European Diploma in Critical Care Echocardiography (EDEC)

Transkript

1 European Diploma in Critical Care Echocardiography (EDEC) Martin Balík KARIM 1. LF UK a VFN, Praha, EU Klinika anesteziologie, resuscitace a intenzivní medicíny 1. lékařské fakulty UK a Všeobecné fakultní nemocnice v Praze Adresa: U nemocnice 2; Praha 2

2 Zvyšující se nároky na kvalifikaci intenzivistů - Obor IM jako garant péče o kriticky nemocné v rozvinutých zdravotnických systémech UPV+hemodynamika RRT UZ.+FOB 2

3 Proč by měl intenzivista umět echokardiografii Hemodynamika, RTG, lab., anamn. okamžitá aplikace TTE/TEE nálezu Komplexní bez prodlevy v aplikaci Porembka DT: Crit Care Med 2007 Jones: Crit Care Med 2004 Okamžitá, neinvazivní a komplexní Zavádějící data z invazivních (PAC) u traumat, sept. šoku a post CPR Poelaert JI, Chest 1995 Burns JP, J of Trauma 2005 EGDT fungují jen u 55% Osman, Crit Care Med 2007

4 Úroveň kompetencí Expert level Basic level Cholley B, Price S: Intensive Care Med 2006, 2008

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6 FATE / FEEL: 4 planes + bilat. pleural space 2D: pericardium LV/RV size and contractility preload pleural

7 FATE...+ FAST Blood/air in the chest/abdomen? 5 trunk regions (5 P): Pericardial Perihepatic (Morrison s pouch) Perisplenic Pelvic (pouch of Douglas) Pleural + paracolic bilateral Q: is a fluid/blood present? Extended FAST (efast):...pneumothorax? = indication to urgent chest drain. pneumoperitoneum?

8 Cobatrice: Changes after 2014 Competence Title: Practical procedures: Cardiovascular system Syllabus Changes: Add competence Noninvasive haemodynamic assessment with echocardiography Relationship to other, existing competencies Describes ultrasound techniques for vascular localisation, 5.12 Describes how to perform pericardiocentesis, 5.16 Performs abdominal paracentesis,

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12 Současné kombinované TTE+TEE akreditace pro intenzivisty ve světě Australia: Certification in Echocardiography For the Critical Care Physician (Diploma in Dg. Ultrasound for intensivists, since 2009, coordinated by ASUM&ANZICS) Level I Rapid cardiac assessment (analogous to FAST in trauma) Level II Comprehensive cardiac and haemodynamic examination Level III Echocardiography at units with established echo research and training reputations: support for LII (clinical, research, education) France: Initiated in 2004, Echo-in-ICU group : Frech Society of Cardiology (SFC), French Society of Intensive Care (SRLF), French Society of Anaesthesia and Intensive Care Medicine (SFAR) 1st year (intensivists, cardiologists, anaesthetists): Echo lab, 120 TTE 2nd year (intensivists): 20h specific courses, exam, hands-on in ICU: 70 TTE+50 TEE 12

13 Curicullum CCE, Intensive Care Med : A two level model First level (national, CSARIM): Basic TTE 30 supervised certified TTE as part of training Certified course plus test as prerequisite to sit the national exam Second level (international expert level, ESICM EDEC): Compulsory course certified by ESICM EDEC group Structured logbook: 100 supervised TTEs and 35 TEEs during 2 years MCQ test, reporting test, practical on manequins Enrollment open since autumn 2015, 1 st exam in Milan

14 ICU echoprotokol Může fungovat pro TTE i TEE Ne všechno lze vždy odebrat pro obtížnost vyšetření Guideline ke studiu pro lékaře v tréninku Unifikovaná forma pro akreditační účely (log book)

15 Jak začít? 1.) Najít registrovaného supervizora, nebo ho registrovat u ESICM - najít mentora 2.) Absolvovat 40h certifikovaných kurzů a webinars (ESICM endorsed, kurz na LIVES - 11h- je povinný) 3.) Poté zahájen strukturovaný logbook/24 měsíců, zkouška umožněna po prvních 60 cases ESICM Directory Board Chair EDEC Committee Designated EDEC National Representative Supervisor Mentor Registered EDEC Learner 15

