📚 Guideline basis
ASE recommendations for standardised echocardiography reporting; ACCP/SRLF competence statement (Chest 2009); Expert Round Table international consensus on advanced CCE training (Intensive Care Med 2014); PRICES statement (Sanfilippo F, et al., Intensive Care Med 2021, PMID 33275163); national accreditation frameworks (BSE, EACVI, NBE).
Why the report is the deliverable
The images are transient; the report persists and is acted upon by clinicians who did not perform the study and cannot see what the operator saw. Three failure modes recur, and all three are documentation failures rather than imaging failures:
- A focused study reported in the language of a comprehensive one. "Normal LV function, no significant valvular disease" written after a two-view subcostal scan will be read six hours later as an exclusion of valvular disease.
- Findings recorded without loading conditions. A stroke volume, gradient or E/e′ without heart rate, rhythm, blood pressure, vasoactive dose and ventilator settings is uninterpretable and cannot serve as a comparator.
- Absent limitations statement. What could not be seen is as clinically important as what could.
The minimum dataset
Element | Detail |
Indication and clinical question | Stated explicitly, in the words the referrer would use |
Study level | Basic (focused) / advanced / comprehensive / TEE — the single most important classificatory statement |
Operator and competence level | Name and credential status |
Date, time, machine, preset | Serial comparison depends on it |
Views obtained, and views attempted but not obtained | The second list is what makes the limitations statement credible |
Image quality | Good / adequate / poor / non-diagnostic — with the reason |
Loading conditions | Heart rate, rhythm, blood pressure, vasoactive agents and doses, ventilator mode, PEEP, tidal volume, temperature, and (if on support) circuit flow |
Measurements | With the view used for each; LVOT diameter recorded once and reused for the admission |
Findings | Structured by chamber, valve, pericardium, great vessels |
Limitations | Explicit; see below |
Conclusion | Answers the clinical question directly, in one or two sentences |
Recommendation | Comparison study, escalation to TEE, repeat interval, or referral |
The limitations paragraph
This is the most important paragraph in a critical care echocardiography report, and the most frequently omitted. It should state, in plain terms, what the study cannot be used to exclude.
Examples of adequate wording:
- "Focused study. Doppler was not performed; valvular disease has not been excluded."
- "Transthoracic study in a ventilated patient. Acoustic shadowing from the mitral prosthesis means prosthetic mitral regurgitation is not excluded; TEE is required if clinically suspected."
- "Apical windows were unobtainable. Regional wall motion in the lateral and apical segments was not assessed."
- "Severity grading performed at MAP 55 mmHg on noradrenaline 0.4 µg/kg/min; regurgitation severity is likely under-estimated at this loading. Reassessment at normalised loading is recommended."
- "TEE performed; the distal ascending aorta and proximal arch were not adequately visualised owing to tracheal air. Type A dissection is not fully excluded."
Note what these have in common: they name the specific thing not excluded, rather than issuing a generic disclaimer.
Structured templates
Focused (basic) study
Indication · Level: basic focused study · Views: subcostal 4C, subcostal IVC, PLAX, A4C · Quality
Pericardium: effusion present/absent; tamponade physiology present/absent
LV: visual estimate — hyperdynamic / normal / moderately impaired / severely impaired; cavity size
RV: size relative to LV; septal motion
IVC: size and respiratory variation
Loading conditions
Limitations: no Doppler performed; valvular disease and filling pressures not assessed
Conclusion: direct answer to the question asked
Haemodynamic study
Adds: LVOT diameter and VTI, stroke volume, stroke volume index, cardiac output and index, heart rate, mitral E and A, septal and lateral e′, E/e′, TR peak velocity, estimated PASP, hepatic vein flow, fluid responsiveness test performed and result, lung B-line count.
Comprehensive / TEE study
Adds: full valve assessment with mechanism and quantification, biplane volumes and EF, all 17 segments, aorta, shunt assessment, and for TEE the probe depth and multiplane angle for each key finding, sedation used, and complications.
Image archiving
A clinical study performed to inform a decision must be stored. An unrecorded study cannot be reviewed, audited, taught from, compared against, or defended.
Requirements: storage in the institutional archive (PACS or equivalent); linkage to the medical record; retention per local policy; loops of every view acquired, including the poor ones, because the follow-up study depends on the baseline. Store the LVOT diameter image explicitly and label it, so that it is reused rather than re-measured (Chapter 11).
