SCCM Resource Library-Pro/Con: Is There Evidence for Critical Care Echocardiography?

Video Transcription

Hello, my name is Tony Hernandez. I'm with Vanderbilt University Medical Center. I want to thank the program committee of the site of critical care medicine for inviting me  to participate in this year's Congress, and especially to talk about this topic, which is dear to me. In terms of disclosures, I have no financial disclosures. I am a member  of the National Board of Echocardiography, the critical care echocardiography examination and certification committees. Also, I have an NIH KOA grant, and I'm to report to you  that I did not use any funds or time supported by this grant to prepare this presentation. So my approach for this presentation is to hit these four points. One is to make sure  that we have the same communication, that when we say critical care echocardiography, we are in fact referring to the same thing, because there's multiple terms out in the  literature that seem to be used equally. The role of critical care echo in rapid diagnosis  and management is something that we'll discuss, and then we'll move on to directing therapy at the right time and place. And last, we'll finish with the role of echocardiography and  the improvement of outcomes. Let me begin with the first point, and by saying that you change outcomes, not any of these tools. Echocardiography is a powerful  tool because it provides visual images, and we have a tendency to be visual learners. So the thing about echocardiography is that it allows us to transition from suspicion  to identification, seeing is believing. And what we've noted is that it allows us to narrow  that differential diagnosis promptly. However, I will say that experience and training seem  to play a key role for how powerful this technology is in the management of critically ill patients.  I'll use the example of the story of PA catheters and how they may hurt patients. There's a body  of literature that states that PA catheters do not help and might even hurt patients. One of the latter publications to make this point is the one by Paul Merrick, where he  describes a trial where he enrolls critical care physicians to interpret a simple pulmonary artery occlusion pressure tracing. And in fact, there's up to 50% disagreement in the  interpretation of this tracing. Here is the data where, and actually there's a big difference.  In this case, we want agreement with the contact experts and the critical care physicians enrolled  in the trial, but what you notice that there's a big difference. I bring this information  to you only because echocardiography is no different. You could absolutely generate incorrect  information that could lead to the wrong therapy for the patient. So it's important that you have  that skill set before making a decision. So how do we identify how much training and time is  required? This is just a slide showing what some of our cardiology colleagues do. And so for us,  we should be very facile in emergency echo, particularly in the field, the FATE, the FAST  exam. That's mandatory. But what we really should be striving for is something, quite frankly,  now expected is that we're at level one to level two in some cases. And look at the table at the  right upper corner where you note the months of training, the minimal TE exams that are required  for performance, and then also interpretation. It's quite a feat. I will tell you that for advanced perioperative transesophageal echocardiography, the goal there is 150  performed and 150 interpreted. So focused critical care echo involves the use of echocardiography  at the bedside. And what really separates this approach is that we perform this exam serially.  You identify a patient in shock, you do an exam, and then you collect your images and you lead to  an intervention, perhaps it's fluids, perhaps it's a diuretic or inotropes. And then 60 minutes later,  sooner or later, you repeat that exam and determine if your intervention actually led to the  response that you were looking for. The key is that it's typically involving emergent problems  in the critical care setting. Now, limited trans thoracic echocardiography is quite robust. It  just does not involve the same amount of views that a formal echo entails. And so you should  know that it's quite quantitative and robust. When you compare, for example, the focused cardiac  ultrasound, which is what we would do where you're not archiving images, you're essentially almost  like having a handheld and you're using this to enhance your physical exam. And you might put some  of the findings in your note versus on the limited trans thoracic echo, you're going to have somebody  with advanced qualifications, they're going to develop a report and include that in the medical  record and submit a bill. And lastly, happy consulting discussion with a primary service.  So where is critical care echocardiography? Well, we're nibbling at the heels of the light exam with  the limited TTE. That's what we are really targeting for so that you can have a meaningful  and advanced exam that can serve your patients better. So we've talked about what critical care  echocardiography is in current terms. Now let's look at the diagnosis, management, and  prognosis. So this publication talks about the use of echocardiography  in the emergency department, and they also use this outside of the hospital. And what they  identified is that when you have this technology available, it will influence what you do. In fact,  89% of the time, CPR was changed. There was something changed about CPR based on the images  developed. And in the periresuscitation period, it was 66%. This group goes on to report the true  PEA and the pseudo PEA, and they show the number of patients in the subcategories of pseudo PEA  and in terms of survival. Of note, this group of authors do not make the claim  that there is an associated benefit in mortality. Now, in a very recent publication by Philippe  Vignon, he talks about the role of critical care echo in diagnosis, but also in prognosis.  