Society for Critical Care Anesthesiologists

Section Editor: Avery Tung

E SPECIAL ARTICLE
Critical Care Basic Ultrasound Learning Goals
for American Anesthesiology Critical Care Trainees:
Recommendations from an Expert Group
R. Eliot Fagley, MD,* Michael F. Haney, MD, PhD,† Anne-Sophie Beraud, MD, MS,‡ Thomas Comfere, MD,§
Benjamin Adam Kohl, MD,∥ Matthias Johannes Merkel, MD, PhD,¶ Aliaksei Pustavoitau, MD, MHS,# Peter
von Homeyer, MD,** Chad Edward Wagner, MD,†† and Michael H. Wall, MD‡‡

OBJECTIVE: In this review, we define learning goals and recommend competencies concerning
focused basic critical care ultrasound (CCUS) for critical care specialists in training.
DESIGN: The narrative review is, and the recommendations contained herein are, sponsored by
the Society of Critical Care Anesthesiologists. Our recommendations are based on a structured
­literature review by an expert panel of anesthesiology intensivists and cardiologists with formal training
in ultrasound. Published descriptions of learning and training routines from anesthesia–critical care
and other specialties were identified and considered. Sections were written by groups with special
expertise, with dissent included in the text.
RESULTS: Learning goals and objectives were identified for achieving competence in the use of
CCUS at a specialist level (critical care fellowship training) for diagnosis and monitoring of vital
organ dysfunction in the critical care environment. The ultrasound examination was divided into
vascular, abdominal, thoracic, and cardiac components. For each component, learning goals and
specific skills were presented. Suggestions for teaching and training methods were described.
DISCUSSION: Immediate bedside availability of ultrasound resources can dramatically improve
the ability of critical care physicians to care for critically ill patients. Anesthesia--critical care
medicine training should have definitive expectations and performance standards for basic
CCUS interpretation by anesthesiology--critical care specialists. The learning goals in this review
reflect current trends in the multispecialty critical care environment where ultrasound-based
diagnostic strategies are already frequently applied. These competencies should be formally
taught as part of an established anesthesiology-critical care medicine graduate medical educa-
tion programs.  (Anesth Analg 2015;120:1041–53)

A
lthough clinical use of ultrasound was first technology improvements facilitate better imaging and
described in the 1950s, it remained predominantly ultrasound units have become more mobile and affordable,
an experimental tool until the early 1970s, when it routine use has expanded to the bedside throughout the
was used to detect ascites in cadavers and splenic hemato- hospital, and especially in the ICU.4–9
mas.1,2 Currently, ultrasound is routinely used for diagnostic With widespread availability in the critical care environ-
work and procedural support in many health care settings, ment, ultrasound as a diagnostic device and procedural
including the intensive care unit (ICU).3 Because ultrasound adjunct is increasingly used in critical care practice. When
ultrasound devices and trained practitioners are available,
From the *Department of Anesthesiology, Virginia Mason Medical Center, they can be successfully used in immediate assessment of
Seattle, Washington; †Umeå University Anesthesiology and Intensive life-threatening cardiopulmonary or circulatory dysfunc-
Care Medicine, Umeå, Sweden; ‡Department of Anesthesiology, Stanford
University School of Medicine, Palo Alto, California; §Department of tion in patients in the ICU.
Anesthesiology, Mayo Clinic, Rochester, Minnesota; ∥Department of Since bedside ultrasound in the ICU has become com-
Anesthesiology, Perelman School of Medicine, University of Pennsylvania,
Philadelphia, Pennsylvania; ¶Department of Anesthesiology and
mon, expectations for reliable and rapid image acquisition
Perioperative Medicine, Oregon Health and Science University, Portland, and interpretation have led to recognition that ultrasound
Oregon; #Department of Anesthesiology and Critical Care, Johns Hopkins competence can significantly enhance anesthesiology--crit-
University School of Medicine, Baltimore, Maryland; **Department of
Anesthesiology and Pain Medicine, University of Washington, Seattle, ical care medicine (ACCM) training. Thus, many critical
Washington; ††Department of Anesthesiology and Critical Care, Vanderbilt care practitioners have undergone formal ultrasound train-
University School of Medicine, Nashville, Tennessee; and ‡‡Department ing. To meet this need for future ACCM-trained physicians,
of Anesthesiology, Washington University School of Medicine, St. Louis,
Missouri. programs should facilitate systematic teaching, learning, and
Michael H. Wall, MD, is currently affiliated with the Department of assessment of critical care ultrasound (CCUS). As in ultra-
Anesthesiology, University of Minnesota, Minneapolis, Minnesota. sound training programs for other specialties, an ACCM pro-
Accepted for publication October 14, 2014. gram should incorporate formalized learning goals, practical
Funding: None. teaching plans, and published standards for competency for
The authors declare no conflicts of interest. CCUS.7,10–12 Note that CCUS learning goals are distinct from
Reprints will not be available from the authors. those for transesophageal echocardiography (TEE) in cardiac
Address correspondence to R. Eliot Fagley, MD, Department of Anesthesiol- anesthesiology. A distinct set of CCUS training and learning
ogy, Virginia Mason Medical Center, 1100 Ninth Ave., Mail Stop B2-AN, P. O.
Box 900, Seattle, WA 98111. Address e-mail to [email protected]. goals is appropriate because interpretation of a given study
Copyright © 2015 International Anesthesia Research Society necessitates a previous understanding of critical illness to
DOI: 10.1213/ANE.0000000000000652 optimize the use of the imaging modality. To improve care,

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E SPECIAL ARTICLE

CCUS must be interpreted in context with other diagnostic Of the 40 respondents, only 4 (10%) currently offered no
and monitoring data that are present for critically ill patients. CCUS training to their fellows. Of the 36 ACCM programs
The goal of this review is to describe a basic level of that offered CCUS training, nearly all incorporated both
knowledge for all advanced ACCM trainees concerning the didactic and hands-on components. Twelve (33.3%) of these
use of ultrasound in the management of critical illness and to programs mandated that a specific number of ultrasound
define expectations for the application of CCUS competence examinations be performed and reviewed with an attend-
to vascular, abdominal, thoracic, and cardiac imaging. This ing intensivist. The responses to the questions regarding the
review has 3 specific goals. First, we aim to define the cur- number of required examinations were 11 to 20 examina-
rent state of CCUS training in ACCM fellowship programs. tions (1 program), between 20 and 50 (5 programs), and >50
Second, we aim to present a set of standard, evidence-based examinations (6 programs). With regard to attending inten-
clinical indications, learning goals, and competencies for sivist practice, 33 programs (82.5%) reported that ≤50% of
the use of ultrasound in ACCM. Finally, we aim to propose the faculty frequently use CCUS to help guide therapy. All
general recommendations to support training and accom- 40 programs reported that their fellows have immediate
plishment of the prescribed learning goals. access to an ultrasound machine with both vascular and
cardiac probes, with 36 programs (90%) reporting that the
METHODS ultrasound machine is stored in the ICU.
The Society of Critical Care Anesthesiologists (SOCCA) With respect to perceived difficulties in training ACCM fel-
assembled an expert panel for this project. Criteria for invi- lows in CCUS, nearly half of the respondents (n = 19) reported
tation to the panel included formal ultrasound training (as that many of their attending intensivist colleagues were not
defined by American Society of Anesthesiologists/American comfortable using CCUS. Nevertheless, a majority of those
Society of Echocardiography/Society of Cardiovascular programs felt that an expert faculty comprising intensivists
Anesthesiologists criteria), current involvement in the prac- and experts from other departments could be assembled.
tice and teaching of critical care medicine to anesthesia fel- Eight programs reported having enough individuals within
lowship trainees, and SOCCA membership. To define the their own division to conduct formal CCUS teaching for fel-
current state of CCUS training in Accreditation Council for lows if such training became mandated. Only 1 program (3%)
Graduate Medical Education--accredited ACCM fellowship reported not having enough faculty members to train their
programs, an online survey was sent to the program direc- fellows in CCUS, even with help from other departments.
tors of those programs. To describe the areas of competency, Of the remaining 31 respondent programs, 25 (63%) felt that
a systematic literature search (MEDLINE, PubMed, and if such a curriculum were mandated, they would need help
Ovid) was performed from years 1970 to 2013 for the key from members of other departments, but that those depart-
words: ultrasound, ultrasonography/standards, intensive ments were likely to do so. However, 6 programs (15%) noted
care, critical care, echocardiography/standards, clinical that cardiology or radiology divisions in their institution were
competence/standards, critical care standards, curriculum, reluctant to train ACCM fellows. Two programs (5%) noted
and education. A total of 69 relevant articles were included that cardiac ultrasound was forbidden in their ICU unless
for analysis. From these articles, and from shared profes- performed by a cardiologist. Sixteen programs (n = 16, 40%)
sional experience in teaching CCUS, the panelists described found ≥1 impediment. The majority of programs (n = 24, 60%)
educational goals and expected competencies for success- did not see any barriers to training fellows in CCUS. With
ful ACCM fellowship-based learning for CCUS. The writ- regard to competency, 28 programs (70%) felt that if CCUS
ing process was performed in groups, facilitated by a group training were required for ACCM fellows, successful comple-
leader, with dissenting viewpoints included in the text. tion of fellowship should, by definition, establish CCUS com-
petency. Twelve respondents (30%) felt instead that a separate
RESULTS certification process would be useful.
Current Ultrasound Training in ACCM
Fellowship Programs Physics, Equipment, and Artifacts
In September 2012, an online survey was sent to the fel- An understanding of ultrasound physics is critical to the
lowship program directors of each of the 51 ACCM fel- accurate interpretation of ultrasound images and artifacts.13
lowship programs in the United States. Forty programs As the name suggests, ultrasound imaging is generated by
(78.4%) responded. The size of the respondent programs aiming mechanical sound waves with the frequency exceed-
varied, with 65% of respondents offering 1 to 5 fellowship ing 20 kHz at the object in question. Diagnostic ultrasound
positions each year, and 35% of respondents offering >5 (3 has frequencies in the 1 to 20 MHz range. Ultrasound images
programs offered ≥9 positions each year). Thirty-nine other are formed through interactions of ultrasound waves with
programs (97.5%) reported that other Accreditation Council tissues, fluids, air, and their interfaces.14,15 Application of
for Graduate Medical Education critical care fellowships these general principles allows the clinician to anticipate
(medicine, surgery) were also offered at their institution. and recognize potential imaging artifacts, which can occur
All 39 of those institutions offered pulmonary critical care because of excessive reflection or impairment of transmission
training, and 32 had surgery critical care programs as well. of sound waves through tissues. Although misinterpreted
With respect to ultrasound training before ACCM fellow- artifacts can lead to misdiagnosis, imaging artifacts can also
ship, 40% of program directors reported an embedded cur- support diagnosis (as in pneumothorax, see section below).16
ricular element on ultrasound practice in the associated Appropriate selection of ultrasound equipment for ICU
residency. Most centers (60%) did offer such training to use requires an analysis of clinical needs, a survey of avail-
residents, with or without embedded curricular elements. able local resources, and an understanding of available

