination, clinical ultrasound offers a valuable complement that can help guide clinical decision-making. In various medical and surgical specialties, it is increasingly used for diagnostic and therapeutic purposes. Due to recent technological advances, smaller and more affordable ultrasound machines are now being developed for use in home hospice care. The purpose of this paper is to describe how clinical ultrasound may be applied in Palliative Care, where it can be a valuable tool to assist the clinician in making better clinical decisions and to assist in accurately guiding palliative procedures. Furthermore, it can be used to identify unnecessary hospitalizations and prevent them from occurring. Training programs with specific objectives are necessary to implement clinical ultrasound in Palliative Care, as well as defining learning curves and promoting alliances with scientific societies that recognize the teaching, care and research trajectory for accreditation of competencies." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "El uso de la ecografía clínica, entendida como una extensión de la exploración física que ayuda a la toma de decisiones clínicas en tiempo real, se ha generalizado en diversas especialidades médicas y quirúrgicas. En los últimos años, los avances tecnológicos han permitido disponer de ecógrafos de bolsillo, económicamente asequibles, que pueden ser utilizados en el propio domicilio del paciente. En esta revisión se describen las principales aplicaciones de la ecografía clínica en Cuidados Paliativos, un escenario de potencial utilidad tanto para mejorar la certeza en el diagnóstico de procesos agudos intercurrentes, que producen un impacto en la calidad de vida del paciente, como para guiar la realización de procedimientos invasivos sin necesidad de desplazamientos al medio hospitalario. Para la implantación de la ecografía clínica en Cuidados Paliativos son necesarios programas formativos con objetivos concretos, definiendo curvas de aprendizaje y estableciendo alianzas con sociedades científicas de reconocida trayectoria docente, asistencial e investigadora para la acreditación de competencias." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "The following are Supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia><elsevierMultimedia ident="upi0015"></elsevierMultimedia><elsevierMultimedia ident="upi0020"></elsevierMultimedia><elsevierMultimedia ident="upi0025"></elsevierMultimedia><elsevierMultimedia ident="upi0030"></elsevierMultimedia><elsevierMultimedia ident="upi0035"></elsevierMultimedia><elsevierMultimedia ident="upi0040"></elsevierMultimedia><elsevierMultimedia ident="upi0045"></elsevierMultimedia><elsevierMultimedia ident="upi0050"></elsevierMultimedia><elsevierMultimedia ident="upi0055"></elsevierMultimedia>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0075" ] ] ] ] "multimedia" => array:16 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 924 "Ancho" => 755 "Tamanyo" => 55399 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "The presence of an anechoic chamber (ascites) can be observed and, in terms of flow, the bowel loops. The image below shows ascites and metastatic liver lesions in a patient with pancreatic adenocarcinoma." ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 631 "Ancho" => 1005 "Tamanyo" => 75378 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Bladder volume calculation (mL). Ellipsoid formula: anteroposterior diameter (cm) × transverse diameter (cm) x longitudinal diameter (cm) × 0.52. In this case the value is 189 mL." ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 747 "Ancho" => 1250 "Tamanyo" => 58979 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Fundamentals of compression ultrasound." ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Point-of-care ultrasound \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Objective \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Abdomen \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Detection of ascites, detection of signs of intestinal obstruction \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chest \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Detection of pleural effusion \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Detection of pulmonary congestion<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Detection of pulmonary consolidation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Focused cardiac \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Detection of pericardial effusion and tamponade \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Blood volume estimation via assessment of the diameter and collapsibility of the inferior vena cava<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Urology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Detection of hydronephrosis and acute urinary retention \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vascular \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Detection of deep vein thrombosis of the lower limbs \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Procedural \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Paracentesis, thoracentesis, venous access \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3336901.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "Non-cancer palliative care (heart failure)." ] ] ] "descripcion" => array:1 [ "en" => "Main applications of point-of care ultrasound in palliative care." ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Ultrasound sign \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Meaning \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Curtain sign \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In normal conditions, both the diaphragm and the subdiaphragmatic structures disappear during inhalation due to the artefact generated in the aerated lung (Video 4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Thoracic spine sign \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Visualisation of the vertebral skeleton in the presence of abundant PE (Video 5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Jellyfish sign \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Swimming movement of the collapsed lung in PE \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Plankton sign \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Refers to the presence of punctiform echogenic images that move with respiration and could indicate the haemorrhagic or exudative nature of the PE (Video 6) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3336902.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Ultrasound signs related to pleural effusion.<a class="elsevierStyleCrossRefs" href="#bib0125">25,26</a>" ] ] 5 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 492796 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:5 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] 6 => array:5 [ 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Special article

