Mary Beth Brady, MD, FASE

Nanhi Mitter, MD

In 2001, emergency medicine was the first specialty to approve specialty specific guidelines for the use of ultrasonography, with a revision published in 2009. In addition, in 2010 the American Society of Emergency Physicians teamed up with the ASE to publish a consensus statement on focused cardiac ultrasound in the emergent setting. Currently, according to the American Accreditation for Graduate Medical Education (ACGME), competence in bedside ultrasound is mandated for all graduates of emergency medicine. Although critical care medicine seems to be moving in a similar direction and some authors suggest that training in transthoracic echocardiography should be part of all critical care programs, presently ACGME does not mandate competence by ICU trainees. As a result, not all programs include echocardiography as part of their curriculum. In addition, there are no established ICU-specific ultrasound guidelines, but this seems likely for the future. Walking through the ICU nowadays, it is apparent that echocardiography use is becoming more and more commonplace. In the past, ICUs depended on providers from the echocardiography laboratory or the cardiac ORs to conduct and interpret the echocardiographic exam. Echocardiography training and interest have increased while cost has decreased. Although not mandated to do so, many intensive care programs provide curriculums to trainees which include echocardiography as one of the skill sets. Today, handheld units provide transportable, cost-efficient and powerful echocardiographic capability which can be housed in and paid for by the ICU. Finally, disposable and very small TEE probes are available and used as continuous monitoring devices.

Those in critical care medicine use echocardiography in multiple ways, similar to that in the emergency room: a focused examination for diagnostic use, specifically addressing gross abnormalities or reasons for hemodynamic compromise. For others, it is used not only as a diagnostic tool, but also as a noninvasive measure of preload and function, which can quickly and dramatically change in critical ill patients and which is essential to goal-directed therapy. Finally, many ICU providers have begun to use echocardiography on a serial basis as a component of their bedside exams, conducting daily echocardiographic exams during ICU rounds. In this way, echocardiography is essentially serving as an extension of the traditional physical examination.

Certainly, the feasibility of teaching the basics of this modality has been shown in several studies. In a recent review of echocardiography in the ICU, Field et al summarized several studies which demonstrate that focused training is feasible and efficient in novice ultrasonographers. It is important to note that these studies address only the very basic echocardiographic skill sets. Nonetheless, it is these very basic skill sets which intensivists utilize and strive for in their training. As Field states, “Intensivists with limited echocardiography training will clearly still need to rely on advanced echocardiographers to perform comprehensive echocardiography exams.”

Although there is much pushing echocardiography into the ICU setting, there are still limitations which currently prevent its widespread use in individual ICUs. These limitations include faculty competence, lack of curricular consensus, uncertainty regarding a certification process, and lack of a clear foundation for quality assurance and quality improvement. In addition, despite the decrease in equipment cost, funding can still be a limiting factor.

Despite the limitations, the use of echocardiography in the ICU is certainly on the rise. What Boorstin said about knowledge indeed seems to apply: “increasing by dispersion and growing by diffusion.” Although no one can predict the future, it appears that echocardiography, if not already present, will soon appear in an ICU near you.