Journal of Cardiothoracic and Vascular Anesthesia 36 (2022) 11321147

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Journal of Cardiothoracic and Vascular Anesthesia

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Review Article
Point-of-Care Ultrasound (POCUS) for the
Cardiothoracic Anesthesiologist
Hari Kalagara, MD*, Bradley Coker, MD*,
Neal S. Gerstein, MD, FASEy, Promil Kukreja, MD, PhD*,
Lev Deriy, MDy, Albert Pierce, MD*,
Matthew M. Townsley, MD, FASE*,1
*
Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham,
Birmingham, AL
y
Department of Anesthesiology and Critical Care Medicine, University of New Mexico School of Medicine,
Albuquerque, NM

Point-of-Care Ultrasound (POCUS) is a valuable bedside diagnostic tool for a variety of expeditious clinical assessments or as guidance for a
multitude of acute care procedures. Varying aspects of nearly all organ systems can be evaluated using POCUS and, with the increasing avail-
ability of affordable ultrasound systems over the past decade, many now refer to POCUS as the 21st-century stethoscope. With the current avail-
able and growing evidence for the clinical value of POCUS, its utility across the perioperative arena adds enormous benefit to clinical decision-
making.
Cardiothoracic anesthesiologists routinely have used portable ultrasound systems for nearly as long as the technology has been available, mak-
ing POCUS applications a natural extension of existing cardiothoracic anesthesia practice. This narrative review presents a broad discussion of
the utility of POCUS for the cardiothoracic anesthesiologist in varying perioperative contexts, including the preoperative clinic, the operating
room (OR), intensive care unit (ICU), and others. Furthermore, POCUS-related education, competence, and certification are addressed.
Ó 2021 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/)

Keywords: Point-of-Care Ultrasound; lung ultrasound; transthoracic echocardiography; airway ultrasound; gastric ultrasound; ultrasound education

POINT-OF-CARE ULTRASOUND (POCUS) is the use of
portable bedside ultrasound imaging for a variety of expedi-
tious clinical assessments or as guidance for a multitude of
acute care procedures. With the increasing availability of
affordable ultrasound systems over the past decade, POCUS
use has burgeoned over a similar time frame, with low-cost
portable systems now considered the 21st-century stetho-
scope.1,2 Ideally, POCUS use in clinical management should
be goal-directed, rapid, and reproducible. Varying aspects of
nearly all organ systems can be evaluated using POCUS (see
Table 1), and there are increasingly more clinical conditions
1
Address correspondence to Matthew M. Townsley, MD, FASE, 619 South
19th St, JT 804, Birmingham, AL 35249-6810.
E-mail address: mtownsley@uabmc.edu (M.M. Townsley).
in which the utilization of POCUS may have a role.3,4 In par-
ticular, this growth has been accelerated further with the
availability and accessibility of small handheld ultrasound
devices. In certain clinical contexts (eg, pneumothorax
[PTX], hemidiaphragmatic paresis), POCUS has superior
diagnostic sensitivity and specificity compared to other diag-
nostic modalities, while also mitigating the higher costs and
possible radiation side effects of non-ultrasound imaging.5
Various medical societies (eg, Society of Critical Care Medi-
cine, American Society of Echocardiography) have devel-
oped POCUS guidelines for its usage across a wide range of
clinical settings.6,7
Cardiothoracic anesthesiologists routinely have used porta-
ble ultrasound systems for nearly as long as the technology has
been available, particularly as a tool to guide vascular access

https://doi.org/10.1053/j.jvca.2021.01.018
1053-0770/Ó 2021 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)
 H. Kalagara et al. / Journal of Cardiothoracic and Vascular Anesthesia 36 (2022) 11321147 1133

Table 1 success rate than traditional inspection and palpation meth-

Common Point-of-Care Ultrasound (POCUS) Applications ods.11,12 The utilization of ultrasound for preprocedural identi-
POCUS Structures Utility
fication of tracheal rings, as well as pre- and paratracheal
anatomy and blood vessels (especially abnormal vasculature),
Airway CTM, trachea Cricothyroidotomy, is helpful in assisting with the correct location and safe place-
endotracheal intubation ment of a percutaneous tracheostomy.13,14 AUS also is useful
Breathing (lung) Pleura, lung, diaphragm Pneumothorax, lung
parenchymal disease,
for performing airways blocks to facilitate awake fiberoptic
pleural effusion, intubations, improving airway and intubating conditions com-
pulmonary edema pared to blind tecnhiques.15,16
Circulation (cardiac) LV, RV, cardiac valves Myocardial ischemia, AUS also has shown utility in confirming correct endotra-
CHF, valvular lesions cheal tube placement and in discerning between esophageal
Pericardium Tamponade
Aorta & aortic arch Aneurysm and dissection
and endotracheal intubation. With endotracheal intubation, a
Gastric Antrum Gastric volume and single bullet sign (single air-mucosal interface with increased
contents posterior artifact shadowing) will be visualized, along with the
Vascular Veins Central and peripheral presence of bilateral lung sliding. Esophageal intubation has a
venous cannulation unique double-tract sign appearance and absence of bilateral
Arteries Invasive monitoring,
IABP
lung sliding. In a systematic review by Das et al., the authors
IVC Volume status found that AUS had a pooled sensitivity of 0.98 (95% CI,
VExUS scan Fluid overload 0.97-0.99) and pooled specificity of 0.98 (95% CI, 0.95-0.99)
Deep veins DVT in confirming endotracheal intubation.17 A meta-analysis by
Abbreviations: CHF, congestive heart failure; CTM, cricothyroid membrane;
Gottlieb et al., which included 17 studies and a total of 1,595
DVT, deep vein thrombosis; IABP, intra-aortic balloon pump; IVC, inferior patients, showed transtracheal ultrasonography was 98.7%
vena cava; LV, left ventricle; POCUS, point-of-care ultrasound; RV, right sensitive (95% CI, 97.8-99.2) and 97.1% specific (95% CI,
ventricle; VExUS scan, venous excess ultrasound scan. 92.4-99.0) in confirming endotracheal intubation, with a mean
time to confirmation of 13 seconds (95% CI, 12.0-14.0).18
procedures and for echocardiographic applications. Since AUS is a valuable and reliable adjunct for endotracheal intuba-
transesophageal echocardiography (TEE) is used routinely by tion in cardiac arrest situations in which the end-tidal CO2 is
most cardiothoracic anesthesiologists, POCUS applications low.19,20 AUS has been described for the prediction and
are a natural extension of existing practice.8,9 This narrative assessment of difficult airways and evaluation of the epiglottis
review presents a broad discussion of the utility of POCUS for and vocal cords.21,22 Skin-hyoid distance is known to predict
the cardiothoracic anesthesiologist in varying perioperative difficult mask ventilation and difficult laryngoscopy, while the
contexts, including the preoperative clinic, the operating room epiglottis-to-vocal cord space has been shown to correlate
(OR), and intensive care unit (ICU). Furthermore, POCUS- with Cormack-Lehane intubation grade.23,24 Specifically, the
related education, competence, and certification are addressed. mean standard deviation of the minimum distance from the
hyoid bone to skin surface was 0.88 (0.3) cm in the easy mask
ventilation group versus 1.4 (0.19) cm in the difficult mask
Airway Ultrasound (AUS)
ventilation group. The mean of this distance increased accord-
ing to the level of difficulty of mask ventilation and laryngos-
POCUS of the airway is useful for identification of airway
copy. The distance of the epiglottis to the vocal cord space
structures, such as the cricothyroid membrane (CTM), tracheal
was found to be a better predictor of difficult laryngoscopy
rings, cricoid cartilage, thyroid cartilage, and hyoid bone (see
compared to the hyomental distance ratio. A distance from the
Table 2).10 In difficult airway scenarios, identification of the
epiglottis to vocal cords of more than 1.77 cm had 82%
CTM by AUS has been shown to be useful for cricothyroidot-
omy procedures (see Fig 1). Kristensen et al. demonstrated
that the identification of the CTM by ultrasound had a higher

