Special Article
International Evidence-Based Recommendations for Focused Cardiac Ultrasound

https://doi.org/10.1016/j.echo.2014.05.001Get rights and content

Background

Focused cardiac ultrasound (FoCUS) is a simplified, clinician-performed application of echocardiography that is rapidly expanding in use, especially in emergency and critical care medicine. Performed by appropriately trained clinicians, typically not cardiologists, FoCUS ascertains the essential information needed in critical scenarios for time-sensitive clinical decision making. A need exists for quality evidence-based review and clinical recommendations on its use.

Methods

The World Interactive Network Focused on Critical UltraSound conducted an international, multispecialty, evidence-based, methodologically rigorous consensus process on FoCUS. Thirty-three experts from 16 countries were involved. A systematic multiple-database, double-track literature search (January 1980 to September 2013) was performed. The Grading of Recommendation, Assessment, Development and Evaluation method was used to determine the quality of available evidence and subsequent development of the recommendations. Evidence-based panel judgment and consensus was collected and analyzed by means of the RAND appropriateness method.

Results

During four conferences (in New Delhi, Milan, Boston, and Barcelona), 108 statements were elaborated and discussed. Face-to-face debates were held in two rounds using the modified Delphi technique. Disagreement occurred for 10 statements. Weak or conditional recommendations were made for two statements and strong or very strong recommendations for 96. These recommendations delineate the nature, applications, technique, potential benefits, clinical integration, education, and certification principles for FoCUS, both for adults and pediatric patients.

Conclusions

This document presents the results of the first International Conference on FoCUS. For the first time, evidence-based clinical recommendations comprehensively address this branch of point-of-care ultrasound, providing a framework for FoCUS to standardize its application in different clinical settings around the world.

Section snippets

Recommendation-Building Methodology

The evidence-based statements and recommendations presented in this document were developed using a rigorous methodologic regimen, previously described, starting with the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) method.36 This approach entails: (1) a preliminary determination of the quality of available evidence and (2) the subsequent development of the recommendations. All articles concerning the conference object were ranked into three levels of quality

Literature Search Results

The complete literature search was then screened for clearly nonpertinent findings; the final bibliography was consistent with the definition of FoCUS and agreed on by the panel. A total of 293 articles (as of June 2012) were retrieved by the two search tracks. Two additional searches were performed over a 15-month period (June 2012 to September 2013), reaching the final number of 382 articles (Appendix 3 in the ESM). These were individually appraised on the basis of established methodologic

Knowledge Gaps and Future Research Directions

The lack of adequately powered outcome-based studies to prove benefit of use of FoCUS in the various specific clinical settings is certainly the major knowledge gap. Exhaustive data on the cost-effectiveness of FoCUS use should also be acquired, especially in the critical care scenario. Validation of integrated clinical ultrasound protocols for FoCUS-driven patient management should be studied. Impact evaluation of FoCUS-based early goal-directed management of septic shock, cardiogenic shock,

Conclusions

The primary impetus for the development and promulgation of FoCUS is to increase access to this important diagnostic tool.

Multiple converging sources of evidence support the fact that FoCUS is a diagnostic tool; its use determines diagnoses contemporaneously with treatment and management and mitigates diagnostic uncertainty. Like all diagnostics, the expectation of FoCUS is to facilitate patient care and, thereby, improve outcomes. FoCUS requires archiving, reporting, and, where relevant,

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    Dr Bowra is a member of the Medical Advisory Board of Signostics Pty Ltd. Dr Neskovic is an advisor to Medtronic and AstraZeneca and has received consultative honoraria from these companies. Dr Neskovic has received honoraria from Merck and research funds from GE Healthcare. Dr Sloth is an uncompensated member of the Medical Advisory Board of GE Vscan and an uncompensated lecturer for Philips. All other members declared no conflict of interest. No direct sponsorship of any kind has been provided by any commercial or industrial source. No honoraria have been given to any of the panel members.

    Promoted by the World Interactive Network Focused on Critical UltraSound (WINFOCUS). Endorsed by the American Society of Echocardiography (ASE), the European Association of Cardiovascular Imaging (EACVI), the British Society of Echocardiography (BSE), the Indian Society of Critical Care Medicine (ISCCM), the Chinese Society of Critical Care Medicine (CSCCM), the International Pan-Arab Critical Care Medicine Society (IPACCS), Associação do Medicina Intensiva Brasileira (AMIB), the European Society of Emergency Medicine (EuSEM), the American College of Emergency Physicians (ACEP), the Australasian College for Emergency Medicine (ACEM), the Asian Society for Emergency Medicine (ASEM), the Emergency Medicine Society of South Africa (EMSSA), the Society for Ultrasound in Medical Education (SUSME), the Australian Society for Ultrasound in Medicine (ASUM), the Saudi Heart Association (SHA), and the Pediatricians with Expertise in Cardiology Special Interest Group (PECSIG).

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