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Licensee OA Publishing London 2013. Creative Commons Attribution Licence (CC-BY)

FOR CITATION PURPOSES: Jørgensen MRS, Bøtker MT, Juhl-Olsen P, Frederiksen CA, Sloth E. Point-of-care ultrasonography. OA Critical Care 2013 Jun 01;1(1):8.

Point-of-care ultrasonography

MRS Jørgensen*, MT Bøtker, P Juhl-Olsen, CA Frederiksen, E Sloth

AbstractIntroductionPoint-of-care (POC) ultrasonography is rapidly expanding within clinical practice. POC ultrasonography is per definition a bedside examination performed and interpreted by the treating physician. The development witnessed, in part, reflects equip-ment of increased quality, mobility and availability—the latter as a result of reduced costs. POC ultrasonog-raphy appears to be a safe and valu-able tool, supporting the physician in patient management. It holds obvious advantages in being an easily repeat-able and real-time examination that supplies images, which correlate directly to the patient’s symptoms or the clinically suspected diagnosis. In terms of airway, breathing, circu-lation (ABC-) ultrasonography, it covers cardiac, pulmonary, abdom-inal and vascular ultrasound. The aim of this critical review was to discuss POC ultrasonography.ConclusionThe diffusion of POC ultrasonog-raphy will continue into the acute care specialities, such as emergency medicine, anaesthesiology and inten-sive care. With appropriate training as well as quality and competence assurance, optimal use of this tech-nology could lead to a reduction in medical errors, accurate diagnosis, optimal treatment, accurate referral and better overall results.

IntroductionPoint-of-care (POC) ultrasonography is performed and interpreted at the bedside by the treating physician. In

recent years, the use of this partic-ular form of focused ultrasonog-raphy has commonly increased. Although formerly POC ultrasonog-raphy belonged to a few specialities, such as radiologists and cardiolo-gists; however, there is an increase in the application of ultrasonography in other specialities also. The use of ultrasonography is rapidly evolving within the acute care specialities, such as emergency medicine, intensive care and anaesthesiology (both used peri-operatively1 and in the pre-hospital setting). The use of focused echocar-diography by non-cardiologists has recently been endorsed by the Amer-ican Society of Echocardiography2.

Major reasons for the diffusion of ultrasonography into other speciali-ties are advances in technology and a considerable reduction in costs of ultrasonographic equipment. Over the last decade, portability has increased with the introduction of cart-based compact models and even handheld devices. Enhanced image quality has improved confidence among physi-cians in image interpretation3,4.

As a real-time examination limited in time consumption and easily repeatable, POC ultrasonography holds obvious advantages. It assists the clinician in screening, diagnosing and decision-making, and is hence, developing into an important tool in supporting the clinical examina-tion and conventional monitoring, of which the latter has shown low sensi-tivity regardless of the setting5.

Indiscriminate use of POC ultra-sonography among inexperienced users can lead to false positive results, further unnecessary testing and increased expenses. Even worse, false negative results can lead to inad-equate examination. Thus, the need to ensure competency among users by training and quality assurance is evident. The increased and to sustain

the quality of this user-dependent technology by education and accredi-tation, preferably involving hands-on practical training, is a major challenge5,6.

This critical review primarily focuses on cardiac POC ultrasonog-raphy. Pulmonary and abdominal applications and vascular access are also briefly addressed.

DiscussionIn this critical review, the authors have referenced some of their own studies. These referenced studies have been conducted in accordance with the Declaration of Helsinki (1964) and the protocols of these studies have been approved by the relevant ethics committees associ-ated to the institution in which they were performed. All human subjects, in these referenced studies, gave informed consent to participate in the studies.