Table 2
Overview of Airway Ultrasound (AUS)

POCUS Structures Techniques

Airway CTM Cricothyroidotomy

Cricoid cartilage Cricoid pressure for RSI
Thyroid cartilage Airway blocks
Hyoid bone Airway assessment
Tracheal rings Percutaneous tracheostomy
Esophagus Endotracheal/esophageal intubation Fig 1. Ultrasound (US)-guided airway examination to identify the cricothy-
roid membrane (CTM). The image on the left demonstrates probe positioning
Abbreviations: CTM, cricothyroid membrane; POCUS, point-of-care for the performance of a US-guided airway examination, while the image on
ultrasound; RSI, rapid-sequence intubation. the right illustrates key anatomy seen in the airway US examination.
1134 H. Kalagara et al. / Journal of Cardiothoracic and Vascular Anesthesia 36 (2022) 11321147

sensitivity and 80% specificity in predicting difficult laryngos- Table 3

copy, whereas a hyomental distance ratio less than 1.085 had a Overview of Gastric Ultrasound (GUS)
sensitivity of 75% and specificity of 85.3% in this prediction. POCUS Structures Assessment Aspiration Risk
Additionally, AUS can be used for the application of cricoid
pressure during rapid-sequence induction.25 Gastric Gastric antrum Gastric volume Low risk (<1.5 mL/
Gastric contents kg)
(liquids or solids) High risk (>1.5
Gastric Ultrasound (GUS) mL/kg)
High risk (solid)
Perioperative aspiration prevention is an important consid- Abbreviations: POCUS, point-of-care ultrasound.
eration during any surgical or interventional procedure, as
aspiration of gastric contents may lead to aspiration pneumo-
Lung Ultrasound (LUS)
nia, which is associated with high morbidity and mortality.26
Evaluation of fasting status or assuring adequate gastric emp-
Lung ultrasound (LUS) (see Table 4) involves the study of
tying has occurred can be challenging in numerous circum-
air-fluid interfaces in the lungs, as well as the interpretation of
stances, such as patients with altered mental status and those
ultrasound artifacts.32 Different transducers, such as phased-
with certain chronic medical conditions (eg, gastroparesis, dia-
array, convex, microconvex, or linear probes, are being used
betes, or chronic renal failure and liver failure). Aspiration risk
for LUS to optimize the artifacts based on the lung pathology
is particularly extant in the context of procedures performed
to be determined and the patient’s body habitus.33 Longitudi-
with moderate or deep sedation without an ETT (ie, out-of-
nal scanning is performed in six or eight zones for focused
operating room transesophageal echocardiograph [TEE]
lung examinations, with transverse scanning recommended in
examinations). GUS allows for the identification and measure-
areas of specific interest for further evaluation of pathology.34
ment of gastric antral cross-sectional area, with accurate
POCUS of the lung is indicated to evaluate dyspnea, hypoxia,
assessment of gastric volume and contents in both the supine
hypotension, thoracic trauma, pleurisy, and chest pain.35 Inter-
and right lateral decubitus positions.27,28 Figure 2 illustrates
national evidence-based consensus recommendations for
probe placement and imaging of the gastric antrum.
point-of-care lung ultrasound from Volpicelli et al. have
A randomized control trial by Kruisselbrink et al., using
proven helpful in guiding the implementation, development,
simulated clinical scenarios in nonpregnant adults with a pre-
and standardization of LUS across a variety of clinical set-
test probability of 50% full stomach, showed that bedside
tings.36 Figure 3 outlines a decision-making algorithm to guide
GUS had a sensitivity of 1.0 (95% CI, 0.925-1.0), a specificity
the assessment of lung pathology with LUS.
of 0.975 (95% CI, 0-0.072), a positive predictive value of
0.976 (95% CI, 0.878-1.0), and a negative predictive value of
Normal LUS Mechanics
1.0 (95% CI, 0.92-1.0) in ruling out a full stomach in patients
in whom the presence of gastric contents was ambiguous.29
Normal lung aeration is characterized by lung sliding,
Using nomogram-based data derived from measured antral
described as movement of the parietal and visceral pleura slid-
cross-sectional area and patient age, gastric volume can be pre-
ing against each other at the pleural line (equivalent to a sea-
dicted (see Table 3) by GUS.30 In summary, GUS can be per-
shore sign on the M-mode Doppler evaluations), as demon-
formed easily at the bedside to provide qualitative and
strated by Video 1. Normal lung parenchyma will have an A
quantitative assessment of gastric contents, aiding in the for-
profile pattern, seen as regular, repetitive horizontal reverbera-
mulation of a safe anesthetic airway management plan to mini-
tion artifacts arising from air below the pleural line (Fig 4).
mize aspiration risk.31 However, there are currently no major
When air is replaced with fluid, the image will show B lines,
society recommendations to replace nothing -by-mouth guide-
which are comet-tail artifacts (vertical hyperechoic lines
lines with gastric ultrasound.

Table 4
Overview of Lung Ultrasound (LUS)

POCUS Structure Assessment Disease

Lungs (LUS) Pleura Lung sliding Pneumothorax

Lung zones A and B lines Pneumonia, ARDS,
pulmonary edema
PLAPS point Lung bases Pleural effusion,
pneumonia
Diaphragm Diaphragm function Weaning/ventilation,
diaphragmatic
Fig 2. Ultrasound (US)-guided gastric scan to assess gastric volume and con- paresis/paralysis
tent. The image on the left demonstrates probe positioning for the performance
of an US-guided gastric examination, while the image on the right illustrates Abbreviations: ARDS, acute respiratory distress syndrome; PLAPS, posterior
key anatomy seen in the gastric US examination. lateral alveolar pleural syndrome; POCUS, point-of-care ultrasound.
 H. Kalagara et al. / Journal of Cardiothoracic and Vascular Anesthesia 36 (2022) 11321147 1135

Fig 3. Decision algorithm for guiding the assessment of lung pathology using
LUS. LUS, lung ultrasound; DVT, deep vein thrombosis; PLAPS, posterior
lateral alveolar pleural syndrome.