And I'm going to use one of his first figures in that paper to really show how this can be impactful  in a critical care setting. In image A, you have evidence of a large pericardial effusion. And so here he uses asterisks or arrows to illustrate the pathology. So in A, you see  a pericardial effusion with some evidence of tamponade. In B, the arrow points to a thrombus  that's identified with a dilated right ventricle and right atrium. In C, you notice there is a  dynamic outflow obstruction, in this case, generated from SAM, systolic anterior motion of the mitral valve. And we note this in patients who have end-stage renal disease  that are dependent on dialysis, and when they have acute volume shifts, they can develop this  pathology. In D, this is more, the stars represent the large thrombus in the mediastinum with some compression of the right heart chambers. In E, there's an intramural thrombus  as a result of a dissection in the ascending aorta. And F is a motor vehicle accident  patient who has a medial flap there at the ascending aorta. So, you know, a lot of times you have a suspicion of what you're going to find, but when you generate these images,  it really kind of solidifies your diagnosis, and you're able to do this promptly. And so that's  important. In terms of prognostication, I only included these references, but there are more where assessing diastolic function, or I should say identifying diastolic dysfunction  and the setting of septic shock is associated with increased mortality. So by employing this technology and making this assessment, we can actually identify those patients that  are expected to do poorly. Now, moving on to more advanced therapies in the ICU  and how we can use critical care echocardiography. For that, I'm going to discuss an example of  venous-venous ECMO. And here we're looking at a two-lumen cannula where you have a drainage port, and the, if you look at the image on the right, the drainage port in the IVC,  and then you have drainage ports in the SVC, and you have the outflow cannula where you would  have oxygen-rich blood directed across the tricuspid valve. So what's, if this is not,  if you don't have this port directing that blood flow, it is unlikely to be successful in oxygenating these patients. So this is a video for some of, from our colleagues in  Mayo Clinic in Florida, where they show that the use of transthoracic echo  is employed to reposition this type of cannula. And you notice here that the cannula is being  advanced into the IVC. Now, the proper position of this cannula is going to be determined again  by whether that blood flow coming back from the oxygenator is directed to the tricuspid valve. So  they have this follow-up video where they show the RV, the right atrium, and the tricuspid valve,  and they illustrate here nicely using superimposed color flow Doppler, how the flow is going across the tricuspid valve, which illustrates proper position of this cannula.  There are other technologies that are available for us, other support devices.  We use the Impella for cardiogenic shock for, you know, time to decision whether the patient will  be able to receive escalation of therapy, such as a transplant or a durable left ventricular support  device. Or sometimes we use these devices to drain the left ventricle in the setting of  venous to arterial ECMO. However, in order to do this, and this is a simple video to illustrate  the placement of this pump, it shows how it actually functions to drain and support the  left ventricle. This is typically advanced through the femoral artery, although there is a surgical  approach through the subclavian artery. And all these pumps function in the same capacity where  they drain blood from the left ventricle and displace it into the ascending aorta, thus reducing the work of the left heart. However, these devices do have a tendency to migrate,  and as such, it's important for us to assess the proper location. And so when there's a position or a suspected change in position of this particular device,  as noted when there's noted evidence of hemolysis or the patient's condition changes, we can easily do a transthoracic echo and verify that this device is three to four centimeters  within the left heart. So we talked a little bit about the role of echocardiography in management, prognostication, advanced therapies, but what about improved outcomes?  This question comes up often, and I do believe there's possibly a misunderstanding that there is  a large body of evidence that supports this. I will say I don't believe that there is a large  body of evidence that supports improved outcomes, but I will share some references here that suggest  that there is. Our colleagues in Canada had this publication, very nice paper, where they  do a very nice approach of limited echocardiography and these techniques that are quickly done and are reproducible. What they did is they did a historical control. They used the  2012 Surviving Sepsis Campaign Guidelines, and they looked at the survival in that group, and then they compared that to a limited echocardiography guided therapy approach.  What they found is an improvement in survival using echocardiography. Now again, this is not  a randomized control trial. This was a historical control, and aside from survival, one of the  things they noted is that there is a reduction in acute kidney injury, particularly stage three,  and this is not unique to this study. Other studies have demonstrated that when you use  echocardiography, you actually have a decreased amount of fluid therapy. Better stated, I would  say we avoid over-resuscitation of patients that seems to affect kidney injury and death. In this publication by Dr. Farada et al., they looked at a subpopulation of  traumatically brain injured patients, and in that group, in that subpopulation, they noted that there was more than 50% reduction in volume administration,  which seemed to be associated with a reduction in mortality, and I've highlighted this in their  table. One of the things that I believe is responsible for this is we, for the last 10 to 15 years, we've raised the bar further ahead, and we've allowed ourselves to really  have more judicious fluid administration when we use this technology, meaning echocardiography.  This group here looked at various modalities that we employ to assess volume responsiveness, and they compared them all, and what they identified is that when you look at aortic  blood flow variability, that this has the best sensitivity, but when you're looking at specificity,  it's the change in SVC diameter that gives you the best specificity, so when you combine them both,  it really gives you a nice recipe for identifying those patients that are going to be volume  responsive. Now, keep in mind, a lot of these techniques were described about a decade ago or  more in patients that were intubated and passively ventilated, and one of the issues as to why this  data is so mixed is because people were using that approach in spontaneously reading patients,  and I think as a community, we recognize that that was not proper, so again, the bar is raised yet  again, and we identify approaches that are more appropriate for those patients that are spontaneously breathing in the intensive care unit, and rather than identifying a different  formula, this group adopted a previously described formula, but they identified a different cutoff.  