Main applications of point-of-care ultrasound in palliative care

Principales aplicaciones de la ecografía clínica en cuidados paliativos

Daniel García-Gila,

Corresponding author

urgenciashupr@gmail.com
daniel.garcia.gil.sspa@juntadeandalucia.es

Corresponding author.

, Luis M. Beltrán-Romerob, Gema Flox-Benítezc, Manuel Castillo-Padrósa,c,d, Alfredo L. Díaz-Gómeza, Abel Mujal-Martíneze, Juan Torres-Machof

a Unidad de Ecografía Clínica Asistencial, Servicio de Medicina Interna, Hospital San Carlos, San Fernando, Cádiz, España. Grupo de Trabajo de Ecografía Clínica de la Sociedad Española de Medicina Interna (SEMI)

b Servicio de Medicina Interna, Hospital Universitario Virgen del Rocío, Sevilla, España. Grupo de Trabajo de Ecografía Clínica dela Sociedad Española de Medicina Interna (SEMI)

c Unidad de Cuidados Paliativos. Servicio de Medicina Interna, Hospital Universitario Severo Ochoa, Leganés, Madrid, España. Grupo de Trabajo de Cuidados Paliativos de la Sociedad Española de Medicina Interna (SEMI)

d Unidad de Cuidados Paliativos, Hospital Universitario Nuestra Señora de Candelaria, Tenerife, España. Coordinador de Grupos de Trabajo de la Sociedad Española de Cuidados Paliativos (SECPAL)

e Unidad de Hospitalización a Domicilio, Servicio de Medicina Interna, Consorci Corporació Sanitària Parc Taulí, Sabadell, España. Coordinador del Grupo de Trabajo Hospitalización a Domicilio y Telemedicina de la Sociedad Española de Medicina Interna (SEMI)

f Servicio de Medicina Interna, Hospital Universitario Infanta Leonor, Madrid, España. Grupo de Trabajo de Ecografía Clínica de laSociedad Española de Medicina Interna (SEMI)