Fig 5. Lung point. The presence of lung point, defined as the appearance and
disappearance of lung sliding with respiration at a particular point, is charac-
teristic and pathognomonic for pneumothorax.

consolidation or effusion at the lung bases, while absence of

Fig 4. Normal lung ultrasound (LUS) images and A lines. Panel A demon-
strates probe positioning for evaluation of ribs and pleura, while panel B dem-
onstrates ultrasound visualization of these structures. Panels C and D
demonstrate probe positioning and visualization of A lines, respectively.
arising from the pleural line and fanning down all the way to
the bottom of the screen) demonstrated by Video 2.
Abnormal LUS Mechanics
PLAPS point suggests other pathology at the lung bases. Nor-
mally, the spine above the diaphragm is not visible. However,
if pleural effusion is present, the spine is visible through the
fluid and is referred to as "spine sign". With a normally aerated
lung, the lung moves downward into the abdomen with inspi-
ration (curtain sign). In the presence of pleural effusion, this
curtain sign is absent. Dynamic air bronchograms signify con-
solidation, while static air bronchograms indicate atelectasis.
A meta-analysis comparing the accuracy of LUS and chest X-
ray (CXR) indicated that LUS had a higher pooled sensitivity
(0.95; 95% CI, 0.93-0.97) and specificity (0.90; 95% CI, 0.86-
0.94) with better diagnostic accuracy compared to CXR in aid-
ing the diagnosis of community-acquired pneumonia (using
chest-computed tomography as the gold standard).40
LUS Versus Other Imaging Modalities

When the ratio of fluid-to-air content increases, the number LUS offers unique advantages over computed tomography,
of B lines increases in lung zones accordingly, resulting in a B as it is portable, reproducible, low cost, low risk, and highly
profile pattern. The presence of B lines rules out PTX.37 Inter- accurate, and possesses no radiation effects. As previously
stitial lung disease and pulmonary edema may be indicated by
the number and distribution of B lines (lung rockets) in each
zone (three or fewer in each lung zone is seen in a healthy
lung). Absence of lung sliding in a particular lung zone should
raise suspicion for PTX. The presence of lung point, defined as
the appearance and disappearance of lung sliding with respira-
tion at a particular point (equivalent to the M-mode strato-
sphere or barcode sign), is characteristic and pathognomonic
for PTX, with a reported overall sensitivity of 66% and a spec-
ificity of 100% for the diagnosis of PTX.37,38 Lung point is
demonstrated in Video 3 and Figure 5, while an algorithm
guiding the diagnosis and exclusion of PTX using LUS is illus-
trated in Figure 6.
The posterior lateral alveolar pleural syndrome (PLAPS)
point is the lowest point in the lung that should be investigated
with a curvilinear probe to rule out pleural effusion and con- Fig 6. Algorithm aiding the diagnosis and exclusion of pneumothorax using
solidation.39 The detection of PLAPS point indicates lung ultrasound (LUS). PTX, pneumothorax.
1136 H. Kalagara et al. / Journal of Cardiothoracic and Vascular Anesthesia 36 (2022) 11321147

Table 5
Diagnosis of Lung Disease Based on Lung Ultrasound (LUS)

Diagnosis Present on LUS Absent on LUS FOCUS

PTX Lung point Lung sliding, B lines, Lung pulse

Barcode or stratosphere sign (M mode LUS)
PNA B lines, air bronchograms, PLAPS Lung sliding
CHF Bilateral B lines, lung sliding Reduced FS, EF, and EPSS
ARDS B lines, lung sliding Normal EF and EPSS
Pulmonary fibrosis B lines Lung sliding
COPD/asthma Lung sliding, A lines B lines, PLAPS
Pleural effusion Anechoic lung base, air bronchograms, spine sign Curtain sign Reduced EF in CHF
Pulmonary embolism Lung sliding, A lines Reduced TAPSE, reduced RV function,
Diaphragmatic paresis Reduced diaphragm excursion and thickness

Abbreviations: ARDS, acute respiratory distress syndrome; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; EF, ejection fraction;
EPSS, endpoint (mitral) septal separation; FOCUS, Focused Cardiac Ultrasound; FS, fractional shortening; LUS, lung ultrasound; PLAPS, posterior lateral
alveolar pleural syndrome; PNA, pneumonia; PTX, pneumothorax; RV, right ventricle; TAPSE, tricuspid annular plane systolic excursion.

described, LUS can be used to diagnose PTX, with better sen- Diaphragm Ultrasound (DUS)
sitivity and specificity compared to CXR.41 A meta-analysis
by Ding et al. indicated that LUS had a higher pooled sensitiv- The diaphragm is the core muscle of respiration, innervated
ity (0.88) compared to CXR (0.52), and similar specificity, in by the phrenic nerve and normally descending caudally and
the diagnosis of PTX.42 Notably, the accuracy of diagnosing increasing in thickness with inspiration. In cases of respiratory
PTX with LUS is associated with the skill of the operator distress, LUS, along with DUS assessment, are useful to rule
(odds ratio, 0.21; CI, 0.05-0.96; p = 0.0455). Chan et al., in a out potential etiologies such as PTX and diaphragmatic paraly-
recent Cochrane Database systematic review examining LUS sis (ie, post-brachial plexus blockade). Diaphragmatic excur-
versus CXR for the diagnosis of PTX in trauma patients, sion during deep breathing (normally 6-7 cm) typically is
reported a sensitivity of 0.91 (95% CI, 0.85-0.94) and specific- assessed by Doppler M-mode, but may be challenging at times
ity of 0.99 (95% CI, 0.97-1.00) for LUS, compared to a sensi- on the left side due to air in the stomach. A novel intercostal
tivity of 0.47 (95% CI, 0.31-0.63) for CXR.43 This review approach that assesses the zone of apposition of the diaphragm
suggested the superior diagnostic accuracy of LUS versus can be used to overcome this issue (see Fig 7). The intercostal
CXR for PTX diagnosis. zone of apposition approach is used to measure diaphragm
LUS also is efficacious in the diagnosis of pulmonary thickness during inspiration and expiration. The thickening
edema.44 Maw et al. established that LUS is more sensitive fraction then is calculated, which can be used to quantify the
(0.88 [95% CI, 0.75-0.95]) than CXR (0.73 [95% CI, 0.70- degree of paresis.55 This thickening fraction is useful for venti-
0.76]) in the detection of pulmonary edema in patients with latory management and in guiding the process of weaning ven-
decompensated heart failure. The relative sensitivity ratio of tilatory support in critically ill patients (normal thickening
LUS compared to CXR was 1.2 (95% CI, 1.08-1.34; p < fraction is 30%-96%). DUS possesses utility in the prediction
0.001), proposing LUS as a useful adjunct modality in the of extubation success by monitoring respiratory load, with
evaluation of patients with heart failure.44 A meta-analysis by
Al Deeb et al. demonstrated the sensitivity of LUS B lines to
diagnose pulmonary edema as 94.1% (95% CI, 81.3-98.3),
with a specificity of 92.4% (95% CI, 84.2-96.4%).45 Similarly,
Platz et al. demonstrated the utility of B lines with LUS for
prognostic purposes of heart failure therapy.46
LUS is efficacious in the diagnosis of lung parenchymal dis-
eases,40 while enabling a better understanding of heart-lung
interactions to assist in ventilatory management.47-50 LUS also
can be used for confirmation of double-lumen tube placement
during lung isolation maneuvers.51,52 Lichtenstein et al. incor-
porated LUS into their bedside lung ultrasound in emergency
(BLUE) protocol for the diagnosis of acute respiratory fail-
ure,39,53 and FALLS (fluid administration limited by LUS)
protocol for the management of acute circulatory failure.53,54
Table 5 highlights the diagnostic utility of LUS signs, along Fig 7. Panel A depicts a supine patient position with the ultrasound (US)
with focused cardiac ultrasound, to help differentiate various probe placed along the midaxillary line. Panel B shows a US image of the dia-
lung diseases. phragm during inspiration (measuring diaphragm thickness of 0.25 cm).
 H. Kalagara et al. / Journal of Cardiothoracic and Vascular Anesthesia 36 (2022) 11321147 1137

