CRITICAL CARE ULTRASONOGRAPHY Notice Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge. PDF | Although medical diagnostic ultrasonography has been used since the Interest in US use in critical care continues to increase as more applications of. PDF | Background: Although critical care ultrasound (CCUS) in the Intensive Care Unit has been increasing exponentially for diagnostic and.
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Critical Care Ultrasound. Study Notes. Compiled by David Tripp. October Ultrasound Physics. 2. Ultrasound in Tissue. 2. Ultrasound Interaction with. Manual of emergency and critical care ultrasound / Vicki E. Noble, Bret P. Nelson. . being such a strong advocate for the field of point-of-care ultrasound. He. FUJIFILM SonoSite is the innovator and world leader in bedside and point-of- care ultrasound. SonoSite's portable, compact, systems are.
This study was designed to assess the clinical applicability of a Point-of-Care POC ultrasound curriculum into an intensive care unit ICU fellowship program and its impact on patient care.
It included 30 hours of didactics and hands-on training on models. Minimum requirement for each ICU fellow was to perform 25—50 exams on respective systems or organs for a total not less than studies on ICU. Impact on patient care including finding a new diagnosis or change in patient management was reviewed over a period of one academic year.
All studies included were done through the POC ultrasound curriculum training. New diagnosis was found in Changes in patient management were found in Ultrasound has been used since the s to aid in patient management and radiologists have long appreciated its benefits.
POC ultrasound is defined as ultrasonography brought to the patient and performed by the provider in real time [ 1 ].
The emergence of POC ultrasound was over 20 years ago and the initial advocates were tertiary centers applying this technology to assist the clinicians in patient management [ 2 , 3 ]. Given the advantages of availability and the reproducible results, POC ultrasound became a useful tool in the clinician armamentarium for managing their patients.
In the last two decades a more focused approach to bedside ultrasound has emerged and its use has expanded in assessing trauma patients [ 2 , 3 ], hemodynamics [ 4 — 6 ], and disaster incidences [ 7 , 8 ] as well as, many applications by the Emergency Medicine EM physicians across the globe [ 9 — 11 ], applications for procedures [ 10 ], and even found its applications in space [ 12 , 13 ]. Currently, POC ultrasound applications and training in the ICU [ 17 , 20 ] are expanding rapidly, yet, only limited model curriculums exist for teaching and implementing POC ultrasound in the ICU, and their impact on patient care is not clear [ 21 ], and currently ultrasound training is highly recommended but not mandated by the Accreditation Council for Graduate Medical Education ACGME for critical care training.
Adequate teaching and competency are needed to ensure patient safety; otherwise consequences of applying inadequate knowledge [ 22 ] are unknown. The Society of Critical Care Medicine and the American College of Chest Physicians offer courses for training and certification of completion of courses as well as certification of training.
Most studies have focused on the aspects of a steep learning curve [ 23 , 24 ], organ or system applications, and the nonradiologist performance of specific ultrasound examination as the Focused Assessment with Sonography for Trauma FAST [ 2 , 3 ], echocardiography [ 23 , 24 ], lung exams [ 25 ], and others, as well as expanding literature emphasizing the benefits of using bedside ultrasound during procedures [ 10 , 26 , 27 ] and hemodynamic support [ 28 ].
The gaps in formal training programs have been identified by the American College of Chest Physicians [ 29 ] and The American Society of Echocardiography and American College of Emergency Physicians addressed in separate published consensus statements and reviews [ 30 ]. After approval by the institutional review board, a retrospective review of POC ultrasound studies and patients charts was conducted. During this process we realized the need for developing a structured curriculum for teaching.
A needs assessment evaluation for a structured POC ultrasound curriculum was conducted through interviews and questionnaires to our ICU faculty and fellows, as well as conducting literature searches [ 16 — 21 , 23 — 25 ].
Data was stored as part of the patient profile and management and also as a record to evaluate the fellow's performances. POC ultrasound was performed by the ICU fellows and was part of the patient management and the standard of care in many institutions. There is a great deal of overlap between the EM and ICU regarding the use of POC ultrasound, and our goal was to create a curriculum that is similar to a successful model which has been in place for a period of time with modifications and adjustments that are suitable for the critical care settings.
The elements of the curriculum were divided into system or organ based sessions.
The curriculum elements included mainly the following:. The modes of instructions included session format of 30 minutes of didactics followed by 60 minutes of hands-on sessions on models to reinforce the techniques. A total of 12 sessions were conducted every year at the beginning of the academic year for the new fellows.
The fellows were required to review the ultrasound topic for the organ or system or the protocol to be discussed by referring to a handbook, textbook, and articles on POC ultrasound.
