Ultrasound Curriculum

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POCUS SCCPDS april 17a ]

Revised 04/17/2017

Point of Care Ultrasound Program

for Surgical Critical Care Fellows

Surgical Critical Care Program Directors Society (SCCPDS)

Ultrasound Committee

Co-Chairs:

Jay Doucet

Paula Ferrada

Members:

Dennis Ashley

Amy Christie

Alison Fecher

Timothy Novosel

 

Background

The use of ultrasound (including general and cardiac) as an extension of the physical examination when treating the critically ill, was born out of necessity; a need for informed decisions regarding real-time anatomic and physiologic information, especially when guiding therapy of a hypotensive patient. The route of education for ultrasound has been different for every specialty, each with barriers and opportunities for enhanced collaboration between disciplines.

There is ample evidence that both general and cardiac critical care ultrasound can be performed and interpreted accurately by intensive care physicians.  Recently, guidelines for the appropriate use of bedside general and cardiac ultrasound for the evaluation of critically ill patients27, as well as international consensus statements regarding the training standards for achieving competency in both general critical care ultrasound (GCCUS) and critical care echocardiography (CCE basic and CCE advanced) have been published.25

The following document is a suggestion for surgical critical care fellowship training programs to standardize training in this emerging bedside technique. These suggestions are for training in CCE, referring to high yield anatomic and physiologic information to guide clinical conduct on a critical care patient.

 

 

 

The suggested curriculum consists of the following components: 

  • At least one surgical critical care faculty member should be skilled in critical care ultrasound to coordinate fellow training in this modality.
  • The faculty responsible for ultrasound training of fellows should at least complete a formal ultrasound course and demonstrate proficiency in the subject of ultrasound as well as in teaching.
  • All training programs should have access to a dedicated ultrasound machine with high quality 2-D imaging and full Doppler capability on a 24-hour basis in the intensive care unit (ICU). The machine should have capabilities for image saving and storing.
  • A course including didactics and hands-on skill stations for performing and interpreting bedside ultrasound.
  • Maintenance of a fellow logbook documenting critical care ultrasound examinations.
  • Twenty five examinations per organ system with proctoring.
  • Supervision and proctoring entails monitoring the real-time image acquisition and interpretation of the test.
  • It is desirable for educational programs to have a system for saving images and clips for quality improvement evaluation of both fellow interpretation and quality of image acquisition.

 

  • Course:
  • We suggest a course that divides critical care ultrasound into GCCUS and CCE-Basic with both didactic lectures and image-based training specific to the designated topic.

 

Suggested objectives of the GCCUS course:

By the end of the course the trainee will be able to

  • Identify normal lung and pleura
  • Identify hemothorax, pneumothorax, and lung consolidation
  • Identify arteries and veins for vessel cannulation and recognition of deep vein thrombosis (DVT)
  • Identify the components screened during the Extended Focused Assessment with Sonography for Trauma (E-FAST)
  • Demonstrate adequate image acquisition for all general systems involved
  • Demonstrate adequate skills for ultrasound-guided intravascular catheter insertion

 

 

Suggested objectives of the CCE-Basic course:

  • Identify normal cardiac anatomy, including each chamber, valves, papillary muscles, etc.
  • Identify and acquire the following cardiac views: parasternal long axis view, parasternal short axis view, apical four chamber view, apical two chamber view, subxiphoid four chamber view, and subxiphoid inferior vena cava (IVC) view
  • Qualitative assessment of left ventricular (LV) size and LV systolic function
  • Qualitative assessment of global right ventricular (RV) size and function
  • Measurement of IVC size and respiratory variation (both in spontaneous breathing and on positive pressure ventilation)
  • Identify cardiac pathologies including, but not limited to, hypovolemic and cardiogenic shock, LV failure, RV failure, cardiac tamponade, pulmonary embolus, severe valvular regurgitation
  • Recognize when a formal study by an echocardiographer may be indicated

For programs that are equipped with transesophageal echocardiography (TEE) capability, suggested objectives of a one-day course on Basic TEE are as follows:

