ICU echo myths! Mayo et al both enthuse and warn.

Echo myths MayoMayo et al outline the misinformation regarding echocardiography use in the ICU. Some additional comments have been added!

1. Every echo exam should be comprehensive – False

Focused assessments are valuable. We are gathering evidence about powerful but easily achieved echo findings.

But stick to the protocol you’re competent with.

2. Echo is not a monitoring tool – False

Intermittent serial quantitative or qualitative measurements are often adequate for assessing trends and guiding therapy.

Serial assessment can be powerful, but this does come at the cost of being relatively labour intensive.

3. Intensivists do not need cardiologists – False

The echo skill sets of ICU doctors and cardiologists is diverging and an experienced echo-intensivist may be more familiar with assessing heart-lung interaction but the cardiologist will always be vital for many diagnoses and cardiac disease management plans.

Ability to acquire images does not imply ability to interpret images.

4. Echo is less reliable than other haemodynamic tools – FALSE

Every monitoring device has its limitations but there are occasions when echo  may be the more accurate (eg in the very unstable patient, active haemorrhage or anatomical abnormalities).

In addition no other modality gives rapid qualitative assessment of the heart.

5. In refractory or complicated shock, echo should be replaced by an alternative device – FALSE

Echo is an excellent diagnostic device in complex instability. Shock aetiology, fluid responsiveness, LV and RV systolic and diastolic function, preload/afterload, RV-ventilator interaction can all be addressed.

The roles of traditional monitoring and echo overlap. Often information really is power.

6. Training in transoesophageal echo is an optional part of advanced echo training – FALSE

This statement may depend on your definition of ‘advanced’ but some questions are very difficult to answer with TTE. Great vessels, some valves and intracardiac shunt (or even PAC placement) for example are better assessed with TOE.

As an advanced practitioner sometimes you’ll be frustrated you don’t have a TOE probe.

7. It’s easy to achieve competence in echo – FALSE

Adequate training is vital. In training you’ll learn as many limitations as applications. Some will be competent to accurately answer simple questions after 50 scans. There must be structured training and a means to maintain competency.

Echo images must be interpreted as meticulously as possible, potential confounders must be appreciated, and the findings put in clinical context.

8. There is a strong evidence base that supports echo – FALSE
9. Echo is academically supported worldwide – FALSE

Echo has been taken up worldwide due to its ‘intuitive obvious utility’ but an outcome benefit is yet to be demonstrated. There is a relatively small group of experienced enthusiasts who publish the bulk of the work in this area. The rise of echo despite this may also prove problematic when looking for equipoise in designing a study.

Do we even know the normal echo dataset for a ventilated patient or the expected effects of inotropes on echo values? We need to gather observational data to begin to generate hypotheses. Get studying!

10. There is no risk of medico-legal issues – FALSE

Train, stay competent and know your limits when interpreting findings.

Documentation about your focused assessment should emphasise that it was asking a specific question so that it is not later assumed that the exam was comprehensive. The patient has had a focused cardiac examination and not a formal echo.

 The multiple qualifications/accreditations are converging quickly and national standards are beginning to appear. It’s not acceptable to ‘dabble’ in echo!

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  1. LITFL Review #165 - LITFL

    […] Mandeville from ICMWK reviews an article by Paul Mayo looking at critical care echo myths, and leaves us with some great pearls. […]

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