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SOCCA Recommendations for Critical Care Ultrasound Training

technology. Practitioners must be able to manage infection volume resuscitation, and diagnosis of aortic aneurysm or
control and equipment storage, data transfer, and electrical dissection.29–31
and ultrasound safety. Practitioners must also thoroughly Vascular ultrasound should also be part of a complete
understand preprocessing and postprocessing functions CCUS curriculum for trainees, as shown in Table 1. Standard
and machine controls to optimize images before recording. image planes in vascular ultrasound are represented in
Operator skills and understanding of anatomy are neces- Figure  1. Learning goals and expected competencies for
sary to properly manipulate the transducer to obtain high- CCUS vascular ultrasound are shown in Table 3.
quality images.
Physics, equipment, and artifacts should also be part Abdominal Ultrasound
of a complete CCUS curriculum for trainees, as shown in Indications for CCUS abdominal examination include (but
Table  1. Learning goals and expected competencies for are not limited to) the following: guidance for paracentesis,32
CCUS-related physics, equipment, and artifacts are shown clinical suspicion for hemoperitoneum, clinical suspicion
in Table 2. for abdominal compartment syndrome or other hypoper-
fusion syndrome, clinical suspicion for retroperitoneal
Vascular Ultrasound hematoma, clinical suspicion for abdominal aortic pathol-
Although vascular ultrasound is commonly used to sup- ogy, including aneurysm and/or dissection,33 laboratory or
port vascular access procedures,9,17,18 current evidence sug- clinical evidence of renal failure,34 and laboratory or clinical
gests that real-time (dynamic) visualization of target vessels evidence of hepatic failure.35 The focused assessment with
during vascular access results in fewer complications than sonography for trauma examination is a structured ultra-
(static) vascular mapping followed by unguided vessel sound examination designed to identify the above elements
puncture.19 Indications for vascular ultrasound include real- that require immediate intervention and has been an impor-
time needle guidance during vessel cannulation for inter- tant contribution to secondary trauma assessment.36 It was
nal jugular, subclavian, axillary, and femoral venous and popularized early based on the idea that the examination
arterial vascular access.17,20 Ultrasound may also be useful can be completed very quickly to support a rapid decision
in securing peripheral venous access in difficult patients.21 for immediate surgical intervention.
Diagnostically, vascular ultrasound is indicated for the Abdominal ultrasound should also be part of a com-
diagnosis of deep venous thrombosis,22–24 suspicion of arte- plete CCUS curriculum for trainees, as shown in Table 1.
rial occlusion or stenosis,25 inferior vena cava diameter and Standard image planes in abdominal ultrasound are repre-
variability during the respiratory cycle (an indicator of sented in Figure 2. Learning goals and expected competen-
right ventricular [RV] preload),26–28 real-time monitoring of cies for CCUS abdominal ultrasound are shown in Table 4.

Table 1.  Learning Goals and Expected Competencies: Equipment and Artifacts

Correctly identifying artifacts Application of ultrasound equipment Application of machine settings and transducer
manipulation
• Shadowing, reverberation, refraction, side • Selecting appropriate ultrasound machine • Selection of appropriate ultrasound probe for specific
lobes, range ambiguity, poor resolution, for clinical needs clinical examination
enhancement, Doppler aliasing, mirror • Safe equipment storage, maintenance, • Selection of appropriate mode of ultrasound and
imaging, and ghosting37 and safety Doppler
• Improving image quality and diagnostic • Adequate infection control • Proper ergonomics of ultrasound scanning
information when artifacts are present • Reliable data acquisition, storage, and • Optimization of image acquisition by manipulating the
transfer transducer by rotation, rocking, sliding, tilting, and
compression
• Application of calculation packages appropriate for
common ultrasound applications

Table 2.  Learning Goals and Expected Competencies: Vascular Ultrasound

Procedural Vascular anatomy and pathology Diagnostics
• Implement extended barrier precautions • Identify relevant arteries (carotid, • Identify relevant veins and arteries
with use of sterile sheath over ultrasound subclavian, axillary, radial, femoral, • Differentiate vascular from surrounding
transducer popliteal, and dorsalis pedis) structures; identify vascular wall dissection
• Ergonomically position ultrasound machine • Identify relevant veins (internal jugular, and hematomas
and other equipment subclavian, axillary, brachial, basilic, • Appreciate anatomic variations
• Apply cross-sectional and longitudinal views femoral, saphenous, and popliteal) • Implement sequential scanning versus 2-point
of vessels to be cannulated • Identify vascular pathology, including venous ultrasonography of femoral/popliteal veins
• Document dynamic ultrasound guidance and arterial thrombosis, and arterial • Identify venous thrombosis using B-mode,
using stored images showing vascular atherosclerotic disease color Doppler, and compression testing.
access, including needle entering • Identify adjacent structures, such as lymph Understand limits of 2-point examination
the vessel nodes, masses, and hematomas
• Ability to obtain vascular imaging with in-plane
and out-of-plane technique