optimal cutoffs greater than 30% to 36% for thickening frac- Table 7
tion, serving as a beneficial tool in detecting diaphragmatic Advanced Modalities With Focused Cardiac Ultrasound (FOCUS)
dysfunction.56 2D View Abnormal Disease
Values
Focused Cardiac Ultrasound (FOCUS)
LA PLAX Increased Dilated LA
In hemodynamically unstable patients, a focused transtho- Aorta PLAX Increased Aortic aneurysm
racic echocardiographic (TTE) examination (FOCUS) is useful RV PLAX, PSAX, Increased RVH, RVF, PE
to evaluate global and regional left and right ventricular func- A4C, SC4C
tion, assess for valvular dysfunction, and identify the presence
of any hemodynamically significant pericardial effusions.57 M mode
Specific cardiac pathology easily recognized with a FOCUS FS and EF PLAX and PSAX Decreased CHF
examination includes aortic stenosis (see Video 4), dilated car- EPSS PLAX Decreased CHF
diomyopathy (see Video 5), pericardial tamponade (see Video
TAPSE A4C Decreased RVF
6), hypertrophic obstructive cardiomyopathy with dynamic
MAPSE A4C Decreased LVF
left ventricular outflow tract obstruction (see Video 7), endo-
carditis (see Video 8), and pulmonary embolism (see Video 9). Diastology
Practice advisory guidelines for the appropriate use of bedside E/A A4C Increased Elevated LAP
cardiac ultrasonography in the evaluation of critically ill e’ A4C Decreased Diastolic dysfunction
patients, as well as grading recommendations regarding
E/e’ (LVEDP) A4C Increased Diastolic dysfunction
FOCUS usage for various cardiac pathologies, chest trauma,
and diseases of the great vessels, are readily available.58,59 CFD/CWD/PWD
FOCUS most commonly is performed with a low-frequency RVSP A4C Increased PHTN
cardiac phased-array probe, with patients typically placed in LVOT VTI PLAX, A5C Decreased LVF
supine or left lateral position to best optimize imaging and
(SV, CO)
acoustic windows.60,61 Basic FOCUS views can be used for
RVOT VTI PSAX Decreased RVF
assessment of cardiac pathology (see Table 6), as well as quan-
titative assessments of cardiac function (see Table 7). Via et al. Abbreviations: A4C, apical four-chamber; A5C, apical five-chamber; CFD, color-
have published international evidence-based recommenda- flow Doppler; CHF, congestive heart failure; CO, cardiac output; CWD,
tions, delineating the nature, technique, benefits, clinical inte- continuous-wave Doppler; EF, ejection fraction; EPSS, endpoint septal
gration, education, and certification in FOCUS to offer a separation; FS, fractional shortening; IVC, inferior vena cava; LA, left atrium;
LAP, left atrial pressure; LV, left ventricle; LVEDP, left ventricular end-diastolic
framework for applying FOCUS applications across different pressure; LVF, left ventricular failure; LVOT VTI, left ventricular outflow tract
clinical settings around the world.62 velocity-time integral; MAPSE, mitral annular plane systolic excursion; PE,
pulmonary embolism; PHTN, pulmonary hypertension; PLAX, parasternal long-
axis; PSAX, parasternal short axis; PWD, pulsed-wave Doppler; RV, right
Table 6 ventricle; RVF, right ventricular failure; RVH, right ventricular hypertrophy;
Overview of Focused Cardiac Ultrasound (FOCUS) RVOT VTI, right ventricular outflow tract velocity-time integral; RVSP, right
ventricular systolic pressure; SC4C, subcostal four-chamber; SV, stroke volume;
FOCUS View Assessment Clinical Indication Pathology
TAPSE, tricuspid annular plane systolic excursion.
PLAX LV, RV, LA, aorta Function, valves, MI, CHF, AS, HOCM
AV and MV effusion
PSAX LV, RV Function, effusion Ischemia, hypovolemia, Hemodynamic perturbations and unexplained hypotension
Pericardium Tamponade are extremely common issues encountered in the perioperative
A4C RA, RV, LA, LV Function, valves, PE, MI, cardiomyopathy, setting, with FOCUS being a useful tool for determining the
TV, MV, AV effusion Tamponade, HOCM
etiology of unexplained hemodynamic instability, as well as
CHF, RVF, PHTN
SC4C RA, RV, LA, LV Function, valves, PE, hypovolemia,
for guiding clinical management and interventions. FOCUS is
effusion Tamponade particularly helpful in detecting right ventricular dysfunction
SC IVC IVC Volume status Hypovolemia and regional wall motion abnormalities following ischemia in
Fluid overload patients presenting with acute coronary syndromes.63,64
SS view Aortic arch and Aortic lesions Aortic dissection
When FOCUS is used to answer a specific clinical question
branches IABP Coarctation of aorta
(eg, investigation of newly discovered systolic murmur or to
Abbreviations: A4C, apical four-chamber; AS, aortic stenosis; AV, aortic determine the underlying etiology of unexplained hemody-
valve; CHF, congestive heart failure; HOCM, hypertrophic obstructive namic instability or decreased functional capacity), its use has
cardiomyopathy; IABP, intra-aortic balloon pump; IVC, inferior vena cava;
a significant impact on perioperative care (eg, altered anes-
LA, let atrium; LV, left ventricle; MI, myocardial infarction; MV, mitral
valve; PE, pulmonary embolism; PHTN, pulmonary hypertension; PLAX, thetic technique, prompted decision to perform invasive moni-
parasternal long-axis; PSAX, parasternal short axis; RA, right atrium; RV, toring, or led to a change postoperative care disposition) in up
right ventricle; RVF, right ventricular failure; SC4C, subcostal 4-chamber; SS, to 82% of patients.65 In the aforementioned study, major find-
suprasternal; TV, tricuspid valve. ings from anesthesiologist-performed FOCUS examinations
1138 H. Kalagara et al. / Journal of Cardiothoracic and Vascular Anesthesia 36 (2022) 11321147

