Head to toe ultrasound: a narrative review of experts’ recommendations of methodological approaches
Journal of Anesthesia, Analgesia and Critical Care volume 2, Article number: 44 (2022)
Critical care ultrasonography (US) is widely used by intensivists managing critically ill patients to accurately and rapidly assess different clinical scenarios, which include pneumothorax, pleural effusion, pulmonary edema, hydronephrosis, hemoperitoneum, and deep vein thrombosis. Basic and advanced critical care ultrasonographic skills are routinely used to supplement physical examination of critically ill patients, to determine the etiology of critical illness and to guide subsequent therapy. European guidelines now recommend the use of US for a number of practical procedures commonly performed in critical care. Full training and competence acquisition are essential before significant therapeutic decisions are made based on the US assessment. However, there are no universally accepted learning pathways and methodological standards for the acquisition of these skills.
Therefore, in this review, we aim to provide a methodological approach of the head to toe ultrasonographic evaluation of critically ill patients considering different districts and clinical applications.
Critical care ultrasonography (US) is considered an essential tool for the initial evaluation and clinical management of critically ill patients admitted to the intensive care unit (ICU), combining simple protocols of US application, a prompt assessment of critical conditions and therapeutic decisions. As a matter of fact, critical care US is nowadays considered not only a diagnostic tool providing information about the source of critical illness but can also be a component of the patients’ physical exam. This approach expands the sensitivity and specificity of clinical examination and basic measurements and is oriented to the peculiarity of the single patient.
The diffusion of critical care US has been slowed down over the last years because of technical issues (portability and availability of the machines), and lack of formal and standardized training programs. These gaps have been recently overcome by technical advances providing high-quality images at the bedside, and by the development of new guidelines for skills certification. Recently, a consensus of the European Society of Intensive Care (ESICM) provided a number or recommendations for the head to toe basic skills to be obtained by intensivists managing critically ill patients , and focusing on five districts (brain, lung, heart, abdomen, and vascular ultrasound).
According to that paper, the aim of this review is to provide a methodological approach of the US evaluation of different body districts and a critical reappraise of available training programs in the literature for the implementation of head to toe US in ICU.
For the purpose of this review, we asked the contribution of ICU Italian physicians with recognized expertise in US use in the critical care setting. Criteria for panel selection included high scientific knowledge and production in the field of ultrasonography and recognized clinical expertise.
We finally involved 12 experts, who were further divided in 5 subgroups, each one addressing different districts: brain, heart, thorax, abdomen, and vessels US. The experts were asked to summarize the methodological issues related to the application of US in the ICU, and to provide a review of the available training programs and studies aimed at providing competences for the application of US in critically ill patients.
Brain ultrasound (BUS) is getting interest as bedside tool for intensivists and emergency physicians, with an important role in the early diagnosis and management of acute intracranial pathology . The use of traditional transcranial Doppler, generally limited to the neurosonology laboratories settings, has expanded over the last years with the introduction of B-mode ultrasound and color Doppler, the transcranial color-coded duplex ultrasonography (TCCD) (Table 1, Fig. 1).
The use of this technique has opened new possibility for the assessment of intracerebral pathophysiology, not only for neurocritical patients but also in general intensive care unit and emergency room settings .
Clinical indications of TCCD currently include the evaluation of cerebral anatomy (midline shift, intracerebral hemorrhage, hydrocephalus), as well as the assessment of cerebrovascular diseases. The analysis of the waveform obtained from the major intracranial vessels allows in fact the management of patients in different scenarios such as traumatic brain injury, subarachnoid hemorrhage, and neurological complications of general ICU patients such as cardiac arrest, sepsis, and respiratory failure .
Clinical applications of BUS include:
The evaluation of normal or altered cerebral anatomy. In particular, TCCD is able to assess the presence of intracranial hemorrhage, midline shift, hydrocephalus, and the need for external ventricular drain [5,6,7,8,9,10].
The use as a confirmatory test in the assessment of brain death, which is determined as oscillatory reverse flow, systolic spikes, and absence of flow .