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E SPECIAL ARTICLE

training.43 Diagnostic information obtained from echocar-

diography acquired and interpreted by the intensivist may
change management in half of cases, including fluid admin-
istration, use of vasoactive medications, and treatment
limitations.44 Image quality in this setting is most often suf-
ficient for both nonventilated and ventilated patients. When
not adequate, a transesophageal approach may provide
better images.44 Protocol-driven rapid or focused transtho-
racic echocardiogram (TTE) examination in this setting can
improve patient care, especially in the setting of cardiac
tamponade, code/cardiac arrest, global cardiac systolic
dysfunction, ventricular enlargement, and hypovolemia.7
Concurrent hemodynamic data analysis may corroborate
diagnoses of myocardial ischemia, cardiac tamponade, iso-
lated RV dysfunction (and pulmonary hypertension), sep-
tic shock with hyperdynamic LV and RV dysfunction, or
hypovolemia.
Focused TTE examination is not meant to replace a
comprehensive TTE study. Rather, TTE allows quick serial
assessments of hemodynamically unstable patients and
their responses to resuscitation. In the acute setting, TEE
is needed infrequently for adequate image acquisition .42
Figure 1. Vascular ultrasound views. SC SV SAX = supraclavicular When presented with uncertain TTE and TEE findings, we
long axis; IC SV LAX = infraclavicular subclavian vein long axis; BrV/ recommend consultation with an expert echocardiographer,
BaV SAX = brachial and basilic vein short axis; AxV LAX = axillary specifically a cardiologist or a cardiac anesthesiologist.46–48
vein long axis; IF SAX = inguinal fossa short axis; PF SAX = popliteal
fossa short axis; C = clavicle; SV = subclavian vein; SA = subcla- Ultrasound in hemodynamic instability should also be
vian artery; P = pleura; BrV = brachial vein; BaV = basilic vein; CV part of a complete CCUS curriculum for trainees, as shown
= cephalic vein; AxV = axillary vein; CFA = common femoral artery; in Table 1. Standard image planes in TTE and TEE are rep-
CFV = common femoral vein; SV = saphenous vein; M = medial; L = resented in Figures  4 and 5. Learning goals and expected
lateral; PV = popliteal vein; PA = popliteal artery.
competencies for CCUS in the identification of causes of
hemodynamic instability are shown in Tables 6–8.
Thoracic/Pulmonary Ultrasound
In contrast to computed tomography scanning or chest
radiograph, thoracic ultrasound (TU) can generate images in LV and RV Systolic Function
In the assessment of systolic LV function, subjective esti-
real time and may be repeated easily and without radiation
mation of LV contractility using TTE is as accurate and
exposure. As with the focused assessment with sonography
reproducible as calculated measures of ejection fraction,
for trauma examination above, in the context of hemody-
including fractional area change, fractional shortening,
namic instability, TU may help diagnose pleural effusion,
and Simpson’s method of disks. Hypovolemic shock is
pneumothorax, hemothorax, interstitial disease, or consoli-
associated with decreased end-diastolic and end-systolic
dation and may facilitate rapid intervention.37 Indications
ventricular volumes, and when severe, LV cavity oblitera-
for performance of TU include (but are not limited to)
tion. In cardiogenic shock, LV hypocontractility and dila-
hemodynamic instability, anatomic guidance for thoracen- tion are often present. In distributive shock states, such as
tesis,5 evaluation of dyspnea,37 and clinical evidence for septic shock, impaired contractility can be observed with
pneumonia,38 interstitial disease,37 pulmonary edema and/ or without LV dilation.3 A complete diagnostic evaluation
or acute respiratory distress syndrome,39 pneumothorax,40,41 for myocardial ischemia is time consuming, can be difficult
and effusion. because of body habitus, positioning, dressing locations, or
Thoracic/pulmonary ultrasound should also be part of a anatomic variation in some patients, and, thus, is outside
complete CCUS curriculum for trainees, as shown in Table the scope of a CCUS examination. In emergency situations,
1. Standard image planes in thoracic/pleural ultrasound are an examination limited to the midpapillary short-axis (SAX)
represented in Figure 3. Learning goals and expected com- view can identify myocardial regions supplied by each of
petencies for TU are shown in Table 5. the major coronary arteries and may facilitate intervention.
The practicing intensivist should understand the struc-
Transthoracic Echocardiography/TEE in Shock tured evaluation and nomenclature of regional wall motion
Critical care knowledge provides diagnostic focus for bed- abnormalities. The system recommended by the American
side echocardiography, which in turn may guide resusci- Heart Association is the 17-region model, which includes 6
tation efforts.42–45 Although performing and interpreting a basal segments assessed on the ventricular side of the mitral
complete echocardiographic examination requires exten- valve, 6 midventricular segments assessed at the mid-
sive training, intensivists have been able to correctly point of the papillary muscles, 4 apical segments assessed
identify normal and abnormal left ventricle (LV) function between the papillary muscles and the apex, and the api-
with a high degree of certainty after relatively little formal cal cap.49 The scoring system awards values of 1 to 5 for

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SOCCA Recommendations for Critical Care Ultrasound Training

Table 3.  Learning Goals and Expected Competencies: Abdominal Ultrasound

Procedural views Abdominal anatomy and pathology Diagnostics
• Right upper quadrant (as part of FAST • Identify normal anatomic structures: • Identify hepatic congestion, IVC diameter >10
examination) abdominal wall, diaphragm, liver, gallbladder, mm, or by systolic flow reversal66
• Right paracolic gutter spleen, kidney, bladder, bowel, bladder, • Identify obstructive nephropathy
• Left upper quadrant (as part of FAST uterus, spinal column, aorta, IVC. Recognize (hydronephrosis)-marked dilation and
examination) variations in normal relationships between distortion of the collecting system with
• Left paracolic gutter anatomic structures thinning of the renal parenchyma67
• Longitudinal and transverse pelvis (as part of • Assess and characterize echodense fluids • Identify signs of cholecystitis, as evidenced
FAST examination) (hemoperitoneum, ascites) by a thickened gallbladder wall, an enlarged,
• Assess urinary bladder size and contents64,65 tender gallbladder, and a pericholecystic fluid
• Identify intra-abdominal fluid, as evidenced by collection68
subhepatic anechoic fluid in Morison’s pouch, • Identify retroperitoneal hematoma, as
pelvic free fluid in the Cul de Sac (Pouch of evidenced by perirenal fluid65,69
Douglas), or a large volume of anechoic fluid
surrounding loops of bowel.66 Assess need
for further imaging or consultation
FAST = focused assessment with sonography for trauma; IVC = inferior vena cava.

Figure 2. Abdominal ultrasound and focused

assessment with sonography for trauma exami-
nation views. RUQ Coronal = right upper quadrant
coronal; RUQ Sagittal = right upper quadrant sag-
ittal; LUQ Coronal = left upper quadrant coronal;
Male Pelvis LAX = male pelvis long axis; Male
Pelvis SAX = male pelvis short axis; Female Pelvis
LAX = female pelvis long axis; Female Pelvis SAX
= female pelvis short axis; L = liver; K = kidney;
HPV = hepatic portal vein; GB = gallbladder; D =
duodenum; IVC = inferior vena cava; S = spleen;
B = bladder; UT = uterus.

Table 4.  Learning Goals and Expected Competencies: Thoracic (Lung/Pleura) Ultrasound

Procedural views Thoracic anatomy and pathology Diagnostics
• Interrogate lateral, nondependent aspects of • Identify normal anatomic structures: • Identify pleural disease: effusion or
pleura and lung diaphragm, chest wall, ribs, visceral pleura, hemothorax, pneumothorax
• Use higher frequency and linear probes for and lung • Identify lung consolidation or interstitial
identification of pathology very near probe • Identify normal dynamic changes of anatomic edema
• Use lower frequency and phased array for structures and relationships
better tissue penetration and distance • Identify other structures visible through
resolution transthoracic windows: liver, spleen, kidney,
heart, pericardium, spinal column, aorta, IVC
• Assess and characterize intrathoracic fluid
collections
IVC = inferior vena cava.

each segment evaluated: 1 is normal (>30% thickening), 2 thickening), and 5 is dyskinetic (paradoxical motion dur-
is mildly hypokinetic (10%–30% thickening), 3 is severely ing systole).50 The walls are named according to their ana-
hypokinetic (<10% thickening), 4 is akinetic (no appreciable tomic position and comprise the basal and midpapillary

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E SPECIAL ARTICLE

velocity, and tissue Doppler may be used to measure the

velocity of the lateral mitral annulus. The E/e’ ratio is rela-
tively independent of loading conditions. An E/e’ ratio >8
is indicative of impaired ventricular relaxation, and the
ratio increases with worsening diastolic dysfunction. The
E/e’ ratio can also be used to identify patients with high
filling pressures as E/e’ ratios >7 correlate well with a pul-
monary capillary wedge pressure >13 mm Hg.6 Accurate
assessment of diastolic function can be challenging and
should be performed only by clinicians in advanced stages
of training.