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Over the past 20 years&#44; increased use of Point-of-Care Ultrasound &#40;POCUS&#41; has been an influential agent of change in the skills of multiple specialties and has led to Scientific Societies encouraging development in terms of medical care&#44; education&#44; and research&#46; Along these lines&#44; the Clinical Ultrasound Working Groups from the Spanish Society for Internal Medicine &#40;SEMI&#41; and the European Federation of Internal Medicine &#40;EFIM&#41; have drafted guidelines for accrediting POCUS training&#44; this being a framework to guide the implementation of training programs at each centre according to the necessary minimum requirements&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> In addition&#44; the National Commission for Internal Medicine Specialty in Spain has already completed the draft of a new training program structured into skill domains specifying&#44; regarding technical skills&#44; POCUS as a specific training activity&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">While medical treatment and comfort care for patients in Palliative Care &#40;PC&#41; are highly standardised&#44; the use of POCUS is this field is uncommon&#46; The search strategy used MeSH terms &#8220;palliative care&#8221;&#44; &#8220;palliative medicine&#8221;&#44; &#8220;home care services&#8221;&#44; &#8220;home care system&#8221;&#44; &#8220;hospice care&#8221;&#44; &#8220;point of care systems&#8221;&#44; &#8220;ultrasound&#8221; and &#8220;ultrasonography&#8221;&#46; Bibliography contributions from data sources such as PubMed-MEDLINE&#44; Scopus&#44; EMBASE and Cochrane Library were scarce&#44; including some revisions and descriptive studies in PC units&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a> It is time to consolidate the use of this modern and appealing technique within PC units by encouraging widespread&#44; structured and high-quality accredited training that is accessible and offers different skill levels&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Point-of-care ultrasound concept</span><p id="par0015" class="elsevierStylePara elsevierViewall">The introduction of the stethoscope by Ren&#233; La&#235;nnec in 1816 revolutionised how clinical examinations were performed&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> Over 200 years passed until the addition of the so-called fifth pillar of physical examination&#44; or &#8220;insonation&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> This term refers to systematic use of ultrasound &#40;US&#41; as an extension to physical examination in the clinical decision-making process in the physical location where the patient is receiving care&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> While it aims to supplement clinical reasoning&#44; the goal is not to replace standard examination by a radiologist or cardiologist&#44; for example&#46; The aim is to find answers to clinical questions &#40;typically dichotomous&#41; via real time studies in circumstances in which US use is cost-effective &#40;high sensitivity and negative predictive value&#41;&#46; In addition to minimising diagnostic delays and uncertainty&#44; other advantages include a fast learning curve for specific goals&#44; repeatability &#40;no ionising radiation&#41;&#44; and the possibility to direct diagnostic-therapeutic procedures&#44; which is a key aspect in patient safety&#46; In short&#44; it is a cost-effective tool with high satisfaction scores from patients and which promotes professional empowerment&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a> Regarding disadvantages&#44; POCUS is an operator-dependent examination&#46; However&#44; this dependency decreases with supervised training by experts on the most common and cost-effective situations as described in this revision&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Modernisation and miniaturisation of ultrasound devices has made it possible to create pocket-sized or ultra-portable devices that&#44; when connected to a tablet or smart phone&#44; allow clinicians to obtain good quality imaging that is also affordable&#46; Some ultrasound machines with this user profile have a single multi-frequency transducer&#44; allowing the option to select the settings that best adapt to the examination to be performed&#46; In addition to the standard storage option&#44; it is also possible to &#8220;upload&#8221; images to a server in real time for remote analysis and feedback from other consultants&#46; Lastly&#44; video tutorials&#44; artificial intelligence programs&#44; and augmented reality programs help optimise images and safely guide invasive procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> All these aspects take on greater importance in the field of PC as most patients are at a stage in their illness that they want to receive care at home&#44; provided they can receive an adequate level of care&#46; Medical care provided with the support of this technology includes&#44; among others&#44; diagnosis of intercurrent processes or the performance of invasive procedures without the need to&#44; in most situations&#44; transfer the patient to a hospital setting with the physical and emotional impact that such a move could involve&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Main applications of point-of-care ultrasound in palliative care</span><p id="par0025" class="elsevierStylePara elsevierViewall">POCUS has been shown to improve the cost effectiveness of physical examination in multiple syndromes&#44; with the development of specific protocols for diverse