Table 8 following return of spontaneous circulation.69 The use of

Vascular Ultrasound Applications FOCUS in this setting also enables clinicians to diagnose
Modality Structures Procedures/Assessments
potentially treatable and reversible causes (eg, pulmonary
embolism, tamponade, or severe left ventricular dysfunction)
Vascular access IJ, subclavian, and Central lines and to guide further therapeutic interventions.
femoral veins Arterial lines
Radial, brachial, and PIVs
femoral arteries Vascular Ultrasound (VUS)
Peripheral veins
Volume assessment IVC CVP, RAP VUS (see Table 8) with a linear probe commonly is used for
Common carotid artery CFT, carotid VTI the placement of central venous, arterial, and peripheral intra-
Common femoral vein Pulsatility (RV
function)
venous catheters. Furthermore, FOCUS examination aids in
VExUS IVC (transverse view) VExUS score for fluid assessing volume status, as central venous pressure or right
Hepatic vein overload atrial pressure estimations (performed using the subcostal infe-
Portal vein rior vena cava [IVC] view), can be obtained by measuring
Renal vein IVC diameter, respiratory variation, and collapsibility index.70
Venous scan Lower extremity veins DVT
A meta-analysis evaluating the utility of using measurements
Abbreviations: CFT, corrected flow time; CVP, central venous pressure; DVT, of IVC diameter and respiratory variation to predict fluid
deep vein thrombosis; IJ, internal jugular; IVC, inferior vena cava; PIVs, responsiveness found the modality more sensitive and specific
peripheral intravenous lines; RAP, right atrial pressure; RV, right ventricle; in mechanically ventilated patients compared to spontaneously
VExUS scan, venous excess ultrasound scan; VTI, velocity-time integral.
breathing patients.71 Other modalities, such as carotid Dopp-
ler, can be used for hemodynamic assessments.72,73 Using
(ie, significant valvular lesions) were confirmed subsequently POCUS to assess change in carotid flow time is an acceptable
by cardiology evaluation in 92% of patients. Massive pulmo- method for noninvasive assessment of fluid responsiveness in
nary embolism and cardiac tamponade are potentially devast- shock states, and also can act as a surrogate for cardiac output.
ing perioperative complications in which FOCUS provides If the IVC transverse diameter is more than 2 cm, the use of
rapid diagnostic confirmation to guide immediate lifesaving combined hepatic vein, portal vein, and renal vein pulsed-
treatments. Valvular stenosis, valvular regurgitation, left and wave Doppler assessments, as a part of venous excess ultra-
right ventricular dysfunction, cardiac masses, and cardiomyop- sound (VExUS) scan, can be done to evaluate for volume over-
athies (ie, hypertrophic cardiomyopathy, dilated cardiomyopa- load and systemic venous congestion. Beaubien-Souligny et al.
thy) can be assessed quickly and, where relevant, quantified described a VExUS scoring system (see Table 9) to quantify
with a FOCUS examination.66 systemic congestion and its impact on renal dysfunction in
FOCUS also is emerging as a valuable tool in the diagnosis post-cardiac surgery patients.74-76 The severity of the VExUS
and management of cardiac arrest. The Focused Echocardio- score is used as a guide for fluids, inotropes, vasodilators, and
graphic Examination in Life protocol describes FOCUS usage diuretic management. Measurement of the right ventricular
during performance of advanced cardiac life support (ACLS) outflow tract velocity-time integral with FOCUS, when com-
protocols.67,68 Importantly, FOCUS can be incorporated into bined with the VExUS scan, enables a global evaluation of
the performance of ACLS without interrupting performance of right ventricular function and, when dysfunction is present, its
standard chest compressions, with subcostal views best facili- effects on systemic organ congestion.
tating this indication. Adequate images may be obtained dur- Additionally, evaluation for the presence of lower-extremity
ing brief (ie, ten-second) periods when compressions are deep vein thrombosis (DVT) is a core part of the POCUS
interrupted to assess for underlying cardiac rhythm and pulse. examination, especially in critically ill patients. A comprehen-
The presence of underlying cardiac activity by FOCUS assess- sive scan should begin with visualization of the common fem-
ment during ACLS has been associated with improved survival oral vein. Subsequently, all five major points of vascular

Table 9
Simplified Venous Excess Ultrasound (VExUS) Scoring System

Organ system VExUS = 0 VExUS = 1 VExUS = 2 VExUS = 3

(No Congestion) (Severe Congestion)

IVC IVC < 2 cm IVC > 2 cm IVC > 2 cm IVC > 2 cm

Hepatic vein Normal pattern Normal Mild abnormality Severe abnormality
Doppler (S > D) (S < D) (S wave reversal)
Portal vein Normal pattern Normal Mild abnormality Severe abnormality
Doppler (<30% pulsatility index) (30%-49% pulsatility index) (>50% pulsatility index)
Renal vein Normal pattern Normal Mild abnormality Severe abnormality
Doppler (continuous monophasic flow) (discontinuous biphasic flow) (discontinuous monophasic flow)

NOTE. Adapted from: Beaubien-Souligny et al.74

Abbreviations: D, diastolic wave; IVC, inferior vena cava; S, systolic wave; VExUS, Venous Excess Ultrasound Score.
 H. Kalagara et al. / Journal of Cardiothoracic and Vascular Anesthesia 36 (2022) 11321147 1139