Airway, breathing and circulation ultrasonographyThe integration of POC ultrasonog-raphy into the systematic airway, breathing and circulation (ABC) assessment of critically ill patients, has given rise to several different POC ultrasonography protocols. Advantages of this integration seem numerous; when performed by the treating physician, ultrasonog-raphy may aid in the identification of life-threatening conditions and enables the physician to immedi-ately intervene with emergency treatment. Information is acquired in real-time, supplying the physician with dynamic images that can be correlated directly with the patient’s symptoms or clinically suspected diagnosis. In light of the time-critical nature of pathologies faced in acute care, the limited time consump-tion of POC ultrasonography is very

* Corresponding authorEmail: [email protected]

The Department of Anaesthesiology and Intensive care, Aarhus University Hospital, Denmark

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important. It is easily repeated if the patient’s status alters, and may serve as a monitoring tool alongside intervention/treatment. If necessary, it may also aid in the referral, to the correct speciality, for a more compre-hensive diagnostic ultrasonographic examination3,5. Furthermore, ultra-sonography is safe. It is non-invasive and does not expose the patient to ionising radiation, in contrast to other imaging techniques, such as X-rays and computed tomography7.

The advantages of the ultrasonog-raphy-assisted examination can be illustrated, when thinking of the multiple differential diagnoses that are plausible in the frequent case of a patient presenting with dyspnoea, low saturation and haemodynamic

instability. However, ultrasonog-raphy is highly user-dependent, and therefore the use of POC ultrasonog-raphy demands both that the treating physician is sufficiently skilled and aware of personal limitations.

Point-of-care cardiac ultrasoundDifferent standardised focused POC cardiac ultrasonography protocols have been developed, which are exem-plified by the focus assessed tran-sthoracic echocardiography (FATE)8 protocol, focused echocardiography entry level (FEEL)9, bedside-limited echocardiography by the emergency physician (BLEEP)10, haemodynamic echocardiography assessment in real time (HEART)11 and Rapid Ultra-sound in SHock (RUSH)12. In general,

they share common goals as follows: to assess systolic function (contrac-tility), diastolic function (compliance and relaxation), cardiac morphology (chamber dimensions, ventricular wall-thickness) and the presence of obvious pathology. Pre-defined clinical questions are examined and bimodal (‘yes/no’), as well as quali-tative/semi-quantitative answers are sought. As with other acute care-related POC ultrasonography, these focused examinations are not meant as a substitute for the comprehen-sive echocardiographic examina-tion performed by the cardiologist; it merely serves as a supplement to the clinical evaluation as illustrated in Figure 1.

The left ventricular contractility is most commonly evaluated by eye-balling, as most alternative quanti-tative measurements are complex, time-consuming, exhibit consider-able variation and hold multiple pitfalls. Ultrasonographic estimation of preload is based on either rela-tively simple volumetric principles or more advanced Doppler-based methods. Afterload assessment, according to LaPlace’s law regarding wall tension, requires information on chamber dimension and myocardial thickness, together with cavity pres-sure. To evaluate diastolic function of the left ventricle, advanced Doppler methods exist, but these are recom-mended only with higher levels of echocardiographic skills. However, the presence of left ventricle hyper-trophy, with normal systolic func-tion and lack of other pathologies, indicate possible diastolic dysfunc-tion, especially in combination with a dilated left atrium13.

The FATE protocol was developed in the 1990’s. It consists of four scanning positions (Figure 2). The objectives of this protocol in partic-ular are as follows: exclude cardiac pathology; assess wall thickness, chamber dimensions and bilateral ventricular function; visualise pleura on both sides and finally, associate the information gathered to the clin-ical context of the patient8.

Figure 1: The concept of the ultrasonography-assisted clinical examination. Qualitative answers are sought and referral if necessary optimised. CT, computed tomography; ECG, electrocardiography; EEG, electroencephalog-raphy; GI, gastrointestinal; MRI, magnetic resonance imaging; PET, positron emission tomography; TEE, transesophageal echocardiogram; TTE, transtho-racic echocardiogram; US, ultrasonography.

