ICU echocardiography: should we use it in a heart beat?

Focused Transthoracic Echocardiography in the Perioperative Period

Ultrasound applications in perioperative medicine have expanded enormously over the past decade. Transoesophageal echocardiography has been performed by anaesthetists during cardiac surgery for over 20 years. With the increasing availability of portable ultrasound systems, the use of ultrasound to assist in vascular cannulation and regional anaesthesia has been well described. Portable ultrasound systems come with a range of probes for different applications, including transthoracic echocardiography. While transthoracic echocardiography has traditionally been the domain of cardiologists, its use has been increasing in critical care, the emergency room and, recently, by anaesthetists in the perioperative period. Unlike formal cardiology-based transthoracic echocardiography, focused, goal-directed transthoracic echocardiography is often more appropriate in the perioperative period to address a particular question and can be performed in just a few minutes. Transthoracic echocardiography allows rapid, noninvasive, point-of-care assessment of ventricular function, valvular integrity, volume status and fluid responsiveness. It can help distinguish undifferentiated systolic murmurs preoperatively, give valuable information on the aetiology of unexplained hypotension and cardiovascular collapse and assess response to therapeutic interventions such as vasoactive drugs and volume resuscitation. Focused transthoracic echocardiography should include qualitative assessment of left and right ventricular function, an estimate of aortic valve gradient, right ventricular systolic pressure and intravascular volume status as minimum requirements. Transthoracic echocardiography is a valuable tool in the perioperative period and ideally the equipment and expertise should be available in all operating rooms.

Echocardiography practice, training and accreditation in the intensive care: document for the World Interactive Network Focused on Critical Ultrasound (WINFOCUS)

Echocardiography is increasingly used in the management of the critically ill patient as a non-invasive diagnostic and monitoring tool. Whilst in few countries specialized national training schemes for intensive care unit (ICU) echocardiography have been developed, specific guidelines for ICU physicians wishing to incorporate echocardiography into their clinical practice are lacking. Further, existing echocardiography accreditation does not reflect the requirements of the ICU practitioner. The WINFOCUS (World Interactive Network Focused On Critical UltraSound) ECHO-ICU Group drew up a document aimed at providing guidance to individual physicians, trainers and the relevant societies of the requirements for the development of skills in echocardiography in the ICU setting. The document is based on recommendations published by the Royal College of Radiologists, British Society of Echocardiography, European Association of Echocardiography and American Society of Echocardiography, together with international input from established practitioners of ICU echocardiography. The recommendations contained in this document are concerned with theoretical basis of ultrasonography, the practical aspects of building an ICU-based echocardiography service as well as the key components of standard adult TTE and TEE studies to be performed on the ICU. Specific issues regarding echocardiography in different ICU clinical scenarios are then described. Obtaining competence in ICU echocardiography may be achieved in different ways - either through completion of an appropriate fellowship/training scheme, or, where not available, via a staged approach designed to train the practitioner to a level at which they can achieve accreditation. Here, peri-resuscitation focused echocardiography represents the entry level--obtainable through established courses followed by mentored practice. Next, a competence-based modular training programme is proposed: theoretical elements delivered through blended-learning and practical elements acquired in parallel through proctored practice. These all linked with existing national/international echocardiography courses. When completed, it is anticipated that the practitioner will have performed the prerequisite number of studies, and achieved the competency to undertake accreditation (leading to Level 2 competence) via a recognized National or European examination and provide the appropriate required evidence of competency (logbook). Thus, even where appropriate fellowships are not available, with support from the relevant echocardiography bodies, training and subsequently accreditation in ICU echocardiography becomes achievable within the existing framework of current critical care and cardiological practice, and is adaptable to each countrie's needs.

The pulmonary artery catheter in Australasia: a survey investigating intensive care physicians' knowledge and perception of future trends in use

A survey was conducted to assess the knowledge and trends of use of the pulmonary artery catheter amongst intensive care practitioners in Australasia. A 31-item multiple choice questionnaire, identical to one previously trialled in studies in the United States and Europe, was distributed to all registered intensive care specialists and trainees working in intensive care units in Australasia. Five-hundred-and-forty-one questionnaires were distributed and 151 (27.9%) were returned, with an average mark of 82.7% +/- 9.3% and a range of 53.3 to 100%. Total score was significantly associated with years of experience in intensive care (P < 0.04), number of pulmonary artery catheters inserted (P < 0.015) and whether or not the respondent had passed the Joint Faculty of Intensive Care Medicine examination (P < 0.01). Scores were significantly higher amongst trainees (P < 0.0001) and physicians who had passed the Joint Faculty of Intensive Care Medicine examination (P < 0.0001). Overall, 44.9% of respondents indicated their use of the pulmonary artery catheter was decreasing, with 42.6% indicating their use was the same over the past five years. Sixty-one percent of respondents indicated they either agreed or strongly agreed with the statement that the use of echocardiography should supersede the use of the pulmonary artery catheter by intensive care specialists in the future. We concluded that in this study, knowledge of the pulmonary artery catheter and its use is better in Australasia than in previous studies in North America and Europe. The majority of respondents in Australasia believe that echocardiography will supersede the use of the pulmonary artery catheter in the future.