bifurcation within the lower-extremity veins are identified, thoracotomy, with these novel interfascial plane blocks play-
with a two-point compression test performed at each point to ing an important role in enhanced recovery pathways for car-
rule out DVT.77,78 A systematic review assessing the accuracy diac and thoracic surgeries. Nagaraja et al., in a comparison of
of emergency physician-performed ultrasound found a sensi- thoracic epidural analgesia versus bilateral erector spinae
tivity of 96.1% and specificity of 96.8% for the diagnosis of plane (ESP) blocks for cardiac surgical procedures, revealed
DVT.79 Also, positive findings from the VUS DVT scan, when comparable pain scores until 12 hours postoperatively, along
accompanied with FOCUS assessment of RV function (along with similar ventilator days and ICU duration of stay, suggest-
with focused LUS), can be helpful in ruling out pulmonary ing ESP block as a viable alternative to thoracic epidural anal-
embolism.80-82 gesia.88 In a second patient-matched controlled study,
continuous ESP block was associated with decreased opioid
Regional Anesthesia consumption and earlier mobilization after open cardiac sur-
gery.89 In a randomized controlled trial comparing serratus
Interfascial plane blocks play an emerging role in periopera- anterior plane block with thoracic epidural analgesia for thora-
tive pain management.83 Due to the risks associated with epi- cotomy, Khalil et al. found comparable pain scores and opioid
dural and paravertebral techniques, interfascial plane blocks consumption in both groups, without a significant drop in
(see Table 10) are a safer alternative for patients after cardiac mean arterial blood pressure compared to baseline values in
surgery and can be incorporated readily into a multimodal pain the serratus block group, suggesting serratus plane block is a
management plan for a number of cardiac, thoracic, and vascu- safe and effective alternative for postoperative analgesia in
lar procedures, due to their relative ease of performance and thoracotomy.90
low level of complications.84,85 The implementation of these
blocks into multimodal cardiac enhanced recovery pathways Focused Assessment With Sonography in Trauma (FAST)
helps to minimize opioid consumption, reduce nausea and
vomiting, reduce postoperative ventilatory time, improve FAST is a commonly used diagnostic modality in trauma
patient satisfaction, and provide cost reductions.86,87 Involve- patients to evaluate for intrabdominal fluid, as well as to guide
ment of the cardiothoracic anesthesiologist with these regional surgical interventions.91,92 In the postoperative setting, FAST
techniques has the additional benefit of providing further expe- can be used rapidly to assess for intra-abdominal fluid collec-
rience in performing LUS, as these interfascial plane blocks tions in the workup for hypotension.93 The FAST examination
are performed on the chest. In particular, it is important to be (see Table 11) can be performed easily at the bedside and
facile in recognizing the presence of pneumothorax, which is a repeated according to the clinical context to guide continued
complication associated with paravertebral blocks. Many cen- clinical management. In a Cochrane review on the evaluation
ters use paravertebral blocks for pain control after of POCUS for diagnosing thoracoabdominal injuries in blunt
trauma, positive findings, such as free fluid in thoracic or
Table 10 abdominal cavities, major solid organ injuries, or lesions of
Ultrasound-Guided Regional Anesthesia Applications for the Cardiothoracic major vessels, were found to help regarding guiding manage-
Anesthesiologist ment decision, with a sensitivity of 0.68 and specificity of 0.95
Regional Site of Injection of Surgical Procedures for abdominal trauma.94 The Rapid Ultrasound for Shock and
Local Anesthetic Hypotension protocol is useful in patients with undifferenti-
ated shock, incorporating POCUS of the heart, IVC, Morison’s
PECS I and II blocks Between PMaM and ICD, pacemaker
pouch, aorta, and pneumothorax to identify rapidly reversible
PMiM and between insertion
PMiM and SAM Right anterior causes of hypotension.95
thoracotomy
SAPB Between the rib and Thoracotomy, VATS, POCUS in the Critical Care Setting
SAM or between Rib fracture
SAM and LDM Minimally invasive
POCUS use in the critical care setting has burgeoned over
cardiac surgery
ESPB Between the TP and Thoracotomy, VATS the past decades, with the core competencies of POCUS now
ESM Rib fracture widely viewed as mandatory skill sets required by the modern
Sternotomy critical care medicine clinician.96 In the following, various
PIFB/TTPB Between PMaM and Sternotomy, applications of POCUS in the ICU are addressed, including
EIM/between IIM sternal fracture
ICU-specific echocardiography, LUS, abdominal ultrasound,
and TTM
and vascular ultrasound.
Abbreviations: EIM, external intercostal muscle; ESM, erector spinae muscle; Echocardiography, both TTE and TEE, long have been used
ESPB, erector spinae plane block; ICD, implantable cardioverter-defibrillator; in the ICU. The causes of ICU-related hemodynamic instabil-
IIM, internal intercostal muscle; LDM, latissimus dorsi muscle; PECS block,
ity are diverse and include, but are not limited to, ventricular
pectoral nerve block; PIFB, pecto-intercostal fascial block; PMaM, pec major
muscle; PMiM, pec minor muscle; SAM, serratus anterior muscle; SAPB, dysfunction, myocardial ischemia, arrhythmias, sepsis, acute
serratus anterior plane block; TP, transverse process; TTM, transversus blood loss, cardiac tamponade, and respiratory failure.97 Mul-
thoracic muscle; TTPB, transversus thoracis plane block; VATS, video- tiple examples exist within the literature demonstrating the
assisted thoracoscopic surgery value of POCUS for diagnosing etiologies of hemodynamic
1140 H. Kalagara et al. / Journal of Cardiothoracic and Vascular Anesthesia 36 (2022) 11321147
Table 11
Focused Assessment With Sonography in Trauma (FAST)
FAST View Structures
RUQ Liver, right kidney, hepatorenal pouch, diaphragm, right lung
LUQ Spleen, left kidney, splenorenal recess, diaphragm, left lung
Pelvic sagittal and transverse Bladder, rectum, uterus (in women)
Extended FAST Lungs (LUS)
(e-FAST) Cardiac (SC4C)
Abbreviations: +, blood present; LUQ, left upper quadrant; LUS, lung ultrasound; RUQ, right upper quadrant; SC4C, subcostal four-chamber view.
instability.95,98 The utility of TTE and TEE for the manage-
ment of hemodynamically unstable cardiac and patients after
noncardiac surgery has been shown to result in the determina-
tion of definitive diagnosis and subsequent change in clinical
management in 58.8% of patients in this context.99
Patients in the ICU benefiting from the use of POCUS also
include those requiring mechanical circulatory support devi-
ces. Lu et al. demonstrated that trained intensivists can per-
form adequate bedside TTE, TEE, and FAST examinations on
patients with mechanical circulatory support to guide medical
and surgical management.100 In their study, 189 rescue
POCUS examinations were performed in a mixed cardiac med-
ical/surgical ICU, of which 4% led to extracorporeal mem-
brane oxygenation or ventricular assist device cannula
reposition, 2% lead to extracorporeal membrane oxygenation
or ventricular assist device setting change, and 1% led to right
ventricular assist device insertion.
In addition, POCUS has utility in the evaluation of fluid
responsiveness and to help guide appropriate fluid resuscita-
tion. When combined with LUS, echocardiography (specifi-
cally IVC imaging) can aid in fluid resuscitation management
in the critically ill, as demonstrated by Lee et al.101 By com-
bining current literature on lung and IVC ultrasound with
expert opinion on the ability of transthoracic ultrasound to pre-
dict fluid responsiveness, investigators were able to develop a
qualitative fluid resuscitation guide that categorized critically
ill patients into one of three broad groups: fluid resuscitate,
fluid test, and fluid restrict. Validation of this resuscitation
guide to help clinicians prescribe fluid therapy still is pending.
LUS is helpful in the evaluation of respiratory failure and
can diagnose acutely and guide treatment for a wide range of
lung pathologies, including pulmonary edema, pleural effu-
sion, pneumonia, and PTX.39 The FALLS protocol uses ele-
ments of the BLUE protocol, in combination with basic
echocardiography, to rule out other causes of shock (obstruc-
tive, cardiogenic, and hypovolemic) while highlighting an end-
point of resuscitation for distributive shock (the transition on
lung ultrasound from an A-profile to a B-profile).
In addition, LUS can aid in identifying the need for postop-
erative ventilatory support, as established by Dransart-Raye
et al.49 In this study, the presence of two areas of consolidated
lung was associated with a lower PaO2 per FIO2 ratio, the need
for postoperative ventilatory support, longer intensive care
stays, and episodes of ventilator-associated pneumonia
Positive Signs
Morison’s pouch +, inferior pole of liver +
Splenorenal pouch +, subphrenic space +
Rectovesical pouch + (men)
Pouch of Douglas + (women)
Pneumothorax
Hemothorax
Tamponade
requiring antibiotics. In summary, LUS has the ability to diag-
nosis acutely and accurately the causes of respiratory failure,
aid in volume resuscitation, identify patients likely to need
postoperative ventilatory support, and assist in weaning
mechanical ventilation.
Abdominal POCUS long has been used in emergency medi-
cine; has a reported sensitivity, specificity, and accuracy of
bedside sonography in identifying intraperitoneal hemorrhage
of 81.8%, 93.9%, and 90.9%, respectively; and is able be per-
formed in less than a minute in most ICU patients.102 The ini-
tial abdominal ultrasound protocol (FAST examination) has
been updated to the extended FAST examination (e-FAST),
which incorporates LUS for the assessment of PTX and was
found to have sensitivities and specificities superior to those of
CXR.103 FAST and e-FAST examinations are unique in their
ability to allow the intensivist to evaluate fresh postoperative
cardiac surgery patients experiencing hypotension for abdomi-
nal or thoracic hemorrhage. Abdominal ultrasound also has
been used to measure abdominal aortic aneurysm diameter and
to diagnose aneurysm rupture.104 In addition, bedside abdomi-
nal ultrasound can be used to evaluate, quantify, and guide par-
acentesis for abdominal ascites.6 POCUS also has been used to
diagnose obstructive nephropathy,6 hydronephrosis,105 neph-
rolithiasis,106 and bladder distention,107 as well as assisting in
difficult Foley catheter placement.108 All of these attributes
make abdominal ultrasound ideally suited for routine use in
the ICU.
The use of vascular ultrasound in the ICU ranges from vas-
cular access (central venous access, arterial access, and periph-
eral venous access) to the diagnosis of DVT. Central venous
access has been an accepted application of POCUS for a long
period of time, as demonstrated by multiple studies in the liter-
ature, dating back to the early 1990s.109-112 The benefits of
vascular ultrasound for central venous access include identifi-
cation of appropriate vessels for cannulation, identification of
aberrant vascular anatomy, verification of vessel patency, and
real-time confirmation of correct device placement,113 as well
as higher first attempt success rates and lower mechanical
complication rates.114 These benefits are associated most
strongly with internal jugular vein access, while being associ-
ated less strongly with subclavian and femoral vein access.114
POCUS also has been demonstrated to be superior to tradi-
tional blind cannulation techniques for both peripheral IVs and
arterial lines regarding success rate, time to cannulation, and
 H. Kalagara et al. / Journal of Cardiothoracic and Vascular Anesthesia 36 (2022) 11321147
number of skin punctures.115-118 Another useful application of
vascular ultrasound in the ICU is the detection of DVT. One
study demonstrated that proximal lower-extremity DVT diag-
nosed by POCUS had an 86% sensitivity and 96% specificity
compared to formal ultrasound studies.119 POCUS allows for
the early detection and timely intervention in thromboembolic
disease processes seen in the ICU.
Limitations of POCUS
It is critical to understand the limitations of each POCUS
application in clinical practice. Identification of an appropriate
POCUS indication based on clinical presentation and knowl-
edge of the pre-test probability are the first steps for successful
POCUS usage. Understanding the sensitivity and specificity of
each POCUS application, in comparison to other standard
techniques, plays a key role in the successful application of
POCUS for diagnostic purposes. Both individual patient fac-
tors and operator experience should be taken into consider-
ation. The complete clinical context of the patient should be
taken into account rather than simply treating the images
obtained. It is advisable to seek expert help and archive images
in situations of especially challenging POCUS diagnoses to
ensure safe patient care and avoid errors in clinical manage-
ment. Adequate training, as well as adherence to established
competencies and credentialing, are essential.
POCUS Education and Certification
Ultrasound use has become ever more ubiquitous across a
variety of medical disciplines, and ultrasound education is
now part of the core curriculum of multiple medical
schools.120 A four-component rationale for incorporating ultra-
sound education into medical education has been proposed by
education leaders in the California medical school system, pos-
iting that ultrasound education (1) enhances traditional medi-
cal education, (2) improves the diagnostic and procedural skill
set of trainees, (3) promotes more efficient patient care, and
(4) serves as a basis for more advanced and specialty-specific
ultrasound training during residency training and beyond.121
In the context of anesthesiology, POCUS education includes
echocardiography (transesophageal and transthoracic), proce-
dural ultrasound for vascular access and regional anesthesia,
as well as a growing variety of diagnostic uses (abdomen-
chest-airway evaluation, gastric volume determination, and
intracranial pressure estimation).122 While cardiac echocardi-
ography and ultrasound for regional anesthesia have been
well-established core elements of anesthesiology residency
education, as yet, no single structured POCUS curriculum or
professional society guidelines have become uniform across
all anesthesiology training programs.123 With the introduction
of novel surgical techniques two decades ago, a similar situa-
tion was faced by the American College of Surgeons (ACS),
with a need to demonstrate proficiency in these laparoscopic
and endoscopic surgeries. The ACS engendered the Funda-
mentals of Laparoscopic Surgery (FLS) and Fundamentals of
Endoscopic Surgery (FES) programs, which enable the
1141
evaluation of surgical trainees’ knowledge base, technical
skills, clinical judgment, and overall competency in these
respective surgical areas.124,125 In 2019, the National Board of
Echocardiography, in conjunction with 9nine medical socie-
ties, administered the first Examination of Special Competence
in Critical Care Echocardiography, with successful completion
leading to testamur status.126 The Examination of Special
Competence in Critical Care Echocardiography content tran-
scends cardiac-specific topics and includes content germane to
a variety of POCUS topics: ultrasound physics, ultrasound
technical skills, ultrasound image optimization, lung and
pleura imaging, as well as focused vascular and abdominal
imaging. Though significant momentum for POCUS education
is occurring at the medical school and graduate medical educa-
tion level, a need now exists to incorporate all of the aforemen-
tioned POCUS applications and content into both
anesthesiology residency education and for those clinicians
beyond training. For clinicians beyond training seeking ultra-
sound and POCUS training, a variety of regional and national
medical societies (eg, American Society of Anesthesiologists,
Society of Critical Care Medicine, American Society of
Regional Anesthesia, Society of Cardiovascular Anesthesiolo-
gists), as well as independent commercial organizations (eg,
POCUS Certification Academy), offer POCUS-related educa-
tional activities; additional options after training typically
include self-directed learning and simulation-based training.123
In a 2017 survey of a variety of 343 critical care medicine
clinicians of varying backgrounds, as compared to other spe-
cialties, those clinicians with primary residency training in
emergency medicine were more likely to have received
POCUS training during their residency training (73.5%, p <
0.001) compared to the other surveyed specialties (8.7%). Of
the nonemergency medicine specialties, including anesthesiol-
ogy, POCUS training was derived from an external educa-
tional course (26.5%) or through self-guided learning
(17.2%).127 To date, there is no literature specifically examin-
ing POCUS education in the training context versus thereafter
via conferences and workshops. Hence, at present, quality
assurance as to the education experience for a given clinician
only may be assessed by competency evaluations, which
include mandating a minimum number of reviewed POCUS
scans and imaging analogous to existing echocardiography
certification pathways.128 As growing numbers of periopera-
tive clinicians, who already have completed training seek
POCUS education, as well as the broad variety of POCUS
training options outside of the formal medical education sys-
tems, the need for codifying what constitutes adequate POCUS
education and competency should be prioritized.
As POCUS continues to evolve in its diagnostic and proce-
dural applications, there is yet to be a single unified or codified
POCUS training curriculum in the United States analogous to
the ACS FLS and FES programs. In a 2016 call to action, Mah-
mood et al. outlined three components needed for the develop-
ment of a core POCUS educational program: (1) during
anesthesiology residency, POCUS training should be
“continuous and structured” and (2) residency programs
should develop individual ultrasound education tools and
1142 H. Kalagara et al. / Journal of Cardiothoracic and Vascular Anesthesia 36 (2022) 11321147

