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428
Table 27.3 (continued)
CCUS
applications Knowledge Skills
Pleural
ultrasound
Pulmonary
ultrasound
Focused
abdominal
ultrasound
Vascular
ultrasound
Procedural
ultrasound
CCUS critical care ultrasound (includes focused cardiac ultrasound), ACLS advanced cardiac life
support, TTE transthoracic echocardiography, TEE transesophageal echocardiography, IVC inferior vena cava, DVT deep venous thrombosis
a
Both TTE and TEE windows and views as required by specic needs of a provider
b
TEE is required only for providers with specic needs in their patients
Understand ultrasound manifestations
of pneumothorax and understanding
of the limitation in diagnosis of
pneumothorax
Understand ultrasound
characterization of pleural effusion
and limitations of ultrasound
evaluation
Understand ultrasound manifestations
of lung consolidation
Understand ultrasound manifestations
of extravascular lung water
Understand ultrasound
characterization of intraabdominal
uid and limitations of ultrasound
evaluation
Understand ultrasound manifestations
of large DVT in femoral veins
Principles of needle/wire guidance
with ultrasound for bedside
procedures, including vascular access,
thoracentesis, paracentesis, etc.
Ability to rule out and to rule in
pneumothorax
Ability to assess pleural effusion
characteristics: Size, location, degree
of loculation
Ability to assess consolidated lung
Ability to assess alveolar/ interstitial
syndrome
Ability to assess intraabdominal uid
characteristics: Size, location,
volume, presence of debris septae
Ability to recognize large DVT in
femoral veins
Ability to guide bedside procedures
with ultrasound (e.g., vascular access,
thoracentesis, paracentesis)
A. Pustavoitau and E. Su
future applications, because as mentioned in recommendations by the SCCM
[9] the critical care community does not universally use them.
Table 27.4 describes knowledge and skills required for successful execution of
ACCE.
There are naturally other additional potential future applications, as some are
performed at select centers depending on their practitioners’ skillsets and needs.
Skills Acquisition
While there is no number of ultrasound examinations that denitively ensure competence, currently available guidance documents in critical care provide some
numeric targets. The targets are based either on expert consensus opinion [6, 7] or
on standards in emergency medicine [10] and anesthesiology [11]. In fact, documents from these specialties require the same number of performed echocardiographic examinations: 30 examinations for basic cardiac ultrasound and 200 for
ACCE.A difference between the statements is that the SCCM recommendations
require examinations to be interpreted in addition to ones personally performed:
27 Critical Care Medicine
Table 27.4 Knowledge and skills required for successful execution ACCE
Knowledge Skills
Comprehensive TTE and/ or TEE views Ability to perform comprehensive TTE/
Qualitative and quantitative echocardiography Ability to quantify ows and pressures
Heart-lung interactions in spontaneously
breathing and mechanically ventilated patients
Diseases of the heart relevant to care of critically
ill or injured patients (e.g., dynamic left
ventricular outow tract obstruction, systolic
anterior motion of the mitral valve)
Normal and abnormal left ventricular systolic
function, including segmental wall motion
abnormalities
Normal and abnormal left ventricular diastolic
function
Normal and abnormal right ventricular function Ability to quantify right ventricular systolic
Commonly encountered complications of acute
coronary syndrome
Valve dysfunction and its hemodynamic
consequences
Tamponade physiology Ability to evaluate hemodynamic
Comprehensive evaluation of uid responsiveness Ability to assess uid responsiveness in
Anatomy, physiology, and implications of
intracardiac and intrapulmonary shunts
Echocardiographic manifestations of intracardiac
masses and thrombi
Detailed knowledge of other diagnostic modalities
relevant in hemodynamic management of
critically ill or injured patients
ACCE advanced critical care echocardiography
TEE exam
across various cardiac chambers
Ability to acquire comprehensive
hemodynamic data
Ability to quantify systolic left ventricular
function
Ability to quantify diastolic left ventricular
function
function
Ability to recognize subtle left ventricular
wall motion abnormalities, and evaluate
complications of acute coronary syndrome
Ability to quantify normal and abnormal
native and prosthetic valvular function
consequences of pericardial effusion and
tamponade
spontaneously breathing and mechanically
ventilated patients using validated dynamic
indices of preload
Ability to assess for the presence of
intracardiac and intrapulmonary shunts
Ability to assess for intracardiac masses
and thrombi
Ability to recognize limitations of ACCE
and identify additional diagnostic
modalities necessary for the management
of a critically ill patient
429
total of 50 for basic cardiac ultrasound and total of 400 for ACCE (these numbers
including examinations personally performed). The SCCM recommendations also
specify targets for diagnostic noncardiac CCUS:
– Twenty examinations performed for pleural and pulmonary ultrasound, with
total of 30 examinations interpreted.
