General and Cardiac Ultrasonography Guidelines

2015 - 6 December - Quality Improvement
Heidi L. Frankel, MD, FCCM
This article centers on general and cardiac ultrasonography guidelines released by SCCM.

Critical Care Medicine has recently published guidelines to inform critical care practitioners of the appropriate evidence-based indications for the use of ultrasonography in critically ill adults and, where appropriate, pediatric patients.(1) The members of the ultrasound guidelines committee have prepared and submitted a second document to the journal, which has received Society of Critical Care Medicine (SCCM) and American College of Critical Care Medicine (ACCM) approval, addressing the indications for focused echocardiography/cardiac ultrasonography in critically ill adults and pediatric patients. The authors hope that this manuscript will be accepted for publication in the spring of 2016. It is anticipated that these two sets of guidelines will be beneficial to membership regarding the clinical role of focused ultrasonography by critical care practitioners in various practice settings.

Ultrasonography in the critical care environment has come a long way since the comprehensive supplement published by Critical Care Medicine in 2007.(2)  In many ways, it still has a bit farther to go for appropriate use, at least outside of Europe, where critical care physicians were early adopters and are at the cutting edge of exciting work. In the United States and other areas around the world (Latin America and the Middle East, for example), introductory courses are still sought. (SCCM provides basic and advanced courses in the United States and has exported them internationally as well.) Further, in the several years since the SCCM ultrasound guidelines committee was charged to produce this work, several additional considerations have come to the fore, particularly in North America. First, it is clear that not only are physicians using this technology, but so are medical students, advanced practice nurses, physician’s assistants, and, in some instances, bedside intensive care unit nurses. Use in pediatric patients continues to expand, and, where data were present, the guidelines addressed appropriate indications in this population. Finally, at least in the United States, there appears to be an appetite for addressing how best to certify and credential providers.(3)  Although the clinical guidelines do not address these issues, SCCM has previously published a document in this realm and is currently in discussion with the relevant groups to provide further clarity.(4)
   
Like the membership of SCCM, the authorship of the guidelines document was multidisciplinary, including providers from anesthesia, surgery, medicine and emergency medicine backgrounds. A well-trained intensivist and methodologist provided high-level expertise on the use of evidence-based methodology. Key strong recommendations were made on the use of ultrasonography for diagnosing pneumothorax and pleural effusion and assisting its drainage, ascites drainage, central venous cannulation, particularly for internal jugular and femoral sites, and for diagnosis of deep venous thrombosis. Conditional recommendations were given to the use of ultrasound for diagnosis of acalculous cholecystitis, renal failure and interstitial and parenchymal lung disease. The cardiac guidelines address the use of focused echocardiography to gauge fluid responsiveness and cardiac performance in a variety of clinical settings.

The guidelines authors are aware that critical care practitioners are not immune from pushback from hospital administrators on the purchase of ultrasound technology. It is anticipated that these guidelines can help frame the necessary conversations between critical care practitioners and administrators regarding the evidence for appropriate use of ultrasound in various patient populations and clinical settings.

 

References:
1.  Frankel HL, Kirkpatrick AW, Elbarbary M, Blaivas M, Desai H, 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. Crit Care Med 2007; 35: Supplement.
3.  Mandapakala, C., Lee, S. (2015). The Role of Critical Care Specialty Societies in the Certification and Credentialing of Bedside Ultrasonography. Critical Connections, 14 (4), 14.
4. Pustavoitau A, Blaivas M, Brown SM, et al. From the Ultrasound Certification Task Force on behalf 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. Society of Critical Care Medicine. http://journals.lww.com/ccmjournal/Documents/Critical%20Care%20Ultrasound.pdf. Accessed January 11, 2016.