Targeted bedside echocardiography in the management of critically ill patients

Dear Editor,

We thank Hall et al. ¹ for their recent evaluation into the impact of Focused Intensive Care Echo (FICE) protocol in the management of critically ill patients. Their findings are very much in keeping with our experience since the widespread dissemination of FICE training in Kent, Surrey and Sussex.

In addition to the necessary reasons behind the study, we feel that another strength in the delivery of FICE is the ability to provide round the clock rapid targeted assessment at the bedside in the hyper acute setting, especially by trainees.

At East Surrey Hospital, we have Sonosite X-Porte devices in our Critical Care Department, Emergency Department and Acute Medical Unit. This enables us to deliver rapid point of care echocardiographic assessment on admission, and the uniformity of the hardware means that practitioners have familiarity with equipment regardless of clinical environment.

As enthusiastic practitioners of FICE, we have been able to alter patient management in the absence of expert assessment on a number of occasions. This included cases such as severely impaired ventricular function and tamponade. Of note, one of our FICE accredited trainees was pivotal in recognising the need for an emergency pericardial drain for tamponade secondary to a type A aortic dissection. Following this intervention, the patient was urgently transferred to a cardiac centre, receiving a proximal aortic arch replacement and making a full recovery to discharge from hospital. Had there been a delay in recognising the cardiac tamponade using FICE, the patient’s outcome would not have been so favourable.

It is satisfying to note that even though the study by Hall et al. did not report any false positive findings, there were a significant number of false negatives. We feel this beautifully highlights the fact that FICE and a full British Society of Echocardiography (BSE) study serve very different purposes. The FICE protocol can be safely delivered by any appropriately trained acute care practitioner and gives us valuable information with a significant potential to affect clinical management in our patients.

However, we should not regard this as a substitute for a full BSE study. The amount of echocardiographic experience required to enable a practitioner to accurately discriminate between for example subtle differences in degrees of ventricular dysfunction or minor valve lesions is vast and clearly beyond the defined scope of FICE.

There are issues to resolve around governance, storage and reporting of images, but it is crucial that we overcome these rather than continue to rely solely on user generated reports without images.

We hope that now the benefit and importance of FICE is clearly established, this resource will become a core part of the training curriculum not only in Critical Care Medicine, but also in the allied acute specialties including Anaesthesia, Emergency Medicine and Acute Medicine. The principle advantage of FICE is rapid delivery at the bedside and we would suggest due consideration is given to incorporating FICE into specialty trainee rotations, which can only serve to improve upon the delivery of safe and effective healthcare.