Ultrasound training in critical care medicine fellowships

Overview

Critical care ultrasound (CCU) is a noninvasive tool used for diagnostic evaluation and for guiding procedures in critical care patients. Ultrasound improves success and lowers complication rates when used to guide procedures such as vascular access and fluid drainage. Despite these advantages, formal training in CCU has not been incorporated into many fellowship programs, and training in this skill remains heterogeneous. The American Board of Internal Medicine (ABIM) has recommended that fellowship training in critical care medicine include training in the use of ultrasound to guide thoracentesis and central venous access. The definition of competence in CCU, suggested training guidelines, the prevalence of fellowship training in this skill, and current barriers to ultrasound training are considered in this chapter.

Definition of competence in critical care ultrasound

A consensus statement sponsored jointly by the American College of Chest Physicians (ACCP) and La Société de Réanimation de Langue Française (SRLF) outlined specific competency guidelines for achieving proficiency in CCU. The statement divides CCU into general ultrasound (pleural, lung, abdominal, vascular access, and vascular diagnostic) and echocardiography (basic and advanced). For each, the panel defines a reasonable minimum standard of specific skills required to achieve proficiency in CCU. Importantly, competence is distinguished from certification, which refers to the recognition of competence by an external agency. In the United States, no formal certification process for CCU is currently available. The specific competency skills outlined in the ACCP/SRLF document will be briefly summarized here.

Skills for achieving competency in the basic principles of critical care ultrasound

Knowledge of basic ultrasound physics is required to acquire images and recognize artifacts. Also important is knowledge of the machine controls and how to manipulate the transducer to obtain images. Intensivists should be aware of when the examination required exceeds the scope of their capabilities and seek appropriate assistance when necessary (see Chapters 1 and 57 ).

Skills for achieving competency in pleural ultrasound

Skills for competency in pleural ultrasound revolve largely around correctly identifying a pleural effusion and locating a safe site for needle insertion. Competency requirements include being able to identify the pleural space and surrounding anatomic boundaries, the presence or absence of fluid, and the characteristics of the fluid. A semiquantitative assessment of fluid volume should also be performed.

Skills for achieving competency in lung ultrasound

Competence in lung ultrasound requires being able to distinguish normal aeration from an alveolar interstitial pattern by using signs such as A-lines, B-lines, and lung sliding. Additional requirements include using the presence of lung sliding and B-lines to rule out pneumothorax (while understanding the limitations of not visualizing these signs) and using the lung point to rule in pneumothorax.

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