You notice in the intubated and passively ventilated patients, you might see a cutoff  of 12 to 18, depending on which approach you use. Here, they use 42, and this has been replicated  by another group, so again, just showing that we have a constant evolution of how we use this  technology, so going back to the use of this technology now in a more recent publication  in the emergency department, this group, and I'm going to show you very quickly the data from the  first group where they break down the pseudo-PEA, and they report the survival here. In this new  publication, they actually tell you the survival at different phases. They show you the recovery of  spontaneous circulation, survival at admission, and survival at discharge, and this is the kind  of data that I think people outside of medicine can get excited about in terms of, like, administrators  who might want to invest in this technology. This is the kind of data that would be a little bit  more meaningful for them. We will look at other aspects in addition to this, so there are data  that show worsening outcomes when you apply POCUS, and I use POCUS because that's what the term was  described in that particular study, and my colleague will talk more about this here in the con section, but I think the reason the data are mixed is because I'm not sure we're  comparing apples with apples. I think we use the term POCUS. You know, is it similar as focus  cardiac ultrasound? Is it the same as critical care ultrasound, or is that the same as focus  critical cardiac cardiography? So what I believe is we've had an evolution of our skill set and thus  also the terminology with most recently critical cardiac cardiography being the one, and so what that means is as a community we've continued to push that bar upward. So how do we  come to terms as to what defines an appropriate exam? I'm not suggesting this is the pathway, but this is a current pathway that emerged recently as various societies got together,  and we have representation from various societies, including ours, where there is a pathway for  certification to demonstrate competence in this area. Now this is not the first time the NVE has  done this. They've done this with TEE for perioperative physicians, most commonly anesthesiologists,  but there was a time when people were doing TEE without taking the test. Then they evolved to  taking the test was adequate, and then they evolved to where they said, you know, you really need a  certification, and we have a recertification to maintain our credentialing. So in summary, I just want to say overall there's a rising evidence that critical care echocardiography  contributes in a positive fashion to the management of critically ill patients.  I can't say there's a large body of evidence to support improved outcomes, but I'm very excited  about randomized controlled trials that are going to be emerging in the near future, because I think  at this point the bar is high, and we're able to capture those data points in a more granular  fashion. Lastly, I think what we really need to be thinking about is when we're doing this  echo in the ICU, we need to think of ourselves as consulting physicians, you know, providing a  consulting discussion, submitting a report, archiving images, and participating in credentialing,  which will likely be based on a certification pathway of some sort in the future. I want to  thank you for your time and attention, and I look forward for your questions. Thank you. Hello, my  name is Eric Hsu. I'm an assistant professor at the University of Texas Houston in the Montgomery  Medical School in the Department of Pediatrics. Today I will be debating whether or not there  is evidence for critical care echocardiography from the con side. This is a very interesting topic to me, and I really appreciate the invitation from the society to speak on it,  and with that we will begin. In terms of disclosures, I have none. I should mention that as a topic I have pursued a variety of educational and academic projects in this,  so I am actually one of the least qualified people to do this lecture, but this is what happens to  kids who are on the high school debate team when they grow up. To start, let's look at the premise  that echocardiography in the hands of intensivists is of clinical utility. The use of ultrasound in  emergency care has contributed to improvement in quality and value, specifically in regard to  procedural safety, timeliness of care, diagnostic accuracy, and cost reduction. This was stated in  the ASAP ultrasound guidelines in 2018 as an endorsement of the utility of the technology in routine clinical care, and certainly is propagated in that arena, but there are certain  premises that are made in these statements that we have to consider. It is accurate and consistent. It is teachable and distributable to the population of clinicians who are wanting  to put it into use, and it impacts patient care. Let's address the first question. Is it accurate?  In the evaluation of shock, we frequently encounter these ultrasound protocols for the differentiation of shock using critical care echocardiography. One of the fundamental aspects  of it is the basic assessment of functional status of the LV and the RV as well as effusion.  This is just an example of one of these protocols. It's the RUSH protocol that was proposed by Weingart et al in 2006. What it basically does is it looks at applying  phenotyping of shock based on ultrasound findings. Of course, a lot of these protocols  divide the general characteristics of the heart into several different aspects that we can look  for, and then based on the process of decision trees and categorizing what function is in this  example here in this first row, the pump, the qualification of whether or not the left ventricle  is acting as a good pump or a bad pump, and then further evaluating the quote-unquote tank,  the vascular space and its contents in terms of how well the volumic status of the patient  is addressed and whether or not there are additional interventions necessary, and then this question of pipes, the general quality of the vasculature itself and whether  or not there is something there that could be contributing to shock. When we take these various  factors, we're supposed to be able to develop a judgment from these findings that leads us to  a hemodynamic intervention, but let's just start with one aspect. One of the core aspects of this is contractility, so let's look at poor contractility. When we look at a heart,  there are a number of things that can lead to poor contractility. Let's just consider that  if we're looking at the protocol as a way of phenotyping the heart as whether or not  there's poor contractility to intervene on, of all the multitude of causes, we have to think in realistic terms as to, well, what could this patient have? I'm going to provide a few  examples. This patient could have myocarditis here on the left or dilated cardiomyopathy as a consequence of that. The function could also be diminished in this middle example,  arrhythmogenic cardiomyopathy in this patient who is cardioverted out of AFib.  