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Point-of-Care Ultrasonography in the Intensive Care Unit

Alain Broccard, MD
Professor of Medicine
Division of Pulmonary, Allergy, Critical Care and Sleep Medicine
University of Minnesota and Fairview South Dale Hospital
Minneapolis, MN

Introduction

The physical exam and the traditional imaging pathways have limitations in the ICU that point-of-care ultrasonography (PCUS) helps address. In the traditional imaging model, the clinician sends a request for a bedside ultrasound or echocardiogram when specific information cannot be obtained otherwise (e.g., by physical exam). The study is subsequently done (typically by a technician in the USA) and the images are forwarded to a physician for interpretation. The latter often has a limited knowledge of the patient’s condition. The clinical questions that lead to the study are not always clearly communicated to the interpreting physician. The images are, nevertheless, interpreted. A report is generated and sent back to the clinicians. When the results of the study do not fully address the clinical question that motivated the test, the bedside physician needs to discuss with the interpreting radiologist or the cardiologist, which can be challenging when studies are read offsite, a practice becoming more common.  

Although this time-consuming and inefficient process can be shortened, there may be significant advantages in having ultrasounds performed and read by the bedside physician who best know the patient's condition, knows what specific information is needed to care for the patient and will act based on the study findings. Ultrasounds performed and interpreted by the bedside clinician allow for quicker, more direct answers to critical questions as they arise in the ICU. In this dynamic process, the intensivist is in a unique position to integrate his knowledge of the patient, critical care medicine and the imaging data generated with PCUS to test diagnostic hypothesis or to adjust the treatment as needed This new imaging paradigm has the advantage of providing relevant information to the clinicians in a timely fashion regardless of  time of the day or night and makes the performance of serial exams more feasible (e.g., to assess for the response to an hemodynamic intervention).  Ultrasound guided procedure (e.g., line placement) also contributes to reduce the risk of complication. Overall PCUS has the potential to contribute to enhance effective and safe care delivery.   

The availability of affordable and portable US/echocardiography machines and the growing interest for PCUS in the ICU has generated a need for ultrasonography training that is specific for intensivists. One should emphasize that (1) PCUS is unlikely to replace all the traditional indications for echocardiography or ultrasonography and (2) this new image paradigm will only benefit our patients in the ICU if the intensivist community establishes training guidelines for fellows and practitioners as well as provides educational opportunities to make it effective, safe and fun.  We hope that the websites gathered here may contribute to PCUS education.

Last Update: December 2009

Search

A Google™ search for “point of care ultrasound” got 64,700 page results.  Limiting the above search to pages containing “critical care” or “intensive care” or “emergency” and excluding PDF files reduced the number of relevant pages to 41,400. A search for "point of care ultrasound" (with the quotes) resulted in 1720 hits. Limiting the above search to pages containing “critical care” or “intensive care” or “emergency” and excluding PDF files reduced the number of relevant pages to 1440 pages. A similar research strategy in which “point-of-care echocardiography" (with the quotes) was used instead of "point-of-care ultrasound" produced 365 page hits. The above search strategies were complemented by a survey of the faculty of the PG course on PCUS in San Francisco at the 2007 ATS International Conference.

Best Websites

Basic Ultrasound for Clinicians

This site is maintained by the Department of Circulation and Imaging, Faculty of Medicine, Norwegian University of Science and Technology. It is an excellent introduction to the physics needed to understand the principles of ultrasonography.

  1. Authority: Dr. Asbjørn Støylen, the author of this page, is a well-published authority in echocardiography. Rating: 5

  2. Currency: The last update was in March 2006. Rating: 5

  3. Accuracy: The information is accurate and compares well with other sources. Rating: 5

  4. Navigation & Readability: The layout is clear and logical. No complex navigation is required. The text and all animations are presented in one page. The reader can easily scroll up and down as needed or move directly to the desired section using the index provided at the top of the page. Rating: 5

  5. Utility: This site makes excellent use of animations to explain the physics of ultrasonography. The physics of the Doppler effect is also explained and illustrated. Rating: 5

Summary: This is a good place to start to understand the physics of ultrasonography.*****

Cardiothoracic Imaging

This site is maintained by Dr. Jaffe and colleagues, Section of Cardiovascular Medicine, Yale Medical School. It is well organized and constitutes a beautiful atlas of cardiothoracic imaging. It contains strong sections on cardiothoracic anatomy and normal echocardiography. An extensive list of echocardiographic videos illustrates the findings seen in common and less-common cardiac conditions. The site is also an excellent reference and learning tool for pulmonary imaging (radiograph and CT).

