Focused cardiac ultrasound: a training course for pediatric intensivists and emergency physicians

BMC Medical Education

Artur F Delgado¹  Cláudio Schvartsman²  Rogério R do Prado³  Jose L Andrade⁴  Werther B de Carvalho¹  Alessandro C Lianza⁴  Samira S Morhy⁴  Heloisa A Gaspar¹ 

[1] Pediatric Intensive Care - Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina, São Paulo University, Rua do Carreiro de Pedra 111 apto 152C, Jd. Caravelas, CEP 04728-020 São Paulo, Brazil;Emergency Medicine Department, Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina, São Paulo University, São Paulo, Brazil;Department of Statistics, Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina, São Paulo University, São Paulo, Brazil;Radiology Department - Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina, São Paulo University, São Paulo, Brazil

关键词: Children;    Medical education;    Training course;    Ventricular function;    Critical care;    Echocardiography;   

Others  :  1118425
DOI  :  10.1186/1472-6920-14-25

 received in 2013-10-31, accepted in 2014-02-03,  发布年份 2014

【 摘 要 】

Background

Focused echocardiographic examinations performed by intensivists and emergency room physicians can be a valuable tool for diagnosing and managing the hemodynamic status of critically ill children. The aim of this study was to evaluate the learning curve achieved using a theoretical and practical training program designed to enable pediatric intensivists and emergency physicians to conduct targeted echocardiograms.

Methods

Theoretical and practical training sessions were conducted with 16 pediatric intensivist/emergency room physicians. The program included qualitative analyses of the left ventricular (LV) and right ventricular (RV) functions, evaluation of pericardial effusion/cardiac tamponade and valvular regurgitation and measurements of the distensibility index of the inferior vena cava (dIVC), ejection fraction (EF) and cardiac index (CI). The practical training sessions were conducted in the intensive care unit; each student performed 24 echocardiograms. The students in training were evaluated in a practical manner, and the results were compared with the corresponding examinations performed by experienced echocardiographers. The evaluations occurred after 8, 16 and 24 practical examinations.

Results

The concordance rates between the students and echocardiographers in the subjective analysis of the LV function were 81.3% at the first evaluation, 96.9% at the second evaluation and 100% at the third evaluation (p < 0.001). For the dIVC, we observed a concordance of 46.7% at the first evaluation, 90.3% at the second evaluation and 87.5% at the third evaluation (p = 0.004). The means of the differences between the students’ and echocardiographers’ measurements of the EF and CI were 7% and 0.56 L/min/m², respectively, after the third stage of training.

Conclusions

The proposed training was demonstrated to be sufficient for enabling pediatric physicians to analyze subjective LV function and to measure dIVC, EF and CI. This training course should facilitate the design of other echocardiography training courses that could be implemented in medical residency programs to improve these physicians’ technical skills and the care of critically ill patients.

【 授权许可】

   
2014 Gaspar et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

Figure 3.

Figure 4.

Figure 5.

Figure 6.