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Position 1: Sub-costal four-chamber view: The patient is placed in the supine position. If possible, prolonged inspiration often improves image. The transducer is placed below the right costal curvature and close to the midline. The orientation marker should be pointing towards the patient’s left side, and the probe should be rotated approximately 20° counter clockwise to the skin. The ultrasound beam should be directed towards the heart or approximately towards the left shoulder. From this view, it is possible to roughly assess dimensions of the different cham-bers, as well as the contractility of the left ventricle. In particular, peri-cardial fluid can be visualised as a black, hypoechoic area around the heart (Figure 3).

Position 2: Four-chamber apical view: This can often be visual-ised with the patient placed in the supine position. If possible, placing

the patient on the left side generally improves imaging. The transducer is placed at the apex of the heart (ictus cordis). The orientation marker should point towards the patient’s left side and the ultrasound beam directed towards the right shoulder. From this view, the size of the different chambers can be measured and systolic function can be assessed semi-quantitatively and categorised as normal, or mildly, moderately or severely impaired.

Position 3: Parasternal long-axis (PLAX) and short-axis (PSAX) views: This can often be visualised with the patient in the supine posi-tion. If possible, prolonged expiration and placing the patient on the left side generally improves images. The transducer should be placed imme-diately to the left of the sternum, at a line from ictus cordis to the medial part of the right clavicle. With the orientation marker directed towards

the patient’s right shoulder, the long-axis view appears and with a 90° rotation clockwise and the orienta-tion marker directed towards the left shoulder, the short axis appears. The PLAX projection allows for measurements of the left ventricle systolic dimension, ejection fraction and hypertrophy, i.e., septal- and posterior-myocardial wall thickness. In case of myocardial ischemia and regional myocardial dyskinesia, the PSAX view makes it possible, roughly to differentiate which individual coronary artery is affected. Further-more, in the PSAX view, signs of pulmonary embolism can be evident as an apparent D-configuration of the left ventricle due to the septal impression caused by elevated right ventricular pressure.

Position 4: Pleural view – bilater-ally: The patient is placed in the supine position with the thorax slightly elevated. The transducer is placed on the lateral, posterior thoracic wall, approximately parallel to the posterior axillary line, at the level of the diaphragm. The diaphragm will appear as a curved hyperechoic line, above the liver or spleen. This view can reveal pleural effusion or haemo-thorax, which will appear hypo-echoic (pay attention to gravitational effects, i.e., fluid shifting with patient position).

Clinical implicationHaji et al. have recently reviewed the impact and accuracy of tran-sthoracic echocardiography (TTE) performed by non-cardiologists4. Their review concluded that TTE, when performed by intensivists, caused a change in management (e.g., initiation or alteration of inotropic or vasoactive agents and fluid therapy) in 16%–51% of intensive care unit (ICU) patient cases. When performed on intubated patients, they found only 2.0%–4.5% failure in obtaining interpretable images. Regarding physicians in the emergency depart-ment (ED), Haji et al. highlighted a randomised trial by Jones et al.14,

Figure 2: Scanning position 1–4 (outlined in the text), according to FATE protocol.FATE, focus assessed transthoracic echocardiography.

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Figure 3: Ultrasonographic images of normal Basic FATE-views and examples of corresponding pathological findings for each scanning positions.AO, aorta; FATE, focus assessed transthoracic echocardiography; LA, left atrium; LV, left ventricle; PE, pleural effusion; PeE, pericardial effusion; RA, right atrium; RV, right ventricle.

which demonstrated that the prob-ability of detecting the correct diag-nosis of non-traumatic hypotension increases from 50%–80%, with early TTE, performed by ED-physicians. Furthermore, Haji et al. presented four studies regarding POC TTE performed by anaesthetists in the

peri-operative settings of non-cardiac surgery. Here, change in manage-ment (e.g., changes in anaesthetic technique, cancellation of surgery or referral to comprehensive pre-opera-tive echo) ranged from 43%–82% of patient cases4. The accuracy of non-cardiologist-performed TTE is high,

with regard to assessment of left ventricular function and the presence of pericardial effusion in critical-care patients, when compared to expert cardiologists. Some studies report a diagnostic agreement up to 96%4.

