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S T ANDARD S O F C E R T I F I C A T I ON CENTER OF CLINICAL ULTRASOUND (CECLUS)
FACULTY OF HEALTH AARHUS UNIVERSITY
medical science – education – implementation – better patient care
Thomas Fichtner Bendtsen
Lars Bolvig
2012
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Content
0. Introduction ...........................................................................................................................................6 0.1 Background.................................................................................................................................................... 6 0.2 Training Recommendations .................................................................................................................... 7
1. Anaesthesiological ultrasound................................................................................................... 11 1.1 Introduction..................................................................................................................................................11
1a. Anaesthesiological ultrasound – airway .............................................................................. 12 1a.1 Introduction ...............................................................................................................................................12 1a.2 Level 1 ..........................................................................................................................................................13 1a.3 Level 2 ..........................................................................................................................................................17 1a.4 Level 3 ..........................................................................................................................................................18
1b. Anaesthesiological ultrasound - pleura and lung ............................................................ 19 1b.1 Introduction ...............................................................................................................................................19 1b.2 Level 1..........................................................................................................................................................20 1b.3 Level 2..........................................................................................................................................................23 1b.4 Level 3..........................................................................................................................................................25
1c1. Anaesthesiological ultrasound - heart................................................................................ 26 1c1.1 Introduction .............................................................................................................................................26 1c1.2 Level 1 .......................................................................................................................................................27 1c1.3 Level 2 .......................................................................................................................................................32 1c1.4 Level 3 .......................................................................................................................................................35 1c1.5 Maintenance of Skills ..........................................................................................................................35
1c2. Anaesthesiological ultrasound – vascular access ........................................................ 37 1c2.1 Introduction .............................................................................................................................................37 1c2.2 Level 1 .......................................................................................................................................................38 1c2.3 Level 2 .......................................................................................................................................................42 1c2.4 Level 3 .......................................................................................................................................................44 1c2.5 Maintenance of Skills ..........................................................................................................................44
1c3. Anaesthesiological ultrasound – eFAST (extended Focused Assessment with Sonography in Trauma) ...................................................................................................................... 46
1c3. 1 Introduction............................................................................................................................................46 1c3.2 Level 1 .......................................................................................................................................................46 1c3.3 Maintenance of Skills ..........................................................................................................................51
1d. Anaesthesiological ultrasound – nerve blocks ................................................................. 52 1d.1 Introduction ...............................................................................................................................................52 1d.2 Level 1..........................................................................................................................................................53 1d.3 Level 2..........................................................................................................................................................57 1d.4 Level 3..........................................................................................................................................................60
2. Obstetric (fetal medicine) ultrasound ...................................................................................... 61 2.1 Introduction..................................................................................................................................................61 2.2 Level 1 ............................................................................................................................................................62 2.3 Level 2 ............................................................................................................................................................67
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2.4 Level 3 ............................................................................................................................................................69 2.5 Maintenance of skills................................................................................................................................69
3. Gynecological ultrasound............................................................................................................. 70 3.1 Introduction..................................................................................................................................................70 3.2 Level 1 ............................................................................................................................................................71 3.3 Level 2 ............................................................................................................................................................74 3.4 Level 3 ............................................................................................................................................................75 3.5 Maintenance of skills................................................................................................................................76
4. Endocrinological ultrasound ....................................................................................................... 77 4.1 Introduction..................................................................................................................................................77 4.2 Level 1 ............................................................................................................................................................78 4.3 Level 2 ............................................................................................................................................................82 4.4 Level 3 ............................................................................................................................................................83
5. Pediatric ultrasound ........................................................................................................................ 84 5.1 Introduction..................................................................................................................................................84
5c1. Pediatric FATE (focus assessed transthoracic echocardiography) ....................... 85 5c1.1 Introduction .............................................................................................................................................85 5c1.2 Level 1 .......................................................................................................................................................86 5c1.3 Level 2 .......................................................................................................................................................92 5c1.4 Level 3 .......................................................................................................................................................94 5c1.5 Maintenance of skills...........................................................................................................................95
5c2. Pediatric extended FAST (focused assessment with sonography in trauma) ... 96 5c2.1 Introduction .............................................................................................................................................96 5c2.2 Level 1 .......................................................................................................................................................96
5c3. Pediatric ultrasound guided vascular access ...............................................................102 5c3.1 Introduction .......................................................................................................................................... 102