Noninvasive and indirect evaluation of intracranial pressure (ICP) and cerebral perfusion pressure, based on different techniques obtained from the flow velocity waveform analysis , optic nerve sheath diameter , and midline shift assessment. Recently, a large multicenter study  suggested an excellent negative predictive value for TCCD for the evaluation of ICP, thus suggesting that this tool can be used to exclude the presence of increased ICP in different clinical contexts, including the focused assessment sonography for trauma.
Angiographic vasospasm and delayed cerebral ischemia are the most severe consequences in aneurysmal subarachnoid hemorrhage (aSAH) patients: in this context, TCCD ultrasonography has shown to be reliable even in comparison with digital subtraction angiography (DSA) in the detection of increased flow velocity in the middle cerebral artery .
Cerebral autoregulation (CA) is the ability of the brain to maintain cerebral blood flow (CBF) constant despite changes in cerebral perfusion pressure: the flow velocity is directly correlated with CBF; therefore, TCD allows evaluation of both static and dynamic components of CA, including transient hyperemic response test, cuff test, and the Mx index, calculated as the correlation coefficient between flow velocity and arterial blood pressure [16, 17].
BUS is generally performed using four specific insonation windows: transtemporal, transforaminal (or suboccipital), submandibular and transorbital. A phased array 1.5–4 MHz low-frequency probe is used for the insonation of intracranial structures, while linear 7–15 MHz high frequency is used for ultrasound of optic nerve sheath.
Training paths and skills certification for the use of BUS by intensivists are still matter of debate among Scientific Societies and experts. Currently, only the American Academy of Neurology advises for the routine use of TCD in the neurocritical care setting 
Lung ultrasound gained a leading position in critical care both as a diagnostic and a monitoring tool [18,19,20], facing a large spread during coronavirus 2019 disease (COVID-19) pandemic [21, 22]. It is now considered part of the basic core competences for all intensivists . Different approaches in terms of probe, scan, and number of examined regions are found in literature [24,25,26,27]. Different types of examinations in the critically ill have been proposed. A complete and systematic one includes the evaluation of 6 regions per hemithorax [24,25,26,27]: anterior, lateral, and posterior fields which are identified by sternum, anterior and posterior axillary lines, respectively, and each field is divided into superior and inferior regions (Fig. 2E). In case lung ultrasound is performed to rule in/out a specific diagnosis, especially in emergency, we suggest performing a focused approach to answer the specific question. For example, to rule out pneumothorax in supine thoracic trauma, one scan per side in anterior fields will be enough .
Although a significant difference in probes performance could not be found in children , we suggest starting in anterior fields with a linear probe, as this is the one validated with quantitative computed tomography (CT) scan . In modern machines, it is important to abolish artifact-erasing software and harmonics to optimize the artifacts’ visualization . The switch to a low-frequency probe is useful in case consolidations/pleural effusions are visualized or if the chest wall is particularly thick. For lung US examination, the probe can be oriented longitudinally (i.e., aligned with craniocaudal axis) or transversally (i.e., aligned with intercostal space). A longitudinal approach allows the identification of the bat sign and therefore of the intercostal space; it is recommended for beginners or in any case of difficult examination (for example: subcutaneous emphysema making unclear the pleural line visualization). A transversal approach allows the visualization of wider pleura  but requires higher expertise; it is recommended for the measure of interpleural distance and the quantification of pleural effusions . With any approach, once the pleural line identified, the probe has to be tilted searching for the A-lines, reverberation artifacts visible when the probe is well-oriented perpendicular to the pleura: they can be considered a marker of good-quality images (Fig. 2A–D).
Bi-dimensional images can be associated to M-mode, particularly useful to confirm the presence/absence of lung sliding (respectively visualized with seashore and stratosphere signs), thanks to its higher frame rate.
Color Doppler is rarely used in lung ultrasound; it can help identifying shunt in consolidated lobes , although this assessment is purely qualitative so far; it has recently been proposed also for the diagnosis of ventilator-associated pneumonia .
Automation has been proposed to facilitate the interpretation of lung ultrasound in the critically ill [35,36,37]: it showed good correlation with extra-vascular lung water and good diagnostic accuracy for cardiogenic/non-cardiogenic lung edema and COVID-19 pneumonia; however, so far visual analysis of the expert remains the most reliable tool.