Cardiac Output
The measurement of stroke volume (SV) and the derivation
of cardiac output (CO) can be performed during a CCUS
TTE examination. The calculation of SV and CO requires 2
different echocardiographic windows. The diameter (DLVOT)
of the LV outflow tract (LVOT) is measured just underneath
the aortic valve (AV) in a long-axis (LAX) view. In midsys-
tole, the cross-sectional area of the LVOT (ALVOT) can be esti-
mated using the formula for the area of a circle: ALVOT = π
× (DLVOT / 2).2 To estimate SV, pulsed-wave Doppler veloc-
ity time integral (VTILVOT) through the LVOT is measured
from an apical 5-chamber view in TTE or deep transgastric
view in TEE. The SV calculation is as follows: SV = ALVOT ×
VTILVOT.7

Pulmonary Arterial Systolic Pressure

Estimation of pulmonary artery systolic pressures should
be performed routinely where tricuspid valvular regurgita-
Figure 3. Pleural ultrasound views. Pleural LAX = pleural long axis;
tion is present. Color Doppler echocardiography is used to
Pleural LAX M-Mode = pleural long axis M-mode; SQ = subcutane-
ous tissue; R = rib; M = muscle; NVB = neurovascular bundle; P = identify any tricuspid regurgitation (TR). The TR jet maxi-
pleura; L = lung; SL = sliding lung; LP = lung parenchyma. mal velocity (Vmax) is recorded. The pressure gradient (ΔP)
between the right atrium (RA) and the RV in systole is calcu-
lated using the simplified Bernoulli equation: ΔP = 4 × Vmax.2
anteroseptal, anterior, anterolateral, inferolateral, inferior,
This ΔP is then added to the estimated RA mean pressure or
and inferoseptal walls. In the apical LV, there are anterior,
central venous pressure reading to estimate the RV systolic
lateral, inferior, and septal segments.49
pressure. In the absence of pulmonic valve pathology and/
Global RV function and RV pressures can also be
or severe TR, this approach provides a good estimation of
assessed using TTE. Tricuspid annular planar systolic
systolic pulmonary artery pressure.54
excursion of the lateral aspect of the tricuspid valve pro-
vides a reliable estimate of RV systolic function, with an
Assessment of Severe Valvular Dysfunction
excursion distance <14 mm, indicating RV failure.51 RV The level of detail in the assessment of valvular dysfunc-
dilation is present when the basal RV diameter is >42 mm tion will be determined by echocardiographic operator
in 4-chamber views.52 Flattening or D-shaping of the inter- experience and clinical context. Severe mitral stenosis (MS)
ventricular septum and akinesia of the mid-free wall of the or aortic stenosis (AS) and severe acute mitral or aortic
RV in combination with a normally functioning RV apex insufficiency (mitral regurgitation [MR] and aortic regurgi-
(McConnell’s sign) can also indicate acute RV dysfunc- tation) may cause acute hemodynamic decompensation in
tion attributable to volume and/or pressure overload and the ICU. If present, severe valvular lesions should be cor-
may be present in pulmonary hypertension or pulmonary rectly identified by the intensivist. Common chronic valvu-
embolism.53 In this way, regional LV function and global RV lar lesions may also complicate the course of the critically ill
function can be assessed using CCUS. patient. TTE assessment of the AV involves the parasternal
LAX, parasternal SAX, apical 5-chamber and 3-chamber,
Diastolic Function and in some cases, subcostal SAX AV. The TEE examination
Assessment of LV filling pressure and diastolic function in involves the ME AV SAX, ME AV LAX, and deep transgas-
the hemodynamically unstable patient4 can be estimated tric views. TTE mitral valve assessment is performed via
by measurement of the early diastolic maximal transmi- the parasternal LAX, parasternal SAX (basal view), apical
tral flow velocity (E) and the early diastolic tissue velocity 4 chamber, and apical 2 chamber. TEE interrogation of the
of the mitral valve annulus (e’). In an apical 4-chamber or mitral valve involves the ME 4-chamber, ME commissural,
midesophageal (ME) 4-chamber TEE view, pulsed-wave ME 2-chamber, ME AV LAX, and transgastric SAX (basal)
Doppler may be used to measure the transmitral flow views.

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SOCCA Recommendations for Critical Care Ultrasound Training

Table 5.  Learning Goals and Expected Competencies: Cardiac Ultrasound Views and Anatomy
Procedural transesophageal echocardiography views and
Procedural transthoracic echocardiogram views and anatomy to identify anatomy to identify
• Parasternal long axis—evaluation of pericardium, anteroseptal, • Midesophageal aortic valve short axis—evaluation of AV, left atrium,
and posterior LV walls, right ventricle, left atrium, MV, LVOT, AV, and tricuspid valve, RV, and pericardium
ascending aorta • Midesophageal AV long axis—evaluation of LVOT, AV, proximal
• Parasternal short axis—evaluation of pericardium, left and right ascending aorta, pericardium, anteroseptal and posterior LV walls, left
ventricles, and regional LV walls atrium, and MV
• Apical 4 chamber—evaluation of lateral and septal LV walls, MV, left • Bicaval view—evaluation of IVC (including intrahepatic portion) right
atrium, RV, tricuspid valve, right atrium, and pericardium atrium, SVC, fossa ovalis, left atrium, and pericardium
• Apical 5 chamber—evaluation of LVOT and AV • Right ventricular inflow---outflow—evaluation of right atrium, tricuspid
• Apical 2 chamber—evaluation of inferior and anterior LV walls, left valve, RV, pulmonic valve, left atrium, AV, and pericardium
atrium, MV, and pericardium • Midesophageal 4 chamber—evaluation of lateral and septal LV walls,
• Apical 3 chamber—evaluation of inferolateral and anteroseptal LV MV, left atrium, right atrium, tricuspid valve, RV, and pericardium.
walls, left atrium, MV, LVOT, AV, and pericardium • Midesophageal 2 chamber—evaluation of anterior and inferior LV walls,
• Subcostal 4 chamber—evaluation of pericardium, LV, MV, left atrium, left atrium, left atrial appendage, MV, and pericardium
RV, right atrium, and tricuspid valve • Transgastric short-axis—evaluation of pericardium and regional wall
• Subcostal IVC—evaluation of IVC and right atrium motion
• Descending aorta short-axis—evaluation of thoracic descending aorta
and pleural spaces
• Aortic arch long-axis—evaluation of aortic arch and main PA
• Pulmonary artery long-axis—evaluation of main, right, and left PA and
the ascending aorta
LV = left ventricle; RV = right ventricle; MV = mitral valve; IVC = inferior vena cava; PA = popliteal artery; SVC = superior vena cava; LVOT = left ventricle outflow
track; AV = aortic valve.

Figure 4. Critical care ultrasound transthoracic

echocardiograph views. PS LAX = parasternal long
axis; PS AV SAX = parasternal aortic valve short
axis; PS SAX = parasternal short axis; AP 4Ch =
apical 4 chamber; AP 2Ch = apical 2 chamber; AP
3Ch = apical 3 chamber; SC 4Ch = subcostal 4
chamber; SC IVC = subcostal inferior vena cava;
Liv = liver; IVC = inferior vena cava; RA = right
atrium; Dia = diaphragm.

Aortic Stenosis diameter larger than two-thirds of the LVOT diameter and
AS is detected in LAX and SAX views by identifying cal- holodiastolic flow reversal in the aortic arch.56
cified left, right, and noncoronary leaflets and restricted
leaflet motion. Color-flow Doppler (CFD) will reveal turbu- Mitral Stenosis
lent flow from the AV into the proximal ascending aorta. MS may be identified by calcification/thickening of mitral
Continuous-wave Doppler (CWD) velocity measurements, valve leaflets and restricted mitral leaflet opening. The
taken in the apical 5-chamber view by TTE or the deep trans- severity of MS can be quantified by measuring the trans-
gastric view by TEE, may provide more quantitative infor- mitral gradient in diastole with CWD. A mean transmitral
mation, with severe AS defined as peak aortic velocities >4 diastolic gradient >10 mm Hg is indicative of severe MS.
m/s.55 However, in patients with low CO states, measured However, when severe MR is present, the transmitral gradi-
velocity across the AV may underrepresent the severity of ent will be artifactually increased because of increased flow.
AS because of reduced aortic outflow.
Mitral Regurgitation
Aortic Insufficiency MR or insufficiency is assessed by evaluation of anterior
Aortic insufficiency is assessed by CFD. Moderate-to-severe and posterior leaflet coaptation and by using CFD to
aortic insufficiency will be characterized by a vena contracta determine the shape of the regurgitant jet. The severity of

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Figure 5. Critical care ultrasound transesopha-

geal echocardiograph views. ME 4 chamber =
midesophageal 4 chamber; ME AV SAX = mid-
esophageal aortic valve short axis; ME 2 cham-
ber = midesophageal 2 chamber; ME AV LAX =
midesophageal aortic valve long axis; RV inflow/
outflow = right ventricular inflow and outflow; ME
bicaval = midesophageal bicaval; TG SAX = trans-
gastric short axis; dTA SAX = descending thoracic
aorta short axis; PA LAX = pulmonary artery long
axis.

Table 6.  Learning Goals and Expected Competencies: Cardiac Ultrasound Assessment

Procedural routine measurements Thoracic anatomy and pathology Diagnostics
• Identify normal anatomic structures and • Identify cardiac arrest • Identify LV failure and associated findings
chamber sizes • Identify and characterize intravascular volume • Identify RV failure and associated findings,
• Identify normal left and right ventricular abnormalities by ventricular filling and IVC including RV failure from acute PE and cor
contraction size with respiratory variation pulmonale
• Estimate LV and RV systolic pressures (MV • Identify significant wall motion abnormalities • Assess LV or RV dysfunction in septic shock
inflow and TV peak regurgitation, respectively) • Identify pericardial effusion, tamponade, and • Identify traumatic aortic disruption,
associated findings mediastinal hematoma, and hemopericardium
• Identify and characterize severe valvular
dysfunction
LV = left ventricle; RV = right ventricle; MV = mitral valve; TV = tricuspid valve; IVC = inferior vena cava; PE = pulmonary embolism.

