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Australasian Journal of Ultrasound in Medicine logoLink to Australasian Journal of Ultrasound in Medicine
. 2017 Feb 23;20(1):41–46. doi: 10.1002/ajum.12041

Minimum standards for ultrasound equipment in intensive care. Recommendations from CICM Ultrasound Special Interest Group

Cartan Costello 1,✉, Konstantin Yastrebov 2, Yang Yang 3, Andrew Hilton 4, Sanjiv Vij 5, Sam Orde 6
PMCID: PMC8409823  PMID: 34760469

Abstract

Critical care ultrasonography allows rapid bedside assessment and monitoring of severely ill patients. It provides important information on a real‐time basis for patients' management and clinical decision‐making, leading to improvements in delivered quality of care. Provision of this service is not possible without appropriate equipment. This document recommends minimum standards for ultrasound equipment required for use in intensive care units in Australia and New Zealand.

Keywords: critical care, echocardiography, general ultrasound, equipment focussed studies

Introduction

Critical care ultrasonography allows rapid bedside assessment and monitoring of severely ill patients. It provides important information on a real‐time basis for patients' management and clinical decision‐making, leading to improvements in delivered quality of care.1, 2, 3, 4, 5, 6 Critical care ultrasound is a fundamental component in diagnostic and treatment algorithms of hemodynamic emergencies such as pulmonary embolism, cardiac arrest and blunt trauma.7, 8, 9, 10, 11, 12 The Australian and international practice of intensive care medicine has evolved to incorporate the use of ultrasound, and this practice change has been validated and supported in multiple peer‐review articles and professional body consensus statements.1, 2, 5, 6

Critical care ultrasonography requires specific knowledge and skills, which differentiates it from ultrasonography performed for a general population. It is performed on critically ill patients by the treating physician, interpreted real time in the clinical context existing at that moment and is often repeated to monitor progress or response to interventions. Adequate training of intensive care practitioners in diagnostic ultrasound is essential for the provision of this timely specialised service and thus has been included in the CICM training curriculum. Recommendations for minimum training standards in critical care ultrasonography are being developed as a separate document by the CICM ultrasound Special Interest Group.

Provision of an ultrasound service for critically ill patients and all associated training is not possible without appropriate equipment. The matrix of ultrasound equipment consists of both hardware and software components. Absence of guidelines for ultrasound equipment required to provide modern intensive care service has resulted in a substandard and unstructured approach to the provision of ultrasound equipment, absence of adequate future planning and frequently inadequate or absent access to obligatory ultrasound imaging archiving. It has resulted in substandard provision of relevant clinical service for ICU patients, poor relevant training standards and undeveloped clinical and translational research. The intention of this document is to provide guidelines that empower practitioners and ICU administrators to optimise future ultrasound services within critical care units in Australia and New Zealand. This document is designed to provide a review of current knowledge and practice as well as to assist with applications for resource provision. These recommendations are mostly based on a collective Australian and New Zealand expert opinion, and legal advice sourced by the authors in respect to image archiving. Structural approach to these recommendations will undergo progressive change with the advances in research and available literature, thus triggering future reviews of the text.1, 2, 3, 4, 5, 6, 11, 12, 13, 14, 15, 16

Levels of ultrasound scanners

Many ultrasound platforms are available in Australia and New Zealand. These include the following:

  1. Hand‐held ultra‐portable devices

  2. Light‐cart and laptop‐sized devices

  3. Mid‐range multipurpose and specialised full‐cart devices

  4. High‐end ultrasound platforms

The choice of the specific platform for individual intensive care units should reflect current and anticipated clinical service, case‐mix of patients and appropriate level of skills and training among intensive care practitioners within each unit. It should also reflect existing and developing education and research ultrasound projects.

In order to provide timely patient assessment and provide training for CICM trainees, ultrasound equipment dedicated to the ICU should be available at all times.

The benefits and extent of engagement with other services such as cardiology and radiology in a collaborative approach to service provision and teaching should be considered in each institution. Exclusive availability of ultrasound equipment for ICU patients remains paramount for such collaboration.