5d. Pediatric neurology ultrasound .............................................................................................109 5d.1 Introduction ............................................................................................................................................ 109 5d.2 Level 1....................................................................................................................................................... 109 5d.3 Maintenance ........................................................................................................................................... 113
6. Oto-rhino-laryngeal ultrasound ................................................................................................114 6.1 Introduction............................................................................................................................................... 114 6.2 Level 1 ......................................................................................................................................................... 115 6.3 Level 2 ......................................................................................................................................................... 120 6.4 Level 3 ......................................................................................................................................................... 121 6.5 Maintenance of skills............................................................................................................................. 121
7. Orthopedic surgery ultrasound ................................................................................................123 7.1 Introduction............................................................................................................................................... 123 7.2 Level 1 ......................................................................................................................................................... 125 7.3 Level 2 ......................................................................................................................................................... 130 7.4 Level 3 ......................................................................................................................................................... 133 7.5 Maintenance of skills............................................................................................................................. 133
8. Rheumatological ultrasound .....................................................................................................135 8.1 Introduction............................................................................................................................................... 135 8.2 Level 1 ......................................................................................................................................................... 137 8.3 Level 2 ......................................................................................................................................................... 142
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8.4 Level 3 ......................................................................................................................................................... 145 8.5 Maintenance of skills............................................................................................................................. 145
9. Infectious Diseases Ultrasound ...............................................................................................146 9.1 Introduction............................................................................................................................................... 146
10. Cardiology.......................................................................................................................................147 10.1 Introduction ............................................................................................................................................ 147 10.2 Level 1 ....................................................................................................................................................... 148 10.3 Level 2 ....................................................................................................................................................... 154 10.4 Level 3 ....................................................................................................................................................... 159 10.5 Maintenance of Skills.......................................................................................................................... 159
11. Lung Medicine Ultrasound .......................................................................................................160 11.1 Introduction ............................................................................................................................................ 160 11.2 Level 1 ....................................................................................................................................................... 161 11.3 Level 2 ....................................................................................................................................................... 164 11.4 Level 3 ....................................................................................................................................................... 166 11.5 Maintenance of skills .......................................................................................................................... 166
12. Ultrasound in Surgical Gastroenterology ..........................................................................167 12.1 Introduction ............................................................................................................................................ 167 12.2 Level 1 ....................................................................................................................................................... 168 12.3 Level 2 ....................................................................................................................................................... 172 12.4 Level 3 ....................................................................................................................................................... 174 12.5 Maintenance of skills .......................................................................................................................... 174
13. Ultrasound of vascular surgery .............................................................................................175 13.1 Introduction ............................................................................................................................................ 175 13.2 Level 1 ....................................................................................................................................................... 176 13.3 Level 2 ....................................................................................................................................................... 180 13.4 Level 3 ....................................................................................................................................................... 182 13.5 Maintenance of skills .......................................................................................................................... 183
14. Ultrasound of neurology ...........................................................................................................184 14.1 Introduction ............................................................................................................................................ 184 14.2 Level 1 ....................................................................................................................................................... 185 14.3 Level 2 ....................................................................................................................................................... 189 14.4 Level 3 ....................................................................................................................................................... 191 14.5 Maintenance of skills .......................................................................................................................... 191
15. Ultrasound of general medicine.............................................................................................192 15.1 Introduction ............................................................................................................................................ 192 15.2 Level 1 ....................................................................................................................................................... 193 15.3 Maintenance of skills .......................................................................................................................... 197
16. Ultrasound of geriatric medicine ...........................................................................................198 16.1 Introduction ............................................................................................................................................ 198 16.2 Level 1 ....................................................................................................................................................... 199 16.3 Maintenance of skills .......................................................................................................................... 203
17. Medical Gastroenterology Ultrasound ................................................................................204 17.1 Introduction ............................................................................................................................................ 204 17.2 Level 1 ....................................................................................................................................................... 205 17.3 Level 2 ....................................................................................................................................................... 209 17.4 Level 3 ....................................................................................................................................................... 211
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17.5 Maintenance of skills .......................................................................................................................... 211 18. Contacts...........................................................................................................................................213
0. Introduction
0.1 Background The increasing applications of ultrasound imaging throughout medical practice, together
with the increasing availability of cheaper and smaller ultrasound scanners, mean that
more medical personnel is using ultrasound equipment to perform and interpret ultrasound
scans.
