Bedside Ultrasound With ConfidenceHow to Start?

Paul Elbers, MD, PhD - Intensivist

ICARUS - Intensive Care Ultrasound

The diagnosis of hyponatremia

makes the distinction between

the lucky doctors who master its

physiopathologic mechanism,

and the others

Life without ultrasound…

At least some support

by cardiologist

and radiologist

is required

Direct supervision by a colleague

is extremely helpful

Competence

vs

Certification

Clearly define local competence

EG: our Basic CCE does not cover valves

And define what this implies

EG: if clinical picture cannot be adequately explained by our basic CCE, cardiologist

consultation is needed

To store or not to store?

• Not storing– Addition to physical examination– No medicolegal issues

• Storing– Good for teaching– Review your own images

Certification

• Stronger need for advanced ultrasound– No need for basic ultrasound?

• Route to certification– By previous experience– By additional training– Within existing critical care training

The Ideal World

• Ultrasound is taught bedside– By experienced colleague– With clearly defined goals

• General Critical Care Ultrasound• Basic Critical Care Echocardiography• Advanced Critical Care Echocardiography

• Full support by cardiology and radiology• No medicolegal issues• Certification for all

Diagnosis determines therapy

• Edema• Embolism• Pneumonia• COPD / Astma• Pneumothorax

Ultrasound correlations

Diagnosis

Ultrasound Images

???

Pulmonary EdemaSliding Anterior PLAPS

52/54 Yes B No

Pneumonia (1 of 3 slides)Sliding Anterior PLAPS

34/83 Yes A Yes

9/83 No C Yes

Ultrasound correlations

Diagnosis

Ultrasound Images

???

Sliding, A dominance and PLAPS

Sliding, B dominance (any PLAPS)

PPV NPV

Although physicians applying ultrasound raise concerns about the medicolegal implications should their diagnosis or resultant management be incorrect, the opposite also has to be considered.

When the considerable benefits it confers to patients are well known, not utilizing ultrasound in the management of patients could be considered inexcusable.

A structured certification program is probably the best approach to equip practitioners with the necessary skills and knowledge.

Although from the medicolegal perspective, competence rather than certification is important, the latter greatly assists in achieving relevant standards of practice

ICARUS

• VUmc Amsterdam– Local ICU fellows and Anesthesia Residents

• Also for doctors outside Vumc– Course continues in own hospital

• Tailored to intensive care practice – Strong focus on lung– Standardized ICARUS views– 30 supervised ultrasound exams– Compulsory recording and reporting

ICARUS - Lung

ICARUS – Heart

ICARUS reporting

PDMS based

PDMS based

PDMS based

ICARUS

• VUmc Amsterdam– Local ICU fellows and Anesthesia Residents

• Also for doctors outside Vumc– Course continues in own hospital

• Tailored to intensive care practice – Strong focus on lung– Standardized ICARUS views– 30 supervised ultrasound exams– Compulsory recording and reporting