Guidance and standards in training and service delivery of

focused ultrasound and echocardiography (FUSE) in UK

intensive care medicine

Prepared by the writing group of the FUSE ICM collaboration, April 2009

1

Table of contents

1. Introduction to focused ultrasound and echocardiography (FUSE)2. Philosophy of FUSE3. Training modules available for FUSE ICM4. Standards and recommendations for FUSE ICM training5. Standards and guidelines in delivering a FUSE ICM service6. Guidance on ultrasound machines and technology7. Guidance on interactions with specialist services8. Appendices

i) The FUSE ICM haemodynamic datasetii) Example of focused echocardiography report formiii) Summary sheet to accompany images for reviewiv) Programme for haemodynamic modulev) Programme for lung and pleura modulevi) Programme for vascular interventional modulevii) Theoretical requirements and dataset for lung and pleuraviii) Theoretical requirements and dataset for vascular interventionalix) FUSE transoesophageal echocardiography (TOE) module

9. Documentation control

2

1) Introduction to FUSE and UK context

The provision of focused ultrasound and echocardiography or FUSE (throughout this document transthoracic echocardiography is implied) imaging is evolving at a rapid pace. Whilst initially the almost exclusive domains of cardiology and radiology, allied specialties have made increasing efforts to acquire at least elements of ultrasound technology, adapted to their clinical needs. Examples of this include vascular access, nerve blockade, assessment of free intra-abdominal fluid in trauma and echocardiography/ haemodynamic assessment. This development of ultrasound to direct a limited or “focused” range of imaging or procedures goes under many titles but this document will use the term “focused ultrasound and echocardiography” (FUSE), with a non-exclusive emphasis on the needs of intensive care medicine practitioners.

Intensive care medicine (ICM) in the UK and internationally has found a genuine clinical need and indication for FUSE when managing critically ill patients but to date the development and formal delivery of training has been absent. It is the delivery of safe and effective FUSE, by UK ICM clinicians (typically non-radiologists and non-cardiologists) that this document considers.

Much of the work on delivering FUSE ICM has already been done by others, for example and not-exclusively the FATE group, Royse et al, and FEEL. In this sense FUSE ICM in the UK is not a “new” protocol or acronym to add to an expanding list, but a reflection of an expanding collaboration between intensive care medicine practitioners and beyond (including cardiology, emergency medicine, radiology). The work of others in facilitating UK intensive care medicine is freely acknowledged by this group and the similarities to other available documents or teaching is not a “re-branding” but a testament to their contribution to patient care. Furthermore, the common elements of the College of Emergency Medicine level 2 training are emphasised demonstrating the generic nature of ultrasound to assist care of the critically ill patients, regardless of the hospital department they find themselves in.

3

2) The philosophy of focused ultrasound and echocardiography (FUSE)

FUSE may be defined as an anatomically (eg echocardiogram) or physiologically (a “shock” scan) directed scan performed during patient care to answer a specific clinical query or direct a specific procedure, by a practitioner with a defined but restricted competency and knowledge in that arena

Incorporating clinical data alongside the FUSE scan is essential to direct patient management eg in the setting of circulatory shock and trauma free intra-abdominal fluid is significant, during peritoneal dialysis it is not. In this sense FUSE is an extension of clinical assessment, not a replacement for it

Diagnostic scans should be directed to answering simple clinical questions, complimented by clinical assessments, with simple (ideally binary yes/ no) answers eg does this patient have a significant pericardial effusion?

FUSE training is best delivered on a competency based system with a modular structure to ensure clinicians learn and retain skills used in frequent clinical practice. FUSE should be restricted to regions and techniques which are within a clinician’s scope of frequent practice

FUSE scans may “rule in” (high sensitivity, strong positive predictive

value) or “rule out” a condition: as in all screening both are rarely achieved eg focused abdominal scanning in trauma (FAST) is generally a specific “rule in” test. Practitioners must interpret FUSE scans in the knowledge of these performances

FUSE should compliment or direct fuller departmental scans but does not obviate or replace such scans performed by specialists. Indeed the safe delivery of FUSE requires mutual understanding and support between specialist and non-specialist services

There is a limited range of anatomy and/ or physiology within the FUSE practitioner’s scope of practice: this must be remembered and indeterminate or non-diagnostic scans reviewed with appropriate specialties eg a clinician experienced in focused echocardiography may be tempted to interrogate a prosthetic heart valve, where this is not a part of their regular clinical case-mix

The temptation to “over-interpret” into areas outside of area of competencies is an acknowledged danger to safe practice of FUSE and requires constant reflection and awareness by practitioners eg commenting on haemodynamic significance of adult congenital heart disease

4

Clinicians need not fully interpret all findings on a scan. Identifying something atypical or “funny” and seeking advice is an acceptable and desirable outcome, which would not have otherwise occurred without FUSE

FUSE should never delay or detract from more definitive therapies or investigations

Ultrasound fails in many circumstances, most notably at an air interface. Situations where FUSE is technically unlikely to be successful should be rapidly identified and the scan abandoned eg persisting in attempting an echocardiogram FAST scan in the presence of extensive pneumothorax/ peritoneum

It is readily apparent therefore that the safe delivery and interpretation of FUSE scans requires good judgement and awareness by practitioners and is best described in qualitative rather than quantitative terms. To paraphrase “A fool with a stethoscope will be a fool with an ultrasound machine”.

