Overview of Diagnostic POCUS for Anesthesiology

The American Society of Anesthesiologist does not currently have guidelines for the use of diagnostic point of care ultrasound (POCUS) other than established for transesophageal echocardiography. Diagnostic POCUS implies the use of ultrasound to answer a clinical question and not as guidance in a specific procedure. As such we do not currently have guidance regarding scope of practice, recommendations for minimum training to attain competence or right of the American Society of Anesthesiology members to practice in this domain.  Here we explore the latest literature regarding these questions. 

Scope of Practice of Diagnostic POCUS for Anesthesiology

Right to Practice Diagnostic POCUS

This scope of practice on POCUS by Anesthesiologists has been defined by the Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Anesthesiology (ABA). Both have identified applications for POCUS as core competency for anesthesiologists. Anesthesiology Residency Programs must train physicians in the use of surface ultrasound to evaluate "organ function and pathology as related to anesthesia, critical care, and resuscitation". Specific requirements by the ACGME include transthoracic ultrasound for cardiac function/ pathology, pulmonary ultrasound, and hemodynamic assessment. The ABA currently includes focused ultrasound as part of the certification process and includes the focused ultrasound of the following organ systems: heart, lungs,  and abdomen ( gastric and focused assessment with sonography in trauma). These are the core areas explored in showmethepocus.com.  

 

Additional organ systems have a particular relevance within certain subspecialties and can be considered secondary to the aforementioned areas. These may include focused ultrasound of the following areas: Airway, Ocular, Renal and Gentourinary, Transcraneal Doppler,  Musculoskeletal and Deep vein thrombosis. . 

According to the American Medical Association, ultrasound imaging is within the scope of practice of property trained physicians and hospitals should grant privileges to perform ultrasound imaging in accordance with specialty-specific guidelines. Properly trained anesthesiologists should thus have the right to practice diagnostic POCUS if it is done within their scope. This scope of practice has been defined by the Accreditation Council for Graduate Medical Education and the American Board of Anesthesiology. 

Minimum Training Needed to Achieve Competence 

Patients expect doctors to be competent to diagnose, plan management, carry out practical procedures, and they expect them to behave in a reasonable way demonstrating a caring and humanistic attitude while doing so. In this sense competency is the ability to provide safe care and to accurately assess and to critically think while providing evidence-based  care. To achieve this goal a clinician must complete a minimum of required procedures for any medical intervention.

 

Professional medical societies set the standard in their respective field. In regards to POCUS, professional societies differ in what minimum training is needed to attain competence in diagnostic POCUS. The American Board of Anesthesiology has jet to produce this minimum standard. It is only through an expert panel of ASA members representing various subspecialties from 21 different North American Medical Centers that we have guidance on this topic. The training recommendations are grounded on the basis of limited experience on ultrasound in any of its presentations and an expert in diagnostic POCUS is available to supervise the learner's acquisition and interpretation of a portfolio of diagnostic POCUS examinations. Here we focus on the training minimums required to guide training of anesthesiology residents and fellows. Diagnostic POCUS competence can be achieved for practicing Anesthesiologists though self study guides, vetted online resources, POCUS courses, textbooks or published articles and simulators with the use of peer attestation. The ASA currently offers an educational certificate of completion program (and not a board certification) in diagnostic POCUS. It is highly unlikely that a dedicated POCUS board will be separate from that of the original specialty since many specialties are in the process of integrating POCUS as part of the training process. 

Regarding credentialing and privileging. The number of exams needed for competence should not be the same than those for credentialing and it is up to each Anesthesiology Department and/or hospital to adopt POCUS standards appropriate for the local environment.

Suggested minimum number of supervised studies needed to achieve competence in specific diagnostic point-of-care ultrasound domains. POCUS denotes point of care ultrasound. FAST, focused assessment with sonography in trauma.  * indicates limited data. Table modified from Bronshteyn YS and all. 

References

1.Bronshteyn YS, Anderson TA, Badakhsh O, Boublik J, Brady MBW, Charnin JE, Coker BJ, Deriy LB, Hardman HD, Haskins SC, Hollon M, Hsia HJ, Neelankavil JP, Panzer OPF, Perlas A, Ramsingh D, Sharma A, Shore-Lesserson LJ, Zimmerman JM; American Society of Anesthesiologists Ad Hoc Committee on PoCUS. Diagnostic Point-of-Care Ultrasound: Recommendations From an Expert Panel. J Cardiothorac Vasc Anesth. 2022 Jan;36(1):22-29. doi: 10.1053/j.jvca.2021.04.016. Epub 2021 Apr 17. PMID: 34059438.