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