A training curriculum of 25 supervised examinations resulted adequate to acquire basic skills in lung ultrasound ; however, the exact definition of training for specific signs as air-bronchogram is still matter for research . Finally, quantitative approach for the assessment of lung aeration should not be considered a basic skill  and requires a dedicated training .
The advent of portable ultrasound machines has revolutionized the clinical application of cardiac US, allowing physicians to assess cardiovascular complications at the patient’s bed. In particular, cardiac ultrasound with transesophageal echocardiography (TEE), first used in 1981, was moved from the necessity to evaluate the surgical result immediately and monitor the hemodynamic state of the patients with post-cardiotomy shock in terms of fluid and inotrope in the operating room . That led to the publication of TEE practice perioperative guidelines in 1996 and the development of cardiovascular societies worldwide of many courses for training and practice in cardiac anesthesia (the first TEE examination took place in 1998 and rapidly became the international standard) [42, 43]. That has initiated the era of point-of-care ultrasound (POCUS). However, POCUS did not begin until 1990, when more compact machines were available.
Developing and applying echocardiography within the critical care setting required another 10 years since the American College of Chest Physicians and La Société de Reanimation de Langue Française in 2009 published a consensus statement to describe how the use of ultrasound should be considered and described what type of skills should be mastered to reach competence. This panel divided the use of ultrasound in two main branches: the general critical care ultrasound with focus on the assessment at thorax, abdominal, and vascular level, and the critical care echocardiography (CCE) with two levels of skill, basic and advanced. In particular, basic CCE was intended as the use of ultrasound to perform a “goal-directed examination” with a simple question in the context of clinical syndromes. For instance, questions are “is my shocked patient having cardiac tamponade?” or “have my shocked patients a severely reduced systolic function?”, with a qualitative rather than quantitative assessment. Therefore, basic CCE essentially includes 2D and some M-mode imaging, with limited anatomical or functional quantification parameters.
In contrast, advanced CCE refers to a more comprehensive hemodynamic assessment that requires quantitative evaluation of cardiovascular function (without or with TEE use). For example, in patients with shock, advanced assessment would refer to the quantification of left ventricular ejection fraction, evaluation of diastolic dysfunction and valvular diseases. In this context, color and spectral Doppler modes are applied with the aim to provide an appreciation of patho-physiological conditions.
Considering that the transthoracic echocardiography (TTE) percentage of successful diagnostic exams in the ICU is approximately 50% vs over 90% in the elective cardiac lab, and also that an adequate TTE window is obtained in 36% as compared to 97% with TEE, even if the main focus for echocardiography in ICU remain training in TTE, it must be considered also the importance of achieving education in TEE as well .
For training in CCE, an experts panel representing 13 Scientific Societies of Critical Care has recently determined the basic and advanced skills (Fig. 3). After that, many protocols have been developed worldwide to solve a specific question of monitoring fluid status or cardiac function or a specific situation like cardiac arrest, as the case of the RUSH protocol, also included in the ACLS [46, 47]. Although the step size from basic and advanced cardiac ultrasound is significant, there is a continuum in between. The American College of Cardiology and the American Heart Association documents have provided important knowledge on the cognitive skills required for basic echocardiography . In daily practice, basic CCE skills can have a potentially significant clinical impact on traumatized patients and in case of emergencies requiring a rapid response and differential diagnosis. On the other hand, advanced CCE plays a growing role in cardiac anesthesia and ICU. Of note, availability of online educational material has grown exponentially with smartphones and social media such as Twitter. Also, echocardiography simulators have contributed in expanding training opportunities (especially for TEE use), accelerating at least the image acquisition process. As a result, basic, intermediate, and advanced certifications in TEE for physicians routinely or not practicing cardiac anesthesia are now available (Table 2).
Similar echocardiography disciplines prove that the learning curve for basic CCE may flatten out after 30 supervised studies . The American College of Cardiology and the American Heart Association recommended that anesthesiologists perform at least 50 supervised examinations to reach competence in perioperative TEE, in conjunction with mastering mandatory cognitive skills . Others found that the number of minimum supervised TEE examinations predicting 100% competence is still around 50 scans . However, as “a number” itself derived from a monitoring tool cannot guarantee competence and clinical management, this should be integrated with other physiological and clinical factors.