And on the right here, we have stress cardiomyopathy or Takotsubo's cardiomyopathy from, in this case, acute status epilepticus, where we have diminished contractility of the left  ventricle in this apical four-chamber view with relative sparing of the base of the heart,  which is still moving more so than the apex. All of these are poor function from vastly different  etiologies. Etiologies can also be structural in nature that lead to decreased function. We  have aortic stenosis here on the left. This is a Doppler image looking at the mitral regurgitation  jet. And in this peristonal long axis view, towards the aortic outflow tract, we can see that we have diminished movement of this aortic valve here and a relatively less contractile  ventricle. In the middle, we have the effects of aortic insufficiency leading to volume overload  of a left ventricle here in this subcostal view. And on the right, we have diminished function  as a consequence of extracardiac left-to-right shunting across the PDA. Again, vastly different etiologies that all lead to a common finding of diminished cardiac function.  And the list continues. We can talk about toxicologic cardiomyopathy here on the left. We can talk about post-arrest myocardial dysfunction here in the middle. We can even  talk about hypertension if we aren't paying attention to our vital signs and leading to  diminished contractility. And of course, management for all of these clinical entities differ. So let's look at the response to that. It's all cardiogenic dysfunction. At least,  I don't need to give fluid. But when we don't know the ultimate etiology and all the directions forward differ, does a limited selection of views really help? And does this  help more than the physical exam or any other data that we have at the bedside? Do we need to  be doing this ourselves? And the other question about fluid is that what is your fluid cutoff? What EF are you targeting? What fractional shortening are you targeting? What finding  on these imaging findings are you looking for? And what would you titrate your inotropes and  therapies to if you're going to start epinephrine or milrinone or any other direct contractility  agent? And LV dysfunction is not even the end of the story. So when we look at measurement of the  IVC, one of the fundamental critical care echocardiography applications for shock assessment  in examining fluid responsiveness, we encounter that a lot of the original studies were done on  paralyzed patients with firmly prescribed ventilator settings. But three meta-analyses on the available literature, each of which included more than 10 studies each, found no  association between IVC collapsibility index and fluid responsiveness or CVP.  And this is when we factor in all the other situations that happen in our ICUs. Spontaneous breathing or other modes of mechanical ventilation that do not control every  breath. Measurement methods that when we look at B-mode or two-dimensional methods of following  the IVC through respiration, we get differing performing values than M-mode or one-dimensional measurements with the former likely being superior. It's worth considering also that  a lot of the original data done on this technique was performed in M-mode.  And then, of course, thoracic and abdominal pressures, of course, play a role in the overall accuracy of the technique in affecting venous return. In this study done by Lin et al.  at the Children's Hospital of Philadelphia presented in anesthesiology back in 2016, 24 children undergoing elective surgery had their IVCs evaluated pre and post intubation.  And as we see in this box plot, in conditions where the patients were breathing spontaneously,  they had a much more prominent IVC respiratory variation. And as soon as you put the tube in  and put them on positive pressure ventilation, those parameters all change. So what's accurate?  So we take all of these individual tests, what their individual sensitivities and specificities,  and just like any other form of imaging, we take them and we compose a montage, a summary statement about what we think is going on with the patient.  In critical care echocardiography as a fledgling field, do we really know how much info we need,  especially with all the potential diagnoses that can stem from any one of these problems that we  may be facing in our random encounters in the ICU? And then how do we really assess the diagnostic  accuracy of a summary statement, especially when a lot of our literature is based on individual applications? Let's move to the next point, which is, is this teachable?  This is one of the necessary tenets for propagation of this clinical practice. In this study published by Kimura et al. in the Journal of the American Society of Echocardiography  in 2016, 30 internists practicing up to seven years after graduation underwent re-evaluation  of their ultrasound knowledge from an ultrasound curriculum they'd experienced during training.  Of this population, if you didn't use it for over a year, you didn't pass without additional preparation and studying.  And in the population of people who were evaluated, 30% of the views obtained were inappropriate.  And these were little errors, 10 of 42 of these errors were that the probe was backwards.  And then when we look at the acquisition of images, some of the primary views that are necessary for cardiac evaluation, such as a sub-costal four-chamber view, only 56% of  participants could recreate the view. The recollection for these individual imaging targets within a population of trainees that  had studied this for the duration of their residency was not adequate for ongoing practice after graduation.  And also a fundamental question in all of this is how well is it being taught? In this study by Millington et al. in the Journal of Ultrasound Medicine in 2016, 154  observations of recorded data were performed by six content experts who evaluated both the image quality of individual views as well as the total interpretability of protocols  that were obtained. And though there was good inter-observer concordance for image generation in terms of looking at  specific areas, one view after the other, the total interpretability of these protocols was weak, with only a weak association between interpretability amongst reviewers for RV  function and volume responsiveness and no concordance evaluating left ventricular function and pericardial assessment, which leads to the question of whether or not each content  expert is on the same page. So why is there such a big differential between individual observers who are educators in critical cardiography?  Well, when we look at what adult cardiologists and pediatric cardiologists have to do, from the time they start cardiology fellowship through the end of their imaging fellowships,  they're really looking at completing about 1,000 studies divided both into performed and observed studies, those that are listed here next to parentheses O, or interpreted  studies under the guidance of supervising physicians, here listed next to parentheses I here in the individual cells of this table.  In the fledgling field of critical care echocardiography, those numbers are still yet to be determined,  and we're working from consensus guidelines from best estimates by other point-of-care ultrasound providers.  