5

3)Training modules available for FUSE ICMWhile the following list is not intended to be exhaustive it is hoped to reflect the major modules relevant to UK ICM trainees and their primary clinical considerations/ scenarios. This list is adapted from the Royal College of Emergency Medicine (EM) level 1 and 2 competency documentation. This includes the EM ultrasound syllabus (http://www.collemergencymed.ac.uk/asp/document.asp?ID=3446), and certification in focused ultrasound (http://www.collemergencymed.ac.uk/asp/document.asp?ID=4412) . This latter document gives a fuller list of available modules within emergency medicine which have been restricted to those of more immediate interest to ICM.

FUSE module Principal clinical questions

Notes

Focused transthoracic echocardiography

Diagnosis during haemodynamic compromise, response to therapy eg fluid

Overlap with a variety of “protocols” eg FATE (Focused Assessment by Transthoracic Echo) or Royse

ACES (Abdominal and Cardiac Evaluation in Shock)

Why is my patient shocked?

A cardiac and non-cardiac protocol considering the major causes of shock including the abdominal aorta

FEEL(Focused Echo Evaluation in Life Support)

Why is my patient in a periarrest state and therapeutic decisions?

FAST (Focused Assessment with Sonography for Trauma)

Is there free intra-abdominal or pericardial fluid in a trauma patient?

Training pathway well described and validated in emergency medicine

Vascular: interventional Real time visualisation of vessel cannulation

Practice is widespread in UK following NICE guidance, training has been delivered ad hoc

Vascular: diagnostic Evaluation of Arteriovenous systems eg DVT diagnosis, renal perfusion, trans-cranial interrogation

It is expected clinicians will restrict competence to prominent areas of clinical practice

Pulmonary and pleura: diagnostic and interventional

Does the patient have pleural fluid or air? Can it be safely drained?Is interstitial oedema present?

Renal Is an obstructed renal tract the cause of acute

6

renal failure?Can renal perfusion be demonstrated?

Hepatobiliary Is an obstructed biliary tree the cause of pain, deranged liver or pancreas function?Can hepatic perfusion be identified?

Is portal pressure elevated/ portal thrombosis present?

Nerve: interventional Real time visualisation of perineural placement of local anaesthetic solution

Specific nerve blocks learned should be restricted to areas of frequent practice

Focused transoesophageal echocardiography

Diagnostic scan to determine cause of haemodynamic disturbance or responses to therapy

Under development by the FUSE working group, see appendix ix)

http://www.fate-protocol.com/portal/

Royse C, Donnan G, Royse A. Pocket guide to perioperative and critical care echocardiography. 1 st ed. Sydney: McGraw-Hill; 2006. p. 218

Royse CF, Seah JL, Donelan L, Royse AG. Point of care ultrasound for basic haemodynamic assessment: Novice compared with an expert operator. Anaesthesia 2006;61:849-55

http://www.emergencyultrasound.org.uk/resources/ACES.ppt

http://journal.ics.ac.uk/pdf/0902197.pdf

http://www.trauma.org/archive/radiology/FASTintro.html

http://www.emergencyultrasound.org.uk/resources/EDUC+Pre-Course+Reading.pdf

http://www.nice.org.uk/nicemedia/pdf/Ultrasound_49_GUIDANCE.pdf

http://www.nice.org.uk/nicemedia/pdf/IPG285Guidance.pdf

7

8

4 Standards and recommendations for FUSE ICM training

The working group anticipate a 5 year period where FUSE is generally the exception in UK intensive care and training will be delivered by enthusiasts, who may not be in the same hospital or even base specialty as the trainee. As a critical mass of clinicians emerges, so delivery of FUSE training will become easier and ultimately FUSE will become a standard of acute intensive care medicine rather than an aspiration

These training recommendations should be read in conjunction with the standards and guidelines for service delivery

Inevitably the training structure and qualifications will evolve. This document will be reviewed at 3 and 5 years by the writing group

FUSE training will often be delivered by clinicians with a non-intensive care medicine background, and this multidisciplinary approach is essential and supported (ie learning a technique rather than a “specialty”)