Hand‐held ultra‐portable ultrasound devices have gained recent popularity due to their small size, but still have inferior imaging quality and archiving capability compared to other platforms. At this stage, they are not recommended as a primary ultrasound platform for the assessment of intensive care patients. Their small size may assist as an adjunct for the assessment of out‐of‐ICU consults and MET calls, as well as during intensive care retrievals. All intensive care staff using ultra‐portable devices for clinical decision‐making should have appropriate training and experience.2, 17, 18

Light‐cart and mid‐range platforms are suitable for daily routine ultrasound investigations and procedural guidance. Light‐cart platforms allow placement of vascular lines, and percutaneous drains and mid‐range platforms allow better imaging for focused cardiac, lung and abdominal ultrasound studies.6, 19, 20

High‐end platforms and some mid‐range platforms are suitable for comprehensive transthoracic and transoesophageal echocardiographic examination, advanced vascular and general ultrasound studies. These platforms allow better quality imaging and more advanced modalities necessary to minimise diagnostic mistakes and to improve comprehensive assessment in intensive care patients with suboptimal echogenic conditions. High‐end platforms offer superior research and educational capabilities in centres with advanced and expert‐level ultrasound‐trained clinicians.

Focused cardiac ultrasound

It is expected that all trainees entering the CICM training programme from 2014 should receive sufficient training and skills to perform unsupervised focused hemodynamic state assessment for critically ill patients by the time of completion of their specialist qualification.13, 14 To achieve competency, trainees must complete a CICM accredited echocardiography course, perform 30 focused studies deemed satisfactory by a CICM approved assessor as well as successful completion of an online MCQ‐style examination.

Focused echocardiographic assessment of hemodynamic state is aimed at identification of major abnormalities responsible for hemodynamic collapse – severe hypovolaemia, major left and/or right ventricular systolic failure, catastrophic valvular disorders, profound arteriolar vasodilation and obstructive shock. It is deployed in emergencies to aid rapid bedside diagnosis and guide appropriate early intervention. It should not be viewed as a replacement of a comprehensive echocardiographic investigation. It is recommended that in cases of identified or suspected significant pathology, careful and thorough clinical re‐assessment followed by a referral for a comprehensive echocardiographic investigation should be performed.

Focused echocardiographic assessment of hemodynamic state in an intensive care unit requires at least a light‐cart laptop‐size scanner with 2D and M‐mode capabilities. Two‐dimensional assessment requires a phased array transducer and specialised ‘cardiac’ software package on‐board of the scanner. When echogenic conditions are poor, higher‐end echocardiographic scanners improve quality of imaging and thus reduce the risk of missed or incorrect diagnosis. Higher‐end equipment is therefore recommended for the use in patients with poor echogenic conditions.1, 2, 19, 20, 21

Focused vascular, lung and abdominal ultrasound

It is expected that many intensive care practitioners already have or will soon have sufficient training and skills to perform unsupervised focused vascular, pulmonary and abdominal ultrasound in critically ill patients.

Vascular focused ultrasound

It is recommended that all central venous jugular and femoral cannulations should be carried out with ultrasound guidance. Technically difficult placements of peripherally inserted central venous lines, subclavian central lines, difficult arterial and peripheral venous cannulations can be improved by utilising ultrasound guidance with high‐frequency linear probes.6, 22

DVT assessment, shunts and arterial studies outside of procedural guidance could also be classified as ‘focused’ investigations. However, the latter require a specific set of skills and should be undertaken only by the staff with advanced training and expertise in vascular ultrasound, which exceeds basic vascular ultrasound training.

Lung and pleural ultrasound

Lung ultrasound is increasingly used in intensive care patients for the diagnosis of pulmonary and pleural pathology. It is a highly sensitive test offering immediate bedside assessment thereby minimising delay in clinical decision‐making, transport of unstable patients and reducing radiation exposure in vulnerable patient populations, compared to other existing modalities. It has been used for immediate exclusion of pneumothorax, pulmonary oedema, pleural effusion etc. It is strongly recommended for the procedural guidance of pleural effusion drainage.6, 23, 24, 25, 26, 27 Lung ultrasound is a valuable adjunct to a clinical examination, but at this stage is not a complete replacement of other modalities, such as chest X‐rays and CT scans. It is expected that all intensive care trainees will soon have sufficient training and experience to perform focused lung ultrasound. Relevant training recommendations are currently being developed.

Abdominal ultrasound

Focused abdominal ultrasound in intensive care patients can support comprehensive assessment of intra‐abdominal and retroperitoneal organs, targeting specific questions – cholecystitis, renal obstruction, presence of fluid in peritoneal cavity etc.6 Retrospective case series show improved success rates with peritoneal diagnostic and therapeutic taps performed under ultrasound guidance as well as reduced complication rates including bleeding. Advanced training is required for investigations of renal perfusion, liver ultrasound etc. At this stage, basic abdominal ultrasound training is not mandated for intensive care trainees and practitioners, although it is likely that this set of training skills will be available for CICM trainees in the near future, similar to ACEM trainees.6, 10, 11, 12, 13

Recommended equipment

Focused vascular ultrasound requires linear array transducers with frequencies of at least 5 MHz (preferably 8 MHz and higher) and specialised ‘arterial’, ‘venous’ or ‘vascular’ software package ‘on‐board’ of the scanner. It must be capable of 2D modality, M‐mode, colour Doppler and spectral Doppler modalities.2, 3, 6

Procedural guided ultrasound insertions such as pleural, pericardial and peritoneal drains should be performed using at least light‐cart laptop‐sized scanners with availability of linear, curved and phased array transducers.