【 参考文献 】

• [1]Perkin RM, Levin DL: Shock in the pediatric patient. Part I. J Pediatr 1982, 101:163-169.
• [2]Tabbutt S: Heart failure in pediatric septic shock: utilizing inotropic support. Crit Care Med 2001, 29:S231-S236.
• [3]Spenceley N, MacLaren G, Kissoon N: Monitoring in pediatric cardiac critical care: A worldwide perspective. Pediatr Crit Care Med 2011, 12:S76-S80.
• [4]Vincent JL, Rhodes A, Perel A, Martin GS, Della Rocca G, Vallet B, et al.: Clinical review: Update on hemodynamic monitoring-a consensus of 16. Crit Care 2011, 15:229. BioMed Central Full Text
• [5]Cheitlin MD, Armstrong WF, Aurigemma GP, Beller GA, Bierman FZ, Davis JL, et al.: ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: summary article. A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. Circulation 2003, 108:1146-1162.
• [6]Brown JM: Use of echocardiography for hemodynamic monitoring. Crit Care Med 2002, 30:1361-1364.
• [7]Vieillard-Baron A, Prin S, Chergui K, Dubourg O, Jardin F: Hemodynamic instability in sepsis: bedside assessment by Doppler echocardiography. Am J Resp Crit Care Med 2003, 168:1270-1276.
• [8]Vignon P: Hemodynamic assessment of critically ill patients using echocardiography Doppler. Curr Opin Crit Care 2005, 11:227-234.
• [9]Klugman D, Berger JT: Echocardiography as a hemodynamic monitor in critically ill children. Pediatr Crit Care Med 2011, 12:S50-S54.
• [10]Mayo PH, Beaulieu Y, Doelken P, Feller-Kopman D, Harrod C, Kaplan A, et al.: American College of Chest Physicians/La Société de Réanimation de Langue Française statement on competence in critical care ultrasonography. Chest 2009, 135:1050-1060.
• [11]Labovitz AJ, Noble VE, Bierig M, Goldstein SA, Jones R, Kort S, et al.: Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr 2010, 23:1225-1230.
• [12]Expert Round Table on Ultrasound in ICU: International expert statement on training standards for critical care ultrasonography. Intensive Care Med 2011, 37:1077-1083.
• [13]Spencer KT, Kimura BJ, Korcarz CE, Pellikka PA, Rahko PS, Siegel RJ: Focused cardiac ultrasound: recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr 2013, 26:567-581.
• [14]Mertens L, Seri I, Marek J, Arlettaz R, Barker P, McNamara P, et al.: Targeted neonatal echocardiography in the neonatal intensive care unit: practice guidelines and recommendations for training. J Am Soc Echocardiogr 2011, 24:1057-1078.
• [15]Vignon P, Dugard A, Abraham J, Belcour D, Gondran G, Pepino F, et al.: Focused training for goal-oriented hand-held echocardiography performed by noncardiologist residents in the intensive care unit. Intensive Care Med 2007, 33:1795-1799.
• [16]Melamed R, Sprenkle MD, Ulstad VK, Herzog CA, Leatherman JW: Assessment of left ventricular function by intensivist using hand-held echocardiography. Chest 2009, 135:1416-1420.
• [17]Manasia AR, Nagaraj HM, Kodali RB, Croft LB, Oropello JM, Kohli-Seth R, et al.: Feasibility and potential clinical utility of goal-directed transthoracic echocardiography performed by noncardiologist intensivist using a small hand-carried device (sonoHeart) in critically ill patients. J Cardiothorac Vasc Anesth 2005, 19:155-159.
• [18]Kuhl M, Wagner R, Bauder M, Fenik Y, Reissen R, Lammerding-Koppel M, et al.: Student tutors for hands-on training in focused emergency echocardiography – a randomized controlled trial. BMC Med Educ 2012, 12:101. BioMed Central Full Text
• [19]Lai WW, Geva T, Shirali GS, Frommelt PC, Humes RA, Brook MM, et al.: Guidelines and standards for performance of a pediatric echocardiogram: a report from the task force of the pediatric council of the american society of echocardiography. J Am Soc Echocardiogr 2006, 19:1413-1430.
• [20]Rosenberg D, Moss M: The american college of critical care medicine of the society of critical care medicine. Guidelines and levels of care for pediatric intensive care units. Crit Care Med 2004, 32:2117-2127.
• [21]Barbier C, Loubières Y, Schmit C, Hayon J, Ricome JL, Jardin F, et al.: Respiratory changes in inferior vena cava diameter are helpful in predicting fluid responsiveness in ventilated septic patients. Intensive Care Med 2004, 30:1740-1746.
• [22]Vignon P, Mücke F, Bellec F, Marin B, Croce J, Brouqui T, et al.: Basic critical care echocardiography: validation of a curriculum dedicated to noncardiologist residents. Crit Care Med 2011, 39:636-642.
• [23]Spurney CF, Sable CA, Berger JT, Martin GR: Use of a hand-carried ultrasound device by critical care physicians for the diagnosis of pericardial effusions, decreased cardiac function, and left ventricular enlargement in pediatric patients. J Am Soc Echocardiogr 2005, 18:313-319.
• [24]Longjohn M, Wan J, Joshi V, Pershad J: Point-of-care echocardiography by pediatric emergency physicians. Pediatr Emerg Care 2011, 27:693-696.
• [25]Sasaki N, Srivastava S: Systolic and diastolic dysfunction in the intensive care unit. Minerva Pediatr 2011, 63:385-397.
• [26]Frommelt PC: Update on pediatric echocardiography. Curr Opin Pediatr 2005, 17:579-585.
• [27]Pershad J, Myers S, Plouman C, Rosson C, Elam K, Wan J, et al.: Bedside limited echocardiography by the emergency physician is accurate during evaluation of the critically ill patient. Pediatrics 2004, 114:667-671.
• [28]Alhashemi JA, Cecconi M, Hofer CK: Cardiac output monitoring: an integrative perspective. Crit Care 2011, 15:214. BioMed Central Full Text
• [29]Mayer J, Boldt J, Poland R, Peterson A, Manecke GR Jr: Continuous arterial pressure waveform-based cardiac output using the FloTrac/Vigileo: a review and meta-analysis. J Cardiothorac Vasc Anesth 2009, 23:401-406.
• [30]Senn A, Button D, Zollinger A, Hofer CK: Assessment of cardiac output changes using a modified FloTrac/Vigileo algorithm in cardiac surgery patients. Crit Care 2009, 13:32.
• [31]Costa MG, Rocca GD, Chiarandini P, Mattelig S, Pompei L, Barriga MS, et al.: Continuous and intermittent cardiac output measurement in hyperdynamic conditions: pulmonary artery catheter vs. lithium dilution technique. Intensive Care Med 2008, 34:257-263.
• [32]Feissel M, Michard F, Faller JP, Teboul JL: The respiratory variation in inferior vena cava diameter as a guide to fluid therapy. Intensive Care Med 2004, 30:1834-1837.
• [33]Mandavia DP, Hoffner RJ, Mahaney K, Henderson SO: Bedside echocardiography by emergency physicians. Ann Emerg Med 2001, 38:377-382.
• [34]Royse CF, Haji DL, Faris JG, Veltman MG, Kumar A, Royse AG: Evaluation of the interpretative skills of participants of a limited transthoracic echocardiography training course (H.A.R.T.scan® course). Anaesth Intensive Care 2012, 40:498-504.
• [35]Tanzola RC, Walsh S, Hopman WM, Sydor D, Arellano R, Allard RV: Brief report: focused transthoracic echocardiography training in a cohort of Canadian anesthesiology residents: a pilot study. Can J Anaesth 2013, 60:32-37.