Diaphragm ultrasound has been increasingly employed in daily clinical practice and research to assess diaphragmatic function both in and outside ICU [1, 51,52,53,54,55,56,57]. Recently, the evaluation of diaphragmatic excursion through ultrasonography during weaning from invasive mechanical ventilation (IMV) has been recommended as a basic skill for ICU physicians . Despite this increasing interest, there is a wide variability in diaphragmatic ultrasound methodology that makes difficult to draw definite conclusion on the clinical and research impact of this tool at bedside. To enhance the standardization of diaphragmatic ultrasound assessment in the critical care setting, an international experts’ consensus statement has been just published . The sonographic evaluation of the diaphragm involves the assessment of diaphragmatic muscle mass inferred by the measurement of muscular thickness as well as its changes over time, i.e., the diaphragmatic contractile activity as described by thickening fraction, and excursion during active breath [58,59,60]. Diaphragmatic excursion has been employed to predict noninvasive ventilation response in patients admitted to emergency department for hypoxic-hypercapnic respiratory failure . Advanced respiratory monitoring of diaphragmatic thickness and thickening fraction have been used in patients requiring noninvasive respiratory support for acute respiratory failure related or not to coronavirus 2019 disease , in- and outside the ICU [52, 62, 63]. More recently, the assessment of diaphragmatic thickness and thickening fractions have shown to be helpful to ascertain the development of IMV-induced diaphragmatic atrophy as well as to predict IMV liberation  (Table 3).
As depicted in Fig. 4A, the ultrasound evaluation of diaphragmatic excursion is conducted in M-mode by directing a 2–5 MHz sectorial/convex probe towards the dome of the diaphragm . The depth is adjusted to catch the maximum excursion of the diaphragm paying attention to set the gain in order to obtain the right contrast with surrounding structures. The sonographic evaluation of diaphragmatic thickness is obtained using a 7–12-MHz linear transducer, perpendicularly placed on the chest area delimited by the middle and anterior axillary lines and by the 8th and 11th ribs (Fig. 4B). The probe is indiscriminately positioned in line with or perpendicular to the intercostal space. The diaphragmatic thickness evaluation is conducted in the zone of apposition of the diaphragm to the chest wall, with the lung slightly appearing into the image. The diaphragm is described as a three-layer structure, i.e., peritoneal, fibrous, and pleural line from the liver surface to the chest wall. The gain is optimized to obtain the sufficient contrast with surrounding structures in B- or M-mode. Diaphragmatic thickness is measured positioning the caliper as close as possible to the pleural and peritoneal edge, excluding these lines by measurements. Diaphragmatic displacement and thickness acquired on the right side reflect the activity of the whole diaphragm in absence of unilateral disease. The placement of a cutaneous marker on the area selected for diaphragmatic ultrasound has demonstrated to enhance reliability as well as the intra- and inter-rater agreement of diaphragmatic sonographic assessment .
The ultrasound report should always include mechanical ventilator settings (including the applied pressure support and positive end expiratory pressure), patient positions (recumbent, semi-recumbent, sitting or standing), and previous comorbidities (e.g., chronic obstructive pulmonary diseases or myopathies) because all these factors possibly affect the measurements of diaphragmatic muscle mass and function.
In the absence of ultrasound experience, the learning curve for gaining sufficient skills to conduct a diaphragmatic ultrasound assessment for thickness and displacement in clinical practice requires at least 40 bilateral examinations, of which 20 under the expert supervision , even if this threshold does not consider the previous ultrasound experience of the practitioner. However, its authors’ opinion that diaphragmatic ultrasonography should always be performed in light of highly variable context specific cut-offs, depending on different clinical scenarios and variable targets (i.e., predictors of weaning, extubation or noninvasive ventilation failure, muscle exhaustion, or titration of mechanical ventilation).
As future perspectives, new ultrasound applications have been proposed in the assessment of diaphragmatic activity, i.e., diaphragmatic tissue Doppler analysis, diaphragmatic shear wave elastography, and diaphragmatic speckle tracking analysis, evaluating diaphragmatic excursion kinetics, stiffness, and strain, respectively, during respiratory cycle . The real impact of these tools needs to be addressed in large multicenter investigations.