The teaching sessions were provided by ICU and EM attending physicians, cardiologists, radiologists, and cardiac technicians. Emphasis was placed on certain aspects of POC ultrasound. These aspects were as follows:. Minimum requirement for each ICU fellow was to perform 25—50 exams on respective systems or organs for a total not less than exams on ICU patients during their fellowship.
The requirements for achieving competency in different elements are listed in Table 1. The competency requirements were adopted from the EM curriculum [ 30 ] that has been in use for many years. Part of the total exams required by each fellow was directly supervised by the attending ICU physician before the fellow is deemed able to perform POCUS and submit reports for review.
This decision was made taking into consideration other societies recommendation [ 30 ] and after direct observation of the studies performed by the ICU fellows. POC ultrasound curriculum exams requirements. To be performed by each ICU fellow during their fellowship. Some applications, like the procedural vascular access, require fewer cases, given the prior knowledge and clinical experience with the landmark guided techniques.
Documentation was done for all POC ultrasound exams and stored initially in the ultrasound unit, or on a worksheet, and some were transferred to a server system Qpath Telexy Healthcare, Everett, WA, USA that was housed in our institution where the exam video clips, still images, and reports could be stored.
Initially, the exams were supervised by one of the instructors a total of 3 instructors performed the supervision as shown in Table 1 , after which the fellows total of 3 fellows for the academic year were deemed able to perform the exams on their own but still needed review by the attending physician for the final diagnosis to be confirmed.
Competency evaluations and quality assurance QA systems were an integral part of the curriculum.
The objective of the QA process is to evaluate the images for technical competence and interpretations for clinical accuracy and to provide feedback to improve physician performance. The methods for QA included the following. Parameters evaluated included image resolution, anatomic definition, and other image quality acquisition aspects such as gain, depth, orientation, and focus. Providing feedback to the fellow after reviewing their POC ultrasound examination: Reviewers evaluated images for accuracy and technical quality and communicated the reviews to the ICU fellow.
Data was reviewed for consecutive patients a total of ultrasound exams admitted to the SICU over a one-year period where POC ultrasound was performed as part of their management. The admitting diagnosis was made by the attending ICU physician and was established on the basis of history, physical examination, laboratory, and radiological findings.
POC ultrasound was performed to aid in patient diagnosis and management. All evaluations were done almost in real time by the fellows or within minutes of the exam to ensure correct diagnosis and aid in patient management. Review of the reports was done by more than one attending physician to confirm the ultrasound diagnosis, and where there was discrepancy, the reports were not included in the final analysis.
The reviewing physician was not blinded to the patient diagnosis. Outcomes measured were whether POC ultrasound led to finding of at least one new diagnosis not identified without the use of POC ultrasound and whether POC ultrasound resulted in change in management of the patient defined as any change in medications, fluids, new laboratory or radiological tests, or new procedures.
The statistical methodology included retrospective descriptive frequencies and percentages of the various study types that were obtained. The two outcomes of interest new diagnosis and change in management were recorded as yes or no based on if they occurred in at least one of the ultrasound studies completed on each patient.
During a one-year academic period, 3 ICU fellows performed ultrasound studies in consecutive patients, and the data was included for analysis in a retrospective clinical investigation. The ultrasound exams performed for procedural purposes were not included in the analysis.
The most common exams performed were The POC ultrasound examinations resulted in at least 1 new diagnosis in By implementing the Point-of-Care ultrasound curriculum, a new diagnosis is found in POC ultrasound is currently used in the management of many disease processes seen in the critically ill patient and is considered in many instances part of the standard of care for patients management.
Formal curriculum is yet to be standardized for training the ICU fellows. Many societies have announced support and published statements for the use of POC ultrasound [ 29 , 30 ].
The curriculum that we designed was adopted from other successful programs and after careful review of literature and years of experience. Most critical care programs that implement a curriculum use something similar in core teaching and training. Most studies have focused on system based ultrasound exams or certain protocols [ 20 , 23 — 25 ]. Many studies have evaluated the performance of POC ultrasound by nonradiologists in comparison to radiologists.
This is the first study to report the outcomes from implementing a structured POC ultrasound curriculum in an ICU fellowship program. Neri et al.
Their approach was a systematic airway, breathing, circulation, deformity, and exposure ABCDE where all the systems were examined. The curriculum was extensive and required more time and training to achieve the required levels of competencies. It can serve as a more focused approach to the presenting problem, keeping in mind that at any time the operator can choose to perform a full exam as time permits.
Manno et al. Findings showed that ultrasonographic findings modified the admitting diagnosis in Manasia et al. Lim et al. The learning curve for POC ultrasound is steep [ 23 , 24 ]. There are certain exams like the limited echocardiography exam that will require more time to master, but, generally, what we found was that implementing the curriculum with didactics and practice sessions for 30 hours followed by supervision of the trainees for a period of time, to achieve self-sufficient status, was achievable over a period of about 3 months.
