Purchasing an ICU Ultrasound: 5 Questions a
Bedside Practitioner Should Ask

Aliaksei Pustavoitau, MD*
Assistant Professor
Department of Anesthesiology and Critical Care Medicine
Johns Hopkins University School of Medicine
Baltimore, Maryland, USA

Ultrasound-based technology has emerged as a useful tool in several areas of medical practice: cardiology, radiology, emergency medicine, surgery and anesthesiology. Though long-recognized as a useful adjunct to the practice of critical care medicine, ultrasonography made its way into intensive care units (ICU) only recently. Several manufacturers of ultrasound equipment have recognized this growing demand, and the market for the equipment is evolving rapidly. One must carefully consider a unit’s needs, in addition to the direct cost of acquisition, prior to making decisions about buying a new ultrasound machine.

Are you considering purchasing ultrasound equipment? It is important to gain the perspective of the bedside provider. Below are five questions to consider before purchasing an ultrasound system; the answers address current knowledge as well as potential ideal characteristics.

How much will the ultrasound machine cost?
The answer to this question involves multiple considerations, as the pricing structure may be complex. Prices may or may not include the cost of probes for multiple applications and accessories. As a rule, purchasing several ultrasound units will result in a lower cost per unit. Manufacturers also may include warranty packages in the final price; like most warranties, these vary in duration as well as in the comprehensiveness of their coverage. It is also important to research which software packages are included in the baseline price. For expanded applications, echocardiography in particular, additional software usually must be purchased separately. Consider customer support services, though they commonly are covered in the original purchase. Other perks could include loaner programs that offer temporary replacements should a machine malfunction, regular equipment and software upgrades, and training sessions. Such amenities may be acquired together or separately from the original purchase.

How reliable is the equipment?
The term reliability implies the ability of the equipment to perform its functions consistently over an extended period of time. Characteristics to look for include:

• Durability of both the machine and the probes
• Time required to start the machine
• Battery life once fully charged

The ICU environment requires that machines be durable; they are moved regularly and used by multiple providers. Boot-up time must be short to accommodate emergency situations, and battery life must be sufficient to handle several serial examinations when immediate charging is impossible.

Is the equipment provider friendly?
The obvious answer to this question is to purchase a machine that is easy to use. However, this requirement should be considered at multiple levels. The fewer knobs the machine has, the easier it is for providers to learn. This is a great advantage in places where providers frequently rotate through the unit. On the other hand, if the provider pool consists of a core group of seasoned critical care physicians, simple “knobology” may be insufficient for advanced applications of ultrasound. Thus, this requirement is determined by the needs of the ICU. Finally, remember that size matters. Portable systems are preferable because they allow for quality examinations in a confined bedside space often limited by life-sustaining equipment.

What are the clinical applications of the equipment?
Clinical applications are probably the single most important factor to consider, besides cost. The equipment can perform as much or as little as the operator desires; applications may be narrow or broad. Modern, state-of-the-art ultrasonography allows the operator to investigate every organ system, and the ultrasound machine serves as an extension of the physical examination. The following systems can be investigated and irregularities uncovered:

Airway: presence or absence of sinusitis, pre-intubation airway assessment, single-lumen endotracheal tube, double-lumen tube and laryngeal mask airway position verification; and extubation assessment

Lungs: presence or absence of pulmonary edema, consolidation, pulmonary embolism, pleural effusion and pneumothorax

Heart: presence or absence of pericardial effusion and tamponade, right and left ventricular failure (systolic and diastolic, global and regional), common types of cardiomyopathies, hemodynamically significant valvular lesions, bacterial endocarditis, and mechanical complications of acute myocardial infarction

Trauma: presence or absence of hemoperitoneum, hemopericardium, and hemothorax Intra-abdominal source of infection: cholelithiasis, cholecystitis, common bile duct obstruction, intraabdominal fluid collections, bowel obstruction, intrahepatic and intraparietal gas

Kidneys: hydronephrosis and renal calculi

Procedural guidance is considered by some to be the only application for ultrasound technology. Procedures such as central venous catheter placement, thoracentesis, paracentesis, pericardiocentesis and fluid collection aspiration can employ ultrasound to ensure safety and efficiency.

As a rule most providers start their practice with a relatively narrow range of applications and later expand their areas of expertise as skills and knowledge grow. It is important to consider carefully the modes that ultrasound machine allows (M- and B-modes, color, pulse-wave and continuous-wave Doppler, 3D). If the equipment is bought initially for simple applications, consider whether it can be upgraded to a more comprehensive unit later. The three related considerations then include screen resolution, memory and calculations package. More complex applications, especially echocardiography, are better served with large, highresolution screens. More extensive memory is required to support Doppler-based technology and appropriate documentation. Calculation packages are needed for software support of these expanded applications.

How well will the new equipment be integrated into the daily practice of the ICU?
The new machine must integrate easily into the hospital system to provide appropriate documentation. Such options may include wireless connectivity and downloading into picture archiving and communication systems (PACS) from a hard drive, flash drive or DVD. Options provided by the vendor should synchronize with acceptable hospital practice. Appropriate documentation also supports billing practices for services provided and plays a significant role in establishing quality assurance processes, with well-established services, such as radiology and cardiology, usually providing oversight of the patient evaluations. Infection control is vital in every ICU; ensure that equipment can be cleaned easily with common solutions so that it can be available for multiple examinations.

Once a system is selected and purchased, it can be used in a variety of capacities within the ICU. Ultrasound is a helpful, additional tool to expand and refine patient evaluations. Broad adoption of this technology will ensure the next generation of critical care providers is well equipped for practice. No matter how capable the machine is, its results are only as good as the operator who performs and interprets the examination. The equipment’s use is limited only by physical characteristics of ultrasound, patient anatomy and an operator’s skill and imagination.

Disclosures:

*Author has no disclosures to report