Certification in Critical Care Echocardiography: The Evolution of an Emerging PICU Practice

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The practice of critical care echocardiography (CCE) in the ICU has been an evolving innovation, with an expanding role more recently at the PICU bedside. Despite CCE’s increasing role as a core intensivist competency (1) and burgeoning literature on the use of bedside ultrasound in the critically ill child (2), defining the practice is a struggle in a world where ultrasound was largely a tool of diagnostic consultants just 2 decades prior.
In a recent article in Critical Care Medicine, Díaz Goméz et al (3) described a plan to help fill that void in CCE. In a partnership with eight professional societies including the American Society of Echocardiography, Society of Critical Care Medicine, and American College of Chest Physicians, and American Thoracic Society to name a few, the National Board of Echocardiography will soon offer a board certification for CCE for physicians including intensivists. It will focus on cardiac assessment and cover additional topics in vascular, lung, and abdominal ultrasound. Though this examination is rooted in the adult literature, the test is relevant to pediatric critical care for more reasons than it is not.
Contemporary literature on the cardiac use of CCE in the PICU, operating room, and emergency department describes the evaluation and management of undifferentiated shock, respiratory failure, and cardiac arrest, in addition to other applications using CCE (2). Methods described include assessment of ventricular contractility and volume status, in addition to reversible causes of cardiac arrest, and are largely identical to methods describing the dysfunctional but structurally normal adult heart. This bears some contrast with the important role of diagnostic imaging by pediatric cardiology specialists that hinges upon exquisite structural assessment of dysmorphology (4). Despite the ubiquity of congenital heart disease as the most common class of major cardiac malformations, it is only found in ~0.8–1.0% of live births yearly (5), and therefore fundamental methods used in adult CCE are likely useful in the PICU as well.
Ultrasound’s advantages in children include its being noninvasive, painless, and with limited exposure risk over technologies involving intravascular pressure monitoring or imaging with ionizing radiation. Add to that the potential in CCE for serial bedside examinations by the primary clinical team and it is remarkably well suited to the assessment and monitoring of children.
Certification also bears significant implications for credentialing and CCE’s future. It helps overcome barriers to acceptance of the practice in the ICU. It provides a testable foundation for the evaluation of clinicians and helps define CCE’s clinical role. Though the book on CCE in the PICU is clearly not closed, this crucial foundation is established on essential expert-reviewed skills. What pediatric CCE will become rises from these fundamental underpinnings.
The National Board of Echocardiography’s board in CCE is a boon to pediatric critical care for reasons above among others. It has important implications for patient care and could also influence intensivist training. With it comes a challenge for clinicians to pursue this opportunity and play a role in CCE’s ongoing development, especially in the PICU.

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