Discussion
The advantages of using FICE routinely in the intensive care unit are well recognised and are highlighted by this case. In this instance information gleaned directly from the FICE scan led to diagnosis and definitive treatment, potentially avoiding a delay in diagnosis and further life-threatening embolic events. Left atrial tumours have high embolic potential5 and embolisation to the cerebral arteries is common. Emboli are also often found in the pulmonary artery and peripheral vasculature6.
Although the remit of FICE is to make a basic assessment of cardiac function, significant cardiac pathology can be identified by the competent practitioner. Echocardiography is playing an increasing role in the management of critical care patients and given the finite availability of BSE accredited practitioners, FICE plays an important role in bridging this clinical service gap.
In a single centre study of the use of FICE in critical care, 68% of FICE scans showed previously unknown findings7, illustrating its value in clinical decision making. In the majority of cases this was left ventricular dysfunction or hypovolaemia. Identifying these common critical care issues is what the FICE protocol was designed for, yet in the process of training to identify these common issues practitioners can also develop their understanding of cardiac anatomy to a point that recognition of more complex pathology can be achieved accurately enough to trigger additional investigation. This is an area of FICE accreditation which has not been fully explored - likely because of concerns about encroaching on the remit of those with advanced skills in TTE and more importantly concerns that FICE images will be used to incorrectly diagnose conditions beyond the scope of the protocol. Of course, those carrying out FICE scans need to understand its limitations and obtain more specialist investigations if concerned about scan findings in a patient. Importantly, the use of FICE is not in replacing formal echocardiography but to ascertain some basic information or as a bridge to formal echocardiography.
The case we have reported here also highlights the argument for carrying out a FICE scan on every critical care patient as part of their admission investigations. Had this lady had a scan on admission, she potentially would have had her operation 24 hours earlier. Thus, routine FICE scans on admission could have a direct and positive impact upon time to definitive management for complex patients. Indirectly this can reduce time to extubation and discharge from intensive care, which as we know affects mortality and morbidity in critical care patients. This is in addition to reducing pressure on other limited clinical resources. The flipside to routine FICE scanning is increased incidental findings potentially leading to over-investigation.
Internationally it is accepted that ‘basic’ level echocardiography is a skill which all critical care practitioners should possess8. FICE accreditation is an accessible means of achieving this aim. FICE already appeals to critical care trainees as they can achieve the accreditation in a relatively short timeframe. FICE scans offer wider benefits for patient care and management of clinical resources. Routine FICE scans for all critical care admissions would also offer a greater number of training opportunities in echocardiography for critical care practitioners. More crucially, routine FICE scans on admission would increase diagnostic yield particularly in more complex patients as this case demonstrates.