situations such as acute dyspnoea or shock&#44; which are typical examples of the cost effectiveness of multi-organ point-of-care ultrasound&#46; This approach is also applicable to various PC scenarios as these days it is considered that POCUS&#44; like traditional physical examination&#44; should be performed in a standardised manner in patients with various syndromes including fever&#44; dyspnoea&#44; chest pain&#44; abdominal pain&#44; musculoskeletal pain&#44; etc&#46; The contribution of this tool to the diagnosis of conditions such as pneumonia&#44; pneumothorax&#44; pulmonary embolism&#44; or acute heart failure&#44; among other processes&#44; is no longer a controversial topic&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Without losing sight of this concept&#44; this manuscript aims to concisely detail the utility of POCUS in specific situations that could arise during the provision of medical care to patients receiving oncological palliative care &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">In its positioning statement on the addition of POCUS to Internal Medicine services&#44; the SEMI established an approach towards the components and educational time frame for basic ultrasound training&#44; with 3 different successive levels&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> For the goals proposed for PC&#44; even in Level 1&#44; clinicians must perform at least 20 supervised examinations&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Malignant ascites</span><p id="par0040" class="elsevierStylePara elsevierViewall">Ascites is common in patients with peritoneal carcinomatosis&#46; The cost effectiveness of physical examination in terms of detection is low&#44; particularly if volume is low or patients are obese or have significant meteorism&#46; When the traditional signs are examined&#44; such as flank dullness and bulging flanks&#44; sensitivity and specificity are 75&#37; and 57&#37;&#44; respectively&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a> In addition&#44; at least 1&#44;500&#8239;mL fluid volume is needed for such findings to be detected&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Ultrasound is the exam of choice to confirm the presence of ascites and its volume&#44; and also enables paracentesis to be performed at the care site&#46; This latter is a safe technique that can be performed in the patient&#8217;s own home&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Complications resulting from the procedure are significantly reduced when ultrasound is used &#40;4&#46;7 vs 1&#46;4&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Likewise&#44; it enables guided insertion of permanent tunnelled catheters&#46; Ascites is identified as a homogeneous anechoic collection&#46; However&#44; in neoplastic ascites&#44; altered echogenicity of the fluid&#44; septa or loculations&#44; peritoneal implants&#44; and in the mesentery&#44; can be observed&#44; in addition to increased vascularisation of the parietal peritoneum&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The ultrasound findings from a patient with malignant ascites can be seen in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> and Video 1&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Intestinal obstruction</span><p id="par0055" class="elsevierStylePara elsevierViewall">This is a fairly common condition in advanced stages of gastrointestinal or pelvic neoplasm&#46; POCUS enables the identification of small bowel obstruction with a sensitivity of up to 90&#37; and specificity of 97&#37;&#44; meaning it is the superior technique compared to conventional radiological exams&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Due to the accessibility&#44; lack of ionising radiation&#44; and rapid implementation&#44; POCUS has been established as the first-line diagnostic technique for this condition&#44; used to select patients who could benefit from undergoing abdominal computed tomography &#40;CT&#41; or&#44; depending on the circumstances of the disease&#44; more conservative management without the need for this imaging test&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Many different ultrasound signs may be seen<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">20&#44;21</span></a>&#58; bowel loops dilated and filled with fluid&#44; with a small bowel diameter greater than 25&#8239;mm measured between the external walls&#46; Peristalsis is absent and the intestinal content has a whirling movement&#44; also called &#8216;to-and-fro peristalsis&#8217;&#46; In more advanced cases&#44; thickening of the intestinal wall &#40;&#62;3&#8239;mm&#41; and the valvulae conniventes &#40;&#62;2&#8239;mm&#59; keyboard sign&#41; can be observed&#44; together with the presence of free fluid interspersed between bowel loops &#40;tanga sign&#41;&#46; The prominence of the valvulae conniventes tends to point to the obstruction having a jejunal location&#46; Lastly&#44; the colon lumen&#44; identifiable by the presence of haustras&#44; is collapsed&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">A case of small bowl obstruction can be observed in Video 2&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Pleural effusion</span><p id="par0070" class="elsevierStylePara elsevierViewall">Pleural effusion &#40;PE&#41; is a common clinical problem in PC and can affect between 15 and 20&#37; of cancer patients &#40;particularly lung and breast&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The sensitivity of physical examination in detecting PE is directly proportional to its size&#44; with diagnosis highly unlikely when fluid