Specific skill set and goals of focused echocardiography for critical care clinicians

Crit Care Med 2007; 35[Suppl.]:S144–S149

Yanick Beaulieu, MD, FRCPCPresented by R1 江銘彥Supervised by VS 沈修年

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Introduction Echocardiography:

A powerful and noninvasive diagnostic technique,anatomy, EF, valvular function, volume status

Factors limiting the widespread use: Echocardiography Competency Guidelines

“Goal-directed” or “focused” echocardiography:Acceptable overall level of accuracy

Echocardiography CompetencyGuidelines Currently Established America (ASE):

Level I (3-mo, 75 perform, 150 interpret): independent performance or interpretation of an echocardiographic study using HCU Level II (6-mo, 150 perform, 300 interpret): perform&interpret echocardiogram independently

Canada, French Australia, New Zealand

>300 performance, >600 interpretation

Perioperative Echocardiography:

Perioperative TEE: an essential tool for the optimal perioperative management of many types of surgical p’ts

Official perioperative-TEE program for anesthesiologists

Echocardiographic programs in intensive care environment and intensivists

A Model for the Development of Critical Care Echocardiography

A Need for Critical Care-Oriented Echocardiography Programs

A 2-yr academic program for intensivists and anesthesiologists for the assessment of severely ill patients

Perioperative-TEE training program and certification for intensivists

Transthoracic approach of echocardiographynoninvasive, portability, widespread availability, rapid diagnostic capability

Goal-Directed or Focused Echocardio-graphic Examination for the Intensivist

Complete echocardiographic examination “ Goal-Directed” or “Focused”

Echocardiography:Extension of PE

Limited-scope, goal-directed TTE:Assessment of LV and RV function, pericardial effusion and tamponade, and volume status

Studies:

Manasia et al. The potential clinical utility of goal-directed TTE

performed by noncardiologists intensivists Ten 1-hr-session tutorials by experienced cardiologist echocardiographers Performed successfully in 94% of patients Correct interpretation in 84% of patients

Melemaed et al. Ability of intensivists with limited echocardiography training to evaluate LV function with a portable echo machine 2 hrs of didactic and 4 hrs of hands-on training Bedside echo to detect LV dysfunction Sensitivity: 77% Specificity: 94% Positive predictive value: 94%

Croft et al. Residents’ HCU to define LV function, wall thickness, valvular disease, pericardial effusion Five 3-hr sessions of case review and five 1-hr sessions of supervised hands-on tutorial Obtained diagnostic images in 94% of cases Interpreted them correctly 93% of the time Management decisions were reinforced in 76%, changed in 40% of patients

DeCara et al. Internal-medicine residents 20 hrs of didactic instruction and performance of 20 goal-directed TTE Point-of-care echo scans Sensitivity: 63% Specificity: 92% 80% sensitivity for clinically important findings likely to affect patient care

Goal-Directed or Focused Echocardio-graphic Examination for the Intensivist

Echocardiography: highly operator-dependent Different levels of training according to the

degree of competency Entry-level training:

the initial step should be part of the critical care fellowship aimed at “focused” echocardiographic exam

More advanced level of training: more complete echocardiographic examination

Proposed Curriculum for Critical Care Echocardiography Training:

Focused Critical care Ultrasound Study Level I:12 hrs of didactic and practical

sessionsUltrasound basics and instrumentation Anatomy, views, and orientation LV function RV function Pericardial space and tamponade Volume status

The FOCUS Program

Proposed Curriculum for Critical Care Echocardiography Training:

General principles Reporting Documentation of Training Demonstration and Maintenance of Competence

The FOCUS Program

Conclusion Development of training program and

guideline Viewed as an extension to PE Limitations according to their level of training A reliable and valid assessment methodology Basic training:

should be part of the intensivist’s curriculum