The modern intensivist should have a modular training, aspects of which will be dependent upon practice specialisation. We suggest this comprises 3 “base” modules common to all intensivists: 1) Focused haemodynamic assessment and transthoracic

echocardiography(transthoiracic echo), with a selectable FUSE transoesophageal echo (TOE) module

2) Vascular interventional3) Lung and pleura

The content and programme for these modules is covered in the appendices

Additional modules to be selected will reflect the interest and specialisation of the practitioner. For example a neurointensivist may wish to examine cerebral haemodynamics and transcranial Doppler, a specialist in liver disease may select hepatobiliary

We suggest trainees dedicate the equivalent of at least one session per week over 6 months to achieve FUSE ICM certification in the 3 base modules.The exact time required will vary depending upon trainee aptitude, case availability etc. .

All examinations undertaken should be recorded in a logbook and representative samples of all the examinations stored for potential review

The focused haemodynamic module should include 50 complete examinations with 10 reviewed in detail with the supervisor. Of these 10, 2 should demonstrate a complete examination (see appendix 1) and may thus be of normal individuals: the remaining 8 should demonstrate a range of the haemodynamic disturbances. These reviewed cases should be accompanied by a clinical history, summary of the ultrasound findings, therapy instituted and patient outcome (see appendix)

9

Within the haemodynamic module, no more than 2 of these echocardiograms should be focused TOE ie 8 should be TTE

The lung and pleura FUSE ICM module should focus on 3 main pathologies, namely pneumothorax, pleural effusion and pulmonary interstitial oedema (eg ARDS). This module would require 25 scans undertaken to evaluate pneumothorax, 25 pleural effusion and 25 interstitial oedema. The detailed review should incluse 3 images of each of these pathologies, 2 demonstrating abnormality and 1 normal by comparison

The vascular interventional module should include 25 internal jugular, 25 femoral and 25 axillary/ subclavian vein assessments. 25 arterial examinations (suitable for invasive monitoring) should be included. Records of at least 2 examples from at least 2 anatomical venous sites and 2 arterial should be reviewed with the trainer demonstrating real-time vessel cannulation.

All trainees should have an identified training supervisor who should hold the equivalent of level 2 training in emergency medicine ultrasound. Specialist training and CCST/ CCT in an ultrasound based specialty eg a consultant cardiologist or radiologist would clearly allow training supervision as would specialist ultrasound training eg an echocardiography technician holding British Society of Echocardiography accreditation

Perhaps of equal importance to the supervisor qualification is their ability to recognise FUSE philosophy and training requirements, and not deliver comprehensive ultrasound examination training to individuals who actually seek FUSE

It is recognised that some areas of practice eg nerve blockade and vascular are practiced and taught by many experts, but that no formal qualification currently exists. A “grandfather clause” is being considered with the Royal College of Anaesthetists, Association of Anaesthetists and Intensive Care Society and Intercollegiate Board of Intensive care Medicine to allow such clinicians the opportunity to pass on their knowledge and recognise/ formalise their skills and training with a qualification

The qualification as outlined above for FUSE in UK intensive care medicine shall be termed “FUSE ICM trained” and is intended to recognise clinicians with a training equivalent to level 2 Emergency Medicine accreditation within the modules undertaken. This level of qualification has been supported by the Royal College of Emergency Medicine and is endorsed by the Intensive Care Society

It is emphasised that FUSE ICM is not a new discovery, course or acronym and draws extensively on the work of others- it is the delivery of focused ultrasound training within the UK ICM system. Components of it are already being delivered, to a high standard, on an ad hoc basis

Ultimately it is anticipated that FUSE ICM training can be incorporated and formalised in the UK Diploma of Intensive Care Medicine (DICM)

10

11

5 Standards and guidelines in delivering a FUSE ICM service

A lead clinician should be identified within the intensive care unit with responsibility for training and service delivery of FUSE. This individual should act as a supervisor for training and have a keen interest in ultrasound education and service development

The FUSE lead should be encouraged to dedicate a session per week or equivalent to ultrasound and have a significant clinical involvement in clinical cases requiring ultrasound evaluation

FUSE trainers are encouraged to pursue their own ongoing training and ultimately to obtain training equivalent to comprehensive, non-focused scanning eg BSE accreditation in echocardiography

“Competence” in providing FUSE examinations in intensive care is described in the terms of FUSE ICM training and under the general philosophy of focused scanning. In requiring extensive clinician judgement in performing and interpreting FUSE scans an explicit list of required competencies is challenging to produce and the “philosophy” is equally important

It is imperative that excellent working relationships are maintained with appropriate specialist departments to support clinicians providing focused scans. The philosophy and context of this scanning must be understood by those within and without the intensive care