Quality assurance
A CCE programme without QA drifts, and drift is invisible from inside.
Component | Implementation |
Blinded over-read | A sample of studies (a defined proportion per operator per period) reviewed by an independent expert, with structured feedback |
Correlation audit | Compare CCE findings against subsequent comprehensive studies, TEE, CT, and invasive data where available |
Discrepancy review | A no-blame process for reviewing cases where the CCE conclusion differed materially from the eventual diagnosis |
Measurement variability audit | Periodic inter-observer measurement of the same stored loops — LVOT diameter and VTI in particular |
Volume and logbook tracking | Numbers of studies performed and reported per operator, against the training pathway (Chapter 1) |
Machine and probe governance | Preset management, maintenance, TEE probe leak testing, high-level disinfection records, probe tracking |
Remediation pathway | A defined route back to supervised scanning when QA identifies a problem |
The single highest-yield QA activity is the blinded over-read, because it is the only one that detects systematically wrong interpretation of technically adequate images.
Medico-legal considerations
Issue | Practical response |
Reporting beyond the study performed | State the study level; never report exclusions the study cannot support |
Competence documentation | The report should make clear who performed it and at what level; institutions should hold current credentialling records |
Duty to escalate | Written escalation criteria (Chapter 1) convert escalation from a personality trait into a protocol, and document that the pathway was followed |
Incidental findings | Must be documented and communicated, with a named recipient and a follow-up plan — a suspected mass or aneurysm found during a shock study cannot simply be omitted because it was not the question |
Consent for TEE | Document the risk-benefit reasoning where the patient lacks capacity |
Unarchived studies | An undocumented study that informed a decision is indefensible; archive everything |
Verbal reporting | Acceptable for urgent findings, but must be followed by a written record; document who was told and when |
Handover
Serial echocardiography is only useful if the trend crosses shift boundaries. A handover should transmit:
- The question each prior study was answering
- The key numbers with their loading conditions — LVOT VTI, E/e′, RV:LV, B-line count
- The direction of travel since the last study
- What is scheduled next, and what would trigger an earlier repeat
A useful discipline: maintain a single running haemodynamic line in the notes — date, time, HR, MAP, vasoactive dose, VTI, E/e′, RV:LV, B-lines — so that the trajectory is legible in one glance rather than reconstructed from a stack of narrative reports.
Research reporting
Studies of critical care echocardiography should follow the PRICES recommendations, an ESICM expert consensus checklist specifying which clinical and echocardiographic parameters must be reported in four domains — LV systolic function, LV diastolic function, RV function, and fluid management. PRICES specifically recommends that LV systolic assessment report MAPSE, s′ and GLS alongside LVEF, and that cardiac rhythm at the time of the study be recorded — both requirements this book has carried into its clinical reporting standard.
🛑 Critical pitfall: Writing "normal echocardiogram" after a focused study. The word "normal" implies a comprehensive assessment. Write what was assessed and what was not.
🛑 Critical pitfall: Reporting measurements without the vasoactive dose and ventilator settings. The next operator cannot compare, and the number becomes noise.
🛑 Critical pitfall: Performing clinically decisive studies without archiving them. This is the commonest governance failure in critical care echocardiography programmes.
- 💡 Clinical pearl: Write the clinical question at the top of the report before you scan. It disciplines the examination and it makes the conclusion easy to write.
- 💡 Clinical pearl: Keep one running haemodynamic line per patient across the admission. It is worth more than any individual report.
- 💡 Clinical pearl: Volunteer your studies for over-read. Operators who seek review improve; those who do not, drift without knowing it.
References
- Sanfilippo F, Huang S, Herpain A, et al. The PRICES statement: an ESICM expert consensus on methodology for conducting and reporting critical care echocardiography research studies. Intensive Care Med 2021;47:1–13. PMID 33275163.
- Expert Round Table on Echocardiography in ICU. International consensus statement on training standards for advanced critical care echocardiography. Intensive Care Med 2014;40:654–66.
- Mayo PH, Beaulieu Y, Doelken P, et al. ACCP/SRLF statement on competence in critical care ultrasonography. Chest 2009;135:1050–60.
- Mitchell C, Rahko PS, Blauwet LA, et al. Guidelines for performing a comprehensive TTE examination in adults. J Am Soc Echocardiogr 2019;32:1–64.