– Twenty examinations performed for limited abdominal ultrasound, with total of
30 examinations interpreted.
– Twenty examinations performed for vascular ultrasound, with total of 30 exami-
nations interpreted.
430
In regard to procedural ultrasound, vascular access guidance (central venous
access in particular) is the most fundamental needle guidance skill; achieving competence requires at least 10 personally performed ultrasound-guided procedures.
Once vascular access guidance skills are acquired, any additional needle guidance
procedure (thoracentesis, paracentesis, pericardiocentesis, and others) requires ve
additional ultrasound-guided performances.
A. Pustavoitau and E. Su
Certication
The general consensus in critical care medicine community is that CCUS does not
require certication to establish competence in its applications. ACCE, on the other
hand, is a more complex application and requires certication [6, 7, 9]. Certication
involves an external agency validating competence through a set of requirements. This
commonly involves an examination. Currently, there is no established certication
process in ACCE, and the SCCM recommends achieving certication status in the
National Board of Echocardiography’s examination of special competence in adult
echocardiography (ASCeXAM) or perioperative transesophageal echocardiography
(advanced or basic PTEeXAM), until an ACCE-specic process is developed.
Credentialing andMaintenance
Credentialing is the process of qualifying providers as competent for performance
of certain skills within the scope of practice of medical staff in a given health system. The process of credentialing requires an institutional commitment to document
the ultrasound activities of practitioners and structure their clinical conduct with
regard to the technology. Credentialing standards will naturally differ by institution,
and can range from informal agreements between institutional departments to
requirements for practical and didactic education, certication, as well as requirements for ongoing education. See Chapter 20–Credentialing and Privileging.
A baseline of mandatory didactic and practical education, followed by proctored
scanning has been pioneered by specialties such as emergency medicine and is mentioned above. Such a regimen is easily translated to the ICU arena in institutions
where emergency medicine providers already have an established program in pointof- care ultrasound. However in other hospital systems where clinical imaging is
predominated by other specialties which may use and teach ultrasound primarily
practically in clinical settings, such as urology, the landscape may differ. In settings
where credentialing requirements are less structured, a greater level of specialty
collaboration is necessary for prompt study verication. Ultimately a mutually
accepted agreement on credentialing standards (with or without concrete requirements) is useful and necessary for determining when clinicians are ready to perform
ultrasound in CCM practice environments.
27 Critical Care Medicine
Maintenance of skills is also relevant for ongoing practice in terms of skill
upkeep and reception of new developments in the eld. Little is published on what
degree of ongoing training is necessary among ICU providers, though some have
proposed recommendations such as World Interactive Network Focused on Critical
Ultrasound. The WINFOCUS echocardiography recommendation statement [5]
advises that advanced echocardiography providers perform at least 50 studies per
year. We recommend 100 ultrasound examinations per year, 50 of which are CCUS
examinations and 50 ACCE examinations (including 20 TEE examinations of ongoing competence in TEE is desired) for maintenance of certication, in line with
SCCM recommendations [9]. We also recommend ongoing education in ultrasound,
which includes at least 10h of CME credits annually or their equivalents, or other
ultrasound-related activities in CCUS and ACCE [9]. As standards at this time
remain elusive, it is likely that they will continue to evolve to meet demands. If
certication becomes a part of CCUS credentialing, existing certication for the
ASCeXAM and PTEeXAM occur on a 10-year cycle requiring periodic follow-up.
431
Program Infrastructure
Program Director
Ultimately a director of a CCUS program serves as advocate for a program and
implementation of ultrasound in the ICU.Though little has been published on this
topic, the director ultimately supervises primary program objectives. He is responsible for interacting with other specialties using ultrasound, overseeing quality
assurance, and introduces novel technology to the critical care environment. The
following are areas where a director and other members of an ultrasound program
may invest time, though this is not an exclusive list (Chap. 2).
Management ofEquipment andPractical Material Needs
A director is a key stakeholder in management of an effective ultrasound eet. This
involves both ongoing maintenance and new procurement. Since the success of a
program depends on utility of the technology, a director of an ultrasound program
should be assured the equipment is performing adequately at least every week by a
personal visit or subsidiary, and verify whether consumables important for machine
operation, such as gel and appropriate cleaning materials, are adequate. This is
important, particularly if a machine needs to be taken out of service for an easily
missed, potential patient hazard such as a cracked transducer housing or battery
failure. A director also should be centrally involved in new ultrasound equipment
purchases for the ICU as this person will bring to the table an intimate knowledge
of ultrasound use and ongoing needs important for machine selection. In this sense
a director should also advocate for responsible billing of ultrasound services.
