In June 2016, Critical Care Medicine published Part II of guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients. Part I of the guidelines focused on general ultrasonography while Part II focused on the indications for cardiac ultrasonography and echocardiography.1,2 The guidelines provide evidencebased recommendations for the appropriate use of bedside ultrasonography in the intensive care unit. Their goal is to help critical care practitioners use this technology appropriately to improve patient outcomes by focusing on answering clinically relevant and time-sensitive questions.
Bedside cardiac ultrasound is an established technique
used to evaluate cardiac function. While not
specifically addressed by these guidelines, the adoption
of the guidelines raises questions moving forward for
intensive care practitioners and healthcare systems
about the need for certification and credentialing of
physicians for the use of bedside ultrasonography. The
Society of Critical Care Medicine (SCCM) previously
published a document providing recommendation
for achieving and maintaining competence in critical
Current trainees will be
able to achieve competence longitudinally across their
training. A number of medical schools have begun to
incorporate ultrasound training into their curricula.4
Training in the use of ultrasonography can then
continue during residency and fellowship. For current
providers in practice who have not received formal
ultrasound training, SCCM and other specialty societies
offer training programs.
Another potential question surrounding the publication
and implementation of these guidelines is whether
the use of cardiac ultrasonography performed by the
critical care practitioner at the bedside should replace
formal echocardiographic assessment by a cardiologist.
These guidelines recommend that bedside ultrasound
assessment be used as an extension of the intensivist’s
The advantage of the
practitioner’s bedside ultrasound examination is that
it can be repeated over time to allow the practitioner
to assess the patient’s response to therapy and changes
in clinical course. Additionally, the bedside ultrasound
examination can be performed with specific clinical
questions in mind with the goal of obtaining real-time
information relevant to care of the critically ill patient.
For more complex cardiac issues, a formal echocardiographic
assessment may be indicated.
The guidelines provide a separate framework of recommendations for practitioners with basic versus
expert levels of expertise in utilizing ultrasound. While
the recommendations focus on both basic and expert
levels, the authors acknowledge that practitioners have
varying levels of expertise and training within the spectrum
of basic to expert that may be difficult to define.2
Bedside providers should perform only elements of the
examination for which they have demonstrated competence
in image acquisition and interpretation. This
is perhaps most important regarding recommendations
for the use of transesophageal echocardiography
(TEE). TEE receives several recommendations for use
by advanced practitioners who have been specifically
trained in its use. However, it is likely that, as technology
evolves with such advances as minimally invasive
TEE and automated cardiac output, practitioners with
lower levels of expertise may be able to competently
analyze new parameters and utilize this modality.
These new guidelines represent evidenced-based recommendations
for the use of bedside ultrasonography.
It is believed that the field of critical care ultrasound
will undergo transformation due to increased training
and adoption of bedside ultrasonography across many
fields. As ultrasound technology advances, critical care
practitioners will increasingly utilize bedside cardiac
ultrasound as part of routine patient assessments to
enhance the care of critically ill patients.
1. Frankel HL, Kirkpatrick AW, Elbarbary M, et al. Guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients—Part I: general ultrasonography. Crit Care Med. 2015 Nov;43(11):2479-2502.
2. Levitov, A, Frankel, HL, Blaivas, M, et al. Guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients—Part II: cardiac ultrasonography. Crit Care Med. 2016 Jun;44(6):1206-1227.
3. Pustavoitau A, Blaivas M, Brown SM, et al; Ultrasound Certification Task Force on behalf of the Society of Critical Care Medicine. Official Statement of the Society of Critical Care Medicine: Recommendations for achieving and maintaining competence and credentialing in critical care ultrasound with focused cardiac ultrasound and advanced critical care echocardiography. Mount Prospect, IL: Society of Critical Care Medicine. http://journals.lww.com/ccmjournal/Documents/Critical%20Care%20Ultrasound.pdf. Accessed February 13, 2017.
4. Solomon, SD, Saldana, F. Point-of-care ultrasound in medical education—stop listening and look. N Engl J Med. 2014 Mar;370(12):1083-1085.