With only 25 studies for cardiac being a minimum in adult emergency medicine, and in critical  care echocardiography for the critical care echo exam or CCE exam, 150 total transthoracic exams. That's a pretty big differential.  And onto the next category, does it impact patients? This is where the money is. So when we put critical care echocardiography to use and ask, did this lead to clinical  efficacy, there is a representation from this type of paper in the literature. In this study examining 968 adult ICU patients at three centers, the use of critical care  echocardiography in POCUS changed diagnosis in 302 patients, and changed management in 534 patients.  It is worth noting that IVC assessment led to the greatest impact for all of its benefits and vulnerabilities.  When we look at the application of diagnostic echo in the realm of pediatric patients, 78  PICU patients with septic shock were retrospectively assessed for the utility of individual diagnostic  measures obtained by experts obtaining diagnostic echo, and found that, yeah, sure, you can  identify findings, 72% had LV dysfunction, 63% had RV dysfunction, but no echocardiographic measures were associated with mortality.  So we can use these numbers in our echo reports, but do they mean something for bedside management?  And when we look at something and have decided that we're going to do a management decision  or a diagnosis decision based on imaging finding, such as seeing a pericardial effusion and deciding that we're going to wave our hands in the air like we just don't care, does that  still mean it was the right thing to do? So what happens when we actually do a prospective RCT of ultrasound?  In this six-center international study, 273 patients were randomized either to ultrasound-based  management or to conventional non-ultrasound-based management, where the ultrasound arm received  abdominal, lung, and cardiac ultrasound within 60 minutes of admission to the emergency department.  And overall, ultrasound management had no effect on 30-day survival or hospital discharge survival or the amount of fluid they received or the dosages and quantity of inotropes they  received or admission rates from the ER. Ultimately, it was terminated for futility, with its target having been 400 patients.  Follow-up studies were also implemented looking at this data set, examining shock types and undifferentiated hypotension, and they showed also no change in resource utilization, but  instead lengthened resuscitation and cardiac arrest. Well, then should we consider whether or not it's a function of how mature ultrasound is  and how well-developed some of these techniques are? The thing is, let's look at one of the most well-described and protocolized imaging applications  in point-of-care ultrasound, the FAST exam. When we look at a meta-analysis of the FAST published in the Cochrane Database of Systematic  Reviews, it states that with regard to abdominal trauma, a negative POCUS exam does not rule out injuries and must be verified by a reference test such as CT.  This is exactly the target that FAST is supposed to obviate. Continuing, this is of particular importance in pediatric trauma, where the sensitivity  of POCUS is poor, and this is substantiated in prospective RCTs on this topic. In this study published by Holmes and colleagues in JAMA in 2017, 925 children with blunt torso  trauma were prospectively assigned in a randomized controlled trial to FAST exam or other conventional management.  And overall, FAST didn't improve the use of resources, ED length of stay, missed injury, diagnosis, or hospital charges.  And the authors concluded these findings do not support the routine use of FAST in this setting.  This doesn't speak well to the maturity of techniques in becoming more and more applicable in ultrasound in these emergent settings.  And speaking of emergent settings, let's look at cardiac arrest. There's been a lot of attention in the terms of use of echocardiography in assessing the  patient who is in active arrest. And in this great study done by Gaspari et al. in resuscitation, published in 2016, the  recent trial was a international 20-center trial that was a non-random, non-blinded prospective  protocol for observational cardiac ultrasound in cardiac arrest, where operators would attempt to visualize the heart during pulse checks in ACLS.  And it recruited overall 953 patients, of which 208 survived to discharge, and found that lack of movement on ultrasound had a sensitivity of 0.91 and a specificity of 0.90  for failure to achieve ROSC. This complements a decent-sized population of data that suggests that lack of movement  is potentially indicative of failure to resuscitate in cardiac arrest. Let's contrast that with a study done by Hu et al. in the Annals of Emergency Medicine  2018, when we took 127 emergency medicine, critical care medicine, and cardiology physicians and asked them, hey, what do you think about these 15 clips of cardiac standstill?  And there was only moderate agreement across all providers. So in this ultimate, life-determining application, we can't even get everyone in the room to  agree on what that looks like, with no variation between specialties.  Add to this the ramifications of whether or not we fully explored all the possibilities  in terms of clinical scenarios that occur when we're using critical care ultrasound.  We published this case series of three pediatric patients presenting in cardiac arrest back in 2017, and all these children demonstrated standstill.  This was evaluated by a pediatric cardiologist at the time of arrest and also reviewed offline.  All these patients had already been committed to VAECMO cannulation, and following cannulation, all of them recovered baseline cardiac function after being placed on ECMO.  What does this say to whether or not we've looked at restoration of cardiac perfusion as an intervention that obviates standstill?  What is standstill from a previous study that questioned several POCUS and curricular echocardiography providers as to their opinions about what standstill imaging was?  We don't have good definitions for what standstill should be characterized as in terms of how long do we study for, what type of equipment do we use,  how do we store and review an adequate protocol of images for it?  And also opens up the can of worms of asking, how can we say that you can use critical care echocardiography to titrate therapies and target resuscitation for good  outcomes when we can't even use it to say for sure if you're alive or dead?  It really begs the question of whether or not we have an Emperor's New Clothes moment and need to stop and say, is there something there?  So in conclusion, how do we say that curricular echocardiography is accurate and answers questions given the scope of potential diagnoses that we could walk into any day in the ICU?  