(833) Fellows in FOCUS: Proficiency of Pediatric Critical Care Fellows in Focused Cardiac Ultrasound

Introduction: Focused cardiac ultrasound (FOCUS) is increasingly used for bedside hemodynamic assessment of acutely ill pediatric patients, facilitating rapid clinical decision making. Despite its growing adoption in the PICU, there is little published data on how pediatric critical care medicine (PCCM) fellows achieve proficiency in FOCUS during their training. This study evaluates PCCM fellows' performance in acquiring and interpreting FOCUS studies in critically ill children after completion of a practice-based FOCUS curriculum.

Methods: We conducted a prospective observational study in a 17-bed pediatric intensive care unit at a tertiary care teaching hospital. PCCM fellows received a 3-hour training curriculum and developed a portfolio of 20 practice FOCUS studies. Fellows then performed FOCUS exams on critically ill pediatric patients with hemodynamic instability, post-cardiac arrest, cardiomegaly, and/or cardiopulmonary symptoms of unknown etiology. They assessed left ventricular systolic function (LVSF), pericardial effusions, and inferior vena cava (IVC) collapsibility. The primary measure was the agreement between fellow assessments and those of a blinded pediatric cardiologist.

Results: Four PCCM fellows completed 32 FOCUS studies. Patients were 66% male with a median age of 2.5 years and median weight of 13 kg; 50% were mechanically ventilated and 78% presented with undifferentiated hypotension and/or tachycardia. Per the cardiologist, 2 patients had moderately or severely diminished LVSF, 1 had moderate-to-large pericardial effusion, and 14 had >50% IVC collapsibility. All 32 studies were deemed adequate for evaluation by the cardiologist. For the clinically significant findings, there was 97% agreement between fellows and cardiologist on moderately-to-severely depressed LVSF (kappa [κ] = 0.78, 95% CI, 0.38-1.19), 97% agreement on absence of significant pericardial effusion (κ = 0), and 78% agreement on >50% IVC collapsibility (κ = 0.60, 95% CI, 0.36-0.84).

Conclusions: A practice-based curriculum can be used to train PCCM fellows in the performance and interpretation of FOCUS studies. Although the prevalence of poor LVSF and pericardial effusions was low in the sample, PCCM fellows demonstrated the ability to identify clinically significant findings with accuracy.