According to recent recommendations from an ASA expert panel, which of the following examinations is MOST likely a primary application of diagnostic point-of-care ultrasound (POCUS) for anesthesiologists?
- □ (A) Airway
- □ (B) Musculoskeletal
- □ (C) Focused assessment with sonography in trauma (FAST)
The use of POCUS has been gaining momentum since the American Medical Association emphasized the use of ultrasound within the scope of practice of physicians. Clinical use of ultrasound is becoming more common due to increased availability and decreased cost. It can be done at the bedside to guide procedures (procedural ultrasound) or to answer clinical questions (diagnostic ultrasound).
“Clinical use of ultrasound is becoming more common due to increased availability and decreased cost. It can be done at the bedside to guide procedures (procedural ultrasound) or to answer clinical questions (diagnostic ultrasound).”
Although the American College of Emergency Physicians, the Society of Critical Care Medicine, and the American College of Chest Physicians have given minimal guidelines for competency, until recently, ASA had not addressed diagnostic POCUS guidelines and did not have even minimal training guidelines. To address this, ASA established a panel of experts to develop a consensus statement with the aim of identifying scope of practice, suggesting minimal training guidelines, and recommending guidelines for safe and ethical use of POCUS. Separately, the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Anesthesiology (ABA) identified core competencies for anesthesiology residents performing diagnostic POCUS to evaluate organ dysfunction, and the ABA added FAST to its board certification.
Expanding on the work of the ACGME and ABA, the ASA expert panel defined the most pertinent, or primary, ultrasound applications for anesthesiologists, which are focused cardiac ultrasound, focused abdominal ultrasound, and focused pulmonary ultrasound. Focused cardiac ultrasound is useful for preoperative screening for pathology and during a crisis to evaluate causes of hypotension. Abdominal ultrasound includes both a gastric scan to assess gastric volume and the FAST examination to screen for intra-abdominal free fluid. Finally, the pulmonary ultrasound can aid in determining causes of respiratory distress and failure.
Because the number of uses for anesthesia-related ultrasound has grown, secondary applications have been proposed by the expert panel; these may be added to training programs when appropriate. They include airway, musculoskeletal/soft tissues, ocular, genitourinary, and transcranial Doppler applications, as well as screening for deep venous thrombosis.
As more data are published, the ASA expert panel has developed minimal requirements to achieve POCUS competency. These requirements specify the minimum number of supervised studies needed to be personally performed and interpreted by the practitioner, as well as the minimum number of additional supervised studies needed to be interpreted but not necessarily personally performed by the practitioner. Depending on the POCUS application, the minimum number of studies personally performed range from 30 to 100. For example, 30 studies are needed in the FAST exam and 100 are needed in focused transcranial Doppler ultrasound. For the additional studies not personally performed, the minimum numbers range from 20 to 100. For both areas, the expert panel was unable to make recommendations for certain applications because of a lack of sufficient data. The recommendations are focused on resident and fellow training but could also be useful for attending anesthesiologists who wish to become proficient and receive a certificate of completion.
Risks of using POCUS are minimal and include transmission of pathogens between patients and inaccurate interpretation of data. There is also a thermal risk involved in ultrasound, especially for ocular and fetal examinations. The expert panel advises that consent be obtained whenever possible.