Clinicians practicing FUSE should restrict this to areas of frequent clinical practice with at least 3- 4 scans per week performed

A forum for multidisciplinary review of images from focused scans is encouraged eg departmental echo meetings or visiting specialists reviewing images on the intensive care unit machine

A machine dedicated to intensive care unit use should be available with probe selection appropriate to its use. Guidance on machines is provided below

Infection control measures and sterilisation of multiple use equipment eg ECG leads and probes should be undertaken in accordance with the manufacturer’s recommendations and local arrangements. In particular invasive probes eg TOE require specific local arrangements

The results of the scan should be recorded and reported in a standardised way, appropriate for the unit and circumstances eg a

12

specialised cardiac unit may include more detailed measurements on a focused scan than a non-cardiac unit. An example of a haemodynamic report sheet, from a non-cardiac general intensive care unit is given in the appendices

Focused scans which are used for diagnostic or therapeutic reasons should be reported by a clinician with training as outlined above and holding FUSE ICM training or equivalent

Ultrasound images must be identifiable by the patient’s name and at least one other unique identifier. The date, time and person performing the scan and an ECG should be included for echocardiograms. Existing conventions on labelling and orientation should be observed. Most of these issues may be quickly resolved by consultation with the specialist department in the hospital and observing existing conventions

Stored images should be available for review and backed up in another format (eg remote hard drive or central drive) according to BSE guidance. All (identifiable) stored images represent confidential patient information and should meet the requirements of data protection and Caldicott principles. Images stored on portable media eg USB memory sticks should observe similar standards of data management

Under most circumstances in intensive care, informed consent is not possible. As a modality ultrasound is largely non-invasive with no material risk; if being used to direct a procedure (eg vascular access) or a semi-invasive scan (eg TOE) informed consent should be sought and recorded where the patient condition allows. Where patients cannot consent it is good practice to inform next of kin and relatives of such scans, in their clinical context

13

6 Guidance on ultrasound machines and technology

Machines should be portable, anticipating movement between clinical areas, and able to transfer to the patient and bedspace easily. There are advantages and disadvantages to hand-held vs cart based systems and selection depends upon clinical use and preference

It is rarely appropriate that FUSE utilises a high-end departmental machine

The machine must support a range of probes. For intensive care medicine this will usually be a high frequency linear array (vascular, pleura, nerve), a phased array “echocardiography” and a lower frequency curvilinear probe (pleura, abdomen and deep nerve)

This range of probes should be capable of providing appropriate depth and resolution 2-D imaging, M-mode, colour flow, continuous and pulse wave Doppler as a minimum

Echocardiograms should be able to include an ECG rhythm recording

The machine should capture examples of static images and cine loops

The machine should be physically robust, waterproof and able to be disinfected between cases

When funding such a service and machine the service contracts can represent a significant ongoing expenditure and most exclude accidental damage to delicate probes. Similarly, software updates can represent significant unexpected costs. Such costs should be anticipated and may be able to be linked to existing contracts within the hospital

The machine may be used by visiting specialists, so it should be appropriate for their use and prior consultation is suggested

The ability to link and archive intensive care images with existing databases within a hospital system is encouraged

14

7 Guidance on interaction with specialist services

The philosophy of focused scanning makes it clear that on frequent occasions consultation with “specialist” services (in particular radiology and cardiology) is essential for correct interpretation and patient care

Such an interaction requires good communication and a clear understanding from the intensive care and the specialist service on what FUSE can offer and what it can’t. It should be understood clear that FUSE may direct or inform specialist investigations and services, but will never replace them and they are complimentary, not competing

The existing governance arrangements for ultrasound and echocardiography within a system should be reviewed and in general FUSE services should try and integrate with these

Aspects of care which may be shared eg report results and documentation should be developed in consultation with the specialist service

The lead for intensive care FUSE should have a nominated point of contact with specialist services for review of cases, education and training and support of service

It is good practice that frequent contact with specialist services (eg multidisciplinary meetings, teaching or case reviews) occurs in a friendly and co-operative environment. FUSE clinicians should be prepared to go outside the intensive care to strengthen these arrangements eg visiting echo lab or ultrasound suite

In brief, where we see FUSE and specialists interacting well, there will be a free flow of information in both directions with neither group feeling threatened or not supported, and with patients undergoing high quality focused scans which improve their management and outcomes.