POC-cardiac ultrasound has also been evaluated during life support and peri-resuscitation. In a prospective trial, Breitkreutz et al. found that the use of TTE led to a change in therapy in 89% of patients undergoing cardiopulmo-nary resuscitation15. The use of POC is recommended in the European Resuscitation Council’s guidelines16.

Jensen et al. examined the feasi-bility of the FATE protocol in intensive care and found that new information was added in 37.3% cases, decision-making was aided in 24.5% of cases and supportive clinical information was provided in 35.6% of cases. The study included 227 examinations and 97% of the images were of sufficient quality8.

The FATE protocol has been successfully performed using a pocket system in comparison to a high-end cart-based system. When performed in semi-recumbent posi-tion, pocket devices showed image quality interchangeable with larger systems17. Using FATE protocol, Fred-eriksen et al. reported improved tech-nical skill among novice examiners, with limited educational intervention of 10 supervised examinations18.

Although the use seems feasible, little has been published concerning POC-cardiac ultrasonography, with patient-centred outcomes. A recent published study by Canty et al., addressed the impact of pre-oper-ative focused TTE by anaesthetists, on mortality of hip fracture surgical patients. The authors concluded that the intervention was associated with lower mortality19. The routine use of POC-cardiac echocardiography in selected patients undergoing surgery could be a focus for future research. Other focus areas for future research could be cardiac arrest, shock and dyspnoea.

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Point-of-care fast examinationIn trauma setting, the focused assess-ment with sonography for trauma (FAST) POC protocol is used for detection of free intraperitoneal or pericardial fluid20. Visualised as hypoechoic black areas, pericardial fluid is diagnosed in the sub-costal view, while free intraperitoneal fluid can be detected around the liver and spleen or in the pelvic area above and around the bladder. The protocol consists of four pre-defined scanning positions; the subcostal cardiac view, the right upper abdominal quadrant, the left upper abdominal quadrant and the longitudinal/transverse bladder view. Time consumption is extremely limited21, and in respect to clinically significant intra-abdominal injury in trauma, specificity above 94% and sensitivity above 70% have been reported5. The FAST exami-nation is usually performed with cart-based ultrasound systems, but studies with handheld devices have also been published. The European guidelines on education, documenta-tion and maintenance of competence exists22 and implementation of these have been shown to impact clini-cians’ decision-making23.

Point-of-care lung ultrasonographyPOC-lung ultrasonography targets both pleural and lung tissue patholo-gies. It holds the potential to diag-nose pleural fluid (haemothorax and pleural effusion) and pneumothorax, interstitial syndrome (e.g., pulmo-nary oedema, lung contusion, pneu-monia and adult respiratory distress syndrome) and alveolar consoli-dation; and can be used to verify correct placement of endotracheal tube. Pleural fluid can be visualised above the diaphragm as a black hypo-echoic area. When diagnosing pneu-mothorax and interstitial syndrome, lung ultrasonography relies on the presence or absence of certain artefacts (e.g., a-lines, b-lines, lung-sliding, lung pulse and lung point). It is beyond the scope of this critical review to give a detailed description of all of these artefacts. With regards

to pneumothorax; ‘lung-sliding’ is an artefact arising from the close associations and movements of the visceral and parietal pleura during respiration. The absence of lung sliding makes a pneumothorax plau-sible, and the presence of a ‘lung point’, which appears where the two pleural leaflets intermittently get into contact, is a highly specific sign of pneumothorax. To visualise very subtle movements, motion (M)-mode is usable. Because air collects at the highest point, in 98% of all patients placed supine, the separation of pleura will be found anteriorly on thorax, and examination should begin here24–26. When assessing patients with trauma, ultrasonog-raphy has been shown more than twice as sensitive as conventional supine chest X-ray scan in detecting occult pneumothorax, with similarly high specificity (>98%)5.