16 Akreditace umožňující statut supervizora/mentora European Society of Cardiology (ESC) TTE accreditation European Society of Cardiothoracic Anaesthesist (EACTA/ESC) TEE accreditation Any EU country cardiology specialist qualification United Kingdom BSE/ICS Critical Care TTE accreditation United Kingdom BSE/ACTA TOE accreditation Diploma in Diagnostic Ultrasound (DDU) Critical Care or Cardiology Australasian Society for Ultrasound in Medicine (ASUM) Cardiology specialist qualification (FRACP / FCSANZ) American Echo Board Exam (ASCeXAM) Graduate Certificate in Critical Care Echo (GCCritCareEcho), University of Queensland

17 ESICM registrovaní supervizoři v ČR Martin Balik A/Prof, MD, PhD, EDIC, ESC TTE accreditation, EDEC examinator, martin.balik@vfn.cz Michal Lips MD, EACTA TEE accreditation, michal.lips@vfn.cz Jan Rulisek MD, EACTA TEE accreditation, jan.rulisek@vfn.cz Jan Kunstyr A/Prof, MD, PhD, EACTA TEE accreditation, jan.kunstyr@vfn.cz Michal Porizka MD, PhD, EDIC, EACTA TEE accreditation, michal.porizka@vfn.cz Michal Matias MD, EACTA TEE accreditation, michal.matias@vfn.cz Petr Kopecky MD, EACTA TEE accreditation, petr.kopecky@vfn.cz Frantisek Mosna MD, DESA, EACTA TEE accreditation, fmosna@seznam.cz Petr Plasil MD, EACTA TEE accreditation, peta.plasil@seznam.cz Tomas Tencer MD, EDIC, EACTA TEE accreditation, tencer_tomas@yahoo.com Tomas Mraz, MD, EACTA TEE accreditation, tomas.mraz@homolka.cz Jiri Roith MD, EACTA TEE accreditation, j.roith@seznam.cz Petr Kramar MD, EACTA TEE accreditation, petr.kramar@ikem.cz

18 EDEC exam Struktura zkoušky EDEC Teoretická písemná část (I): 50 MCQs, 5x T/F, 250 points, 90 min Praktická část reportující kazuistiky (II): 10 Cases, 3x SBAQ, 30 points, 60 min Praktická zkouška (hands-on) (III, TEE CAE trenažér): 20 min, physiology planes, 1 prompt allowed Logbook, praktická část akreditace 100 TTE + 35 TEE /2 years, 60 cases as prerequisite to sitting the exam. Re-certifikace -?

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20 MCQs..(1 min 48 sec/1 otázku) The echocardiographic findings in septic shock usually include: reduced end-systolic volume increased end-diastolic volume aortic valvular regurgitation tricuspid valvular regurgitation reduced systolic-diastolic function of left ventricle In a critically ill patient on IPPV the following measurements are made: LVD(d) 5.5 cm, LVD(s) 3.7 cm, LVOT diameter 2.0 cm, transaortic peak velocity 2.8 m/s, subaortic peak velocity 2,1 m/s. The following statements are true: The patients has mild aortic stenosis Subaortic stenosis is not present The effective orifice area using continuity equation is approximately 0.8 cm 2 The ejection fraction is approximately 65% The presence of moderate AR would invalidate analysis of stenosis severity

21 ..Case No.6.. (6 min/1 case) Case 6: 38 year old patient presents with dyspnea. Was treated with diuretics and brought on non-invasive ventilation (PSV 8 mbar, PEEP 8 mbar, FiO ) to the ICU. He has peripheral saturation of 96% and tidal volumes 580 ml, sinus 80/min, IBP 140/70 mmhg. The patient admits bounces of tachycardia in the past. TTE is performed:

22 .Case No.6

23 The echocardiography shows: i. Severely dilated left ventricle with restrictive filling pattern ii. Severely reduced left ventricular contractility with LV relaxation disorder iii. Severely dilated left ventricle with pseudonormal filling iv. Severely reduced left ventricular contractility with low cardiac output What is the estimated left ventricular end-diastolic pressure? i mmhg ii mmhg iii mmhg iv. Over 25 mmhg How do you interpret the stroke volume variation? i. Hypovolaemia after aggresive diuretic treatment ii. d-down effect of non-invasive ventilation iii. d-up effect of the non-invasive ventilation iv. Vigorous inspiratory efforts not met by the ventilator setting

24 Těším se na Vás u evropských zkoušek!

25 Co pro Vás musíme zajistit (společně s odpovědnými českými politiky).. 25

26 Děkuji za pozornost Department of Anaesthesia and Intensive Care 1 St. Medical Faculty of Charles University, General University Hospital U nemocnice 2; Prague 2, EU T: F: E: martin.balik@vfn.cz