volume is less than 300&#8239;mL&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Standard chest x-ray with anteroposterior images is useful when fluid volume is greater than 200&#8239;mL&#46; Ultrasound has a 100&#37; sensitivity for pleural fluid volumes greater than 100&#8239;mL and can even detect volumes less than 20&#8239;mL&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;24</span></a> In addition to observing the details &#40;septa&#44; loculations&#44; echogenicity of the fluid&#44; etc&#46;&#41;&#44; this technique allows for characterisation of the lung parenchyma &#40;atelectasis&#44; condensation and masses&#41; and the chest wall &#40;masses&#44; costal lytic lesions&#44; pleural thickening or nodularity&#41;&#44; though this aspect is not the focus of this review&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Pleural fluid accumulates in the most dependent areas of the chest&#44; particularly in the posterolateral costophrenic recess when patients are seated or semi-recumbent&#46; Five structures can be identified in the coronal plane&#58; liver&#47;spleen&#44; diaphragm&#44; pleural fluid &#40;anechoic or of variable echogenicity&#41;&#44; lung &#40;typically collapsed&#41; and the chest wall &#40;Video 3&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Some of the ultrasound signs associated with PE are mentioned in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">While there are different formulas for calculating pleural fluid volume&#44;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> we suggest a qualitative evaluation&#46; In small or loculated PE&#44; it is recommended that thoracentesis be performed under ultrasound guidance in real time&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> This helps the technician locate the best puncture site&#44; ensuring the needle is visible throughout the entire procedure&#46; With this approach&#44; complications &#40;pneumothorax&#44; haemothorax&#44; and failed punctures&#41; are very rare &#40;&#60;1&#37;&#41;&#46; Nevertheless&#44; within the context of PC&#44; if the fluid chamber is large&#44; the technique can be performed statically in real time&#44; with the operator measuring the distance between the skin and the effusion and marking the puncture site without visualising the needle during the procedure&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">While the traditional recommendation is to not drain more than 1500&#8239;mL&#44; there is no firm evidence restricting the amount of drained fluid&#46; The limiting factor is symptom onset during the procedure&#44; such as chest pressure&#44; dyspnoea&#44; or persistent cough&#46; Once completed&#44; normal pleural sliding can be confirmed&#44; indicating the absence of iatrogenic pneumothorax&#46; Routine chest x-ray is not indicated after thoracentesis&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> This technique can be safely performed in the homes of PC patients&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> Lastly&#44; POCUS is useful for guiding the insertion of tunnelled catheters and other procedures indicated in cases of recurrent pleural effusion&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Pericardial effusion and cardiac tamponade</span><p id="par0100" class="elsevierStylePara elsevierViewall">Lung&#44; breast&#44; oesophagus&#44; and lymphoma neoplasm often cause pericardial metastasis&#46; Drug toxicity &#40;chemotherapy and immunotherapy&#41; and radiation therapy are other aetiologies that can be considered in PC&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> The sensitivity of the classic Beck&#8217;s triad &#40;low blood pressure&#44; distension of the jugular veins&#44; and muffled heart sounds&#41; in tamponade diagnosis is low&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> Unless pulsus paradoxus occurs &#40;drop in systolic blood pressure &#62; 10&#8239;mmHg upon inhalation&#44; sensitive but not specific finding&#41;&#44; neither classic physical examination nor ECG or chest x-ray findings can predict the presence of tamponade&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> Ultrasound has a sensitivity and specificity of over 90&#37; in detecting effusion&#44; even when performed by physicians with little experience&#46; It therefore reduces pericardiocentesis delays whenever this is clinically indicated&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Any pericardial effusion should be classified according to its hemodynamic impact&#44; size&#44; distribution&#44; composition and form of presentation &#40;acute&#44; subacute&#44; or chronic&#41;&#46; When the diameter between the parietal and visceral pericardium at end-diastole is greater than 2&#8239;cm &#40;20&#8239;mm&#41;&#44; this is considered severe and is correlated with a fluid volume greater than 700&#8239;mL&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">While comprehensive echocardiogram should examine of all the planes&#44; the approach of choice is subcostal or subxiphoid in PC&#46; Pericardial effusion is identified as an anechoic structure of variable distribution around the chambers of the heart&#46; In neoplasm involvement&#44; echogenicity may be altered&#44; and it is possible to observe septa and a pericardium that is thickened or looks nodular&#46; Collapse of the right cavities at end-diastole is the finding that implies haemodynamic compromise&#46; In these cases&#44; the inferior vena cava &#40;IVC&#41; may have plethora &#40;&#62;20&#8239;mm&#41; with no respiratory variations&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> Swinging heart refers to the