Ultrasonography-guided vascular accessUltrasonography can successfully be used as guidance for vascular access, i.e., central- and peripheral-venous catheters and arterial cannulation5. Two main approaches are described; the in-plane technique, where the needle travels within the ultra-sonographic images and are visu-alised in its full length, and contra, the out-of-plane technique, where the needle-tip travels in and out of the ultrasonographic images, as the transducer and needle alternately are advanced27. The latter is also referred to as the dynamic needle tip posi-tioning (DNTP). Web-based teaching and short-time practical tutorials of ultrasonography-guided vascular access (UGVA) have proven effi-cient28,29. Recommendations, based on expert consensus, to assist physicians and guide future clinical research have recently been published30.

EducationThe rapidly increasing availability of POC ultrasonography within clinical practice and the highly user-dependent nature of the tech-nology urge large-scale system-

atic education. Though educational requirement is present within most specialities, uniquely positioned in dealing with primary ABC patient-assessments and in being specialist in multi-organ pathophysiology, it seems highly relevant that acute care physicians (within emergency medicine, anaesthesiology and inten-sive care), achieve ultrasonographic skills. Furthermore, the develop-ment calls for education of medical students. Several medical faculties have already endorsed ABC ultra-sonography. The University of South Carolina, School of Medicine is an example of such an integrated-ultra-sound curriculum, across all four years of medical school course31.

Recently, the European Society of Intensive Care Medicine (ESICM), in collaboration with 11 critical care societies, published an interna-tional expert statement on training standards for critical-care ultra-sonography32. The panel agreed that general critical-care ultrasonog-raphy (covering abdominal, lung, pleural and vascular ultrasound) and ‘basic’ critical-care echocardiography should be mandatory in the curric-ulum of ICU physicians32.

POC-cardiac ultrasonography training programmes aimed at non-cardiologists, have been developed in several countries (i.e., Basic FATE Denmark, fast assessment diag-nostic echocardiography (FADE) Portugal33), following recommenda-tions from several different inter-national ultrasound societies and groups34–36, amongst those the World Interactive Network Focused on Crit-ical care Ultrasound (WINFOCUS)6. The WINFOCUS group especially points out that a combination of supervised practical training and interactive online learning will facili-tate learning at basic level6.

ConclusionThe interest in POC ultrasound is rapidly increasing, as is the expa-sion of equipment. The diffusion of POC ultrasonography will continue

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into the acute care specialities, such as emergency medicine, anaesthesi-ology and intensive care. With appro-priate training as well as quality and competence assurance, optimal use of this technology could lead to a reduction in medical errors, accu-rate diagnosis, optimal treatment, accurate referral and better overall results. Future research should focus on patient outcome in relation to implementation.

Conflict of interestsErik Sloth has given lectures for GE of BK-medical and in return received a minor fee.

Abbreviations listABC, airway, breathing and circula-tion; ED, emergency department; FAST, focused assessment with sonography for trauma; FATE, focus assessed transthoracic echocardiog-raphy; ICU, intensive care unit; PLAX, parasternal long-axis; POC, point-of-care; PSAX, parasternal short-axis; TTE, transthoracic echocardiog-raphy; WINFOCUS, World Interac-tive Network Focused on Critical care Ultrasound

References1. Johnson DW, Oren-Grinberg A. Perio-perative point-of-care ultrasonography: the past and the future are in anaesthe-siologists’ hands. Anesthesiology 2011 Sep;115(3):460–2.2. Labovitz AJ, Noble VE, Bierig M, Gold-stein SA, Jones R, Kort S, et al. Focus cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr. 2010 Dec;23(12):1225–30.3. Royse CF, Canty JD, Faris J, Haji DL, Veltman M, Royse A. Core review: physician-performed ultrasound: the time has come for routine use in acute care medicine. Anesth Analg. 2012 Nov;115(5):1007–28.4. Haji DL, Royse A, Royse CF. Review article: Clinical impact of non-cardiol-ogist-performed transthoracic echo-cardiography in emergency medicine, intensive care and anaesthesia. Emerg Med Australas. 2013 Feb;25(1):4–12.