Focused lung ultrasound can be performed utilising phased array transducers, linear array transducers or curved‐array transducers. Specialised software packages are not required, but the operator must have basic knowledge of image optimisation, transducers properties and artefacts interpretation. At least light‐cart laptop‐size scanners are required to perform basic lung ultrasound. Interpretation of artefacts‐based imaging can be complex and mid‐range machines could offer better resolution in many ICU patients when compared to the lower‐range scanners.

Focused abdominal ultrasound should be performed using at least light‐cart laptop‐sized scanners with curved‐array transducer and ‘abdominal’ software package. Ideally, mid‐range machines should be employed.

Comprehensive echocardiographic examination

Any echocardiographic examination of a critically ill patient apart from focused hemodynamic state assessment should be as complete as possible. Even when the clinical question may appear narrowly defined (i.e. assessment of a particular valve), comprehensive echocardiographic assessment is paramount for provision of vitally important clinical care in a very complex clinical environment. When performing comprehensive echocardiographic examination, an intensive care practitioner should attempt to utilise all available echocardiographic windows, imaging of all cardiac chambers and all cardiac valves, great vessels and dynamic flows. Image optimisation with patient positioning, ventilator adjustments, probes and scanner settings optimisation may be required.1, 2, 3, 4, 5, 20

Poor echogenic conditions exist frequently within the ICU patient population. This is the consequence of often limited ability to obtain optimal patient position for imaging, hyperinflation of lungs due to positive pressure ventilation, presence of drains obstructing views as well as inadequate patient fasting prior to abdominal scanning.

High‐end ultrasound platforms have better image quality, superior technology for image optimisation options and therefore offer maximum compensation for poor echogenic conditions. Technical advances with automated image processing algorithms offer practical clinical and time efficiency benefits, improved accuracy and reproducibility in rapid quantification of volumes, hemodynamic values and valvular lesions.

While light‐cart laptop‐sized and mid‐range full‐cart devices may be sufficient in a proportion of ICU patients, availability of a high‐end ultrasound platform is frequently necessary. Significant recent advances in quality of equipment has resulted in transthoracic echocardiography (TTE) being sufficient for most intensive care patients. However, the specifics of intensive care patients, especially in cardiothoracic units, often dictate requirements for availability of transoesophageal echocardiography equipment for immediate advanced assessment of rapidly deteriorating patients, where TTE could be insufficient.

All scanners for comprehensive echocardiographic examination must be equipped with the following:

  1. At least one phased array transducer with variable frequencies and harmonic/fundamental capabilities.

  2. A dedicated small footprint continuous wave Doppler transducer.

  3. A transoesophageal probe.

  4. 2D and M‐mode capabilities with cardiac software package.

  5. Spectral Doppler (pulse wave and continuous wave) and colour Doppler capabilities.

  6. Tissue velocity imaging with quantification capacity.

  7. Cardiac quantification package, adjusted for local requirements (semi‐automated and automated quantification systems are preferred).

It is recommended that all intensive care units with available advanced and expert‐level echocardiographic expertise should be equipped with dedicated high‐end ultrasound platforms. Mid‐range multipurpose and specialised ultrasound platforms are acceptable when compliant with the above minimum requirements.1, 2, 3, 5

Intensive care units involved in advanced ultrasound training and research

Involvement in research and advanced training is an essential part of CICM curriculum and constitute part of defined contractual duties for ICU staff specialists. Intensive care units, involved in ultrasound research and advanced echocardiographic training by expert‐level intensive care practitioners, must possess an adequate level of equipment to enable appropriate level of training and modern competitive research. It is therefore recommended that highly advanced modern ultrasound technology with 3D capabilities, speckle‐tracking, strain and strain rate imaging, contrast imaging modalities should be available for each site based on individual requirements and available expertise.

Formal vs. informal ultrasound studies

Apart from teaching and ‘scout’ assessment for ultrasound conditions, there should be no studies deemed ‘informal’ when conducting ultrasound examinations in intensive care unit. Any ultrasound study independently of being regarded as a ‘focused’ or ‘comprehensive’ examination, which is used for diagnostic purpose, clinical decision‐making or invasive procedural guidance should be regarded as ‘formal’ and should only be performed by appropriately trained staff, utilising appropriate for specific study ultrasound equipment.