How do we say that curricular echocardiography is teachable  given issues with acquisition and disagreements between how we evaluate it? And how do we say that it impacts patient care for the better given its performance across multiple  domains and shock resuscitation in terms of evaluations and trauma and evaluations in cardiac  arrest? And with that, that's the end of the presentation. I really appreciate the opportunity  to talk about this topic as it is an incredible thought exercise for me and would love to hear your thoughts and comments about it. Thank you very much.  Hi. Good morning, everybody. It is my pleasure to moderate this session regarding protocol on critical cardiac echocardiography. I will go right away on our questions given the fact  that we only have 16 minutes to address all these wonderful questions. The first question, actually, by one of my high esteem colleagues in the SCCM, Dr. Sanati, he's asking to our  speakers, what is the current evidence with randomized clinical trials regarding the evidence for critical care echocardiography but outside critical care? What is that evidence?  Showing that echocardiography can improve those outcomes.  Hi, and thanks for the opportunity to speak again and to be invited to this session. I think the  shock study from Atkinson et al really demonstrated the potential for echo to be deployed in a randomized control setting to try to help guide management ultimately demonstrated,  as we saw, no detectable impact. They've tried to pursue this multiple times with follow-up  studies that also not demonstrated efficacy. As to how to improve this, we don't have a clear  sense of that. There are other studies that have spoken to the utility of echo in a retrospective  and looking at outcomes. A prospective study is really lacking in our field.  Dr. Hernandez?  I agree. I think a prospective study, there are some studies out that do illustrate a benefit. They are based on retrospective analysis and the query database that's in existence.  But I do think there might be... I mean, I see value in those studies, of course.  I think to tweak this out a little bit further, we need to examine this in a prospective fashion  and really using an approach that is easily reproducible. That's easily reproducible in multiple centers, not just unique to specific centers. That's going to be the challenge that  we have before us to really identify if this technology does show a strong mortality benefit.  Thank you. Just to kind of add a quick comment to Susanari, definitely the ICU is becoming more  present in the general wards in the emergency department. Just to share with you, there are  some data regarding some secondary outcomes that might be important right now, such as patient  experience, such as time efficiency, such as length of stay. So definitely there are some data.  These are prospective studies and I'm anticipating that in the coming years, probably this will be  mounting evidence. Dr. Susanari asked another question also regarding what is the framework  for bedside echo? What are we intended here, as is to bundle it with our clinical documentation  and billing or basically doing this separately as a diagnostic procedure? And if there was any data comparing that versus having CT scans or just radiograph? Dr. Hsu?  Yeah, sure. In terms of looking at the implementation, sure. We could easily, we've said that it is approximate to the stethoscope in our hands and that we can use it  for assessment as such. A couple of the aspects are that there's increasing oversight over its use and it generates a lot of data, a lot of data that's recordable.  And also there's a paradigm for the use of that data already in the medical record. So  how do we modulate that? How do we make that something that makes sense in current practice  where there's now a different form of ultrasound that oversight agencies are going to be looking  at? And the other aspect of things too is that unlike the CT scan and several other things, we are seeing newer and newer modalities develop in critical care ultrasound. And the  thresholds for intervention and what numbers or what findings are using specifically to guide  therapy, we're still trying to figure that out across the board. And we're talking about not one thing to test. We're talking about thousands of individual types of tests with  different sensitivities and specificities and thresholds to determine. And so I think there  is something to be said for trying to determine those thresholds and the research that needs to move forward and then translate that into clinical practice. Dr. Hernandez?  Yeah, real quick. There's a few questions in that question. I just read his question. Let me just say there is some evidence to show that the timing to identify the pathology is  shorter. And I provided one of the references in the slide set. So I do think there's a timing  benefit with this technology. The other thing I want to say is in terms of I think billing and  documentation. So I think this is different, right? So I think it comes down to the fact that  what kind of study are you performing? If you're performing a high quality study in a consulting  fashion, meaning if, for example, for me, if I'm going to have this discussion with a surgeon,  the exams we develop, we want to develop a report to document the exam in the medical record  and have a consulting discussion. If we're just looking maybe for a plural effusion, I might not  do that. And a lot of it depends on what you're doing. But I do think that by having the  infrastructure, the expectation that we're going to document and bill for this exam raises the bar.  It causes the whole group in the critical care group, at least for us, is that they're going to  have to bring up the bar to perform all the elements of the exam necessary to generate a bill  and a report. And of course, with that report usually comes questions from other consulting  physicians. So I really, that's my two cents on that. Thank you. Dr. Shapshack from Alabama is  asking, she wants some suggestions for online modules or live courses to help intensities  to refine their skills. Dr. Hsu. Yeah, the SECM has a robust library of educational resources in  terms of critical care echocardiography courses, as well as textbook and various other types of  at-home types of educational resources. There's the various board review courses for the critical care echo boards. And there are a number of apps available on your mobile app store  that are helpful from some of the major vendors. Dr. Hernandez. Very briefly, I assure you, I know  it may seem like I'm biased, but I am not. I was formally trained and I can tell you that the SECM  live ultrasound courses are second to none. In fact, we've had instructors from other courses  offered not only in the country, but in the world. And we are often told, wow, you really need to know  what you're doing to teach in these courses. And if I at least over on one hand, at least over five  times, people have told us that. So it is a very robust program. It's a program over two days,  in some cases, three days. So I would strongly encourage you to pursue that course, not because  I'm speaking here at this conference, but because I genuinely believe that that is the best course  on the market. Thank you. I will try to combine a couple of questions for the sake of the time.  