15

Appendices

i) FUSE ICM haemodynamic dataset This dataset is intended to represent the FUSE “full examination” which should be obtained where time and technical conditions allow.This dataset has been adapted from the Royal College of Emergency Medicine ultrasound level 2 standards (http://www.collemergencymed.ac.uk/asp/document.asp?ID=4565&subID=249&Cat=College of Emergency Medicine ) , British Society of Echocardiography tyransthoracic echocardiography minimum dataset (http://www.bsecho.org/index2.php?option=com_docman&task=doc_view&gid=33&Itemid=61) and WINFOCUS intensive care echocardiography recommendations (http://www.cardiovascularultrasound.com/content/pdf/1476-7120-6-49.pdf) . In practice many focused scans do not include all this data for technical or clinical reasons and the reviewed scans for FUSE ICM training should therefore include two complete examinations which, be necessity, may be performed on healthy individuals.

The patient should be identified by name and at least one other unique identifier (typically date of birth and hospital number)

The clinician should be identified (eg initials) An ECG rhythm strip should be recorded

Abbreviations used belowThese abbreviations are used in clinical practice and adapted from the BSE minimum data set:

PLAX (parasternal long axis), PSAX (parasternal short axis), LV (left ventricle), LA (left atrium), RV (right ventricle), RA (right atrium), LVOT (LV outflow tract), LVID (LV internal diameter in systole/ diastole), TV (tricuspid valve), PV (pulmonary valve), VTI (velocity time integral), SV (stroke volume), CO (cardiac output), PAP (pulmonary artery pressure), RWMA (regional wall motion abnormalities), FS (fractional shortening), FAC (fractional area change), A4C (apical 4 chamber view,etc), EF (ejection fraction), TAPSE (Tricuspid annular plane systolic excursion), RVSP (RV systolic pressure), V1 (LVOT velocity), V2 (AV velocity), LAP (left atrial pressure)

View Modality Structures assessed Measurements CalculationPLAX 2D LV cavity size, wall

thickness, RV cavity size and functionLA sizeAortic rootAortic and mitral valve appearance and function

LVIDs, LVIDdLA in 2 dimensionsLVOT and sino-tubular junction

FS(Derive Teicholz values and understand limitations)

PLAX M-mode LVIDs, LVIDd FS

16

Mitral valve tipsAortic valve tips

LV cavity size, wall thickness, RV cavity size

LVOT, LA size, AV excursion

LA in 2 dimensionsLVOT and sino-tubular junction

PLAX CFD(Colour flow Doppler)

MVAVVenricular septum

PLAX RV inflow

2D RV function and sizeTV function

PLAX RV inflow

CFD TV assessment

PLAX RV outflow

2D RVOT and PV structures

PLAX RV outflow

CFD PV

PLAX RV outflow

Spectral Doppler

PV Peak, mean and VTI

SV, PV gradient, if PR PAPd and mean

PSAXAortic valve level

2D LA, RA, interatrial septum and movementTVRV cavity size and functionPV and RVOT/ pulmonary arteryAV short axis function, coaptation

Surrogate LAP

PSAXAV level

CFD AV, TV, PV and interatrial septum

PSAXAV level

Spectral Doppler

RVOT Peak, mean and VTI

SV, PV gradient If PR PAPd

PSAXMV level

2D MV MV area planimetry

PSAX Mid papillary

2D LV function and RWMA’s

LVIDs, LVIDd, ventricular septumPlanimetry LV area systole

FSFAC

17

and diastole

A4C 2D LV cavity size, function (septum and lateral walls)RV cavity size and functionRelative RV/ LV sizesLA and RA interatrial septumMVTV

AreaVolume (Simpson’s)

EFSV and COSurrogate LAP

A4C M-mode TV annulus Motion TV annulus

TAPSE

A4C CFD MVTVVentricular and atrial septa

A4C Spectral Doppler

LV inflowTV

e/a wavePeak vel TR jet

RVSP

A5C(LVOT view)

2D LV cavity size and functionAV function and LVOT

A5C CFD LVOT and AVA5C Spectral

DopplerLVOT and AV Peak, mean

velocities V1 and V2VTI

Peak and mean gradients and significance of V1 vs V2SV and CO

A2C 2D LV cavity size and function (anterior/ inferior)MV leaflets

A2C CFD MV

18

A3C(A long axis)

2D LV cavity size and functionMVAV(TV may be seen)

A3C CFD MVAV

A3C Spectral Doppler

LVOT and AV V1 and V2 peak and mean, VTI

Peak and mean AV gradientSV and CO

Subcostal 4 chamber

2D LV and RV cavity and function, relative sizePericardiumInteratrial septum motion

Surrogate LAP

Subcostal4 chamber

M-mode Pericardial effusion Dimensions/ consistency effusion

Subcostal 4 chamber

CFD MV, TV and interatrial/ ventricular septa

Subcostal SAX

2D LV cavity size and functionAtrial septum

LVIDs, LVIDdLVAs, LVAd

FS,FACSurrogate LAP

SubcostalSAX

CFD Interatrial septa

19

Supra-sternalview

2D Descending aorta dimensions

Descending aorta area

Supra-sternal view

CFD Aortic blood flow and direction

Supra-sternal view

Spectral Doppler

Aortic velocity VTI SV and CO

IVC view 2D and M-modeHepatic vein

IVC sizeRespiratory variation (spontaneous ventilation)