Image archiving and reporting

All ultrasound images used in patient care form part of a patient's medical record, with associated clinical and legal requirements for archiving. The choice of specific platform for archiving and reporting is based on its ability to optimise patient care, comply with local legislation and mitigate medico‐legal risk associated with medical record keeping for practitioners and organisations.28

Archiving systems must have the ability to record patient identifiers, to include at least the patient's full name, UR and date of birth. It is recommended that patients' weight and height, clinical indication for the study, referring and performing practitioner should also appear in the record. All stored studies should be readily available for future clinical QA assessment and progress review, for medico‐legal reasons and teaching. Uniformly compatible DICOM format should be used for image storage. Appropriate data protection, backup and archiving maintenance must be undertaken by those designated responsible for medical records within each organisation. The choice of having stand‐alone archiving systems or linked to the general database should be based on local hospital requirements. It is better, when echocardiographic archiving is performed in conjunction with other services (cardiology, anaesthetics, and radiology) as this ensures continuity and quality of patient care. Intensive care studies may be labelled accordingly to ensure easy identification of ICU studies among the general pool for the purpose of review and reporting.

A range of DICOM‐based proprietary archiving and reporting systems are available from many manufacturers. The choice cannot be advocated and should be based on scanner characteristics, specifics of local requirements and preferences. It must be noted that some of the quantification systems are still lacking uniformity between manufacturers (i.e. strain rate imaging). In these cases, establishment of the local reference ranges is recommended by institutional ultrasound laboratories.

Quality and age of the equipment

Bad ultrasound imaging with resulting diagnostic and management errors is potentially catastrophic for critically ill patients. The choice of the equipment should reflect individual patients' characteristics, posed clinical questions, available medical expertise and specifics of intensive care unit. The best available equipment should be used by the clinician to optimise the quality of imaging in the attempt to reduce diagnostic error.

It is recommended to avoid using ultrasound equipment older than 10 years, with the optimum being no more than 5 years of age. This ensures currency of the technology, reliability and safety. All ultrasound equipment must be TGA approved and currently serviced. It is the responsibility of each institution that all equipment used for clinical or diagnostic purposes have service contracts in place, undergoes regular biomedical checks and is maintained in a good working order. Departments must ensure that staffs are appropriately orientated in the use of specific ultrasound equipment. It is recommended that service contracts should include ongoing staff education and training by the ultrasound vendors in the use of their equipment.

Institutional administrators should seek input and recommendations from ultrasound expert‐level and advanced‐level trained intensive care staff before making purchase decisions for ultrasound scanners in intensive care units.

Infection control

Infection control measures are paramount for patients’ safety and for the prevention of infectious diseases transmission. This is especially important when handling immunocompromised patients and patients with resistant organisms.

Regular equipment cleaning and probes disinfection procedures must be established in each intensive care unit. Cleaning solutions and procedures can be guided by manufacturers’ recommendations. The use of sterile protective sleeves is obligatory when performing sterile invasive procedures using procedural guidance ultrasound with each unit having sufficient stock available at all times.

Cleaning of transoesophageal probes can be undertaken either by centralised hospital CSSDs or by specifically trained intensive care staff. Local protocols approved in collaboration with the individual ID departments should be in place should the cleaning be undertaken outside CSSD. All cleaning history should be documented and available for auditing.29, 30

Summary of recommendations

  • Ultrasound is a part of the routine practice of modern intensive care.

  • Better image quality leads to improved clinical decision‐making and patient outcomes.

  • Focused echocardiography requires at least light‐cart laptop‐size scanner with 2D and M‐mode capabilities.

  • Post‐2014 CICM curriculum requires equipment of standard suitable for performance of focused echocardiography.

  • Hand‐held ultra‐portable ultrasound devices are not recommended as a primary ultrasound platform for the assessment of intensive care patients.

  • Light‐cart laptop devices are the minimum recommended standard for the performance of critical care vascular, lung and abdominal ultrasound scans.

  • High‐end echocardiography equipment is recommended for use in patients with poor echogenic conditions and should be available for each site based on individual requirements and local expertise.

  • Ultrasound equipment dedicated to the ICU should be available at all times.

  • Ultrasound images form part of the medical record and should be archived using systems that are accessible, retrievable and comply with relevant local legislation.

  • No ICU ultrasound scans should be deemed ‘informal’.

  • Equipment should be maintained in working order with contingency provision for breakdown, service and infection control.

  • Adequate training of practitioners undertaking independent diagnostic ultrasound is essential. Relevant recommendations for Minimum Training Standards in critical care ultrasonography are being prepared as a separate document by the CICM ultrasound SIG subcommittee.

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