Table 7.  Learning Goals for Focused Transthoracic Ultrasound During Shock

Procedural view To be rapidly assessed Diagnostics
• Parasternal long axis • Pericardial space, right ventricular size and • Global LV size and function
• Parasternal short axis function, left ventricular size and function, • Global RV size and function
• Apical 4-, 2-, and 3-chamber view mitral and aortic valves, and proximal aortic • Volume status, LV and RV filling, IVC variability
size and size
• LV, RV, intraventricular septum, and pericardial • Pericardial effusion
space • Pericardial tamponade
• RV and LV, right and left atrium, tricuspid • Gross valvular function
valve, mitral valve, and aortic valve • Assess LV or RV dysfunction in septic shock
• Identify traumatic aortic disruption,
mediastinal hematoma (TEE) and
hemopericardium
LV = left ventricle; RV = right ventricle; IVC = inferior vena cava; TEE = transesophageal echocardiography.

MR is affected by LV afterload, which can vary depend- mitral valve lesions may require consultation of another
ing on positive-pressure mechanical ventilation, positive subspecialist with echocardiographic expertise.
or negative inotropic support, vasopressors, or vasodila-
tors. Cardiogenic shock resulting from severe acute MR Tricuspic Regurgitation
is usually caused by papillary muscle rupture, trauma, Severe TR can be associated with symptoms of venous con-
or endocarditis.57 CFD is a simple means to visualize gestion (e.g., hepatic congestion, peripheral edema, and jug-
systolic regurgitation into the left atrium. Complicated ular venous distention). TR can be qualitatively described

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SOCCA Recommendations for Critical Care Ultrasound Training

Table 8.  Sample Curriculum for Critical Care Ultrasound

Title Type Time or no.
Equipment and artifacts Didactic 30 min
Equipment and artifacts practicala Wet lab 15 min
Vascular ultrasound Didactic 45 min
Vascular ultrasound practicala Wet lab 30 min
Vascular ultrasound study review Exam 10
Vascular ultrasound study performance Exam 10
Abdominal ultrasound Didactic 90 min
Abdominal ultrasound practicala Wet lab 60 min
Abdominal ultrasound study review Exam 30
Abdominal ultrasound study performance Exam 30
Lung and pleural ultrasound Didactic 45 min
Lung and pleural ultrasound practicala Wet lab 30 min
Lung and pleural ultrasound study review Exam 10
Lung and pleural ultrasound study performance Exam 10
Transthoracic echocardiographic views and anatomy Didactic 90 min
Transthoracic echocardiographic views and anatomya Wet lab 90 min
Transesophageal echocardiographic views and anatomyb Didactic 60 min
Transesophageal echocardiographic views and anatomyab Wet lab 60 min
Transthoracic and transesophageal echocardiographic pathology Didactic 120 min
Transthoracic echocardiographic study review Exam 50
Transthoracic echocardiographic study performance Exam 50
Transesophageal echocardiographic study reviewb Exam 50
Transesophageal echocardiographic study performanceb Exam 50
Critical care ultrasound quality assurance and quality improvement Meeting At least quarterly
a
May include simulation sessions.
b
Strongly suggested, but not required.

as severe when the regurgitant jet occupies more than two- of ongoing shock or arrest. Valvular abnormalities causing
thirds of the area of the RA. arrest would likely be catastrophically severe. (See previ-
ous section for more information on valvular interrogation.)
Tricuspid Stenosis Acute MR from a papillary muscle rupture or acute MR
Tricuspid stenosis can be suspected when leaflet thicken- and aortic regurgitation from endocarditis could result in
ing or limited leaflet opening is observed in the setting of profound shock or cardiac arrest. Severe aortic and mitral
signs and symptoms of venous congestion. Quantification stenosis may be a rare cause of primary arrest, but it may
by velocities and estimated pressure gradients is of limited prolong arrest or shock states that occur for nonvalvular
value. reasons. After ROSC, the ascending and descending aorta
should be examined again with TEE for aortic dissection. LV
Echocardiographic Evaluation During and RV dysfunction after ROSC may be the primary inciting
Cardiopulmonary Arrest event or postarrest or posthypoxic myocardial stunning.58
During cardiac arrest and in the periarrest period, echocar- Echocardiographic findings suggestive of acute pulmonary
diography can noninvasively and rapidly provide a large embolism as a cause of circulatory collapse include acute
quantity of critical information that is easier to interpret RV dysfunction (TTE and TEE) and clot in the main and
than indirect measures such as direct visualization of peri- right pulmonary artery (TEE).
cardial fluid (as a sign of tamponade rather than equaliza- Hypertrophic obstructive cardiomyopathy and systolic
tion of intracardiac pressures) or acute RV dilation and anterior motion of the mitral valve are uncommon but
McConnell’s sign (as a sign of pulmonary embolism ver- potentially treatable causes of circulatory collapse. Aortic
sus spiral computed tomography scan). In both scenar- outflow obstruction or turbulent subvalvular flow can be
ios, TTE may more rapidly facilitate therapeutic decision generated in patients with small hypertrophic LVs who
making.25,56–58 are hypovolemic and/or tachycardic and may be assessed
The first step in echocardiographic evaluation during by a high CWD gradient in the LVOT. These high systolic
cardiac arrest is to compare the rhythm seen on the electro- flow velocities can lead to motion of the anterior mitral leaf-
cardiogram with the ventricular contraction pattern visual- let into the aortic outflow tract (systolic anterior motion),
ized by echocardiography and the presence or absence of resulting in subaortic obstruction and severe MR. With cor-
a palpable pulse: asystole versus pulseless electrical activ- rection of hypovolemia, discontinuation of inotropic drugs,
ity versus pseudopulseless electrical activity (ventricular and increased afterload, this dynamic and functional sys-
electrical and mechanical activity that generates no pulse).7 tolic outflow obstruction decreases and can be observed
The next step is to assess the cause of arrest, looking closely using CWD in LAX views through the LVOT.
for evidence of conditions such as cardiac tamponade, pul- One of the limitations of ultrasound assessment dur-
monary embolism, pneumothorax, or aortic dissection. ing cardiac arrest is the challenge of imaging the heart and
Upon return of spontaneous circulation (ROSC), a more lungs during chest compressions. Neither TTE nor TEE
complete examination can further explore potential causes should interfere with ongoing advanced cardiovascular

