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Point-of-Care Ultrasonography in the Intensive Care UnitAlain Broccard Professor of Medicine Division of Pulmonary, Allergy, Critical Care and Sleep Medicine University of Minnesota and Fairview South Dale Hospital Minneapolis, MN IntroductionThe physical exam and the traditional imaging pathways have limitations in the intensive care unit 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 not obtained otherwise (e.g., by physical exam). The study is subsequently done (typically by a technician in the USA) and the images obtained forwarded to a physician for interpretation. The latter often has a limited knowledge of the patient’s condition and the questions asked from the study are not always clearly communicated to this 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 answer the question that motivated the test, the bedside physician needs to have a conversation with the radiologist or the cardiologist who interpreted the ultrasound. Although this time-consuming and inefficient process may be shortened, there may be significant advantages to having ultrasound performed and read by the physicians who know the patient's condition the best. Ultrasound performed by the bedside clinician may allow quicker, more direct answers to critical questions as they arise in the management of the patients. In this dynamic process, the intensivist is in a unique position to integrate direct knowledge of the patient, of critical care medicine, and of the imaging data generated with PCUS to test hypotheses or change treatment. This new imaging paradigm makes the process more efficient for the critically ill patients. This approach also makes performing serial exams more feasible (e.g., to assess for the response to hemodynamic intervention). In addition, when delays are prevented and procedures are ultrasound-guided, the delivery of care may become safer and more effective. The availability of affordable and portable US/echocardiography machines --that facilitate answering rapidly simple and important bedside questions-- will generate a strong demand for PCUS development in the ICU, similar to what is happening in emergency room departments. One can anticipate that the intensivists will be carrying small wireless devices that will have the combined characteristics of a stethoscope and of an ultrasound/echocardiogram machine during ICU rounds in the future! During the mean time, one should emphasize, however, that (1) point-of-care ultrasonography is unlikely to replace all the traditional indications for echocardiography or ultrasonography and (2) this technology will only be helpful if intensivists commit to the training needed to make this approach effective, safe, and fun. The websites gathered here may contribute to this process. Last Update: December 2007 SearchA Google® search for point-of-care ultrasonography 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 point-of-care ultrasonography in San Francisco at the 2007 ATS International Conference.Best WebsitesBasic Ultrasound for CliniciansThis 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.
Summary: This is a good place to start to understand the physics of ultrasonography. Cardiothoracic ImagingThis 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 (X-ray and CT).
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 CareThis 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 the pathophysiology and intensivists. It has excellent educational material and relevant literature references can be found there.
Summary: The site is outstanding for understanding the potential contribution of echocardiography to the assessment of the hemodynamics in the critically ill patients with strong emphasis on cardiopulmonary interactions. A must visit site for everyone interested in echocardiography in the intensive care unit. High-quality Medical Education WebsiteThe 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.
Summary: This is an unfinished product but the educational videos provided are very helpful to beginners. Ultrasound Resource of the American College of Emergency PhysiciansThis 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.
Summary: This site provides helpful information for intensivists interested in starting an ultrasound point-of-care program in their ICUs. The section “ultrasound guide for emergency physicians is well done and is a very helpful introduction to point of care ultrasound . Other Important Sites
DisclaimerThe author has no personal or financial interest in any of the websites discussed above. References
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