In case of unexplained shock associated to abdominal pain or not, bedside ultrasound assessment of the abdomen should be performed to diagnose possible underlying conditions. Furthermore, bedside sonographic reassessment of worsening patients suffered from blunt trauma should be executed to visualize previously undetected free fluids or to monitor the evolution of already known small amount of free fluid. Finally, abdominal ultrasound should be part of a systematic sonographic assessment of septic patients for searching the source of sepsis.
Despite significant evidence on the use of abdominal ultrasound in critical care , a structured formal training on how to perform abdominal ultrasound in the critically ill and how to certificate adequate competence has not yet been completely defined. Papers published in the last two decades from various scientific societies in different settings suggest that such an educational program should include formal didactic or web-based teaching of the basics of ultrasound, anatomy and pathology, and ultrasound-guided interventional procedures. The initial training should include laboratory training on healthy volunteers and simulators. Only after the trainee has met a minimum score of proficiency in the simulation phase a proctored clinical phase can be started, and then, provided there has been adequate progress along the learning curve, a personal learning phase with distant supervision may occur .
Recently, a consensus statement from the ESICM  included among the basic skills for intensivists the sonographic scanning from the epigastrium up to the mesogastrium at the level of umbilicus, both in a transverse and longitudinal plane, for ruling out or confirming a ruptured aortic abdominal aneurysm in case of unexplained shock, abdominal pain, pulsatile mass, or lower extremities emboli .
The minimal requirements for optimal imaging acquisition and interpretation are reported in Table 4.
Studies have reported that different physicians from various subspecialties and different levels of training can be able to identify the aorta using ultrasound with enough degree of accuracy. Hoffmann et al. have found that also inexperienced sonographers might achieve acceptable performance with an appropriate training requiring > 25 proctored examinations needed to ensure competency . Nguyen et al. further confirmed that novices could be trained to sonographic diagnosis of abdominal aortic aneurysm after 15 days of training, consisting in both theoretical and practical components, the letter including a learning curve of 50 examinations on average . Furthermore, training on technically difficult cases should be part of the credentialing process.
No significant data have been published on how many examinations are needed per year to maintain proficiency in the setting of critical care.
When hydronephrosis is identified, both kidneys and the bladder should be evaluated . In fact, bladder outlet obstruction usually presents with bilateral hydronephrosis, while unilateral hydronephrosis can be an early sign of disease. Ultrasound allows to estimate urine volume in the bladder, to rule out bladder overdistension and define the need of catheterization.
High value (> 0.77) of resistive index of the renal interlobar arteries assessed through pulse-wave color Doppler has been shown to predict adverse outcomes and renal failure progression in septic patients and after major or cardiac surgery .
Regarding sonographic diagnosis of hydronephrosis, Sibley et al. have found that a learning curve consisting in 25 examinations at least may be enough to achieve proficiency . On the other hand, Herbst and coll. have proved that a good accuracy in sonographic diagnosis of hydronephrosis can be achieved after a 2-week course including no less than 50 examinations as the main learning curve 
Training for evaluation of Doppler-derived renal resistivity index (RI) is not defined yet and requires further evidence.
In patients with acute abdominal pain, unexplained shock or septic shock, abdominal ultrasound is useful to assess differential diagnosis and to define the need of further radiological exams to identify possible underlying conditions. However, in this context, abdominal ultrasound performed bedside by intensivists reaches its maximum effectiveness only if clinically driven.
The presence of previously undetected abdominal free fluids in a symptomatic patient suggests acute abdomen needing further diagnostic exams and eventually surgery consultation .
Increased echogenicity of the peritoneal stripe with multiple reverberation artifacts may be a sign of free intraperitoneal air due to perforation .
A dilated small bowel loop with reduced or absent peristalsis, characterized by the “to-and-fro” movement of the intestinal content, also associated to gastric distension suggests bowel occlusion .
In a context of sepsis or septic shock and jaundice associated to elevated liver function tests, sonographic appearance of the gallbladder characterized by thickened walls (> 3 mm) associated or not to fluid peripheral collections, gallbladder dilation (length > 4 cm), hydrops in conjunction with large gallbladder stones, and presence of biliary sludge or pus are signs of acute cholecystitis .