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life support. However, the use of TEE allows fewer and feedback and encouragement, support optimal interpre-
shorter interruptions in cardiopulmonary resuscitation and tation, and review and endorse the documentation in the
should probably be the primary echocardiographic choice patients’ records.
when equipment is available. Echocardiographic evaluation The amount of didactic teaching time that is recom-
of circulatory arrest is appropriate as a diagnostic adjunct mended by most groups to provide new trainees with an
when treating any patient who has cardiopulmonary arrest. appropriate introduction to CCUS ranges from 4 to 10 hours
for echocardiography. The recommended times take into
Cardiac Function in Septic Shock consideration the depth of the training, which ranges from
Myocardial depression with sepsis peaks within the first basic 2D assessment63–65 to semiquantitative evaluation
few days and resolves in survivors by 7 to 10 days. Unlike using CFD, CWD, and pulse Doppler.11,67,68 Given the scope
classic cardiogenic shock, it is associated with low or nor- of focused echocardiography proposed in these sugges-
mal filling pressures.55,56 Septic cardiomyopathy occurs in tions, we recommend a total didactic time of no <10 hours
the majority of patients with septic shock during the first 3 for goal-directed echocardiography. Our recommendation
days, with most cases occurring in the first 48 hours.57 Often, is in line with previous proposals and also with the recent
sepsis-induced decreases in afterload can mask myocardial guidelines for vascular ultrasound and TU.65,67–70
dysfunction until administration of vasoconstrictive drugs
exposes a poorly contracting ventricle. Serial assessments Mastering Interpretation Skills
of myocardial function are necessary because myocardial To acquire the skills necessary for interpreting transthoracic
dysfunction can change rapidly in the early phases of septic or transesophageal ultrasound examinations, repetition
shock. The relationship between ventricular function dur- and exposure to a wide range of normal and pathologic
ing sepsis (hyperkinetic or hypokinetic) and survival is not anatomy are necessary. To achieve facility within a reason-
yet clear.55,57,59,60 Because the ventricular dysfunction of sep- able amount of time, supervised performance and review
sis affects both LVs and RVs, changes in chamber volumes of many patient examples are needed, both of which can be
and pressures should be closely monitored when trying to provided in different forms and are most efficiently deliv-
establish optimal preload.55,56,61 ered when an experienced supervisor instructs multiple
Rapid assessment of hemodynamic instability in sep- trainees at one time. These high-volume sessions should
tic shock should also be part of a complete CCUS curricu- review a number of archived studies, with and without
lum for trainees, as shown in Table 1. Learning goals and pathology, conducted in a quiet private room to encourage
expected competencies for rapid assessment of hemody- discussion. These supervised reading sessions will serve the
namic instability in septic shock are shown in Table 8. dual purpose of facilitating the interpretation and journal
documentation of the ultrasound studies and as quality
Levels of Training assurance. The didactic and case review sessions should be
A practical understanding of ultrasound physics, choice of organized and scheduled on a regular basis.
appropriate images, and image interpretation in the con-
text of differential diagnosis are the requirements for CCUS Mastering Technical Skills
competency. During the initial phase of training, learners should perform
The components of any curriculum that focuses on a series of ultrasound examinations under direct supervi-
image acquisition and interpretation should include funda- sion of an experienced clinical ultrasound supervisor. There
mentals of ultrasound physics, cardiac anatomy, and physi- is evidence to support that 12 hours spent with an expert
ology in addition to recognition of normal versus abnormal sonographer during this initial phase is sufficient.71 In the
findings. These topics can be taught via didactic sessions second phase, the learner can perform examinations and
attended locally,62–64 attendance at external courses,65 certi- record images with less oversight, but they should continue
fication through online courses, or taught using ultrasound to record their examinations and review the images (both
simulators.66 for quality and interpretation) with a senior colleague at a
Teaching in the home department should be conducted later time. They should also continue to participate in qual-
using a combination of lectures, bedside demonstration ity assurance discussions that specifically address aspects of
with trainee participation and supervisor oversight, fre- ultrasound image acquisition and analysis. The numbers of
quent repetition of specific predetermined teaching points, studies that are needed until a learner can perform, record,
case presentations, and grouped review of archived video and interpret a CCUS examination independently will vary
recordings of ICU ultrasound examinations. All sessions greatly from learner to learner. It typically takes between
should be supervised by an experienced intensivist or group 30 and 50 independently performed examinations before
of intensivists with responsibility for teaching, patient doc- learners feel as though they have some mastery of simple
umentation, and quality assurance for ultrasound diagnos- image acquisition. Practicing on normal volunteers can be
tics. This type of ICU-based ultrasound teaching/learning useful at the beginning of ultrasound training although
system requires several elements, such as well-maintained the majority of examinations in the training phase should
and easily accessible ultrasound machines in the ICU, a be performed on critically ill patients. Although not neces-
robust system for recording and archiving examinations, sary, an echocardiography simulator can be useful in help-
and a reading station, where a senior intensive care spe- ing learners understand the anatomy, spatial reasoning, and
cialist, who is an experienced supervisor for ultrasound equipment manipulation.
learners, can review all the archived ultrasound studies A critical care fellow should perform ≥50 examinations
together with the individuals who performed them, provide during their training, each reviewed with a local expert in

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SOCCA Recommendations for Critical Care Ultrasound Training

CCUS or a surrogate supervisor. If considered necessary by that for future ACCM practitioners to be recognized as
the supervisor, >50 studies may be required in the train- experts in the diagnosis and treatment of acute critical ill-
ing phase to acquire technical mastery. Each trainee should ness, ultrasound diagnostic techniques should be included
maintain a log of all supervised and independent examina- in the formal ACCM learning goals for training programs.
tions, including the final diagnosis for each examination. Improving and standardizing CCUS training and prac-
The log should include a number of normal examinations as tice are matters of both patient safety and professional
well as a wide range of abnormal findings. Final proficiency development.E
should be identified and documented by the person respon-
sible for the ACCM training program in their institution. DISCLOSURES
Name: R. Eliot Fagley, MD.
Instructors Contribution: This author helped design the study, conduct the
Once a CCUS teaching curriculum is established, bedside study, analyze the data, and write the manuscript.
teaching can be provided by instructor(s) with a critical care Attestation: R. Eliot Fagley approved the final manuscript.
background from anesthesiology, cardiology, surgery, emer- Name: Michael F. Haney, MD, PhD.
gency medicine, or internal medicine. The instructor should Contribution: This author helped design the study, conduct the
have experience with focused examinations and should study, analyze the data, and write the manuscript.
be familiar with critical care interventions in response to Attestation: Michael F. Haney approved the final manuscript.
abnormal findings. It is ultimately the responsibility of Name: Anne-Sophie Beraud, MD, MS.
the ACCM faculty, rather than other potential teachers of Contribution: This author helped conduct the study, analyze
ultrasound, to ensure both optimal patient care and optimal the data, and write the manuscript.
training of ACCM fellows. Therefore, as with the introduc- Attestation: Anne-Sophie Beraud approved the final
tion of any new diagnostic or treatment modality into the manuscript.
ICU, 1 or more members of the ACCM physician staff will Name: Thomas Comfere, MD.
need to prepare themselves to serve as supervisors for the Contribution: This author helped design the study, conduct the
study, analyze the data, and write the manuscript.
basic aspects of ultrasound signal acquisition and interpre-
Attestation: Thomas Comfere approved the final manuscript.
tation in the ICU.
Name: Benjamin Adam Kohl, MD.
Contribution: This author helped design the study, conduct the
Equipment study, analyze the data, and write the manuscript.
Necessary equipment for the successful incorporation of Attestation: Benjamin Adam Kohl approved the final
CCUS into an ICU includes: the ultrasound machines them- manuscript.
selves; appropriate transducers for vascular, cardiac, and Name: Matthias Johannes Merkel, MD, PhD.
transesophageal examinations; an image archiving system; Contribution: This author helped design the study, conduct the
and ready access to archived examinations in a location ame- study, analyze the data, and write the manuscript.
nable to teaching. All CCUS examinations should be inter- Attestation: Matthias Johannes Merkel approved the final
preted and their results reported in a standardized manner. manuscript.
A preliminary report may be completed by the trainee but Name: Aliaksei Pustavoitau, MD, MHS.
should be finalized with expert review. The report should Contribution: This author helped design the study, conduct the
be archived with the examination images. study, analyze the data, and write the manuscript.
Attestation: Aliaksei Pustavoitau approved the final
DISCUSSION manuscript.
As with other aspects of ACCM practice and teaching in Name: Peter von Homeyer, MD.
the ICU, CCUS practice and teaching should be multidisci- Contribution: This author helped conduct the study, analyze
plinary and include local experts from anesthesiology, inter- the data, and write the manuscript.
nal medicine critical care, surgery critical care, cardiology, Attestation: Peter von Homeyer approved the final manuscript.
vascular surgery, and emergency medicine according to Name: Chad Edward Wagner, MD.
their formal supervisory and teaching roles for ACCM fel- Contribution: This author helped design the study, conduct the
lows. The final responsibility for this aspect of ACCM train- study, analyze the data, and write the manuscript.
ing resides with those responsible for the ACCM fellowship Attestation: Chad Edward Wagner approved the final
in each institution. This responsibility includes assuring manuscript.
availability of training material and equipment in the work- Name: Michael H. Wall, MD.
Contribution: This author helped design the study, conduct the
place. Communicating expectations, clear learning goals for
study, analyze the data, and write the manuscript.
trainees, and provision of means to achieve those goals are
Attestation: Michael H. Wall approved the final manuscript.
the responsibilities of the ACCM fellowship program direc-
This manuscript was handled by: Avery Tung, MD.
tors and departmental leadership.
In this review, a SOCCA expert group proposed a set of REFERENCES
learning goals and expectations for both ACCM trainees 1. Goldberg BB, Goodman GA, Clearfield HR. Evaluation of asci-
and fellowship programs concerning modern CCUS. These tes by ultrasound. Radiology 1970;96:15–22
goals are based on published literature and are similar to 2. Kristensen JK, Buemann B, Kuhl E. Ultrasonic scanning
in the diagnosis of splenic haematomas. Acta Chir Scand
those proposed by other acute medical specialties. ACCM 1971;137:653–7
practice and training has seen the widespread introduction 3. Roelandt JR. Ultrasound stethoscopy: a renaissance of the
of informal diagnostic ultrasound use in ICUs. We conclude physical examination? Heart 2003;89:971–3

