Scott J. Millington

Point of Care Cardiac Ultrasound Applications in the Emergency Department and Intensive Care Unit - A Review

The use of point of care echocardiography by non-cardiologist in acute care settings such as the emergency department (ED) or the intensive care unit (ICU) is very common. Unlike diagnostic echocardiography, the scope of such point of care exams is often restricted to address the clinical questions raised by the patient’s differential diagnosis or chief complaint in order to inform immediate management decisions. In this article, an overview of the most common applications of this focused echocardiography in the ED and ICU is provided. This includes but is not limited to the evaluation of patients experiencing hypotension, cardiac arrest, cardiac trauma, chest pain and patients after cardiac surgery.

Canadian recommendations for critical care ultrasound training and competency

OBJECTIVE To achieve national consensus on standards of training, quality assurance and maintenance of competence for critical care ultrasound for intensivists and critical care trainees in Canada using recently published international training statements. DATA SOURCES Existing internationally endorsed guidelines and expert opinion. DATA SYNTHESIS In November 2013, a day-long consensus meeting was held with 15 Canadian experts in critical care ultrasound in which essential topics relevant to training ultrasound were discussed. CONCLUSIONS Consensus was achieved to direct training curriculum, oversight, quality assurance and maintenance of competence for critical care ultrasound. In providing the first national guideline of its kind, these Canadian recommendations may also serve as a model of critical care ultrasound dissemination for other countries.

Defining Competencies for Ultrasound-Guided Bedside Procedures Consensus Opinions From Canadian Physicians

This study sought to define the competencies in ultrasound knowledge and skills that are essential for medical trainees to master to perform ultrasound‐guided central venous catheterization, thoracentesis, and paracentesis.

The Rapid Assessment of Competency in Echocardiography Scale Validation of a Tool for Point-of-Care Ultrasound

Increased use of point‐of‐care ultrasound (US) requires the development of assessment tools that measure the competency of learners. In this study, we developed and tested a tool to assess the quality of point‐of‐care cardiac US studies performed by novices.

Outcomes from extensive training in critical care echocardiography: Identifying the optimal number of practice studies required to achieve competency

Purpose Optimal instruction and assessment of critical care ultrasound (CCUS) skills requires an assessment tool to measure learner competency and changes over time. In this study, a previously published tool was used to monitor the development of critical care echocardiography (CCE) competencies, the attainment of performance plateaus, and the extent to which previous experience influenced learning. Materials and methods A group of experts used the Rapid Assessment of Competency in Echocardiography (RACE) scale to rate a large pool of CCE studies performed by novices in a longitudinal design. A total of 380 studies performed by twelve learners were assessed; each study was independently rated by two experts. Results Learners demonstrated improvement in mean RACE scores over time, with peak performance occurring early in training and a performance plateau thereafter. Learners with little experience received the greatest benefit from training, with an average performance plateau reached at the twentieth study. Conclusions Supporting earlier results, the RACE scale provided a straightforward means to assess learner performance with minimal requirements for evaluator training. The results of the present study suggest that novices experience the greatest gains in competency during their first twenty practice studies, a threshold which should serve to guide training initiatives. HighlightsWith the rise of point‐of‐care ultrasound and competency‐based education, there is an urgent need to tools to assess competencyA previously validated assessment tool was applied to a large cohort of cardiac ultrasound scans performed by novicesLeaners improved until the twentieth practice scan; this effect was more pronounced in less experienced leanersThe results suggest a threshold of twenty practice scans for learners as a reasonable starting point in training

Better With Ultrasound: Pleural Procedures in Critically Ill Patients

&NA; Procedures designed to drain fluid or air from the pleural spaces can be technically challenging in patients who are critically ill, and are associated with significant complications. Many individual ultrasound techniques have been described, each with the goal of making pleural drainage procedures safer. This article presents a systemic approach for incorporating many of these tools into procedures such as diagnostic thoracentesis, therapeutic drainage, and pleural catheter insertion. A series of illustrative figures and narrated video presentations are included to demonstrate many of the described techniques.

Advanced Point-of-Care Cardiac Ultrasound Examination: Doppler Applications, Valvular Assessment, and Advanced Right Heart Examination

Basic point-of-care cardiac ultrasound involves assessment of left ventricular systolic function, right ventricular size and systolic function, intravascular volume status, and the pericardium. These simple tools are sufficient to aid in the hemodynamic management of most acutely ill patients; more complex patients may benefit from the use of advanced echocardiographic techniques. This paper describes the use of ultrasound in the advanced evaluation of the right heart, in the assessment of valvular function, and touches on several advanced Doppler applications.