Table 12
Pathways for Attaining POCUS Competency

POCUS Competency Pathways

Supervised Training Pathway Established Expertise Pathway

POCUS Modality
Focused airway u/s
FAST exam
Focused cardiac u/s
Focused gastric u/s
Focused pleural and lung u/s 30
Focused u/s for DVT
Minimum No. of supervised Minimum No. of additional Obtain written/signed endorsement from 3 attending physicians
studies personally performed supervised studies attesting to the following:
and interpreted interpreted but not 1. Explain why letter author is qualified to write the letter.y
personally performed 2. Describe the letter author’s relationship to the candidate
applying for POCUS privileging.
3. Include a specific attestation statement listed below as pertains
to the POCUS domain(s) being discussed (see below).
Each supporting letter should be from an attending physician who
has directly observed candidates’ competence for the given
POCUS application.
Expertise Pathway: Attestation Statements for POCUS Modalities
30 20 “I personally attest that Dr. <Insert Name> is qualified to perform
focused airway u/s. Specifically, in my time working with him/her,
I observed that he/she could properly use u/s to evaluate for,
among other things, the following: laryngo-tracheal anatomy and
endobronchial vs esophageal vs endotracheal intubation.”
30 20 “I personally attest that Dr. <Insert Name> is qualified to perform a
FAST exam. Specifically, in my time working with him/her, I have
observed that he/she could properly use u/s to evaluate for life-
threatening conditions in trauma patients, including but not limited
to: intraperitoneal fluid/hemorrhage and pericardial effusion/
hemopericardium.”
50 100 “I personally attest that Dr. <Insert Name> is qualified to perform
focused cardiac u/s. Specifically, in my time working with him/
her, I have observed that he/she could properly use cardiac u/s to
evaluate for, among other things, the following: pericardial
effusion/cardiac tamponade, gross left ventricular dysfunction,
gross right ventricular dysfunction, and gross hypovolemia.”
30 20 “I personally attest that Dr. <Insert Name> is qualified to perform
focused gastric u/s. Specifically, in my time working with him/her,
I observed that he/she could properly use u/s to evaluate for,
among other things, the following: full stomach (defined as solid
gastric content or clear fluid in excess of baseline secretions
[Grade 2 antrum]).”
20 “I personally attest that Dr. <Insert Name> is qualified to perform
focused lung u/s. Specifically, in my time working with him/her, I
have observed that he/she could properly use lung u/s to evaluate
for, among other things, the following: pneumothorax, pleural
effusions, interstitial syndromes, and consolidation.”
30 20 “I personally attest that Dr. <Insert Name> is qualified to perform
focused u/s for evaluation of DVT. Specifically, in my time
working with him/her, I have observed that he/she could properly
use u/s to evaluate for, among other things, the following: a DVT
in the proximal lower extremity veins and in the internal jugular
vein.