432
A. Pustavoitau and E. Su
Supervision ofUltrasound Use Including Image Archiving
Image archiving is also important in program administration from the standpoint of
appropriate documentation, education, and quality assurance. A director can directly
or indirectly supervise the archiving of images from ultrasound devices. Management
of the archive gives the director a comprehensive perspective of departmental ultrasound use and needs. In addition image review can highlight areas of individual or
group education, as well as areas to improve ultrasound use that could be rectied
with protocols for machine use or new equipment. A well-managed archive facilitates credentialing of staff and trainees for their future program, and justies ongoing use to administration.
Coordination ofQuality Assurance Activities
The Program Director is accountable for the overall conduct of ultrasound activities
in the ICU and therefore has a vested interest in coordinating quality assurance
activities. These activities are detailed in section “Quality Assurance” below.
Structuring ofUltrasound Education intheICU
A director does not need to be the unit expert on ultrasound however should be
familiar with all equipment and technological processes involved in the typical ICU
ultrasound workow as the director will often be called upon to remedy problems.
Organized education facilitates a common knowledge base and dialogue within the
department on ultrasound, and helps maintain a minimum standard for ultrasound
services (Chaps. 5 and 6).
Representation ofProgram toOther Institutional Structures Both
Administrative andClinical
This includes interaction with other imaging specialties that are both primarily
decision- makers at the bedside (Emergency Medicine, Inpatient Medicine) and
diagnostic (Diagnostic Radiology, Neurophysiology). As an advocate for the program, it is essential that the director speaks on behalf of the program to extradepartmental entities when interdepartment discussions are necessary for advice,
collaboration, or issue resolution. In addition the director works with department
entities on accounting for program activities and requests for departmental support.
This is essential in dening the role the program plays within the medical center.
Research Protocol Implementation
The director or designates may also play a role in assurance of clinically responsible
research in line with institutional ethical protocols, and also does not endanger
patients, the program, or its equipment. In this role the director may coordinate use
27 Critical Care Medicine
433
of machines in research balancing existing knowledge on research topics, safe utilization, and support of ICU staff pursuing scientic questions.
Equipment
The capabilities of ultrasound machines assigned to an ICU depend on available
support, needs of the ICU, and practitioner ability to utilize resources well. We summarized recommendations on ultrasound equipment for ICU in Table 27.5. See
Chapter 12–Ultrasound Equipment and Purchase.
A machine should facilitate documentation of ultrasound activities with image
recording and patient identiers. It should also be portable and maneuverable at the
ICU bedside even in congested situations. A battery is not always included in some
higher end machines, but this is useful for moving the machines in cramped or rapidly
changing quarters. Since a machine may see every room in the ICU regularly, easy
device sanitization is also required. A rapid startup time is also an asset in the ICU.
Table 27.5 Suggested machine capabilities based on basic and advanced applications
Categories Basic equipment Advanced equipment
General machine
attributes
Cardiac ultrasound 1. Low-frequency phased array
Airway, pulmonary,
and vascular or
drainage procedural
ultrasound
1. General clinical use US machine
capable of 2D imaging
2. Ability to store patient specic
imaging with identiers
3. Standard output le formats for
ofine visualization
4. Battery that lasts ≥30min
5. Maneuverability at ICU bedside
6. Sanitizable for infectious exposures
7. Rapid startup time<2min
probe
2. Color ow and pulsed- wave
Doppler
3. M-mode 3. Pedoff Doppler probe
1. Linear array transducer with
~8–11MHz center frequency,
~3–5cm face length
2. Color ow and pulsed- wave
Doppler (procedural)
1. Advanced US machine
capable of diagnostic imaging
accuracy (devices marketed
for diagnostic imaging
specialties)
2. Wireless image transmission
3. DICOM format output
1. Additional smaller phased
array probes
2. Transesophageal
echocardiography probe
4. Continuous wave Doppler
5. Echocardiography postprocessing software
6. EKG leads
1. High frequency linear array
probe with >12MHz center
frequency, “hockey stick” or
standard linear array
2. Microconvex array probe
3. Power Doppler (procedural)
(continued)
434
Table 27.5 (continued)
Categories Basic equipment Advanced equipment
Abdominal
ultrasound
Neurological
ultrasound
Regional anesthesia 1. Linear array transducer with
Details of what each core application entails are included in section “Ultrasound Knowledge”
Both focused cardiac ultrasound and advanced critical care echocardiography may include use of
transesophageal echocardiography in addition to transthoracic echocardiography
1. Curvilinear transducer with low
center frequency
1. Low-frequency phased array
probe
2. Linear array transducer with face
length<4cm for eye
3. Ability to adjust US transmission
power
~8–11MHz center frequency,
~3–5cm face length
A. Pustavoitau and E. Su
1. Microconvex array probe
2. Power Doppler
1. Transcranial Doppler
apparatus
2. Microconvex array probe
1. High frequency linear array
probe with >12MHz center
frequency, “hockey stick” or
standard linear array
2. Linear array transducer with
face length>4cm
3. Microconvex array probe
Advanced machine capabilities include advanced quantitative metrics useful for
documentation and research. Wireless image transmission and DICOM format output also facilitate transfer of information to data storage systems and simplify ultrasound workow.
