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.