Absolute size and respiratory variation

RAP and fluid responsiveness

Pleura views

2D and M-mode

PneumothoraxPleural effusionPulmonary parenchyma

Pulmonary comet scores

20

ii) Example of FUSE ICM haemodynamic report sheet included in patient notes from a “general” non-cardiac unit

Ulster ICU Limited Echo Report

Qualitative:

Quantitative:Conclusion & clinical context:

  M MODE    LA (1.9-4.0cm) DOPPLER FLOWS (m/sec)  AO (2.0-3.7cm) Mit E(0.6-1.3) Mit A(0.2-0.6)  Cusps (1.5-2.7cm) DT(139-219ms) E :A (0.7-3.1)  LV IVS (0.6-1.1cm) LVOT(0.7-1.1) AO (1.0-1.7)  LV PW (0.6-1.1cm) Pul ((0.6-0.9)  LV EDD (3.5-5.7cm)  LV ESD (2.5-4.1cm) MVA plan cm2 MVA P1/2 T cm2

RV EDD (0.9-2.6cm) AOV area cm2 AOV Grad mmHg

Fraction Shortening (25-40%)   %        

Signed:

Note: This is a limited study only, and does not replace a departmental echo

Patient Details Indication & Haemodynamics:

Date:

Operator:

Left Heart:

Right Heart & IVC:

Pericardium:

Mitral:

Aortic:

Tricuspid:

Pulmonary:

21

iii) Summary of clinical data to accompany images for haemodynamic FUSE ICM review

The philosophy of focused scanning stresses the importance of interpretation in conjunction with clinical data. The following should accompany images available for review.A hypothetical example is given in italics

Patient identifier John Smith, 01/01/1900

Clinical summary Urgent admission to ICU with shock and chest XR suggestive pneumonia

Clinical question(s) to be answered and likely performance of FUSE

What is the cause of this patient’s shock?What is the main haemodynamic disturbance?What is the next stage in management?

Eg echocardiography has a good sensitivity (rule out) for pericardial effusion but poor sensitivity for submassive pulmonary embolus (rule in)

Main findings of FUSE study

Depressed LV systolic function, no gross valve pathology, RV non-dilated and hyperdynamic, no pericardial effusion. LV collapses at end systole and IVC non-dilated

How were these findings interpreted and how did this assist management?

Consistent with septic shockA fluid challenge and inotrope therapy were added

What was the clinical outcome? Were serial examinations required?

A target MAP of 65mmHg was achieved, urine output increased and plasma lactate normalised. Repeat echocardiography demonstrated a non-collapsing LV, and improved LV systolic function (FS, FAC and EF)

The patient stabilised from a haemodynamic perspective and after 10 days of multiple organ support was discharged from intensive care

22

iv) Programme for the haemodynamic FUSE ICM module

Attend 2 day haemodynamic FUSE ICM theoretical course

The syllabus is directed to how to obtain the dataset (appendix 1) and its interpretation

The trainee should dedicate the equivalent of one session per week over a projected period of 6 months

This is by necessity a guide

Identify a FUSE ICM training supervisor

This may not be an ICM clinician, but the individual should meet the standards outlined in 4.

50 haemodynamic examinations are performed with an attempt to obtain the complete dataset where clinically or technically feasible

A logbook of all examinations must be kept and representative images stored to be available for review.The clinical summary and report sheet form the basis for each case in the logbook

FUSE ICM supervisor and trainee meet

Logbook of 50 cases is reviewed10 cases are reviewed in detail, including clinical summary (appendix iii), a written report (ii) and representative images.2 should be complete examinations with the full dataset (normal individuals acceptable) and the other 8 should demonstrate a range of haemodynamic disturbances

Sign off If the above are satisfactory the trainee has completed the haemodynamic FUSE ICM module

23

v) Programme for the lung and pleura FUSE ICM module

Attend lung and pleura FUSE ICM theoretical course

There are currently many excellent national course on this topic and provided they include the components of the FUSE ICM syllabus they are appropriate

The trainee should dedicate the equivalent of one session per week over a projected period of 6 months

This is by necessity a guide

Identify a FUSE ICM training supervisor This may not be an ICM clinician, but the individual should meet the standards outlined in 4

25 evaluations for each of the major pathologies are undertaken ie pneumothorax, pleural effusion and interstitial oedema