pendular motion of the heart in cases of severe effusion and tamponade&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> Obviously&#44; there are other echocardiogram signs that suggest haemodynamic compromise and whose development is not a basic aim of PC&#46; To diagnose tamponade&#44; POCUS findings must correlate with the presence of arterial hypertension&#44; tachycardia&#44; and signs of low cardiac output&#46; These patients require emergency pericardiocentesis in hospital&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Video 7 shows severe pericardial effusion with compromise of the right cavities &#40;right ventricle collapse&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Hydronephrosis and acute urinary retention</span><p id="par0120" class="elsevierStylePara elsevierViewall">For patients who present with acute impairment of renal function or who are experiencing anuria&#44; the main aim of POCUS is to identify an obstructive uropathy&#44; in some cases enabling immediate intervention such as urinary diversion via placement of a urinary catheter in the event of acute urinary retention &#40;AUR&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Hydronephrosis translates into dilation of the pelvis and renal calyces due to obstructed urine flow due to intrinsic &#40;i&#46;e&#46;&#44; lithiasis&#44; urothelial tumour&#41; or extrinsic causes &#40;i&#46;e&#46;&#44; adenopathies&#44; pelvic or retroperitoneal tumour&#41;&#46; The most distal obstructions produce bilateral hydronephrosis &#40;i&#46;e&#46;&#44; acute urinary retention&#44; pelvic tumour&#44; prostate enlargement&#41;&#46; While computed tomography &#40;CT&#41; is the imaging test of choice for the diagnosis and aetiology of hydronephrosis&#44; POCUS&#44; with close to 90&#37; sensitivity and specificity&#44; represents the initial diagnostic method&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Hydronephrosis can be classified as mild&#44; moderate&#44; or severe&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> In the initial phases of obstruction&#44; the renal pelvis appears anechoic&#46; If this progresses&#44; the calyces dilate&#44; though the pyelocaliceal architecture remains preserved&#46; In severe and prolonged obstruction&#44; the renal pyramids narrow&#44; the pelvis and calyces appear anechoic&#44; and the cortical narrows &#40;Videos 8 and 9&#41;&#46; Hydronephrosis can be confused with the presence of parapyelic cysts&#46; Unlike proximal dilation&#44; cysts are not connected to the excretory route&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Another useful application of POCUS is in calculating the volume of intravesical urine&#44; which facilitates sure-fire AUR diagnosis&#44;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> as described in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46; There are ultra-portable devices that can automatically calculate this&#46; What&#8217;s more&#44; POCUS is useful for confirming correct placement of a urinary catheter&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Deep vein thrombosis of the lower limbs</span><p id="par0140" class="elsevierStylePara elsevierViewall">Active cancer is an independent risk factor for developing venous thromboembolism &#40;VTE&#41;&#46; The difficulties involved in clinical diagnosis of deep vein thrombosis &#40;DVT&#41; of the lower limbs in cancer patients&#44; the elevated mortality in untreated patients due to progression to pulmonary thromboembolism &#40;PTE&#41;&#44; and the risks of haemorrhage of heparin therapy&#44; make early identification or exclusion of this entity a priority&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> In this sense&#44; compression ultrasound &#40;CUS&#41;&#44; when performed by a trained professional&#44; represents a highly cost-effective tool with results comparable to those of a Doppler ultrasound performed by a radiologist&#46; After a rapid learning curve&#44; according to various meta-analyses&#44; the sensitivity of POCUS reaches 100&#37; with a specificity of 91&#8211;98&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">43&#44;44</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Venous structures collapse easily when compressed&#44; which is the basis of CUS &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The absence of complete venous collapse or the presence of echogenic material inside them &#40;thrombus&#41; determine the diagnosis of DVT&#46; If a colour Doppler is available&#44; the lack of flow on the inside can be confirmed&#46; There are no significant differences between two-point &#40;common femoral vein&#44; popliteal vein&#41; and three-point CUS &#40;common femoral vein&#44; femoral vein&#44; popliteal vein&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">45&#8211;47</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0150" class="elsevierStylePara elsevierViewall">Videos 10 and 11 show DVT affecting the common femoral vein and the femoral vein&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Procedure-oriented POCUS</span><p id="par0155" class="elsevierStylePara elsevierViewall">The previous sections made reference to the advantages of POCUS in performing certain procedures such as paracentesis or thoracentesis&#44; which are highly useful techniques in the PC setting&#46; The bibliography endorses safe execution of these techniques in the patient&#8217;s own home&#44; thus avoiding unnecessary hospital transfers &#40;medicine based on efficiency and minimum patient disruption&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;30</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">POCUS