5. Moore CL, Copel JA. Point-of-care ultrasonography. N Eng J Med. 2011 Feb;364(8):749–57.6. Price S, Via G, Sloth E, Breitkreutz R, Catena E, Talmor D, et al. World Inter-active Network Focused On Critical Ultrasound ECHO-ICU Group. Echocardi-ography practice, training and accredita-tion in the intensive care: document for the World Interactive Network Focused on Critical Ultrasound (WINFOCUS). Cardiovasc Ultrasound. 2008 Oct;6:49.7. Brenner DJ, Hall EJ. Computed tomog-raphy – an increasing source of radia-tion exposure. N Eng J Med. 2007 Nov;357(22):2277–84.8. Jensen MB, Sloth E, Larsen KM, Schmidt MB. Transthoracic echocardiography for cardiopulmonary monitoring in intensive care. Eur J Anaesthesiol. 2004 Sep;21(9):700–7.9. Breitkreutz R, Uddin S, Steiger H, Ilper H, Steche M, Walcher F, et al. Focused echo-cardiography entry level: new concept of a 1-day training course. Minerva Anest-esiol. 2009 May;75(5):285–92.10. Pershad J, Myers S, Plouman C, Rosso C, Elam K, Wan J, et al. Bedside limited echocardiography by the emer-gency physician is accurate during evaluation of the critically ill patient. Pediatrics. 2004 Dec;114(6):e667–71.11. Royse CF, Haji DL, Faris JG, Veltman MG, Kumar A, Royse AG. Evaluation of the interpretive skills of participants of a limited transthoracic echocardiography training course (H.A.R.T.scan course). Anaesth Intensive Care. 2012;40:498–504.12. Perera P, Mailhot T, Riley D, Mandavia D. The RUSH exam: Rapid Ultrasound in SHock in the evaluation of the critically ill. Emerg Med Clin North Am. 2010 Feb;28(1):29–56.13. Jensen MB, Sloth E. Transthoracic ultrasound: a necessary standard within intensive, acute and pre-hospital medicine. Ugeskr Laeger. 2006 Dec;168(50):4393–6.14. Jones AE, Tayal VS, Sullivan DM, Kline JA. Randomized, controlled trial of immediate versus delayed goal-directed ultrasound to identify the cause of nontraumatic hypotension in emergency department patients. Crit Care Med. 2004 Aug;32(8):1703–8.15. Breitkreutz R, Price S, Steiger HV, Seeger FH, Ilper H, Ackermann H, et al; Emergency Ultrasound Working Group of the Johann Wolfgang Goethe-University

Hospital, Frankfurt am Main. Focused echocardiographic evaluation in life support and peri-resuscitation of emer-gency patients: a prospective trial. Resus-citation. 2010 Nov;81(11):1527–33.16. Nolan JP, Soar J, Zideman DA, Biarent D, Bossaert LL, Deakin C, et al. ERC Guide-lines Writing Group. European Resuscita-tion Council Guidelines for Resuscitation 2010 Section 1. Executive summary. Resuscitation 2010 Oct;81(10):1219–76.17. Frederiksen CA, Juhl-Olsen P, Larsen UT, Nielsen DG, Eika B, Sloth E. New pocket echocardiography device is interchangeable with high-end portable systems when performed by experienced examiners. Acta Anaesthesiol Scand. 2010 Nov;54(10):1217–23.18. Frederiksen CA, Juhl-Olsen P, Nielsen DG, Eika B, Sloth E. Limited inter-vention improves technical skill in focus assessed transthoracic echocardiography among novice examiners. BMC Med Educ. 2012 Aug;12:65.19. Canty DJ, Royse CF, Kilpatrick D, Bowyer A, Royse AG. The impact on cardiac diagnosis and mortality of focused transthoracic echocardiography in hip fracture surgery patients with increased risk of cardiac disease: a retro-spective cohort study. Anaesthesia. 2012 Nov;67(11):1202–9.20. Scalea TM, Rodriguez A, Chiu WC, Brenneman FD, Fallon WF Jr, Kato K, et al. Focused Assessment with Sonography for Trauma (FAST): results from an interna-tional consensus conference. J Trauma. 1999 Mar;46(3):466–72.21. McKenny KL, Nuñez DB Jr, McKenny MG, Asher J, Zelnick K, Shipshak D. Sonog-raphy as the primary screening technique for blunt abdominal trauma: experience with 899 patients. AJR Am J Roentgenol. 1998 Apr;170(4):979–85.22. Education and Professional Stand-ards Committee. European Federation of Societies for Ultrasound in Medicine and Biology. Minimum training requirements for the practice of medical ultrasound. Ultraschall in Med. 2006 Feb;27(1):79–105.23. Hillingsø JG, Svendsen LB, Nielsen MB. Focused bedside ultrasonography by clinicians: experiences with a basic introductory course. Scand J Gastroen-terol. 2008;43(2):229–33.24. Lichtenstein DA. General ultrasound in the critically ill. Berlin: Springer Verlag; 2005.p.1–19, 96–134.