No robust evidence is still available regarding training and learning curve for abdominal ultrasound performed in a critical care context by intensivists. Further studies are needed.
Ultrasound for detection of free fluids in the acute traumatic abdomen is well known as clinical practice since part of focused assessment with sonography for trauma (FAST) examination recommended by the American College of Surgeons in the Advanced Trauma Life Support Course.
After the first assessment in the Emergency Room, this kind of examination should be repeated also during ICU stay as a monitoring tool or in case of unexplained hemodynamic instability allowing to detect eventually previously undetected free fluids collection or an increase in already known small amount of free fluid.
With the aim of establishing the competency in detecting intraperitoneal free fluids at FAST examination, 10 examinations might not be sufficient . The learning curve starts to flatten at 30 examinations, while after 50 examinations at least high accuracy is reached . These differences among studies are related to the fact that all these studies have attempted to define competency by different methods of analysis.
Bowel dysfunction, associated to vomiting and abdominal distension may be common in the critically ill, especially in patients who underwent major abdominal surgery. Gastric ultrasound allows both a qualitative and quantitative assessment of the stomach allowing to rule out postoperative ileus and to define risk of aspiration [77, 78].
When properly clinically driven, gastric ultrasound reaches high sensitivity (1.0), specificity (0.975), positive predictive value (0.976), and negative predictive value (1.0) .
Arzola and coworkers have found that 33 supervised gastric scans are required to achieve a 95% accuracy in qualitative assessment of gastric content 
Finally, in septic shock, ultrasound allows to detect abscesses, necrotizing fasciitis, cellulitis, or thrombophlebitis as potential underlying source of sepsis with good accuracy [81, 82]. Berger et al. have found that only a minimal training consisting in a 2-day course is required to reach enough accuracy for soft tissue infections diagnosis .
The global use of ultrasound is recommended to assist all steps of ultrasound vascular access device placement: (a) rational choice of appropriate vein and proper approach; (b) prevention of primary malposition; (c) ruling out of respiratory complications; (d) ruling out of late complications (i.e., catheter-related thrombosis, fibrin sleeve)  (Table 5).
General curriculum for ultrasound-guided vascular access procedures should consist of didactic lectures or web-based teaching; laboratory training including simulation training; a clinical phase that includes both closely supervised and distant supervised learning. Following ESAIC guidelines, each trainee should observe and then perform, under supervision, 5 procedures of each kind of approach. Finally, perioperative use of ultrasound-guided for vascular access guidelines from European Society of Anesthesiology and Intensive care (ESAIC) suggests at least 30 US-guided procedures of any type in a 12-month period for completion of competency-based training, as personal learning curve 
In addition, compressive ultrasonography of common femoral vein at the groin, superficial femoral vein at the mid-thigh, and popliteal vein in the popliteal fossa allows to rule out deep vein thrombosis with good accuracy.
Head to toe ultrasonography is becoming a fundamental skill for the bedside assessment of patients in the ICU (Fig. 5).
A standardized training program and certification is required to improve physician’s knowledge and patients care in these settings.
Availability of data and materials
- aSAH :
Aneurysmal subarachnoid hemorrhage
Cerebral blood flow
Coronavirus 2019 disease
Critical care echocardiography
Critical care ultrasonography
Digital subtraction angiography
European Society of Anesthesiology and Intensive care
European Society of Intensive Care
Focused assessment with sonography for trauma
Intensive care unit
Invasive mechanical ventilation
Transcranial color-coded duplex ultrasonography
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RB, DB, FC, ER, SR, FS, and LV declare that they have no competing interests. AM received travel expenses and registration for meetings, congresses, and courses and lecture fees from Vygon, Edwards, Philips and Getinge outside the present work. CR declares lectures fees from Masimo and GE Healthcare outside the present work. FM received fees from GE Healthcare, Hamilton Medical, SEDA spa, outside the present work. SM received fees for lectures from GE Healthcare, outside the present work. GC reports speaking honoraria from Getinge and MSD outside the submitted work.
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Messina, A., Robba, C., Bertuetti, R. et al. Head to toe ultrasound: a narrative review of experts’ recommendations of methodological approaches. J Anesth Analg Crit Care 2, 44 (2022). https://doi.org/10.1186/s44158-022-00072-5