Ultrasound training in critical care medicine fellowships

Published on 22/03/2015 by admin

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Last modified 22/04/2025

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Ultrasound training in critical care medicine fellowships

Overview

Critical care ultrasound (CCU) is a noninvasive tool used for diagnostic evaluation and for guiding procedures in critical care patients. Ultrasound improves success and lowers complication rates when used to guide procedures such as vascular access and fluid drainage.1 Despite these advantages, formal training in CCU has not been incorporated into many fellowship programs, and training in this skill remains heterogeneous. The American Board of Internal Medicine (ABIM) has recommended that fellowship training in critical care medicine include training in the use of ultrasound to guide thoracentesis and central venous access.2 The definition of competence in CCU, suggested training guidelines, the prevalence of fellowship training in this skill, and current barriers to ultrasound training are considered in this chapter.

Definition of competence in critical care ultrasound

A consensus statement sponsored jointly by the American College of Chest Physicians (ACCP) and La Société de Réanimation de Langue Française (SRLF) outlined specific competency guidelines for achieving proficiency in CCU.3 The statement divides CCU into general ultrasound (pleural, lung, abdominal, vascular access, and vascular diagnostic) and echocardiography (basic and advanced). For each, the panel defines a reasonable minimum standard of specific skills required to achieve proficiency in CCU. Importantly, competence is distinguished from certification, which refers to the recognition of competence by an external agency. In the United States, no formal certification process for CCU is currently available. The specific competency skills outlined in the ACCP/SRLF document will be briefly summarized here.

Skills for achieving competency in critical care echocardiography

According to the ACCP/SRLF consensus statement, competence in critical care echocardiography is divided into basic and advanced levels. Because competence in advanced echocardiography requires a high degree of skill and more extensive training than most critical care fellowship training programs would reasonably be able to provide, a discussion of competency in advanced echocardiography is beyond the scope of this chapter (see Chapter 61).

Basic echocardiography involves answering target-oriented clinical questions and assessing the results of therapeutic interventions. Competence in basic echocardiography requires not only the ability to acquire and interpret images but also knowledge of the common clinical syndromes that would prompt echocardiography and the ability to integrate echocardiographic findings into patient management.

Image acquisition requires obtaining images in the parasternal long-axis view, the parasternal short-axis view, the apical four-chamber view, the subcostal four-chamber view, and the inferior vena cava (IVC) view. In interpreting these images, one must be able to evaluate left ventricular (LV) cavity size, systolic function and contraction pattern, and right ventricular (RV) cavity size and systolic function. Additionally important is the ability to identify pericardial fluid and signs of tamponade. IVC diameter and IVC respiratory variation should be assessed. Finally, intensivists should be able to use basic color Doppler to identify severe valvular regurgitation.

The clinical syndromes and associated echocardiographic patterns with which intensivists should be familiar include severe hypovolemia, LV and RV failure, tamponade, acute massive left-sided valvular regurgitation, and circulatory arrest. Competence requires that one be able to formulate a management plan based on these echocardiographic findings. Finally, intensivists must know when it is necessary to obtain consultation from a more advanced echocardiographer.

Suggested fellowship training guidelines

To achieve the aforementioned competencies, a fellow must be trained in both image acquisition and image interpretation. Training in image acquisition requires practice under the supervision of either a physician-sonographer or a trained ultrasound technician. Training in image interpretation is best achieved by reviewing large numbers of normal and abnormal studies with an experienced sonographer. Fellows should also have some means by which to document the studies that they have performed and interpreted to demonstrate competency in CCU.

The European Society of Intensive Care Medicine (ESICM) has recently proposed training guidelines designed around achieving proficiency in the skills outlined by the ACCP/SRLF competence statement.4 The ESICM document proposes that general CCU and basic echocardiography training should be a mandatory component of intensivists’ training and that advanced echocardiography should be an optional component. Furthermore, the authors suggested that to achieve competency in general CCU and basic echocardiography, intensivists should receive at least 10 hours of training in each, divided between lectures and didactics (including image acquisition and interpretation training).

The expert panel could not reach a consensus on the number of examinations required to be performed by the trainee or how many cases of each clinical syndrome the trainee should assess. Rather, the authors suggested that a qualified physician supervisor determine when the trainee has acquired competence in general CCU and basic echocardiography. The guidelines emphasize the necessity of reviewing important abnormal studies as part of their training in image interpretation.

Finally, the authors emphasized the need for documenting training in image acquisition and interpretation. Trainees should maintain a log of the studies that they have performed and interpreted, and these studies should be verified by a qualified supervisor.

Current prevalence of training in critical care ultrasound

A recent survey of critical care medicine and pulmonary/critical care medicine fellowship program directors in the United States examined the prevalence of fellowship training in CCU.1 This survey examined ultrasound training in five specific areas: vascular access, lung/pleural, cardiac, abdominal, and vascular diagnostic. Training in using ultrasound for vascular access was offered by 98% of responding programs. Training in the use of ultrasound in other areas was less prevalent: lung and pleural, 74%; cardiac, 55%; abdominal, 37%; and vascular diagnostic, 33%.1 This survey demonstrated that even though nearly all programs train fellows in ultrasound-guided vascular access, training in other aspects of ultrasound is not universal.

Barriers to training

This same survey of program directors examining the prevalence of CCU training also examined barriers to training in this skill. The most commonly cited barriers to ultrasound training included fellow turnover, lack of faculty trained in ultrasonography, financial considerations, and lack of access to an ultrasound machine.1

Fellow turnover is an unavoidable difficulty faced by critical care fellowship programs when attempting to train fellows in ultrasound. However, as training programs tailor their curricula to comply with the recent recommendation by the ABIM that ultrasound be considered standard in fellowship training, the number of fellows gaining proficiency in this skill will certainly increase. As these fellows graduate, the number of ultrasound-trained physicians will also increase, thereby eliminating the current shortage of qualified ultrasound faculty available to train others. Finally, the financial concerns associated with ultrasound training will be eliminated as more studies demonstrate the cost-effectiveness of CCU. Such studies would also justify the purchase of dedicated ultrasound machines for training programs that currently lack access to one.

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