A logbook of all examinations must be kept and representative images stored to be available for review. By nature not all of these scans will ultimately demonstrate the suspected pathology

FUSE ICM supervisor and trainee meet Logbook of 75 cases is reviewed9 cases are reviewed in detail: 3 for each of pneumothorax, pleural effusion and interstitial oedema. Of these 3 scans 2 should demonstrate the pathology and 1 should be normal by comparison. Any procedures undertaken eg drainage are encouraged to be scanned and reviewed

Sign off If the above are satisfactory the trainee has completed the lung and pleura FUSE ICM module

24

vi) Programme for the vascular interventional FUSE ICM module

Attend a theoretical course on vascular interventional

There are currently many excellent national course on this topic and provided they include the components of the FUSE ICM syllabus they are appropriate

The trainee should dedicate the equivalent of one session per week over a projected period of 6 months

This is by necessity a guide

Identify a FUSE ICM training supervisor This may not be an ICM clinician, but the individual should meet the standards outlined in 4

75 venous and 25 arterial scans are undertaken

These scan should be contained in a logbook. These should include 25 internal jugular vein, 25 femoral vein and 25 axillary/ subclavin vein scans and 25 arterial scans.Of note, given the invasive nature of vascular access, these scans will generally be “assessments” of the vessels along their length in transverse and longitudinal planes and need not be accompanied by vessel cannulation

FUSE ICM trainee and supervisor meet The logbook is reviewed and a number of cases are reviewed in more detail includingAt least 2 examples from at least 2 of the 3 venous sites above showing real-time vessel cannulationAt least 2 examples of arterial cannulation

Sign off If the above are satisfactory the trainee has completed the FUSE ICM haemodynamic module

25

vii) Theoretical requirements and dataset for lung and pleura

Understand physics, knobology and probe selection Functional anatomy pleura, intercostal space, pulmonary

architecture and West zones Pathophysiology of pneumothorax, pleural effusion and interstitial

oedema Describe sonoanatomy and key ultrasound signs of the 3

pathologies in particular

Pathology Sonographic signs

Pneumothorax Absence visceral pleura slide or cometsAbsence lung marking consolidation etcM-mode “stratosphere” or “seashore” sign

Pleural effusion Echo free space, blackLung seen within it, possibly compressedFibrin strands, loculation

Interstitial oedema Consolidation and hepatisation“Bubbling” in parenchymaFrequent cometsUltrasound penetrates deep into lung tissue

Describe ultrasound guided intervention for the 3 pathologies including site selection, unfavourable features/ contraindications to drainage

26

viii) Theoretical requirements and dataset for FUSE vascular interventional

Understand physics, knobology and probe selection for vascular interventional work

Describe the anatomy (including major relations) and sonoanatomy of the major veins used for vascular access including internal jugular, subclavian (and axillary) and femoral

Describe the anatomy of major superficial veins where ultrasound may assist cannulation eg antecubital fossa (PICC lines), external jugular, saphenous

Describe the anatomy of the principal arteries used for cannulation including radial, ulnar, brachial, femoral, dorsalis pedis and tibial

Describe the ultrasound features which distinguish artery from vein and vascular from non-vascular structures

Understand the selection of transverse vs longitudinal views of vessels and their practical implications during real-time cannulation

Supplement 2-D views with M-mode (eg deciding catheter size), colour Doppler and power Doppler (eg distinguishing vascular or non-vascular structures or presence of flow)

Identify major vessel pathology including low flow, absent pulsation, thrombosis, aberrant anatomy

Recognise the role of ultrasound in managing complications eg pneumothorax, (inadvertent) arterial puncture

For the purposes of the logbook many scans undertaken will not demonstrate cannulation and the sequence should demonstrate:

2-D Vessel and relations in transverse and longditudinal planes, with rotation between the two.Determination of venous vs arterial with compression

Real-time cannulation including visualisation of needle in long axis, passage of wire and confirmation of venous placement

M-mode Determination of the vessel diameter or variability

Colour and power Doppler

Demonstrate flow, direction and nature eg pulsatile. Understand limitations each

Please note while this module has overlap with diagnostic vascular scanning (eg assessing venous thromboembolism or carotid stenosis) this module is principally to assist in siting vascular catheters and thus termed “interventional”

27

ix) Focused transoesophageal echocardiography (TOE) module Within cardiac UK intensive care medicine and anaesthesia there has been a strong history of delivering TOE training, culminating in the development of combined BSE and ACTA accreditation; this is still recognised as the “gold standard” of training for a comprehensive TOE examination, performed by an independent practitioner. In parallel with the development of FUSE alongside transthoracic echocardiography (TTE), a focused scanning sequence and dataset has been developed for TOE, termed FUSE TOE.