  1. Authority: The medical editor is C. Carl Jaffe, MD, FACC, Professor of Medicine (Cardiology), Section of Cardiovascular Medicine, Yale Medical School. This site and project were partially funded by an IAIMS Grant (LM05583) from the National Library of Medicine. Rating: 5

  2. Currency: The website is up to date. Rating: 5

  3. Accuracy: The information is accurate and of high quality. Rating: 5

  4. Navigation & Readability: The site is well organized. Sections of interest are relatively easy to locate and navigate. Given the size and depth of this site, the navigation is somewhat tricky. However, this is a minor issue. Rating: 5

  5. Utility: This site makes excellent use of anatomical drawing, video and audio to explain chest anatomy, ultrasonography and echocardiography. Rating: 4

Summary: This is a great place to understand the relationship between the thoracic anatomy and the various echocardiographic views of the heart. A must-visit site for everyone interested in imagining of the heart and chest and a great source of illustration for physicians involved in teaching.*****

Echocardiography in Intensive Care

This site is maintained by the group of Professors Jardin and Vieillard-Baron from the Ambroise-Paré© Hospital, Paris, France. This outstanding site is clearly geared towards the pathophysiology and intensivists. It has excellent educational material and relevant literature references can be found there.

  1. Authority: The medical editors are internationally recognized for their contribution to the field. Rating: 5

  2. Currency: The website is up to date. Rating: 5

  3. Accuracy: The information is accurate and of high quality. Rating: 5

  4. Navigation & Readability: The site is well organized and easy to navigate. Video would enhance the site and help illustrate important hedmodynamic concepts. Rating: 4

  5. Utility: This is an excellent site to understand the potential role of echocardiography in the diagnosis and treatment of the critically ill. Rating: 5

Summary: The site is outstanding for understanding the potential contribution of echocardiography to the assessment of the hemodynamics in critically ill patients with strong emphasis on cardiopulmonary interactions. A must-visit site for everyone interested in echocardiography in the ICU.****1/2

High-Quality Medical Education Website

The High-Quality Medical Education Website is maintained by the Department of Emergency Medicine, Hennepin County Medical Center (HCMC), Minneapolis. The site has an ultrasound section, which consists in a collection of ultrasound images relevant to the practice of emergency medicine. Instructional videos of high quality are also available.

  1. Authority: The emergency room department of HCMC is recognized locally and nationally for its contribution to the development and education of PCUS in the ER. Rating: 5

  2. Currency: The information is up to date and this site provides instructional videos of commonly performed studies and case studies. Rating: 4

  3. Accuracy: The information is accurate and well presented. Rating: 5

  4. Navigation & Readability: The site organization is clear. Sections of interest are easy to locate and navigate. Rating: 4

  5. Utility: This site is still under development. It has excellent instructional videos that the beginner will find very helpful. This website also provides useful links. Rating: 4

Summary: This is an unfinished product but the educational videos provided are very helpful to beginners.***1/2

Ultrasound Resource of the American College of Emergency Physicians

This is the official page of the American College of Emergency Physicians dedicated to ultrasonography. It provides helpful information relative to privileging, credentialing, coding and reimbursement. A limited number of ultrasound images and cases to review are worth mentioning.

  1. Authority: The site is maintained by the American College of Emergency Physicians. Rating: 5

  2. Currency: The information is up to date. Rating: 5

  3. Accuracy: The information presented is accurate. Rating: 5

  4. Navigation & Readability: The site is well organized and easy to navigate and read. Rating: 5

  5. Utility: Information regarding privileging, credentialing, coding and reimbursement for PCUS can be found on this site. A new section has recently been added which provide a nice overview of the most common applications of ultrasonography in the ER. Rating: 5

Summary: This site provides helpful information for intensivists interested in starting a PCUS program in their ICUs. The section "ultrasound guide for emergency physicians" is well done and is a very helpful introduction to PCUS.*****

Other Important Sites

Disclaimer

The author has no personal or financial interest in any of the websites discussed above. The author has no personal or financial interest in any of the websites discussed above. The only exception is the AURUS website. AB is one of the cofounders of this nonprofit, noncommercial association and has no financial interest in it.

References

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  6. Nicolaou, S, Talsky A, Khashoggi K , Venu V. Ultrasound-guided interventional radiology in critical care. Crit Care Med 2007;35(5 Suppl):S186-97.
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  8. Beaulieu Y. Bedside echocardiography in the assessment of the critically ill. Crit Care Med 2007;35(5 Suppl):S235-49.
  9. Lichtenstein DA. Ultrasound examination of the lungs in the intensive care unit. Pediatr Crit Care Med 2009;10(6):693-8.