title: Guidelines for the Appropriate Use of Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients-Part II: Cardiac Ultrasonography.
abstract: OBJECTIVE
  To establish evidence-based guidelines for the use of bedside cardiac ultrasound, echocardiography, in the ICU and equivalent care sites.
  
  
  METHODS
  Grading of Recommendations, Assessment, Development and Evaluation system was used to rank the "levels" of quality of evidence into high (A), moderate (B), or low (C) and to determine the "strength" of recommendations as either strong (strength class 1) or conditional/weak (strength class 2), thus generating six "grades" of recommendations (1A-1B-1C-2A-2B-2C). Grading of Recommendations, Assessment, Development and Evaluation was used for all questions with clinically relevant outcomes. RAND Appropriateness Method, incorporating the modified Delphi technique, was used in formulating recommendations related to terminology or definitions or in 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.
  
  
  RESULTS
  Forty-five statements were considered. Among these statements, six did not achieve agreement based on RAND appropriateness method rules (majority of at least 70%). Fifteen statements were approved as conditional recommendations (strength class 2). The rest (24 statements) were approved as strong recommendations (strength class 1). Each recommendation was also linked to its level of quality of evidence and the required level of echo expertise of the intensivist. Key recommendations, listed by category, included the use of cardiac ultrasonography to assess preload responsiveness in mechanically ventilated (1B) patients, left ventricular (LV) systolic (1C) and diastolic (2C) function, acute cor pulmonale (ACP) (1C), pulmonary hypertension (1B), symptomatic pulmonary embolism (PE) (1C), right ventricular (RV) infarct (1C), the efficacy of fluid resuscitation (1C) and inotropic therapy (2C), presence of RV dysfunction (2C) in septic shock, the reason for cardiac arrest to assist in cardiopulmonary resuscitation (1B-2C depending on rhythm), status in acute coronary syndromes (ACS) (1C), the presence of pericardial effusion (1C), cardiac tamponade (1B), valvular dysfunction (1C), endocarditis in native (2C) or mechanical valves (1B), great vessel disease and injury (2C), penetrating chest trauma (1C) and for use of contrast (1B-2C depending on indication). Finally, several recommendations were made regarding the use of bedside cardiac ultrasound in pediatric patients ranging from 1B for preload responsiveness to no recommendation for RV dysfunction.
  
  
  CONCLUSIONS
  There was strong agreement among a large cohort of international experts regarding several class 1 recommendations for the use of bedside cardiac ultrasound, echocardiography, in the ICU. Evidence-based recommendations regarding the appropriate use of this technology are a step toward improving patient outcomes in relevant patients and guiding appropriate integration of ultrasound into critical care practice.
authors.affiliation: 1Division of Pulmonary and Critical Care Medicine Eastern Virginia Medical School, Norfolk, VA. 2Los Angeles, CA. 3Department of Emergency Medicine, St Francis Hospital, University of South Carolina School of Medicine, Columbus, GA. 4Foothills Medical Centre and the University of Calgary, Calgary, AB, Canada. 5Department of Anesthesiology and Critical Care Medicine The Johns Hopkins University School of Medicine, Baltimore, MD. 6Emergency Ultrasound, Department of Emergency Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA. 7Aerospace and Critical Care Medicine, Mayo Clinic, Rochester, MN. 8Renown Health Reno, Nevada. 9Department of Anesthesiology, University Hospital of the Sarrland, Homburg-Saar, Germany. 10Clinics of Anesthesiology, Intensive Care and Pain Therapy, Hospital of the Goethe University, Frankfurt, Germany. 11Royal Brompton Hospital, London, United Kingdom. 12Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA. 13King Saud Bin Abdulaziz University for Health Sciences, Saudi Arabia. 14Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada.
authors.forename: Alexander
authors.initials: A
authors.lastname: Levitov
authors.forename: Heidi L
authors.initials: HL
authors.lastname: Frankel
authors.forename: Michael
authors.initials: M
authors.lastname: Blaivas
authors.forename: Andrew W
authors.initials: AW
authors.lastname: Kirkpatrick
authors.forename: Erik
authors.initials: E
authors.lastname: Su
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: Matthew
authors.initials: M
authors.lastname: McLaughlin
authors.forename: Paul E
authors.initials: PE
authors.lastname: Marik
authors.forename: Mahmoud
authors.initials: M
authors.lastname: Elbarbary
mesh_terms: D054058:Acute Coronary Syndrome / Q000000981:diagnostic imaging; D000293:Adolescent; D000328:Adult; D022561:Advanced Cardiac Life Support; D001018:Aortic Diseases / Q000000981:diagnostic imaging; D002305:Cardiac Tamponade / Q000000981:diagnostic imaging; D002648:Child; D002675:Child, Preschool; D016638:Critical Illness; D004452:Echocardiography; D005440:Fluid Therapy; D006331:Heart Diseases / Q000000981:diagnostic imaging*; D006349:Heart Valve Diseases / Q000000981:diagnostic imaging; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007362:Intensive Care Units; D010490:Pericardial Effusion / Q000000981:diagnostic imaging; D019095:Point-of-Care Systems; D012772:Shock, Septic / Q000000981:diagnostic imaging; D013898:Thoracic Injuries / Q000000981:diagnostic imaging; D018487:Ventricular Dysfunction, Left / Q000000981:diagnostic imaging; D018497:Ventricular Dysfunction, Right / Q000000981:diagnostic imaging; D055815:Young Adult