May 2015 • Volume 120 • Number 5 www.anesthesia-analgesia.org 1051

E SPECIAL ARTICLE

4. Ballard RB, Rozycki GS, Knudson MM, Pennington SD. The 25. Katsamouris AN, Giannoukas AD, Tsetis D, Kostas T,

surgeon’s use of ultrasound in the acute setting. Surg Clin Petinarakis I, Gourtsoyiannis N. Can ultrasound replace arte-
North Am 1998;78:337–64 riography in the management of chronic arterial occlusive dis-
5. Feller-Kopman D. Ultrasound-guided thoracentesis. Chest ease of the lower limb? Eur J Vasc Endovasc Surg 2001;21:155–9
2006;129:1709–14 26. Mintz GS, Kotler MN, Parry WR, Iskandrian AS, Kane SA.
6. Barillari A, Fioretti M. Lung ultrasound: a new tool for the Reat-time inferior vena caval ultrasonography: normal and
emergency physician. Intern Emerg Med 2010;5:335–40 abnormal findings and its use in assessing right-heart function.
7. Labovitz AJ, Noble VE, Bierig M, Goldstein SA, Jones R, Kort Circulation 1981;64:1018–25
S, Porter TR, Spencer KT, Tayal VS, Wei K. Focused cardiac 27. Kircher BJ, Himelman RB, Schiller NB. Noninvasive estimation
ultrasound in the emergent setting: a consensus statement of right atrial pressure from the inspiratory collapse of the infe-
of the American Society of Echocardiography and American rior vena cava. Am J Cardiol 1990;66:493–6
College of Emergency Physicians. J Am Soc Echocardiogr 28. Bendjelid K, Romand JA, Walder B, Suter PM, Fournier G.
2010;23:1225–30 Correlation between measured inferior vena cava diameter and
8. Lai WW, Geva T, Shirali GS, Frommelt PC, Humes RA, Brook right atrial pressure depends on the echocardiographic method
MM, Pignatelli RH, Rychik J; Task Force of the Pediatric Council used in patients who are mechanically ventilated. J Am Soc
of the American Society of Echocardiography; Pediatric Council Echocardiogr 2002;15:944–9
of the American Society of Echocardiography. Guidelines and 29. Pinsky MR. Hemodynamic evaluation and monitoring in the
standards for performance of a pediatric echocardiogram: ICU. Chest 2007;132:2020–9
a report from the Task Force of the Pediatric Council of the 30. Feissel M, Michard F, Faller JP, Teboul JL. The respiratory varia-
American Society of Echocardiography. J Am Soc Echocardiogr tion in inferior vena cava diameter as a guide to fluid therapy.
2006;19:1413–30 Intensive Care Med 2004;30:1834–7
9. Mallory DL, McGee WT, Shawker TH, Brenner M, Bailey KR, 31. Nazeer SR, Dewbre H, Miller AH. Ultrasound-assisted para-
Evans RG, Parker MM, Farmer JC, Parillo JE. Ultrasound centesis performed by emergency physicians vs the traditional
guidance improves the success rate of internal jugular technique: a prospective, randomized study. Am J Emerg Med
vein cannulation. A prospective, randomized trial. Chest 2005;23:363–7
1990;98:157–60 32. Rozycki GS, Ballard RB, Feliciano DV, Schmidt JA, Pennington
10. Statement on ultrasound examinations by surgeons. Committee SD. Surgeon-performed ultrasound for the assessment of
on Emerging Surgical Technology and Education, American truncal injuries: lessons learned from 1540 patients. Ann Surg
College of Surgeons. Bull Am Coll Surg 1998;83:37–40 1998;228:557–67
11. Mayo PH, Beaulieu Y, Doelken P, Feller-Kopman D, Harrod C, 33. Brivet FG, Kleinknecht DJ, Loirat P, Landais PJM. Acute renal
Kaplan A, Oropello J, Vieillard-Baron A, Axler O, Lichtenstein failure in intensive care units—causes, outcome, and prog-
D, Maury E, Slama M, Vignon P. American College of Chest nostic factors of hospital mortality: a prospective, multicenter
Physicians/La Société de Réanimation de Langue Française study. Crit Care Med 1996;24:192–8
statement on competence in critical care ultrasonography. 34. Han MK, Hyzy R. Advances in critical care management of
Chest 2009;135:1050–60 hepatic failure and insufficiency. Crit Care Med 2006;34:S225–31
12. Physicians ACoE. Use of ultrasound imaging by emergency 35. Rozycki GS, Ochsner MG, Schmidt JA, Frankel HL, Davis

physicians. Ann Emerg Med 2001;4:469–70 TP, Wang D, Champion HR. A prospective study of surgeon-
13. Lawrence JP. Physics and instrumentation of ultrasound. Crit performed ultrasound as the primary adjuvant modality for
Care Med 2007;35:S314–22 injured patient assessment. J Trauma 1995;39:492–8
14. Cahalan MK, Stewart W, Pearlman A, Goldman M, Sears-
36. Lichtenstein DA. Ultrasound in the management of thoracic
Rogan P, Abel M, Russell I, Shanewise J, Troianos C; disease. Crit Care Med 2007;35:S250–61
Society of Cardiovascular Anesthesiologists; American 37. Reissig A, Kroegel C. Sonographic diagnosis and follow-up of
Society of Echocardiography Task Force. American Society pneumonia: a prospective study. Respiration 2007;74:537–47
of Echocardiography and Society of Cardiovascular 38. Gardelli G, Feletti F, Nanni A, Mughetti M, Piraccini A,

Anesthesiologists task force guidelines for training in perioper- Zompatori M. Chest ultrasonography in the ICU. Respir Care
ative echocardiography. J Am Soc Echocardiogr 2002;15:647–52 2012;57:773–81
15. Aldrich JE. Basic physics of ultrasound imaging. Crit Care Med 39. Lichtenstein DA, Mezière G, Lascols N, Biderman P, Courret JP,
2007;35:S131–7 Gepner A, Goldstein I, Tenoudji-Cohen M. Ultrasound diagno-
16. Kremkau FW, Taylor KJ. Artifacts in ultrasound imaging.
sis of occult pneumothorax. Crit Care Med 2005;33:1231–8
J Ultrasound Med 1986;5:227–37 40. Lichtenstein DA, Menu Y. A bedside ultrasound sign ruling out
17. Randolph AG, Cook DJ, Gonzales CA, Pribble CG. Ultrasound pneumothorax in the critically ill. Chest 1995;108:1345–8
guidance for placement of central venous catheters: a meta- 41. Jensen MB, Sloth E, Larsen KM, Schmidt MB. Transthoracic
analysis of the literature. Crit Care Med 1996;24:2053–8 echocardiography for cardiopulmonary monitoring in inten-
18. Shiloh AL, Savel RH, Paulin LM, Eisen LA. Ultrasound-guided sive care. Eur J Anaesthesiol 2004;21:700–7
catheterization of the radial artery. Chest 2011;139:524–9 42. Melamed R, Sprenkle MD, Ulstad VK, Herzog CA, Leatherman
19. Milling TJ Jr, Rose J, Briggs WM, Birkhahn R, Gaeta TJ, Bove JW. Assessment of left ventricular function by intensivists using
JJ, Melniker LA. Randomized, controlled clinical trial of point- hand-held echocardiography. Chest 2009;135:1416–20
of-care limited ultrasonography assistance of central venous 43. Orme RM, Oram MP, McKinstry CE. Impact of echocardiogra-
cannulation: the Third Sonography Outcomes Assessment phy on patient management in the intensive care unit: an audit
Program (SOAP-3) Trial. Crit Care Med 2005;33:1764–9 of district general hospital practice. Br J Anaesth 2009;102:340–4
20. Feller-Kopman D. Ultrasound-guided central venous cath-
44. Griffee MJ, Merkel MJ, Wei KS. The role of echocardiography
eter placement: the new standard of care? Crit Care Med in hemodynamic assessment of septic shock. Crit Care Clin
2005;33:1875–7 2010;26:365–82
21. Maecken T, Grau T. Ultrasound imaging in vascular access. Crit 45. Goodkin GM, Spevack DM, Tunick PA, Kronzon I. How use-
Care Med 2007;35:S178–85 ful is hand-carried bedside echocardiography in critically ill
22. Tracy JA, Edlow JA. Ultrasound diagnosis of deep venous
patients? J Am Coll Cardiol 2001;37:2019–22
thrombosis. Emerg Med Clin North Am 2004;22:775–96 46. Mayo PH. Training in critical care echocardiography. Ann

23. Kory PD, Pellecchia CM, Shiloh AL, Mayo PH, DiBello C,
Intensive Care 2011;1:36
Koenig S. Accuracy of ultrasonography performed by critical 47. Douglas PS, Khandheria B, Stainback RF, Weissman NJ, Brindis
care physicians for the diagnosis of DVT. Chest 2011;139:538–42 RG, Patel MR, Alpert JS, Fitzgerald D, Heidenreich P, Martin ET,
24. Jacoby J, Cesta M, Axelband J, Melanson S, Heller M, Reed J. Messer JV, Miller AB, Picard MH, Raggi P, Reed KD, Rumsfeld
Can emergency medicine residents detect acute deep venous JS, Steimle AE, Tonkovic R, Vijayaraghavan K, Yeon SB, Hendel
thrombosis with a limited, two-site ultrasound examination? J RC, Peterson E, Wolk MJ, Allen JM. ACCF/ASE/ACEP/
Emerg Med 2007;32:197–200 ASNC/SCAI/SCCT/SCMR 2007 appropriateness criteria for