is a useful tool for hard-to-access peripheral catheter insertion or for placing other intravascular devices such as peripherally inserted central catheters &#40;PICC&#41; or midline catheters&#46; Lastly&#44; ultrasound is used to guide invasive procedures to treat cancer pain &#40;plexus or peripheral nerve block&#44; injections for various musculoskeletal conditions&#44; etc&#46;&#41;&#46; These techniques are more complex and require more rigorous training&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a> The focus of this revision is not to provide an in-depth description of these uses&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conclusions</span><p id="par0165" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0170" class="elsevierStylePara elsevierViewall">Point-of-care ultrasound represents an extension of physical examination &#40;the fifth pillar&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0175" class="elsevierStylePara elsevierViewall">It does not replace good clinical reasoning nor standard radiological imaging&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0180" class="elsevierStylePara elsevierViewall">It provides answers to questions&#44; typically dichotomous&#44; at the patient&#8217;s bedside &#40;home&#44; health care centre&#44; or nursing home&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0185" class="elsevierStylePara elsevierViewall">It increases physicians&#8217; problem-solving skills&#44; avoiding diagnostic delays and providing information regarding prognosis and progress&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0190" class="elsevierStylePara elsevierViewall">It is safe and efficient&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">&#8226;</span><p id="par0195" class="elsevierStylePara elsevierViewall">Using POCUS enhances care quality&#44; avoids useless invasive procedures&#44; and improves comfort and quality of life for patients receiving palliative care&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">&#8226;</span><p id="par0200" class="elsevierStylePara elsevierViewall">It is used in highly cost-effective situations such as DVT&#44; ascites&#44; pleural or pericardial effusion&#44; and more&#46; It can be used to guide procedures without the need to move or transfer the patient&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">&#8226;</span><p id="par0205" class="elsevierStylePara elsevierViewall">It increases both patient and professional satisfaction&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">&#8226;</span><p id="par0210" class="elsevierStylePara elsevierViewall">It is time to implement this tool in Palliative Care units&#44; fostering alliances and partnerships with other scientific societies to create a common&#44; organised educational structure with the goal of guaranteeing quality training and skills accreditation&#46;</p></li></ul></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Funding</span><p id="par0215" class="elsevierStylePara elsevierViewall">This research did not receive any specific funding from agencies from the public sector&#44; commercial sector&#44; or not-for-profit organisations&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of interest</span><p id="par0220" class="elsevierStylePara elsevierViewall">The authors declare that they do not have any conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Main applications of point-of-care ultrasound in palliative care"
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          "titulo" => "Malignant ascites"
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          "titulo" => "Intestinal obstruction"
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          "titulo" => "Pleural effusion"
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          "titulo" => "Pericardial effusion and cardiac tamponade"
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          "titulo" => "Hydronephrosis and acute urinary retention"
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            0 => "Ecograf&#237;a cl&#237;nica"
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            2 => "Cuidados paliativos"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Combined with a physical examination&#44; clinical ultrasound offers a valuable complement that can help guide clinical decision-making&#46; In various medical and surgical specialties&#44; it is increasingly used for diagnostic and therapeutic purposes&#46; Due to recent technological advances&#44; smaller and more affordable ultrasound machines are now being developed for use in home hospice care&#46; The purpose of this paper is to describe how clinical ultrasound may be applied in Palliative Care&#44; where it can be a valuable tool to assist the clinician in making better clinical decisions and to assist in accurately guiding palliative procedures&#46; Furthermore&#44; it can be used to identify unnecessary hospitalizations and prevent them from occurring&#46; Training programs with specific objectives are necessary to implement clinical ultrasound in Palliative Care&#44; as well as defining learning curves and promoting alliances with scientific societies that recognize the teaching&#44; care and research trajectory for accreditation of competencies&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El uso de la ecograf&#237;a cl&#237;nica&#44; entendida como una extensi&#243;n de la exploraci&#243;n f&#237;sica que ayuda a la toma de decisiones cl&#237;nicas en tiempo real&#44; se ha generalizado en diversas especialidades m&#233;dicas y quir&#250;rgicas&#46; En los &#250;ltimos a&#241;os&#44; los