Why we need critical US evidence-based clinical recommendations (CR) and consensus statements (CS)?
Numerous new challenges have emerged with the appearance of “Critical Ultrasound”, but one can recognize eight major domains. The first challenging domain may be definition and nomenclature. One can find several names or terms for a single sign such as the B-lines that were also called comet tail artifacts ultrasound lung comets, multiple B-line pattern, indicated as lung rockets or B-plus [1–3]. This is seen in many new signs that are given different names by various investigators resulting in a degree of confusion or at least difficulty in scientific communication. The second domain is the technology. This domain is particularly challenging as it is rapidly and continuously evolving and is affected by huge industrial funding and advertisement. To keep current with technology and decide which specific aspects or features are clinically useful to the patient and cost effective is quite challenging. This third domain of cost-effectiveness is not only restricted to new technology assessment, but also covers the whole strategy of this new US enhanced management in comparison with other conventional diagnostic and management strategies. The fourth domain is the technique itself. We observed the progress of the original FAST technique to e-FAST (extended FAST, including pneumothorax assessment) [4–6], to the FASTER (FAST, including extremities and respiratory tract) , up to the FAST-ABCDE (FAST including airway-breathing-circulation-disabilities and exposure) , with an increase from the initial three abdominal windows (suprapubic, peri-splenic and peri-hepatic) to several integrated windows over different body districts. Similarly, there is great variability in definition of lung zones that should be covered during lung ultrasound scanning [9–13]. Having consensus on the basic technique will facilitate the diagnostic process, patient management and clinician training. The fifth domain: “training, education and credentialing” is extremely important. It critically impacts not only practice privileging, patient management and outcome, but also has legal and financial consequences. The sixth domain deals with clinical outcomes or endpoints where it examines specific clinical conditions with clear patient-oriented endpoints related to mortality, morbidity and quality of life in comparison to conventional management (such as in the case of pneumothorax) . This domain also addresses certain clinical scenarios that may be encountered in critical settings. Many examples can be listed under this domain such as acute respiratory failure, lung ultrasound-guided fluid therapy, focused ECHO in shock management, ultrasound in resuscitation, lung ultrasound in monitoring alveolar recruitment [12, 15–18].
Critical ultrasound, as most topics in medicine, is not without risks. Concerns have been raised regarding infection, technology dependency, time and resource consumption. It may be necessary to devote a seventh domain for potential risks, to address these legitimate concerns and propose solutions or at least develop recommendations to minimize these risks. Finally, the eighth domain that needs consensus and recommendations is the domain of future research. It becomes obvious that there are new challenges and heralds emerging every day in the field of Critical Ultrasound. The only way to face these challenges and overcome the heralds is scientifically sound, well-conducted and clinically relevant research. We need to set up the priorities according to the patient’s best interest. We need to direct the researchers to what really is needed. We, as clinicians and patient advocates, need to direct the industry and not be driven by their own agenda. We should be the master of technology not the reverse. The alternative is detrimental because “when technology becomes the master, disaster will come faster”.
It is also important to stress the multi-disciplinary nature of this consensus guideline creation process. Unilaterally created guidelines from single societies often conflict with guidelines issuing from different specialties and may make little impact outside of that particular society. It is the mission of WINFOCUS to provide guidelines that can be used all over the world, especially given that 80% of the world’s population lives outside of Europe and North America.