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25. Lichtenstein DA. Ultrasound in the management of thoracic disease. Crit Care Med. 2007 May;35(5 Suppl):S250–61.26. Oveland NP, Lossius HM, Aagaard R, Connolly J, Sloth E, Knudsen L. Animal laboratory training improves lung ultrasound proficiency and speed. J Emerg Med. 2013 Sep;45(3):e71–8.27. Berk D, Gurkan Y, Kus A, Ulugol H, Solak M, Toker K. Ultrasound-guided radial arterial cannulation: long axis/in-plane versus short axis/out-of-plane approaches? J Clin Monit Comput. 2013 Jun;27(3):319–24.28. Chenkin J, Lee S, Huynh T, Bandiera G. Procedures can be learned on the Web: a randomized study of ultrasound-guided vascular access training. Acad Emerg Med. 2008 Oct;15(10):949–54.29. Osborn SR, Borhart J, Antonis MS. Medical students benefit from the use of ultrasound when learning periph-eral IV technics. Crit Ultrasound J. 2012 Mar;4(1):2.

30. Lamperti M, Bodenham AR, Pittiruti M, Blaivas M, Augoustides JG, Elbarbary M, et al. International evidence-based recommendations on ultrasound-guided vascular access. Intensive Care Med. 2012 Jul;38(7):1105–17.31. Hoppmann RA, Rao VV, Poston MB, Howe DB, Hunt PS, Fowler SD, et al. An integrated ultrasound curriculum (iUSC) for medical students: 4-year experience. Crit Ultrasound J. 2011 Apr;3(1):1–12.32. Expert Round Table on Ultrasound in ICU. International expert statement on training standards for critical care ultra-sonography. Intensive Care Med. 2011 Jul;37(7):1077–83.33. Marum S, Price S. The use of echocar-diography in the critically ill; the role of FADE (Fast Assessment Diagnostic Echo-cardiography) training. Curr Cardiol Rev. 2011 Aug;7(3):197–200.34. Quiñones M, Douglas PS, Foster E, Gorcsan J 3rd, Lewis JF, Pearlman AS, et al. American Society of Echocardi-

ography; Society of Cardiovascular Anaesthesiologists; Society of Pediatric Echocardiography. ACC/AHA clinical competence statement on echocardiog-raphy: a report of the American College of Cardiology/American Heart Association/American College of Physicians-American Society of Internal Medicine Task Force on clinical competence. J Am Soc Echocar-diogr. 2003 Apr;16(4):379–402.35. Vignon P, Dugard A, Abraham J, Belcour D, Gondran G, Pepino F, et al. Focused training for goal-oriented hand-held echocardiography performed by noncardiologist residents in the inten-sive care unit. Intensive Care Med. 2007 Oct;33(10):1795–9.36. Cholley B, Vieillard-Baron A, Mebazaa A. Echocardiography in the ICU: time for widespread use! Intensive Care Med. 2006 Jan;32(1):9–10.

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