  • Review the clinical indications and scenarios in which placement of a TEE probe may be useful in the hemodynamic monitoring of a mechanically ventilated ICU patient
  • Review safe insertion techniques for TEE probe placement in an intubated patient
  • Identify three limited TEE views for the purpose of hemodynamic monitoring: superior vena cava (SVC) view, midesophageal four chamber view, and transgastric short axis view (papillary muscle level)
  • Qualitative assessment of global LV and RV size and function, as well as identification of fluid responsiveness
  • Be able to obtain quantitative measurements: SVC collapsibility index, LV and RV end-diastolic area (LVEDA and RVEDA), and calculate RVEDA/LVEDA ratio
  • Identify cardiac pathologies including, but not limited to, hypovolemic and cardiogenic shock, LV failure (both global and heterogeneous), RV failure, cardiac tamponade, pulmonary embolus
  • Recognize when a formal TEE study by an echocardiographer may be indicated

In order to attest to the fellow’s capacity to perform bedside critical care ultrasound upon graduation, the following requirements are suggested:

For each area, we suggest obtaining 25 images reviewed by supervising attending (25 for lung, 25 for heart, 25 for abdomen, 25 for vascular)

Limited Bedside Echocardiogram

  • Clip of parasternal long axis view
  • Clip of parasternal short axis view at level of mid-ventricle
  • Clip of apical four chamber view
  • Clip of apical two chamber view
  • Clip of subxiphoid long axis view
  • Clip of IVC during inspiration/sniff

Extended Focused Assessment with Sonography for Trauma

  • Clip of bilateral sliding lungs
  • Clip of hepatorenal interface showing the costophrenic angle and liver tip
  • Clip of subxiphoid long axis view
  • Clip of splenorenal interface showing subphrenic space and costophrenic angle
  • Clip of pelvic rectovesical interface

Limited Bedside Venous Ultrasound

  • Clip of compression of proximal femoral vein
  • Clip of compression of superficial femoral vein
  • Clip of compression of popliteal vein

Limited Bedside Thoracic Ultrasound

  • Clip of bilateral sliding lungs
  • Clip of bilateral upper and lower lung looking for B-lines (4 separate clips)
  • Clip of bilateral costophrenic angles

Procedural Ultrasound

  • Clip of needle in vein (peripheral or central) OR
  • Clip of main portion of whatever bedside procedure being performed (thoracentesis, thoracostomy tube placement, etc.)

Limited Transesophageal Echocardiography (for programs with TEE capability)

  • Clip of SVC view
  • Clip of midesophageal four chamber view
  • Clip of transgastric short axis view (papillary muscle level)

 

Particularly for bedside echocardiography, we suggest 3 levels of proficiency

Level 1 requirements:

  • Perform the basic echocardiographic examinations safely and accurately, acquiring all standard views. The ideal windows are parasternal long axis (PLAX) view, parasternal short axis (PSAX) view, apical four chamber (A4CH) view, subxiphoid long axis (SLAX) view, and subxiphoid IVC (SIVC) view.
  • Recognize and differentiate between normal and abnormal cardiac anatomy and physiology (presence of a pericardial effusion, global decrease of LV or RV function, severe hypovolemia )
  • Recognize when a second opinion is indicated
  • Describe the relationship between echocardiographic images and other diagnostic techniques
  • 25 proctored transthoracic echocardiography (TTE) examinations

 

Level 2 requirements:

  • Perform the echocardiographic examinations safely and accurately and acquire all standard views
  • Recognize and correctly diagnose life-threatening conditions within the cardiovascular system (severe hypovolemia, cardiac failure, pulmonary emboli, cardiac tamponade, severe valvular regurgitation)
  • Understand and perform M-mode and color flow Doppler
  • 25 proctored TTE examinations, and additional 10 TTE proctored examinations with pathology, as well as demonstrating competency in performing M-mode and color Doppler, 50 TTE logged examinations, and one-day CCE course
  • *For programs with TEE capability, 25 proctored TEE examinations, 10 of these proctored TEE examinations with pathology, a total of 50 TEE logged examinations

