Therapeutic impact of basic critical care echocardiography performed by residents after limited training.

BACKGROUND: The objective was to assess the agreement between therapeutic proposals derived from basic critical care echocardiography performed by novice operators in ultrasonography after a limited training (residents) and by experts considered as reference. Secondary objectives were to assess the agreement between operators' answers to simple clinical questions and the concordance between basic two-dimensional measurements. METHODS: This observational, prospective, single-center study was conducted over a 3-year period in a medical-surgical intensive care unit. Adult patients with acute circulatory and/or respiratory failure requiring a transthoracic echocardiography (TTE) examination were studied. In each patient, a TTE was performed by a resident novice in ultrasonography after a short training program and by an expert, independently but within 1 h and in random order. Each operator addressed standardized simple clinical questions and subsequently proposed a therapeutic strategy based on a predefined algorithm. RESULTS: Residents performed an average of 33 TTE studies in 244 patients (156 men; age: 63 years [52-74]; SAPS2: 45 [34-59]; 182 (75%) mechanically ventilated). Agreement between the therapeutic proposals of residents and experienced operators was good-to-excellent. The concordance was excellent for suggesting fluid loading, inotrope or vasopressor support (all Kappa values > 0.80). Inter-observer agreement was only moderate when considering the indication of negative fluid balance (Kappa: 0.65; 95% CI 0.50-0.80), since residents proposed diuretics in 23 patients (9.5%) while their counterparts had the same suggestion in 35 patients (14.4%). Overall agreement of responses to simple clinical questions was also good-to-excellent. Intraclass correlation coefficient exceeded 0.75 for measurement of ventricular and inferior vena cava size. CONCLUSIONS: A limited training program aiming at acquiring the basic level in critical care echocardiography enables ICU residents novice in ultrasonography to propose therapeutic interventions with a good-to-excellent agreement with experienced operators.

Basic critical care echocardiography: validation of a curriculum dedicated to noncardiologist residents.

OBJECTIVE: To assess the efficacy of a limited, tailored training program for noncardiologist residents without experience in ultrasound to reach competence in basic critical care echocardiography. DESIGN: Prospective descriptive clinical study. SETTING: Medical-surgical intensive care unit of a teaching hospital. PATIENTS: 201 patients (125 men; age: 61 ± 16 yrs; Simplified Acute Physiologic Score II: 37 ± 17; 145 ventilated patients) who required a transthoracic echocardiography were studied. INTERVENTION AND MEASUREMENTS: The curriculum consisted of a 12-hr learning program blending didactics, interactive clinical cases, and tutored hands-on sessions. After completion of this tailored training program, all eligible patients subsequently underwent a transthoracic echocardiography performed in random order by a recently trained resident and an experienced intensivist with expertise in critical care echocardiography who was used as a reference. The agreement between responses to clinical questions provided by the two investigators who independently interpreted the transthoracic echocardiography study at bedside was used as an indicator of effectiveness of the tested curriculum. MAIN RESULTS: Residents performed a mean of 33 transthoracic echocardiograms during the study period (range: 29-38). Experienced intensivists had significantly fewer unaddressed clinical questions than did residents (57 [5.7%] vs. 111 [11.0%] of 1,005 clinical questions: p < .0001). When compared to residents, the experienced intensivists performed shorter transthoracic echocardiography examinations (3.0 ± 1.0 min vs. 7.0 ± 2.5 min: p < .0001) with more acoustic windows (888 vs. 828 of 1,005 potential windows: p < .0001). Residents adequately assess global left ventricle systolic function (κ: 0.84; 95% confidence interval: 0.76-0.92). They accurately identified dilated left ventricle (κ: 0.90; 95% confidence interval: 0.80-1.0), dilated right ventricle (κ: 0.76; 95% confidence interval: 0.64-0.89), dilated inferior vena cava (κ: 0.79; 95% confidence interval: 0.63-0.94), and pericardial effusion (κ: 0.79; 95% confidence interval: 0.58-0.99) and diagnosed two cases of tamponade. CONCLUSIONS: A 12-hr training program blending didactics, interactive clinical cases, and tutored hands-on sessions dedicated to noncardiologist residents without experience in ultrasound appears well suited for reaching competence in basic critical care echocardiography.