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SOCCA Recommendations for Critical Care Ultrasound Training

transthoracic and transesophageal echocardiography: a report transesophageal echocardiography during cardiopulmonary

of the American College of Cardiology Foundation Quality resuscitation. J Am Coll Cardiol 1997;30:780–3
Strategic Directions Committee Appropriateness Criteria 58. Jardin F, Brun-Ney D, Auvert B, Beauchet A, Bourdarias

Working Group, American Society of Echocardiography, JP. Sepsis-related cardiogenic shock. Crit Care Med
American College of Emergency Physicians, American 1990;18:1055–60
Society of Nuclear Cardiology, Society for Cardiovascular 59. Parillo J, Parker M, Natanson C, Suffredin IA, Danner R,

Angiography and Interventions, Society of Cardiovascular Cunnion R, Ognibene F. Septic shock in humans: advances in
Computed Tomography, and the Society for Cardiovascular the understanding of pathogenesis, cardiovascular dysfunction
Magnetic Resonance Endorsed by the American College of and therapy. Ann Intern Med 1990;113:227–42
Chest Physicians and the Society of Critical Care Medicine. 60. Lancellotti P, Moura L, Pierard LA, Agricola E, Popescu BA,
J Am Soc Echocardiogr 2007;20:787–805 Tribouilloy C, Hagendorff A, Monin JL, Badano L, Zamorano
48. Nordanstig J, Rantapaa Dahlqvist S. Nomenclature for tomo- JL; European Association of Echocardiography. European
graphic imaging of the heart: a statement for healthcare pro- Association of Echocardiography recommendations for the
fessionals from the cardiac imaging committee of the council assessment of valvular regurgitation. Part 2: mitral and tricus-
on clinical cardiology of the American Heart Association. pid regurgitation (native valve disease). Eur J Echocardiogr
Circulation 2002;16:539–42 2010;11:307–32
49. Shanewise JS, Cheung AT, Aronson S, Stewart WJ, Weiss RL, 61. Jones AE, Tayal VS, Kline JA. Focused training of emergency
Mark JB, Savage RM, Sears-Rogan P, Mathew JP, Quiñones medicine residents in goal-directed echocardiography: a pro-
MA, Cahalan MK, Savino JS. ASE/SCA guidelines for spective study. Acad Emerg Med 2003;10:1054–8
performing a comprehensive intraoperative multiplane 62. Vignon P, Mücke F, Bellec F, Marin B, Croce J, Brouqui T,

transesophageal echocardiography examination: recommen- Palobart C, Senges P, Truffy C, Wachmann A, Dugard A, Amiel
dations of the American Society of Echocardiography Council J-B. Basic critical care echocardiography: validation of a cur-
for Intraoperative Echocardiography and the Society of riculum dedicated to noncardiologist residents. Crit Care Med
Cardiovascular Anesthesiologists Task Force for Certification 2011;39:636–42
in Perioperative Transesophageal Echocardiography. Anesth 63. Vignon P, Dugard A, Abraham J, Belcour D, Gondran G, Pepino
Analg 1999;89:870–84 F, Marin B, François B, Gastinne H. Focused training for goal-
50. Ghio S, Recusani F, Klersy C, Sebastiani R, Laudisa ML,
oriented hand-held echocardiography performed by noncardi-
Campana C, Gavazzi A, Tavazzi L. Prognostic usefulness of the ologist residents in the intensive care unit. Intensive Care Med
tricuspid annular plane systolic excursion in patients with con- 2007;33:1795–9
gestive heart failure secondary to idiopathic or ischemic dilated 64. Royse CF, Haji DL, Faris JG, Veltman MG, Kumar A, Royse AG.
cardiomyopathy. Am J Cardiol 2000;85:837–42 Evaluation of the interpretative skills of participants of a limited
51. Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher
transthoracic echocardiography training course (H.A.R.T.scan
MD, Chandrasekaran K, Solomon SD, Louie EK, Schiller course). Anaesth Intensive Care 2012;40:498–504
NB. Guidelines for the echocardiographic assessment of the 65. Neelankavil J, Howard-Quijano K, Hsieh TC, Ramsingh D,

right heart in adults: a report from the American Society of Scovotti JC, Chua JH, Ho JK, Mahajan A. Transthoracic echocar-
Echocardiography endorsed by the European Association of diography simulation is an efficient method to train anesthesi-
Echocardiography, a registered branch of the European Society ologists in basic transthoracic echocardiography skills. Anesth
of Cardiology, and the Canadian Society of Echocardiography. Analg 2012;115:1042–51
J Am Soc Echocardiogr 2010;23:685–713 66. Expert Round Table on Ultrasound in ICU. International expert
52. Lau G, Ther G, Swanvelder J. McConnell’s sign in acute pulmo- statement on training standards for critical care ultrasonogra-
nary embolism. Anesth Analg 2013;116:982–5 phy. Intensive Care Med 2011;37:1077–83
53. Zoghbi WA, Enriquez-Sarano M, Foster E, Grayburn PA, Kraft 67. Au SM, Vieillard-Baron A. Bedside echocardiography in criti-
CD, Levine RA, Nihoyannopoulos P, Otto CM, Quinones MA, cally ill patients: a true hemodynamic monitoring tool. J Clin
Rakowski H, Stewart WJ, Waggoner A, Weissman NJ. American Monit Comput 2012;26:355–60
Society of Echocardiography: recommendations for evaluation 68. Troianos CA, Hartman GS, Glas KE, Skubas NJ, Eberhardt
of the severity of native valvular regurgitation with two-dimen- RT, Walker JD, Reeves ST, Echocardiography ftCoI,
sional and Doppler echocardiography: a report from the American Echocardiography VUotASo. Guidelines for performing
Society of Echocardiography’s Nomenclature and Standards ultrasound guided vascular cannulation: recommenda-
Committee and The Task Force on Valvular Regurgitation, tions of the American Society of Echocardiography and the
Developed in Conjunction with the American College of Society of Cardiovascular Anesthesiologists. Anesth Analg
Cardiology Echocardiography Committee, The Cardiac Imaging 2012;114:46–72
Committee, Council on Clinical Cardiology, The American Heart 69. Volpicelli G, Elbarbary M, Blaivas M, Lichtenstein DA, Mathis
Association, and the European Society of Cardiology Working G, Kirkpatrick AW, Melniker L, Gargani L, Noble VE, Via G,
Group on Echocardiography. Eur J Echocardiogr 2003;4:237–61 Dean A, Tsung JW, Soldati G, Copetti R, Bouhemad B, Reissig
54. Baumgartner H, Hung J, Bermejo J, Chambers JB, Evangelista A, A, Agricola E, Rouby JJ, Arbelot C, Liteplo A, Sargsyan A,
Griffin BP, Iung B, Otto CM, Pellikka PA, Quiñones M; EAE/ASE. Silva F, Hoppmann R, Breitkreutz R, Seibel A, Neri L, Storti
Echocardiographic assessment of valve stenosis: EAE/ASE recom- E, Petrovic T; International Liaison Committee on Lung
mendations for clinical practice. Eur J Echocardiogr 2009;10:1–25 Ultrasound (ILC-LUS) for International Consensus Conference
55. Lancellotti P, Tribouilloy C, Hagendorff A, Moura L, Popescu on Lung Ultrasound (ICC-LUS). International evidence-based
BA, Agricola E, Monin JL, Pierard LA, Badano L, Zamorano JL; recommendations for point-of-care lung ultrasound. Intensive
European Association of Echocardiography. European Association Care Med 2012;38:577–91
of Echocardiography recommendations for the assessment of val- 70. Beraud A-S, Rizk NW, Pearl RG, Liang DH, Patterson AJ.

vular regurgitation. Part 1: aortic and pulmonary regurgitation Focused transthoracic echocardiography during critical care
(native valve disease). Eur J Echocardiogr 2010;11:223–44 medicine training: curriculum implementation and evaluation
56. Price S, Nicol E, Gibson DG, Evans TW. Echocardiography in of proficiency. Crit Care Med 2013;41:e179–81
the critically ill: current and potential roles. Intensive Care Med 71. Malave SR, Neiman HL, Spies SM, Cisternino SJ, Adamo

2006;32:48–59 G. Diagnosis of hydronephrosis: comparison of radio-
57. van der Wouw PA, Koster RW, Delemarre BJ, de Vos R,
nuclide scanning and sonography. AJR Am J Roentgenol
Lampe-Schoenmaeckers AJ, Lie KI. Diagnostic accuracy of 1980;135:1179–85

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