 

Level 3 requirements: (Advanced Critical Care Echocardiography)

  • Perform accurately and safely all the TTE windows
  • Understand and perform M-mode, color flow Doppler, tissue Doppler, can obtain LV stroke volume (LVSV) assessment using direct measurement of LV outflow tract area [LVOT(A)], and can obtain diastolic function measurements. Can assess RV size comparing RVEDA/LVEDA ratio, measure RV systolic pressure (RVSP) utilizing continuous wave Doppler, and evaluate for tricuspid annular plane systolic excursion (TAPSE)
  • Must also obtain competence in basic TEE
  • Teach echocardiography at all levels
  • Know and follow the evolution of echocardiography
  • List of suggested number of examinations:
    • 25 proctored TTE examinations in normal
    • 25 proctored TTE examinations with pathology
    • 10 TTE examinations demonstrating proficiency in above measurements
    • 150 TTE total logged examinations
    • 50 proctored TEE examinations
    • 100 logged TEE examinations

 

 Suggested Articles

(1)       Kendall JL, Hoffenberg SR, Smith RS. History of emergency and critical care ultrasound: the evolution of a new imaging paradigm. Crit Care Med 2007; 35(5 Suppl):S126-S130.

(2)       Pershad J, Myers S, Plouman C, Rosson C, Elam K, Wan J et al. Bedside limited echocardiography by the emergency physician is accurate during evaluation of the critically ill patient. Pediatrics 2004; 114(6):e667-e671.

(3)       Sloth E, Larsen KM, Schmidt MB, Jensen MB. Focused application of ultrasound in critical care medicine. Crit Care Med 2008; 36(2):653-654.

(4)       Sloth E. Echocardiography in the ICU. Intensive Care Med 2006; 32(8):1283.

(5)       Ferrada P, Anand RJ, Whelan J, Aboutanos MA, Duane T, Malhotra A et al. Limited transthoracic echocardiogram: so easy any trauma attending can do it. J Trauma 2011; 71(5):1327-1331.

(6)       Mateer J, Plummer D, Heller M, Olson D, Jehle D, Overton D et al. Model curriculum for physician training in emergency ultrasonography. Ann Emerg Med 1994; 23(1):95-102.

(7)       Manasia AR, Nagaraj HM, Kodali RB, Croft LB, Oropello JM, Kohli-Seth R et al. Feasibility and potential clinical utility of goal-directed transthoracic echocardiography performed by noncardiologist intensivists using a small hand-carried device (SonoHeart) in critically ill patients. J Cardiothorac Vasc Anesth 2005; 19(2):155-159.

(8)       Gunst M, Sperry J, Ghaemmaghami V, O’Keeffe T, Friese R, Frankel H. Bedside echocardiographic assessment for trauma/critical care: the BEAT exam. J Am Coll Surg 2008; 207(3):e1-e3.

(9)       Fedson S, Neithardt G, Thomas P, Lickerman A, Radzienda M, DeCara JM et al. Unsuspected clinically important findings detected with a small portable ultrasound device in patients admitted to a general medicine service. J Am Soc Echocardiogr 2003; 16(9):901-905.

(10)     Yim ES, Gillis EF, Ojala K, MacDonald J, Basilico FC, Corrado GD. Focused transthoracic echocardiography by sports medicine physicians: measurements relevant to hypertrophic cardiomyopathy. J Ultrasound Med 2013; 32(2):333-338.

(11)     Vignon P, Dugard A, Abraham J, Belcour D, Gondran G, Pepino F et al. Focused training for goal-oriented hand-held echocardiography performed by noncardiologist residents in the intensive care unit. Intensive Care Med 2007; 33(10):1795-1799.

(12)     Ho AM, Critchley LA, Leung JY, Kan PK, Au SS, Ng SK et al. Introducing Final-Year Medical Students to Pocket-Sized Ultrasound Imaging: Teaching Transthoracic Echocardiography on a 2-Week Anesthesia Rotation. Teach Learn Med 2015; 27(3):307-313.