NOTE. Based on the 2019 Committee Work Product on Diagnostic Point-of-Care Ultrasound of the American Society of Anesthesiologists. (A copy of the full text
can be obtained from ASA, 1061 American Ln, Schaumburg, IL 60173-4973 or online at www.asahq.org.).132
Abbreviations: DVT, deep vein thrombosis; FAST, focused assessment with sonography in trauma; POCUS, point-of-care ultrasound; u/s, ultrasound.
y Examples: (1) possession of a relevant national certificate or certification in u/s, (2) history of teaching at relevant u/s workshops, (3) history of performing and
interpreting diagnostic u/s examinations at their home institution, with an estimated annual volume of relevant u/s examinations that they personally perform
and interpret and number of years they have practiced this modality of diagnostic u/s.

means for evaluation that align with existing Accreditation
Council for Graduate Medical Education milestone expecta-
tions.122 Analogous to the aforementioned FLS and FES pro-
grams, anesthesiology residency programs also should work to
develop a structured and unified approach to anesthesiology
POCUS training, and (3) additional advanced POCUS con-
cepts and skills training at the fellowship level or beyond also
should be part of constructing a unified POCUS educational
curriculum.122 In addition to these three elements, other
authors also highlighted that a complete POCUS educational
curriculum should include maintenance of POCUS skills after
training and professional development.129 The International
Federation of Emergency Medicine published a consensus
document in 2015 that provided stepwise guidance for POCUS
 H. Kalagara et al. / Journal of Cardiothoracic and Vascular Anesthesia 36 (2022) 11321147 1143

Table 13
POCUS Curriculum Levels of Competency

Competency Level Level Description Included Competencies

Level 1  Core  Expected standard of knowledge and practice
 Generic and basic competences to be obtained during residency
training
Level 2  Extended  More advanced level of skill and practice; level 2 practice for
clinicians with specialized interest in u/s
 Overlapping nature of practice is proposed such that a clinician
may be level 2 in one area (ie, vascular access) and level 1 in
another (ie, regional anesthesia).
Level 3 Advanced  Specialized and advanced training (ie, advanced echocardiogra-
phy training)
 Level 3 practice is unlikely to be pertinent to most practicing
perioperative clinicians.
 Able to perform common u/s examinations and interventions
safely and accurately
 Able to recognize normal and abnormal anatomy and pathology
 Able to use u/s in real time to guide common invasive
procedures
 Able to recognize when consultation for a second opinion is
indicated
 Able to understand benefits of u/s imaging and its value and rela-
tionship to other imaging modalities used in perioperative
medicine
 Significant experience of level 1 practice (ie, >12 months)
 Able to perform the complete range of examinations
 Able to recognize significant organ system-specific pathology
 Able to use u/s to guide full range of procedures related to prac-
tice area
 Able to act as mentor and instructor for level 1 clinicians
 Able to accept referrals from level 1 clinicians
 Able to accept referrals from level 2 clinicians and perform spe-
cialized examinations
 Level 3 clinicians are involved in all areas of u/s training and
participate in u/s research.

NOTE. Adapted from the Association of Anaesthetists of Great Britain and Ireland, the Royal College of Anaesthetists, and the Intensive Care Society’s
“Ultrasound in Anaesthesia and Intensive Care: A Guide to Training”.133
Abbreviations: CCM, critical care medicine; u/s, ultrasound.

training in their domain; however, this POCUS training frame-
work is relatively generic and applicable to anesthesiology.130
Applied to POCUS education, this framework began with
defining what applications (core and advanced techniques) are
to be taught and how each of these applications will be taught.
Regarding POCUS education methodology, a four-step pro-
cess should be used: application introduction, experiential use
and development (ie, documented via case log), obtaining
competence (expert review of case log along with skills assess-
ment), and maintenance of competency (continuing POCUS
education and case log maintenance). In assigning levels of
competency, neither the Accreditation Council for Graduate
Medical Education nor any specific American anesthesiology
society has yet to set standards, milestones, or required levels
of training specific to POCUS.128 However, the American
Board of Anesthesiology, as part of the Objective Structured
Clinical Examination component to board certification,
includes testing candidates’ interpretation of basic TEE, basic
TTE, and chest ultrasound imaging, with specific POCUS
applications being added to the Objective Structured Clinical
Examination beginning in 2022.131 Building on the aforemen-
tioned POCUS educational framework concepts, in 2019 the
American Society of Anesthesiologists convened its first Ad
Hoc Committee on POCUS, which, in part, specifically
addressed the minimum level of training in diagnostic POCUS
needed for competence. See Table 12 for the American Society
of Anesthesiologists Ad Hoc Committee’s recommendations
on training requirements required to be considered POCUS
competent based on the 2019 Committee Work Product on
Diagnostic Point-of-Care Ultrasound of the American Society
of Anesthesiologists.132 The Association of Anaesthetists of
Great Britain and Ireland and the Intensive Care Society
POCUS training curriculum offer three competency levels that
could be applied similarly in the United States (see
Table 13).133
Given the expertise and familiarity of cardiothoracic anes-
thesiologists with echocardiography and perioperative ultra-
sound applications, it is natural to conclude that they should
play an important role in all aspects of POCUS education.
Conclusions
POCUS is a valuable bedside diagnostic tool for the expedi-
tious diagnosis of a variety of acute and life-threatening condi-
tions, clearly earning its burgeoning reputation as the 21st-
century stethoscope. For each organ system evaluated, the
application of POCUS has its own unique advantages. LUS
has better sensitivity and specificity over CXR for certain lung
conditions, such as PTX, pulmonary edema, lung consolida-
tion, and pleural effusion. 40,42,44 Cardiac ultrasound has a cen-
tral role in the evaluation of challenging hemodynamic
situations and undifferentiated shock states. Combinations of
POCUS modalities, such as LUS along with FOCUS, have
higher rates of accurate diagnosis in complex situations and
multiorgan system involvement.134,135 Diagnosis and treat-
ment using POCUS should be within the clinical context of the
patient, and the ultrasonographer must be aware fully of the
limitations.136,137 Analogous to the National Board of Echo-
cardiography training and certification standards for echocar-
diography, standardizing POCUS education and delineating
competency levels also are central to ensuring appropriate
quality assurance. This is even more critical as POCUS use
1144 H. Kalagara et al. / Journal of Cardiothoracic and Vascular Anesthesia 36 (2022) 11321147
increases and more physicians seek to attain POCUS expertise
to incorporate this technology more widely into routine clini-
cal practice. With the current available and growing evidence
of clinical value of POCUS, its utility across the perioperative
arena adds enormous benefit to clinical decision-making.
Conflict of Interest
The authors declare no competing interests.
Supplementary materials
Supplementary material associated with this article can be
found, in the online version, at doi:10.1053/j.jvca.2021.01.018.
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