I have one of my Pullman critical care fellows here available, Dr. Gardner, and following up on a question to Dr. Sanotti. And if this is regarding the certification for critical  care echocardiography, it seems to us that it's not as streamlined when people are coming out of  training. And if you can actually combine with the fact that Dr. Sanotti was really concerned  about having, we are setting a bar that probably cannot, hasn't been fulfilled elsewhere when you  are seeing people like cardiology, cardiology specialists, pediatric specialists and trauma surgeons, et cetera. So what is your vision regarding that certification process for  everybody and how we actually, we can make it easier for people? Or are we saying that everybody  has to be board certified in critical care echocardiography or what the kind of bar you  are envisioning at this time? I should preface, I'm actually a sheep in wolf's clothing here in  terms of where I am with ultrasound. I think it, so I'm very pro ultrasound actually, but what I  think as a person who's involved in pediatric ultrasound research, we get pretty pragmatic about things. There's a reality to how much people can invest over time. And I think the  study by Kimura that I mentioned in my talk about how people who used echo or didn't use echo really influenced their future practice. I think there's,  the avenues should be wide open and clear during training for being able to become very refined,  very good at echocardiography and that should be nurtured throughout the career. But as an individual driven process, it's hard to, a certain mandatory minimum level of education is  of course necessary. And we see that reflected in the ABIM boards now where echo is part of that.  But it's hard to demand this, a really high standard from across the board. So there's something you said for having a little bit of leave no doc behind in the education process,  but then to really make some people like content experts, like just like we have QI people, we have vent people, we have shop people in our various units. Thank you. Dr. Hernandez.  So very quickly, I'll just jump back about 20, 25 years. There was a period of time when  to do a transesophageal echo, you just had the will, you needed the will to do one comfortably.  Then that migrated to, well, really you need to have a customer status. You need to demonstrate,  you know, this is years later, you need to demonstrate that you have some competency, you know, go and take the exam. And then that wasn't good enough. Then the question then was,  well, you know, if you're really going to do this invasive procedure, you're going to develop a  report, we really need you to have a certificate. And so then years later, then now, right,  the prerequisite for advanced TE is that you need to have a certification, at least in most  places that I've worked at and the people that I've had these discussions with. There is no prerequisite right now for critical care echocardiography. It doesn't exist at our  institution. I'm not aware that it exists anywhere. But because it's easy to just, it's easy for anybody to grab a probe and kind of develop images and say things that may be  inaccurate, that may lead to injury, meaning it's harder to, it'll be easier for us to hurt a patient if we have people who are not, don't know what they're doing with a probe.  And really you just have to grab it and perform one, right? With TE, it was an invasive procedure,  so there was some credentialing there. But I foresee in the future that that will be the ask. The initial ask will be, somebody is going to need to sign off on you. And that person  eventually will say, why don't you just take the test, take the test. And that way we have something  that we can document. But I imagine it'll be very similar like it happened with TE,  is that we'll go from, it's okay, we want you to take an exam, and then we want you to get certified.  Let's spend the last three minutes on barriers that we have. For instance, our fellows, you know, have issues, you know, to get to the, to actually have the certification itself,  or people are not finding the time to do this documentation when they are doing these exams.  How, what would be your advice about addressing those barriers so we actually can feel more, a more rewarding practice with critical care ultrasonography? Dr. Hsu.  Thanks. One thing in terms of comfort with some of the more didactic oriented topics, one thing we started here in Texas is a teleconference collaborative where statewide  there's a number of ICUs where we speak monthly on a contemporary ultrasound topic and then we do  some board review. So it's still in its infancy, but I think there, because of the density of  ultrasound educators in the country, this type of approach, I'm excited to see it develop and see if  this would be something that more and more people would be willing to do either with us or on their  own. And to expand education, that matters to, to help with help, particularly with board review to,  to get like a good understanding of some of the fundamentals for, for the standardized exam.  Barriers in terms of documentation are always problematic. I think as almost as an inspiration  that we can see how in the echo world that other, other clinically oriented specialties can,  can do it in terms of being able to get studies well substantiated, reviewed and, and documented.  And we need to develop better workflows to, to be able to accomplish that. And I think that, that is an area of research to, to develop competent short protocols that intensivists  can put into place readily. It's one of our goals in our, in our pediatric research collaborative to  be able to develop these things. And it's, it's a balance that we, we have to strike. But ultimately,  because we know we generate such granular data with ultrasound, we, I think there,  a sea change is necessary in terms of us all recognizing that we need to document and we need to account for our doing. Thank you. Dr. Hernandez, wrap it up, 45 seconds.  Yeah, I agree. I would say that this is an opportunity for us to improve the, the, the  program, the SEC live ultrasound. But suffice to say when documentation, you need to show the value  to your administrators. They need to help you develop a form. That's what we did at Vanderbilt.  We developed a form and it was basically checkbox, you know, for each of the individual exams.  And when they see that by doing so, they are going to provide, it's going to provide funds  to replace the platform. And you're not going to go back to having them pay for this. That will help.  They will help you overcome these barriers. And I know we're down to five seconds. Thank you, everybody. I hope you can follow us in the next module. Thank you.