Critical care echocardiography: a certification pathway for advanced users

The content of this issue of Journal supports the broad overall acceptance that point-of-care ultrasound (POCUS) has achieved across many medical specialties. Despite this progress, fundamental confusion persists surrounding the achievement of both competency and certification in POCUS. In this editorial, we seek to demystify and clarify these issues from a Canadian critical care perspective, with special consideration of the recently announced examination and certification pathway in advanced critical care echocardiography. The landscape of competency and certification in POCUS cannot be understood without a firm grasp on the nomenclature that has been adopted thus far (Figure). For POCUS performed by intensivists, critical care ultrasound (CCUS) is the appropriate umbrella term, spanning the two main branches of critical care echocardiography (CCE) and general critical care ultrasound (GCCUS). Critical care echocardiography itself is divided into basic (BCCE) and advanced (ACCE) skill sets. A basic-level provider should be able to generate the five core transthoracic views, interpret left and right ventricular size and global function, identify a pericardial effusion, assess the inferior vena cava, and recognize catastrophic leftsided valvular pathology. So essential to the modern practice of critical care medicine, BCCE has been endorsed as a core skill for all intensivists by the worldwide critical care community and benefits from a growing evidence base. As with other essential intensivist skills (bronchoscopy, central venous access, airway management), BCCE (and likewise GCCUS) should be taught under local expert supervision during fellowship training. Importantly, formal certification for BCCE and GCCUS has been deemed unnecessary both internationally and by the unanimous consensus of Canadian CCUS experts, a position endorsed by the Canadian Critical Care Society in 2013. When it comes to advanced echocardiographic applications, there is a very important departure in the approach and philosophy surrounding training and certification. Advanced applications require greater cognitive and procedural skill, are more quantitative (and therefore subject to error), and are overall closer in scope to a diagnostic echocardiographic examination performed by a cardiologist or an intraoperative examination performed by a cardiac anesthesiologist. Within the scope of ACCE, an intensivist may use a transthoracic or transesophageal approach to address hemodynamic questions (cardiac output, volume responsiveness, or heart-lung interactions), to resolve diagnostic questions (shock etiology, source of embolism, endocarditis, or important valvular dysfunction), or to guide procedures (pacemaker insertion or extracorporeal membrane oxygenation cannulation). Due to this inherent sophistication and resemblance to comprehensive echocardiography, there is S. J. Millington, MD (&) Critical Care Medicine, The Ottawa Hospital, The University of Ottawa, Ottawa, ON, Canada e-mail: smillington@toh.ca

Remote solutions for telementoring point-of-care ultrasound echocardiography: The RESOLUTE study

To the Editor, Point-of-care ultrasound (POCUS), which has revolutionised patient assessment, traditionally relies on the availability of a skilled operator to acquire and interpret images. Although the relevant declarative knowledge needed to perform POCUS is generally available (e.g., medical literature, web-based videos), teaching the required psychomotor skills is challenging without the physical presence of an instructor. Telementoring is a novel, evolving technology in medical education that permits remote instruction of a skill through videoconferencing. We sought to demonstrate that the psychomotor skills required to perform cardiac POCUS can be acquired through telementoring. After institutional ethics review approval (REB 2016081401H), 33 intensive care unit nurses with no previous sonography training were recruited. Participants interacted with a high-fidelity transthoracic echocardiography simulator (VIMEDIX; CAE Healthcare, Ville St-Laurent, QC, Canada) connected via REACTS video conferencing software to a remotely located instructor (R.C.). Following a video-conferenced instructional period, each participant was remotely guided to obtain five standard POCUS views. The simulator was then randomized to one of four pre-set pathologies (anterior myocardial infarction, cardiac tamponade, dilated cardiomyopathy, ventricular fibrillation). The instructor then remotely guided the participant to obtain the views required to diagnose the underlying pathology. Both the subject and instructor were blinded to the pathology. To facilitate psychomotor instruction, two web cameras provided vantage points for the instructor to assess the probe’s position. Instruction of cardinal movements was simplified by colour-coding the probe. Additionally, we utilized the feature of REACTS software that allows the instructor to overlay a pointer (red dot) on the live-feed to direct probe placement on the mannequin (Figure). The instructional period needed to orient participants took a mean (SD) of 142 (40) sec, and the time required to obtain the five standardized POCUS images was 324 (116) sec. The remote instructor subsequently required 84 (49) sec to guide the participants through a focused POCUS examination and obtain a diagnosis of the underlying preset pathology. The acquired loops were subsequently reviewed by two experts (S.M., B.H.) who rated them using a previously validated scale for assessing POCUS image quality. Using the rapid assessment of competence in echocardiography score, both reviewers judged that more than 90% of the echo loops were of sufficient quality for basic image interpretation (scores were C 3), and each correctly identified 32 of 33 cardiac pathologies. We acknowledge that this simulator study has limitations, but we believe that the demonstration that psychomotor skills can be telementored has important E. K. H. Choo, MD (&) R. Chen, MD D. T. T. Tran, MD B. Sohmer, MD Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, ON, Canada e-mail: choo.eugene@gmail.com

Right- and Left-Sided Embolic Phenomena in a Patient With Febrile Neutropenia

A 33-year-old woman presents with febrile neutropenia after initiating treatment with deferiprone, an iron chelating agent. She has a history of beta-thalassemia requiring monthly blood transfusions, complicated by iron overload and significant myocardial iron deposition. Before her hospitalization, she was asymptomatic from a cardiac perspective and had normal left and right ventricular systolic function. On admission, the patient was treated for a retropharyngeal abscess with piperacillin-tazobactam.