Show me the POCUS
In this chapter :
Curriculum and Training Process
Start Here
This website contains all the essential elements for you to be successful in your POCUS journey. It contains all elements you will be expected to know on graduation and much more. Since the idea is to guide you and not overwhelm you, the website also tells you what NOT to focus on if your priority is to get up to speed with knowledge base our specialty is requiring at the moment. At the introduction of each chapter you will be reminded if its is an integral portion of your examination process or not. Specifically when the use of the word Beyond is implemented here you are not required to have this element for examination purposes.
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The following are the areas of focus for your exam:
Rationale
As cardiac complications continue to be a leading cause of perioperative mortality, anesthesiologists are increasingly exposed to a sicker population going for operative interventions. Point of Care Ultrasound (POCUS) is a powerful bedside tool in the evaluation of the critically ill patient to be used to answer specific diagnostic questions. POCUS training aims to provide tools for the anesthesiology trainee that are considered necessary for perioperative clinical practice. POCUS is not meant to supplant a comprehensive cardiac exam but can be used to guide procedures, assist in visualizing pathology and rule out potential life threatening conditions.
POCUS is an important aspect of our armamentarium and now part of the exams set forth by the American Board of Anesthesiology (ASA) examination. The learning experience starts with understanding the indications and limitations of the technology. It then follows with interpretation of the image and ends with integration of the information in the clinical context. Our aim is that residents are able to fully understand the capability of the technology and that they are able to independently conduct and interpret POCUS (this is considered a level 4 milestone on ultrasound by the ASA). Imaging modalities include 2 dimension ultrasound and a limited exposure to color flow Doppler and M mode. Pulsed wave and continuous wave Doppler are technologies of ultrasound that are not part of the curriculum but are encouraged to the eager learner.
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The learner is encouraged to visit the following pages on the overview of diagnostic POCUS for further information.
Training Process
At the time of this publication there is no standardized training format that is expected for the anesthesiologist in-training. However, given advances in technology and the safety profile of ultrasound, the perioperative provider will likely be expected to integrate images obtained from POCUS in clinical decision making. With this in mind, the exposure to POCUS is that of its clinical integration into academic practice and the various domains it permeates.
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POCUS training starts at the PGY-1 year by constructing the building blocks that allow the complex understanding and integration of the clinical information that can be derived from ultrasound and that is acquired at a senior resident level. The trainee is encouraged to revisit areas offered though this website at all stages of training. This website is comprehensive with the OSCEs being front and center.
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As the training progresses to the clinical anesthesia years, residents will have exposure to lectures offered by our staff and having this website as its reference material. The objective at present is for the graduating resident is the completion of at least 30 POCUS assessments. It is also an objective that the resident excels at the Objective Structured Clinical Examination applied exam offered by the ABA.
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The cornerstone of POCUS program heavily relies on an effective supervised experience. This means that at every patient interaction where POCUS is performed this experience starts following an indication, acquisition, interpretation framework (I-AIM) framework. Image acquisition relies on understanding ultrasound physics, adequate probe selection , machine settings, identification of artifacts and patient positioning that have an influence on the quality of the image. Image interpretation relies on how the performer interprets the findings on the image. To view the criteria that can assist image acquisition click here. A preliminary report of the interpretation of findings can be seen here.
Those interested in building a POCUS program from scratch may use the following publication as reference. A list of the objectives for each of the available applications can be found here based on the different POCUS societies and guidelines with selected references. We also provide the acquisition criteria for the different applications offered in the program as well as a pass-grade assessment on major findings needed so that the learner progresses through their training.
Expectations before graduation: Applied OSCE Exam
The OSCE applied content outline provides valuable information regarding expectations for a graduating resident and the relevant information is summarized here. At a skills level the graduating anesthesiology resident should be proficient in interpretation of basic echocardiograms and surface ultrasound of lung or transesophageal, lung and pleura images relevant to anesthesia practice.
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The successful candidate will be able to identify the view, identify relevant anatomy, make qualitative diagnostic assessments, and provide treatment recommendations for scenarios chosen from among the following areas:
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Biventricular function and wall motion
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Presence or absence of an atrial septal defect
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Volume status assessment- hypovolemia and response to volume therapy
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Pulmonary emboli
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Air emboli
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Basic valvular lesions
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Pericardial effusions
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Aortic dissection
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Pleural effusion
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Pneumothorax
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Pulmonary edema
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Transthoracic echocardiography images will be chosen from the following 5 views specified in the International Evidence-Based Recommendations for Focused Cardiac Ultrasound :Parasternal Long Axis, Parasternal Short Axis (Left Ventricle Midpapillary), Apical Four Chamber, Subcostal Four Chamber and Subcostal IVC Assessment. Lung and diaphragm ultrasound images will be chosen from the Anterior Mid-Clavicular Line and Posterior Axillary Line views.