(13)     Frederiksen CA, Juhl-Olsen P, Andersen NH, Sloth E. Assessment of cardiac pathology by point-of-care ultrasonography performed by a novice examiner is comparable to the gold standard. Scand J Trauma Resusc Emerg Med 2013; 21:87.

(14)     Via G, Hussain A, Wells M, Reardon R, ElBarbary M, Noble VE et al. International evidence-based recommendations for focused cardiac ultrasound. J Am Soc Echocardiogr 2014; 27(7):683.

(15)     Ferrada P, Wolfe L, Anand RJ, Whelan J, Vanguri P, Malhotra A et al. Use of limited transthoracic echocardiography in patients with traumatic cardiac arrest decreases the rate of nontherapeutic thoracotomy and hospital costs. J Ultrasound Med 2014; 33(10):1829-1832.

(16)     Ferrada P, Evans D, Wolfe L, Anand RJ, Vanguri P, Mayglothling J et al. Findings of a randomized controlled trial using limited transthoracic echocardiogram (LTTE) as a hemodynamic monitoring tool in the trauma bay. J Trauma Acute Care Surg 2014; 76(1):31-37.

(17)     Ferrada P, Vanguri P, Anand RJ, Whelan J, Duane T, Aboutanos M et al. A, B, C, D, echo: limited transthoracic echocardiogram is a useful tool to guide therapy for hypotension in the trauma bay–a pilot study. J Trauma Acute Care Surg 2013; 74(1):220-223.

(18)     Ferrada P, Vanguri P, Anand RJ, Whelan J, Duane T, Wolfe L et al. Flat inferior vena cava: indicator of poor prognosis in trauma and acute care surgery patients. Am Surg 2012; 78(12):1396-1398.

(19)     Ferrada P, Anand RJ, Whelan J, Aboutanos MA, Duane T, Malhotra A et al. Qualitative assessment of the inferior vena cava: useful tool for the evaluation of fluid status in critically ill patients. Am Surg 2012; 78(4):468-470.

(20)     Pearlman AS, Gardin JM, Martin RP, Parisi AF, Popp RL, Quinones MA et al. Guidelines for optimal physician training in echocardiography. Recommendations of the American Society of Echocardiography Committee for Physician Training in Echocardiography. Am J Cardiol 1987; 60(1):158-163.

(21)     Cahalan MK, Abel M, Goldman M, Pearlman A, Sears-Rogan P, Russell I et al. American Society of Echocardiography and Society of Cardiovascular Anesthesiologists task force guidelines for training in perioperative echocardiography. Anesth Analg 2002; 94(6):1384-1388.

(22)     Ryan T, Armstrong WF, Khandheria BK. Task force 4: training in echocardiography endorsed by the American Society of Echocardiography. J Am Coll Cardiol 2008; 51(3):361-367.

(23)     Neri L, Storti E, Lichtenstein D. Toward an ultrasound curriculum for critical care medicine. Crit Care Med 2007; 35(5 Suppl):S290-S304.

(24)     Mayo PH, Beaulieu Y, Doelken P, Feller-Kopman D, Harrod C, Kaplan A et al. American College of Chest Physicians/La Societe de Reanimation de Langue Francaise statement on competence in critical care ultrasonography. Chest 2009; 135(4):1050-1060.

(25)     International expert statement on training standards for critical care ultrasonography. Intensive Care Med 2011; 37(7):1077-1083.

(26)     Soucy ZP, Mills LD. American Academy of Emergency Medicine Position Statement: Ultrasound Should Be Integrated into Undergraduate Medical Education Curriculum J Emerg Med 2015; 49(1): 89-90.

(27)    Frankel HL, Kirkpatrick AW, Elbarbary M, Blaivas M, Desai H et al. Guidelines for the Appropriate Use of Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients-Part1: General Ultrasonography. Critical Care Medicine 2015; 43(11): 2479-2502.