Video Summary

In this video, Dr. Tony Hernandez and Dr. Eric Hsu discuss the topic of critical care echocardiography. They discuss the role of echocardiography in diagnosing and managing critically ill patients, and the importance of training and experience in using this technology effectively. Dr. Hernandez emphasizes the need for a standardized approach to critical care echocardiography and highlights the potential benefits of using this technology in improving patient outcomes. Dr. Hsu, on the other hand, suggests that there is limited evidence to support the use of critical care echocardiography and questions its impact on patient care. He also discusses the challenges and limitations associated with training and certification in critical care echocardiography. Overall, this video provides an overview of the debate surrounding critical care echocardiography and highlights the need for further research and evidence to support its use.

Asset Subtitle

Procedures, Cardiovascular, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Learning Objectives

Demonstrate how different antimicrobial adsorption and clearance profiles impact optimization of dosing while on extracorporeal therapies such as continuous renal replacement therapy or extracorporeal membrane oxygenation
Assess the barriers of real-time ultrasound in critical care
Describe available evidence on critical care ultrasound and its strengths and weaknesses

Pro: Diagnostic Ultrasound Is a Modality in Development: Give It a Chance
Antonio Hernandez

Con: The Evidence Is Clear: Diagnostic Critical Care Ultrasound Doesn't Work
Erik Su

Meta Tag

Content Type Presentation

Knowledge Area Procedures

Knowledge Area Cardiovascular

Knowledge Level Intermediate

Knowledge Level Advanced

Learning Pathway Cardiothoracic Critical Care

Membership Level Select

Tag Echocardiography

Tag Point of Care

Tag Cardiothoracic Critical Care

Year 2021

Keywords

critical care echocardiography

diagnosing

managing

critically ill patients

training

experience

standardized approach

improving patient outcomes

limited evidence

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