Critical Care Echocardiography Guidelines: Strength in International Cooperation Regarding Terminology and Competency Standards

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We read with attention the guidelines on the application of cardiac ultrasound in the critically ill patient by Levitov et al (1) in a recent issue of Critical Care Medicine. This interesting article extensively reviewed the indications of echocardiography in critical care patients. We agree with the authors that this technique has become the cornerstone of hemodynamic evaluation in patients with circulatory compromise. We have a number of concerns that we feel deserve comment, some in regard to content and others in regard to process.
The section of preload responsiveness, for example, becomes confusing for the reader. Inferior vena cava (IVC) collapsibility was discussed as a good sign of fluid responsiveness in fully ventilated patient during mechanical insufflation, yet the IVC increases in diameter so distensibility rather than collapsibility should be used. Even so, this is limited to those patients on fully supported positive-pressure ventilation with defined tidal volumes as described. A recent publication involving 540 patients demonstrated that the IVC is not so good a parameter in unselected patients to assess fluid responsiveness (2).
The challenge of using evidence-based guidelines in the application of echocardiography in the critically ill population rests upon the experience and competency of the operator performing the test, and the seemingly neat division in the article into basic and advanced levels of expertise sidesteps the major issue of competency.
We propose the term “bedside cardiac ultrasound” is misleading as the great majority of echocardiograms performed in any hospital are performed at the bedside and as such the term does not truly attest to the relative sophistication of the examination. The term should be discarded as it really has no true descriptive value. It is preferably not only to describe the level of competency but also to define them so the aspiring critical care physician is aware of what is required at the basic, advanced, or expert levels, or whatever range of levels is used. For example, in the article by Levitov et al (1), both the use of the Simpson’s method for calculation of the left ventricular ejection fraction and the application of myocardial perfusion techniques are regarded as advanced; yet in most domains, there is considerable difference in expertise to apply them.
It is noted that the authors were appropriately selected to represent the different constituencies of the Society of Critical Care Medicine, contradicting the interference in the conclusion that it was an international panel. In contrast, a truly international panel involving experienced practitioners representing nine critical care societies from around the globe has delivered guidelines on competency for both basic and advanced critical care ultrasound and echocardiography (3, 4). These panels included representatives from critical care organizations in Europe, Britain, Asia, South America, Australia, New Zealand, and North America where two major societies from the United States participated. Training standards and competency levels are considered to be the most important recommendations concerning the advancement of echocardiography in the ICU.
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