avances tecnol&#243;gicos han permitido disponer de ec&#243;grafos de bolsillo&#44; econ&#243;micamente asequibles&#44; que pueden ser utilizados en el propio domicilio del paciente&#46; En esta revisi&#243;n se describen las principales aplicaciones de la ecograf&#237;a cl&#237;nica en Cuidados Paliativos&#44; un escenario de potencial utilidad tanto para mejorar la certeza en el diagn&#243;stico de procesos agudos intercurrentes&#44; que producen un impacto en la calidad de vida del paciente&#44; como para guiar la realizaci&#243;n de procedimientos invasivos sin necesidad de desplazamientos al medio hospitalario&#46; Para la implantaci&#243;n de la ecograf&#237;a cl&#237;nica en Cuidados Paliativos son necesarios programas formativos con objetivos concretos&#44; definiendo curvas de aprendizaje y estableciendo alianzas con sociedades cient&#237;ficas de reconocida trayectoria docente&#44; asistencial e investigadora para la acreditaci&#243;n de competencias&#46;</p></span>"
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            "apendice" => "<p id="par0230" class="elsevierStylePara elsevierViewall">The following are Supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia><elsevierMultimedia ident="upi0015"></elsevierMultimedia><elsevierMultimedia ident="upi0020"></elsevierMultimedia><elsevierMultimedia ident="upi0025"></elsevierMultimedia><elsevierMultimedia ident="upi0030"></elsevierMultimedia><elsevierMultimedia ident="upi0035"></elsevierMultimedia><elsevierMultimedia ident="upi0040"></elsevierMultimedia><elsevierMultimedia ident="upi0045"></elsevierMultimedia><elsevierMultimedia ident="upi0050"></elsevierMultimedia><elsevierMultimedia ident="upi0055"></elsevierMultimedia></p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The presence of an anechoic chamber &#40;ascites&#41; can be observed and&#44; in terms of flow&#44; the bowel loops&#46; The image below shows ascites and metastatic liver lesions in a patient with pancreatic adenocarcinoma&#46;</p>"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Bladder volume calculation &#40;mL&#41;&#46; Ellipsoid formula&#58; anteroposterior diameter &#40;cm&#41;&#8239;&#215;&#8239;transverse diameter &#40;cm&#41; x longitudinal diameter &#40;cm&#41;&#8239;&#215;&#8239;0&#46;52&#46; In this case the value is 189&#8239;mL&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Fundamentals of compression ultrasound&#46;</p>"
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                  \t\t\t\t">Abdomen&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Detection of ascites&#44; detection of signs of intestinal obstruction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Detection of pleural effusion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Detection of pulmonary congestion<a class="elsevierStyleCrossRef" href="#tblfn0005">&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Detection of pericardial effusion and tamponade&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Urology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Detection of hydronephrosis and acute urinary retention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Detection of deep vein thrombosis of the lower limbs&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Paracentesis&#44; thoracentesis&#44; venous access&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Refers to the presence of punctiform echogenic images that move with respiration and could indicate the haemorrhagic or exudative nature of the PE &#40;Video 6&#41;&nbsp;\t\t\t\t\t\t\n
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                      "titulo" => "en representaci&#243;n de la Sociedad Espa&#241;ola de Medicina Interna y de su Grupo de Trabajo de Ecograf&#237;a Cl&#237;nica&#46; Positioning document on incorporating point-of-care ultrasound in Internal Medicine departments"
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                            2 => "P&#46; Garmilla Ezquerra"
                            3 => "L&#46; Beltr&#225;n Romero"
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                        "tituloSerie" => "Rev Clin Esp"
                        "fecha" => "2018"
                        "volumen" => "218"
                        "paginaInicial" => "192"
                        "paginaFinal" => "198"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29519537"
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                      "titulo" => "EFIM&#8217;s ultrasound working group&#46; Point-of-care ultrasound in internal medicine&#58; A position paper by the ultrasound working group of the European federation of internal medicine"
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                          "autores" => array:6 [
                            0 => "J&#46; Torres-Macho"
                            1 => "T&#46; Aro"
                            2 => "I&#46; Bruckner"
                            3 => "C&#46; Cogliati"
                            4 => "O&#46;H&#46; Gilja"
                            5 => "A&#46; Gurghean"
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                      "doi" => "10.1016/j.ejim.2019.11.016"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Intern Med"
                        "fecha" => "2020"
                        "volumen" => "73"
                        "paginaInicial" => "67"
                        "paginaFinal" => "71"
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Article information

ISSN: 22548874
Original language: English

DOI:10.1016/j.rceng.2023.04.009

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