Philosophy and scope of FUSE TOE

It is acknowledged that in most instances TTE will form the basis of haemodynamic assessment. However, there is a place for FUSE TOE in a number of circumstances

A technically inadequate TTE study, where TOE probe position would be superior

TOE and TTE are complimentary and clinicians may derive a superior clinical assessment using both focused techniques together eg assessing the right heart with TTE and left on TOE

Repeated TOE examinations with limited focused views eg transgastric short axis allow sequential studies and thus application of TOE as a monitor eg during fluid challenge or vasoactive titration

Inadequate access to the patient eg during laparotomy where a sterile field and IPPV can can make TTE access very challenging

Of note when considering FUSE TOE Among intubated intensive care/ anaesthetised patients the issues

making TOE less attractive in conscious patients (eg patient acceptability and airway protection) are largely unimportant

Many (cardiac) units have trainees on placements for periods of time insufficient to reach BSE/ACTA accreditation, but long enough to learn focused TOE. It is regretful that they are currently offered “full accreditation or nothing”

The philosophy behind all FUSE is emphasised, and applies equally to FUSE TOE ie this is a focused scan directed to specific clinical queries and is not a departmental systematic examination

Some units may decide (eg on the basis of cost, sterilisation or frequency of use) that FUSE TOE is not for them; this is a decision which individual units must make. For those units where they feel having access to FUSE TOE is desirable, this module is intended to complement their FUSE TTE and haemodynamic assessment

Context and practiceThis module is intended to be used by a recognised supervisor who should hold BSE/ ACTA accreditation for TOE, and a trainee learning under supervision. As such this module omits the technical and governance details eg physics and knobology specific to TOE, infection control or contraindications to oesophageal intubation which are all

28

adequately described in the ACTA/ BSE syllabus and guidelines (http://www.bsecho.org/index.php?option=com_docman&task=doc_download&gid=190) and should be part of the institution’s practice and governance arrangements. Rather this module describes a truncated examination sequence which may be applied, with or without TTE, to answer focused clinical questions, under close supervision of an accredited expert.FUSE TOE is not intended to provide more detailed information beyond the practitioner’s scope of practice eg interrogating a prosthetic replacement mitral valve, where specialist support and input are clearly mandatory.

29

The FUSE TOE datasetThe structure below is adapted from the trans-thoracic dataset where the use of CFD and spectral Doppler is assumed to be primarily to interrogate valves and determine comparable parameters (eg VTI or a peak gradient) to TTE.The views are described in their typical sequence from insertion so the examination may be performed sequentially and rapidly.

TOE View (inc multiplane angle setting)

Modality Structures assessed

Measure Calculations

Mid-oesophageal aortic valve (short axis)40- 60o

2-DM-modeCFD

Aortic valve movement, ascending aorta.May allow window on atria, TV, PV

Poor view (perpendicular) for gradientsIf feasible alternative to TTE AV short axis

Qualitative assess AS/ ARAssess TR, RVSP,PA pressures

Mid-oesophageal aortic valve (long axis)110- 140o

2-D, M-mode, CFD

Aortic valve, LVOT, ascending aorta

Poor view (perpendicular) for gradients

Qualitative assess AS/ AR

Mid-oesphageal4 chamber0o

2-DM-modeCFDSpectral Doppler

Left and right cardiac chambers size, contractility,MV, TV

LVED and S D, LVES and D ALVED and S VPeak and mean gradients

FS, FAC, EF (Simpson’s)RVSP

Mid-oesophageal5 chamber0o

2-DM-modeCFD andDoppler

LVOT and Aortic valve

Peak and mean gradients and VTI,LVOT dimensions

SVAssess AS/AR

Mid-oesophageal long-axis2 chamber90o

2-DM-modeCFDDoppler

LV and LA function and dimensions, esp apex and anterior/ inferior, LA appendage

As for 4 chamber FS, FAC,Combine 4 chamber bi-plane EF

Transgastric short axis (mid-papillary)0o

2-DM-mode

LV dimensions, function and preloadPericardial effusion?

As 4 chamber FSFAC

Transgastric long axis2 chamber90o

2-DM-mode

LV dimensions, function, preload and pericardial effusion(anterior and inferior LV, LA appendage)

As above FSFACEF

30

Documentation controlProduced by the FUSE ICM writing group

Dr Craig Morris, Derbycmorris@doctors.org.uk

Dr Conn Russell, BelfastDr Justiaan Swanvelder, LeicesterDr Sean Bennett, HullDr Steven Burn, Derby

In consultation with the Intensive Care Society Council, Royal College of Emergency Medicine Ultrasound Training Subcommittee, National Point of Care Ultrasound (NPOCUS) group

Date of writing April 2009

Date for 1 st review April 2012

31