Our study showed that implementing a structured POC ultrasound curriculum in the SICU fellowship program led to change in patient management with new diagnosis that would have been missed or delayed without the use of POC ultrasound. Our curriculum was designed on an existing ED model and modifications were done to adapt to our patient population.
Many institutions have also adopted scanning protocols, which can be integrated in the curriculum. The limitations of our study are that it was a single center, single ICU, retrospective data analysis with the possibility of bias being present since the POC ultrasound exam performer and interpreter were aware of the patient status and deciding the management path. Our results were not compared to the gold standard diagnostic modality for different diseases, but we relied on the opinion of expert staff members in POC ultrasound.
The curriculum we developed is not complete, and much more work and revisions will be needed. A structured curriculum needs to be conducted in the near future in a prospective manner with educational and patient outcomes measured.
Those studies will help set the standard of care in POC ultrasound and help ICU physicians to use this modality in the correct and safe manner [ 22 ]. We are offering what we currently practice in our ICU in the hopes that this will stimulate more research and input from experts in the field. Following a structured curriculum with a rigorous QA process and follow-up is of utmost importance to the advancement in POC ultrasound and to our patient's care and safety [ 22 , 31 , 32 ].
The authors declare that there is no conflict of interests regarding the publication of this paper. National Center for Biotechnology Information , U. Crit Care Res Pract.
Published online Nov Author information Article notes Copyright and License information Disclaimer.
Critical Care Ultrasonography
This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Future plans We intend to optimise the set of variables for assessment of the haemodynamic status of the critically ill patient used for guiding diagnostics, prognosis and interventions. Repeated evaluations of these sets of variables are needed for continuous improvement of the diagnostic and prognostic models. Future plans include: 1 more advanced imaging; 2 repeated clinical and haemodynamic measurements; 3 expansion of the registry to other departments or centres; and 4 exploring possibilities of integration of a randomised clinical trial superimposed on the registry.
The basic study is limited to a one-time evaluation of variables.
Critical care ultrasound measurements are not obtainable in all critically ill patients due to positioning issues or insufficient image quality. Introduction Circulatory shock occurs in about one-third of all critically ill patients. Different studies highlight different predictors of mortality: low blood pressures, 8—11 increased lactate levels, 8 9 11—14 prolonged capillary refill times, 15—17 skin mottling, 18—20 oliguria 21 22 and decreased cardiac output 23 24 are identified as prognostic variables.
These contrasting results are also seen in studies that investigated the value of clinical and biochemical variables for diagnosing shock. Several studies selected specific subpopulations eg, patients with sepsis, 8—11 13 17 18 33 acute cardiac failure 16 23 or trauma 15 and some had a retrospective design or used convenience samples from large databases.
These variables have never been evaluated collectively in a large, unselected, prospective cohort of critically ill patients. Therefore, we established the Simple Intensive Care Studies-I SICS-I with the aim to evaluate the diagnostic and prognostic value of a comprehensive selection of clinical and haemodynamic variables in the critically ill. This paper describes the study protocol with the diagnostic and prognostic aims of the basic study as well as the characteristics of the patients included in the cohort so far.
All substudies will be presented here for illustrative purposes without elaborating on each specific rationale and design. Our intensive care unit ICU has 44 beds divided over four subunits to which all types of critically ill adult patients are admitted.
In our department, CCUS is available if considered indicated to inform practice but is not performed in each patient each day. We initiated our study in one unit to deal with start-up issues and to assess feasibility, including 1 whether it was logistically possible to include a broad population of acutely admitted critically ill patients, 2 whether all clinical and haemodynamic measurements could be recorded within a limited time so that it did not obstruct routine patient care and 3 whether novices could obtain CCUS images of sufficient quality after training.
Critical Care Ultrasound Manual
The entire study was purely observational in design; no interventions were applied. After inclusion of our first patient on 27 March , we gradually expanded inclusions to all the four subunits of the department within 1 year.Anaesth Intensive Care. In case of hypovolemia, the heart chambers look underfilled-suggested by a hyperdynamic LV with approximation of the papillary muscles on the PLAX view.
Slonim Although firm evidence is lacking, a systematic, algorithmic approach using ultrasonography could help assess and guide therapy in the hemodynamically unstable patient. A straightforward, practical approach, an abundance of detailed ultrasound images and online video demonstrations provide step-by-step guidance on the principles and effective use of this important imaging modality in both diagnosis and assistance with specific procedures.
So when concerning the circulation the heart glance is the first of the echo examination.
If appropriate, reducing the inspiratory pressures and positive end expiratory pressure PEEP level for a brief period might improve visualization. Ultrasound Evaluation of the Lung Bedside diagnosis of pneumothorax in the ICU can be difficult. If ultrasound is performed incorrectly, the results may be incorrect and be acted upon more quickly.
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