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Transesophageal echocardiography images will be chosen from the following 11 views specified in the Consensus Statement on Basic Perioperative Transesophageal Echocardiography. These include the following: At the midesophageal level :Four Chamber , Two Chamber, Long Axis, Ascending Aortic Long Axis, Ascending Aortic Short Axis , Aortic Valve Short Axis, Right Ventricular Inflow-Outflow, Bicaval. Also Transgastric Midpapillary Short Axis. Then Descending Aortic Short Axis and Descending Aortic Long Axis.
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ACGME milestones and Point of Care Ultrasound Competency are evaluated in section 6 of Patient Care.
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POCUS report template. This template serves as a guide for reporting findings seen on exams.
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Image Acquisition Standards:
The following provides a guide when evaluating the quality of the images/clips obtained during the acquisition/interpretation process (modified from part 3 of the ASA Diagnostic POCUS certificate program):
Best Reference Sites for POCUS
The following are some of the best websites that offer free high quality educational material.
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Standard and focused TTE views through the University of Toronto: Make sure to select Focus cardiac ultrasound in the upper left corner menu.
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The Society of Point of Care Ultrasound offers great educational resources on POCUS
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Pocus101. The educational content on the tutorials is relevant to our clinical practice. The site has great videos.
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Anesthesia toolbox study guide on POCUS. Payed subscription
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Foresight ultrasound is a webpage designed by perioperative and acute care physicians as an open source platform for ultrasound education.
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Core ultrasound is an excellent US resource geared towards ED physicians. It contains a myriad of echocardiographic pathologies
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Gastric ultrasound material will be found here : https://www.gastricultrasound.org/
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Documentation
1. ASA Supplemental Guide. These are the Point of Care Ultrasound milestones Anesthesiology residents are expected to know in order to prepare for the Board examinations prepared for by the Board of Anesthesiology.
2. International Evidenced- Based Recommendations for Focused Ultrasound.
3. POCUS for the Cardiothoracic Anesthesiologist.
4. Basic Perioperative TEE. A Consensus Statement of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists
5. POCUS report template. This template serves as a guide for reporting findings seen on exams.
Other References
1. Levitov, A and all. Guidelines for the Appropriate Use of Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients- Part II: Cardiac Ultrasonography. Crit Care Med. 2016 Jun; 11(6): 1206-27.
2. Canty DJ, Royse CF. Audit of anaesthetist-performed echocardiography on perioperative management decisions for non-cardiac surgery. Br J Anaesth 2009;103:352–8
3. Neelankavil J and all. Transthoracic echocardiography simulation is an efficient method to train anesthesiologists in basic transthoracic echocardiography skills. Anesth Analg. 2012 Nov;115(5):1042-51. doi: 10.1213/ANE.0b013e318265408f. Epub 2012 Jul 19.
4. Cahalan M, Abel M, Goldman M, Pearlman A, Sears-Rogan P, Russell I, Shanewise J, Stewart W, Troianos C. American Society of Echocardiography and Society of Cardiovascular Anesthesiologists Task Force guidelines for training in perioperative echocardiography. Anesth Analg 2002;94:1384–8.
5. Jensen MB, Sloth E, Larsen KM, Schmidt MB. Transthoracic echocardiography for cardiopulmonary monitoring in intensive care unit. Eur J Anesthesiol 2004;21:9:700–7
6. Breitkreutz R, Uddin S, Steiger H, Ilper H, Steche M, Walcher F, Via G, Price S. Focused echocardiography entry level: new concept of a 1-day training course. Minerva Anesthesiol 2009;75:285–92.
7. Lang RM and all. Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Journal of the American Society of Echocardiography. 2015 Jan; 28(1);1-39.
8. Jensen MB and all. Transthoracic echocardiography for cardiopulmonary monitoring in intensive care. Eur J Anaesthesiol 2004; 21:700-7
9. Tanzola RC and all. Brief report: Focused transthoracic echocardiography training in a Cohort of Canadian anesthesiology residents: a pilot study. Can J Anesth (2013) 60:32-37.
10. Cowie B: Three years' experience of focused cardiovascular ultrasound in the peri-operative period. Anaesthesia 66:268-273, 2011
11. Canty DJ and all. The Impact of Pre-Operative Focused Transthoracic Echocardiography In Emergency Non-cardiac Surgery Patients With Known or Risk of Cardiac Disease. Anesthesia 2012; 67: 714-720.