Basic ultrasound head-to-toe skills for intensivists in the general and neuro intensive care unit population: consensus and expert recommendations of the European Society of Intensive Care Medicine

Abstract

Purpose: To provide consensus, and a list of experts' recommendations regarding the basic skills for head-to-toe ultrasonography in the intensive care setting.

Methods: The Executive Committee of the European Society of Intensive Care (ESICM) commissioned the project and supervised the methodology and structure of the consensus. We selected an international panel of 19 expert clinicians-researchers in intensive care unit (ICU) with expertise in critical care ultrasonography (US), plus a non-voting methodologist. The panel was divided into five subgroups (brain, lung, heart, abdomen and vascular ultrasound) which identified the domains and generated a list of questions to be addressed by the panel. A Delphi process based on an iterative approach was used to obtain the final consensus statements. Statements were classified as a strong recommendation (84% of agreement), weak recommendation (74% of agreement), and no recommendation (less than 74%), in favor or against.

Results: This consensus produced a total of 74 statements (7 for brain, 20 for lung, 20 for heart, 20 for abdomen, 7 for vascular Ultrasound). We obtained strong agreement in favor for 49 statements (66.2%), 8 weak in favor (10.8%), 3 weak against (4.1%), and no consensus in 14 cases (19.9%). In most cases when consensus was not obtained, it was felt that the skills were considered as too advanced. A research agenda and discussion on training programs were implemented from the results of the consensus.

Conclusions: This consensus provides guidance for the basic use of critical care US and paves the way for the development of training and research projects.

Keywords: Abdominal ultrasound; Brain ultrasound; Consensus; Echocardiography; Intensive care unit; Lung ultrasound; Ultrasonography; Vascular ultrasound.

Fig. 1

Brain ultrasound. A, B, D Images obtained using phased-array probe placed over the temporal window. Temporal windows are used for insonation of middle cerebral artery (MCA) anterior (ACA) and posterior cerebral artery (PCA). C Sub occipital windows can be performed for insonation of basilar (BA) and vertebral arteries (VA)

Fig. 2

Lung ultrasound. Images obtained using low-frequency curvilinear probe placed with orientation marker directed cranially. Technique for a complete thoracic examination. Panels A–D: when acquiring lung ultrasound images, a structured approach includes proper patient position and exposure and appropriate scanning protocol. A six-area per hemithorax approach is usually considered for a complete thoracic assessment: anterior, lateral and posterior fields are identified by sternum, anterior and posterior axillary lines (red dotted lines). Right upper panel: consolidation with static air bronchogram. Lung ultrasound scan of a posterior-inferior field with a low-frequency phased-array transducer in longitudinal scan. Right lower panel: consolidation with dynamic linear-arborescent air bronchogram. Lung ultrasound scan of a posterior-inferior field with a low-frequency curvilinear transducer in longitudinal scan. The diaphragm is well visualized as one of the basic landmarks (yellow dotted arrow), thus allowing to correctly identify intra-thoracic and intra-abdominal structures. The lung presents complete loss of aeration: the lobe is visualized as a tissue-like pattern. Within the lung, multiple white images are visualized; they move synchronously with tidal ventilation and present a shape mimicking the anatomical airway: they correspond to dynamic linear-arborescent air bronchogram. This pattern suggests the main airway is patent and is highly specific for community-acquired or ventilator-associated pneumonia, depending on the context. A small pleural effusion is also visualized as a hyperechoic space surrounding the consolidated lung (*)

Fig. 3

Standard cardiac views. The images were obtained using a standard phased-array probe. Upper left panel. Parasternal long axis, where probe placed in left parasternal areas, with orientation marker pointing to the patient’s right shoulder; Upper right panel. parasternal short-axis, where probed placed in left parasternal area with orientation marker pointing to patient’s left shoulder; Lower left panel. Apical four-chamber, where probe placed over the apex of the heart with orientation marker pointing to the patient’s left; Lower right panel. Subcostal four-chamber, where probe placed subxiphoid with orientation marker pointing to the patient’s left

Fig. 4

Panels A abdominal ultrasound: images obtained using low-frequency curvilinear probe placed over the right, subcostal area, mid-axillary line with orientation marker pointing cranially. Left: severe hydronephrosis of the right kidney. Right: free fluid in the hepatorenal recess. Panels B vascular ultrasound. Left: short-axis view of the right internal jugular vein (IJV), external jugular vein (EJV) and carotid artery (CA). Right: out-of-plane puncture of the internal jugular vein (IJV) the arrow shows the pressure on the anterior wall of the vein of the tip of the needle

Fig. 5

Summary of the recommendations

Fig. 5

Summary of the recommendations

Fig. 5

Summary of the recommendations

Fig. 5

Summary of the recommendations

Fig. 5

Summary of the recommendations