Criteria, Processes, and Determination of Competence in Basic Critical Care Echocardiography Training: A Delphi Process Consensus Statement by the Learning Ultrasound in Critical Care (LUCC) Initiative.

BACKGROUND: With the paucity of high-quality studies on longitudinal basic critical care echocardiography (BCCE) training, expert opinion guidelines have guided BCCE competence educational standards and processes. However, existing guidelines lack precise detail due to methodological flaws during guideline development. RESEARCH QUESTIONS: To formulate methodologically robust guidelines on BCCE training using evidence and expert opinion, detailing specific criteria for every step, we conducted a modified Delphi process using the principles of the validated AGREE-II tool. Based on systematic reviews, the following domains were chosen: components of a longitudinal BCCE curriculum; pass-grade criteria for image-acquisition and image-interpretation; and formative/summative assessment and final competence processes. STUDY DESIGN AND METHODS: Between April 2020 and May 2021, a total of 21 BCCE experts participated in four rounds. Rounds 1 and 2 used five web-based questionnaires, including branching-logic software for directed questions to individual panelists. In round 3 (videoconference), the panel finalized the recommendations by vote. During the journal peer-review process, Round 4 was conducted as Web-based questionnaires. Following each round, the agreement threshold for each item was determined as ≥ 80% for item inclusion and ≤ 30% for item exclusion. RESULTS: Following rounds 1 and 2, agreement was reached on 62 of 114 items. To the 49 unresolved items, 12 additional items were added in round 3, with 56 reaching agreement and five items remaining unresolved. There was agreement that longitudinal BCCE training must include introductory training, mentored formative training, summative assessment for competence, and final cognitive assessment. Items requiring multiple rounds included two-dimensional views, Doppler, cardiac output, M-mode measurement, minimum scan numbers, and pass-grade criteria. Regarding objective criteria for image-acquisition and image-interpretation quality, the panel agreed on maintaining the same criteria for formative and summative assessment, to categorize BCCE findings as major vs minor and a standardized approach to errors, criteria for readiness for summative assessment, and supervisory options. INTERPRETATION: In conclusion, this expert consensus statement presents comprehensive evidence-based recommendations on longitudinal BCCE training. However, these recommendations require prospective validation.

Management of straddling thrombus through patent foramen ovale complicating pulmonary embolism.

A 60-year-old man was admitted to intensive care unit with the diagnosis of pulmonary embolism. Bedside transthoracic echocardiography revealed the extension of the thrombus into left atrium and ventricle through patent foramen ovale (PFO). A straddling thrombus also described as impending paradoxical embolism is a rare condition when thrombus embolised to the heart gets caught in PFO. Morbidity is extremely high in case of systemic embolisation. Due to rarity, the treatment options are mainly individualised and no guidelines exist. There are few treatment strategies described in literature from surgical to interventional radiology to conservative approach. Treatment strategy should take individual parameters such as patient's age, haemodynamic stability, bleeding risk and comorbidities into consideration. Our patient successfully underwent emergency surgical thrombectomy.

Comparison of different doses of intranasal nitroglycerine in attenuation of pressor response to laryngoscopy and intubation.

AIMS: To observe the various pressor responses to laryngoscopy and intubation in normotensive patient undergoing elective surgery under general anesthesia and use of three different attenuating doses (400, 800, 1200 mcg) of intranasal nitroglycerine administered five minutes before laryngoscopy and intubation, to observe the efficacy and safety. SETTINGS AND DESIGN: Randomized study. MATERIALS AND METHODS: The study was carried out in a total of 60 patients. ASA grade 1 and II patients posted for elective surgeries under general anesthesia were included. Patients received different doses of intranasal nitroglycerine five minutes before induction as given below Group 1-received 400 micrograms-20 patients Group 2-received 800 micrograms-20 patients Group 3-received 1200 micrograms-20 patients. STATISTICAL ANALYSIS: Student's t test. RESULTS AND SUMMARY: Results were statistically analyzed. All three groups effectively attenuated the pressor response to laryngoscopy and intubation. Maximum rise in heart rate was seen in group III (23.86%). Maximum fall in systolic (19.6%), diastolic (30.76%), and mean arterial blood pressure (25.53%) was observed in group III at 10(th) minute of laryngoscopy and intubation. CONCLUSION: Best results of attenuation of pressor response were seen with 400 and 800 micrograms of intranasal nitroglycerine. One thousand and two hundred micrograms dose caused maximum increase in heart rate and caused maximum fall in blood pressure, hence it is advisable to use increased dose with caution in attenuation of pressor response to laryngoscopy and intubation.