With regard to cardiac imaging, a low-frequency phased array transducer is
essential for echocardiography and most devices leverage rapid framerate 2D and
Doppler-based imaging at the expense of image resolution to optimize images
through the cardiac cycle. As practitioners expand their ultrasound acumen,
advanced echocardiographic measures may require specialized equipment such as
an array of smaller echocardiographic probes for difcult imaging. Additional
applications require special probes such as transesophageal or Pedoff probes.
Accurate characterization of systole and diastole for echocardiographic analysis
benets from ECG tracing. Finally, advanced post-processing may be helpful for
quantitative assessment for clinical and research purposes.
Airway, pulmonary, and procedural ultrasound may seem disparate applications
but benet from similar probes. Visualization of the pleural line, trachea, as well as
procedural applications both benet from accurate near-eld visualization of surface
structures less than a centimeter below the surface. A linear array probe is well suited
for these purposes. Advanced applications in these arenas also require similar probes.
A high frequency linear array enhances near-eld visualization further, and in particular a “hockey-stick” style transducer can be used for submental or light pressure
assessments of the airway in addition to difcult peripheral access. A microconvex
array can be used to visualize near-eld structures in a fan-like sector if imaging
windows are limited. This may be helpful in small or contracted patients for both
27 Critical Care Medicine
435
pulmonary and vascular applications. Doppler functions are useful for procedural
applications for identifying vessels to puncture in the case of vascular access, and to
avoid in the case of paracentesis and pericardiocentesis. Color Doppler functions
may also be useful in pleural ultrasound for characterization of pleural effusion.
Though abdominal imaging can be performed using a phased array transducer,
a low center frequency curvilinear array is a mainstay of abdominal imaging due to
its large face and low-frequency imaging which optimizes deep structure resolution at the expense of framerate. At times the size of a large curvilinear may preclude imaging of a small patient. In these cases a smaller curvilinear probe or a
microconvex array are useful. Power Doppler is also useful in this population for
imaging perfusion of organ vessel beds where vascular ow occurs in multiple
directions relative to the probe simultaneously and direction effects are minimized
by the modality.
Regional anesthesia is similar to procedural ultrasound with regard to requiring
good near-eld imaging with a linear or microconvex array. However given that the
majority of these procedures are performed with long-axis needle visualization,
transducer face length is an important consideration as inappropriate transducer sizing can limit needle excursion for the procedure. Therefore a variety of long and
short, low and high frequency linear probes are useful. In addition curvilinear
probes are useful for long-axis insertion in areas limited by imaging window size.
These recommendations also do not speak to the number of devices a unit may
require. Indeed, this is primarily based on utilization and is not predictable based on
strict unit characteristics. As such, procurement of an ultrasound eet is usually
piecemeal based upon demand from clinical services and caregivers. One important
consideration is whether a machine’s use should be distributed geographically
across multiple units. This introduces additional issues in machine availability and
is likely not helpful for an ICU environment.
Equipment management should incorporate regular assessment of ultrasound
devices by the director or designates. These assessments should verify safety and
readiness of the equipment for use with patients including clearing infectious and
electrical hazards.
