title: Guidelines for the Appropriate Use of Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients-Part I: General Ultrasonography.
abstract: OBJECTIVE
  To establish evidence-based guidelines for the use of bedside ultrasound by intensivists and specialists in the ICU and equivalent care sites for diagnostic and therapeutic purposes for organs of the chest, abdomen, pelvis, neck, and extremities.
  
  
  METHODS
  The Grading of Recommendations, Assessment, Development and Evaluation system was used to determine the strength of recommendations as either strong or conditional/weak and to rank the "levels" of quality of evidence into high (A), moderate (B), or low (C) and thus generating six "grades" of recommendation (1A-1B-1C-2A-2B-2C). Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for all questions with clinically relevant outcomes. RAND appropriateness method, incorporating modified Delphi technique, was used in steps of GRADE that required panel judgment and for those based purely on expert consensus. The process was conducted by teleconference and electronic-based discussion, following clear rules for establishing consensus and agreement/disagreement. Individual panel members provided full disclosure and were judged to be free of any commercial bias. The process was conducted independent of industry funding.
  
  
  RESULTS
  Twenty-four statements regarding the use of ultrasound were considered-three did not achieve agreement and nine were approved as conditional recommendations (strength class 2). The remaining 12 statements were approved as strong recommendations (strength class 1). Each recommendation was also linked to its level of quality of evidence. Key strong recommendations included the use of ultrasonography for ruling-in pleural effusion and assisting its drainage, ascites drainage, ruling-in pneumothorax, central venous cannulation, particularly for internal jugular and femoral sites, and for diagnosis of deep venous thrombosis. Conditional recommendations were given to the use of ultrasound by the intensivist for diagnosis of acalculous cholecystitis, renal failure, and interstitial and parenchymal lung diseases. No recommendations were made regarding static (vs dynamic) ultrasound guidance of vascular access or the use of needle guide devices.
  
  
  CONCLUSIONS
  There was strong agreement among a large cohort of international experts regarding several recommendations for the use of ultrasound in the ICU. Evidence-based recommendations regarding the appropriate use of this technology are a step toward improving patient outcomes in relevant patients.
authors.affiliation: 1Los Angeles, CA. 2Foothills Medical Centre and the University of Calgary, Calgary, AL, Canada. 3National and Gulf Center for Evidence Based Health Practice, Riyadh, Saudi Arabia. 4King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia. 5Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada. 6Professor of Medicine, University of South Carolina School of Medicine, Department of Emergency Medicine, St. Francis Hospital, Columbus, GA. 7Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA. 8Department of Emergency Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA. 9Aerospace and Critical Care Medicine, Mayo Clinic, Rochester, MN. 10President and CEO, Renown Health, Reno, NV. 11Department of Anesthesiology, University Hospital of the Sarrland, Homburg-Saar, Germany. 12Clinics of Anesthesiology, Intensive Care and Pain Therapy, Hospital of the Goethe University, Frankfurt, Germany. 13Royal Brompton Hospital, London, United Kingdom. 14Eastern Virginia Medical School, Norfolk, VA. 15Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical Center Harvard Medical School, Boston, MA.
authors.forename: Heidi L
authors.initials: HL
authors.lastname: Frankel
authors.forename: Andrew W
authors.initials: AW
authors.lastname: Kirkpatrick
authors.forename: Mahmoud
authors.initials: M
authors.lastname: Elbarbary
authors.forename: Michael
authors.initials: M
authors.lastname: Blaivas
authors.forename: Himanshu
authors.initials: H
authors.lastname: Desai
authors.forename: David
authors.initials: D
authors.lastname: Evans
authors.forename: Douglas T
authors.initials: DT
authors.lastname: Summerfield
authors.forename: Anthony
authors.initials: A
authors.lastname: Slonim
authors.forename: Raoul
authors.initials: R
authors.lastname: Breitkreutz
authors.forename: Susanna
authors.initials: S
authors.lastname: Price
authors.forename: Paul E
authors.initials: PE
authors.lastname: Marik
authors.forename: Daniel
authors.initials: D
authors.lastname: Talmor
authors.forename: Alexander
authors.initials: A
authors.lastname: Levitov
mesh_terms: D003422:Critical Care / Q000592:standards; D016638:Critical Illness; D004452:Echocardiography / Q000592:standards*; D005069:Evaluation Studies as Topic; D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D000067716:Point-of-Care Testing; D017410:Practice Guidelines as Topic; D011786:Quality Control; D012680:Sensitivity and Specificity; D018608:Ultrasonography, Doppler / Q000592:standards*