Focused Cardiac Ultrasound in the Pediatric Perioperative Setting

Karen R. Boretsky, MD; David B. Kantor, MD, PhD; James A. DiNardo, MD; Achikam Oren-Grinberg, MD


Anesth Analg. 2019;129(4):925-932. 

In This Article

FoCUS Training for Pediatric Practitioners

The implementation of FoCUS is not without barriers and new responsibilities. Accurate use of ultrasound by pediatric anesthesia providers requires additional knowledge, competence in image acquisition and interpretation, and ability to integrate the findings appropriately into clinical management. Given that FoCUS examinations are limited, focused and practice-specific training requirements differ from those set forth by organizations such as the American College of Radiology.[62] A similar distinction was made by the American Society of Echocardiography when they outlined basic training requirements for anesthesiologists performing perioperative transesophageal echocardiography.[63] Currently, there is no certification process for either adult or pediatric providers to ensure that providers of point-of-care ultrasound meet training requirements.[13] Certification is a status conferred by an outside organization and is distinct from credentialing. In a stance that may be informative to anesthesia providers, the American College of Emergency Physicians (ACEP) published a policy statement titled Emergency Ultrasound Certification by External Entities that states, in part, "ACEP strongly opposes the use of any non-emergency medicine external process to validate competency in the use of emergency ultrasound." Notably, for adult providers, the National Board of Echocardiography administered the first Examination of Special Competence in Critical Care Echocardiography in January of 2019 and offered a certification process. No similar examination is planned for pediatric providers. In the absence of a certification process, professional organizations such as the American Society of Anesthesiologists, the Society for Critical Medicine, and the Society for Pediatric Anesthesia must instead advocate for the implementation of internal training programs and credentialing guidelines linked to competency-based assessment and ongoing quality assurance and maintenance of credentialing requirements.[5,62,64,66]

FoCUS-trained pediatric critical care and emergency medicine physicians have demonstrated the ability to diagnose pericardial effusions, cardiac contractility abnormalities, and LV dilation with a high degree of accuracy.[11,37,42,67] Training programs in FoCUS comprise 3 core components: didactic sessions, technical hands-on training in image acquisition, and image interpretation and integration into the clinical scenario. The didactic course should cover basic ultrasound principles, basic cardiac anatomy with the corresponding ultrasound views, and the pathophysiology of common clinical conditions in the pediatric trainee's scope of practice, followed by hands-on training, which should include child models.

Specific recommendations for documentation of competency in either adult or pediatric practice are not available at this time. Ultimately, privileges for the use of ultrasound by anesthesiologists should be granted by the individual anesthesia department.