Data Management
Components for ultrasound documentation recommended by the American Institute
of Ultrasound in Medicine include:
1. Patient’s name and other identifying information (usually date of birth and medi-
cal record number)
2. Facility information
3. Date of examination
4. Image orientation when appropriate
5. In addition, worksheet-based formats may also include exam type, clinically rele-
vant information, examination requested, name of clinical provider if applicable
436
As such, responsible image recording may be limited by workow complexity at
the bedside and a concerted effort is required unit-wide to ensure responsible image
accounting. Measures to improve accounting may include mandatory report states
within the machine requiring operator login, barcode readers, and reminders to clinical staff to appropriately document studies. Importantly imaging studies for procedures require an image visualizing needle placement within the target of interest.
Imaging data should be treated as protected health information and stored within
protected institutional data systems. In particular name-identiable patient images
are easily disseminated and have at times made their way to medical textbooks, so
practitioners should be extremely cautious about transferring les. If possible, corruption resistant storage systems with data duplication (such as mirrored servers or
Redundant Array of Independent Disks [RAID] storage systems) are advisable.
Ultimately, because the data includes protected health information it should be optimally maintained on a hospital-based protected system.
An appropriate indexing system includes patient identiers, study type and indication, and should also incorporate operator identiers for the purpose of training,
quality assurance, and credentialing. A number of solutions for this range between
directory-based cataloging of images, media management software allowing multiple attributes to be attached to images for further analysis, and radiology le management software that usually provides a comprehensive solution including mass
le transfer from devices (Chaps. 17 and 18).
A. Pustavoitau and E. Su
Quality Assurance
Periodic review of program activities and images is fundamental to ensuring good
care delivery with ultrasound. A process of quality assurance review should be supervised by the program director but may take form in multiple ways. Involved parties
should naturally involve ultrasound operators and other skilled providers. These providers may include individuals from within the critical care division as well as imaging experts from other disciplines such as radiology, cardiology, and vascular
imaging, among others. Targets for review should include second read verication of
ultrasound interpretation by novices, periodic review of selected images from credentialed providers, and interesting cases for which a second read is useful.
Meetings should be conducted with regularity dependent on volume of studies to
review and personnel availability. Review can be performed in large group meetings
with other imaging specialists, or in smaller settings on a one-to-one basis as long
as a documentable process for reviewed studies is in place (Chap. 16).
Conclusion
Establishing an ultrasound program in the critical care setting should facilitate provision of ultrasound services in the unique environment of the ICU.Such a process
is similar to other examples in the emergency medicine and inpatient medicine
27 Critical Care Medicine
437
settings, with particular attention towards advanced cardiac and pulmonary imaging. With ongoing ultrasound development, more nuances pertaining to ultrasound
use in the ICU will likely develop. Thoughtful construction of a program will allow
for adaptation of new modalities and further evolution of ultrasound within critical
care medicine.
Pitfalls
1. Failure to establish proper infrastructure can signicantly limit ICU ultrasound
program development and growth.
2. Lack of proper data management can lead to improper storage of sensitive infor-
mation and inability to perform quality assurance reviews.
3. An inadequate number of ultrasound machines, especially if shared across mul-
tiple locations or units can lead to lack of availability when need is critical.
4. Not paying attention to intradepartmental and facility needs which could be
addressed by or raised by ultrasound may limit program support and growth.
5. Not tracking programs directors time and resource utilization may make it harder
to prove the need for support to administration.
Key Recommendations
1. Quality assurance and improvement should be planned for and set up whenever
an ultrasound program in an ICU is being considered.
2. Plan for ultrasound utilization and the number of machines required to limit
unavailability.
3. Work with administration to maintain program support and funding.
4. Pay attention to the needs of the department, program and hospital to expand
upon programs utility and support.
References
1. American Medical Association. Privileging for Ultrasound Imaging.;H-230.960 (Res. 802,
I-99; Reafrmed: Sub. Res. 108, A-00; Reafrmed: CMS Rep. 6, A-10).
2. Critical Care Medicine. Critical Care Medicine: echocardiography in intensive care medicine.
Crit Care Med. 2007;35(8)(Suppl):S123–S307.
3. Critical Care Medicine. Critical Care Medicine: focused applications of ultrasound in critical
care medicine. Crit Care Med. 2007;35(5)(Suppl):309–433.
4. Mayo PH, Beaulieu Y, Doelken P, etal. American College of Chest Physicians/la Societe de
reanimation de langue Francaise statement on competence in critical care ultrasonography.
Chest. 2009;135(4):1050–60. doi:10.1378/chest.08-2305.
5. Price S, Via G, Sloth E, et al. Echocardiography practice, training and accreditation in the
intensive care: document for the World Interactive Network Focused on Critical Ultrasound
(WINFOCUS). Cardiovasc Ultrasound. 2008;6:49. doi:10.1186/1476–7120–6-49.