Ultrasound has an enviable safety record to date. Various bodies, including scientific
societies and manufacturers associations have made recommendations concerning the
safe and prudent operation of ultrasound equipment, but, unlike imaging equipment, which
makes use of ionizing radiation there is virtually no national or international regulation of
ultrasound usage.
The quality of clinical point-of-care (POC) ultrasound depends on the skill of the operator.
To maximize the quality, safety and cost-effectiveness of a clinical ultrasound service and
appropriately address the ethical and legal concerns of inadequately trained ultrasound
operators, the personnel needs to be appropriately trained and to use equipment of
appropriate quality.
An appropriate level of training secures a safe and effective diagnostic, interventional or
clinically focused ultrasound service. However, due to the complexity of issues involved,
few have developed specialized national training schemes for clinical ultrasound and for
instance echocardiography accreditation (through EAE, BSE or the ASE) does not reflect
the requirements of the anesthesiologist and the ICU practitioner, as they contain heavy
emphasis on valvular disease, little haemodynamic monitoring, and an absence of
pathology in the critically ill.
The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB)
has proposed minimal training requirements for the practice of medical ultrasound in
Europe.
The hospital and department managements must acknowledge the requirements to deliver
training: the time commitment of the trainer and trainee, the provision of proper budgeting
and funding, the content and practicability of the curriculum and the availability of trainers
and training courses and provision of appropriate space and equipment.
Training should be related to the specialist requirements of the trainee i.e. training should
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be modular. Within any one level of training it may be appropriate for a trainee to become
proficient in some but not all of the individual modules and only undertake ultrasound
practice in this/these areas. Except level one which contains the basic common trunk.
Training should be given in departments which have a multidisciplinary (medical, surgical,
radiological etc) philosophy, an adequate throughput of work, a trainer with experience
and an interest in training in the module required, appropriate equipment and an active
audit process.
Regular appraisal should take place during the training period. At the end of a period of
training a competency assessment form should be completed for each trainee, which will
determine the area or areas in which they can practice independently. The responsibility to
be adequately trained and to maintain those skills lies with the individual practising
ultrasound. An assessment of competence is a reflection on the position at that moment in
time and no more.
Following training, regular and relevant continued medical education (CME)/continued
professional development (CPD) should be undertaken and documented. It is the
responsibility of the trainee to ensure that their practical skills are maintained by ensuring
regular ultrasound clinics are undertaken and that there is an adequate range of pathology
seen in their ultrasound practice.
0.2 Training Recommendations Training should consist of a theoretical module and practical modules of training.
Theoretical Training
Theoretical training should cover the physics of waves, sound waves and ultrasound, and
ultrasound system controlled imaging, ultrasound user controlled imaging, image recording
and reporting, sonographic image artefacts, sonoananatomy, sonopathology, and the
relevance of other imaging modalities to ultrasound. This element of training may be best
achieved by attending formal courses.
Practical Training
A curriculum for each module for the three levels of training has been developed
incorporating a practical syllabus listing conditions which should be included in the
experience of the trainee. In appropriate circumstances, a limited anatomical or modular
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approach may also be acceptable if full competence in that area is demonstrated and
future clinical practice is confined to that area alone. Practical experience should be
gained under the guidance of a named trainer.
The requirements for the different levels of training are as follows:
Level 1
Practice at this level would usually require the following abilities:
a. to perform common examinations safely and accurately
b. to recognize and differentiate normal anatomy and pathology
c. to diagnose common abnormalities within certain organ systems
d. to perform appropriate interventions and clinically focused protocols
e. to recognize when referral for a second opinion is indicated
Within most medical specialties, the training requisite to this level of practice would be
gained during conventional post-graduate specialist training programs.
Different trainees will acquire the necessary skills at different rates and the end-point
of the training program should be judged by an assessment of practical
competence.
Examinations/certification should encompass the full range of diagnostics/pathological
conditions, interventions/procedures and clinically focused protocols listed in the modules.
A log book listing the number and type of examinations undertaken by the trainee
themselves should be kept.
An illustrated log book of specific normal and abnormal findings may be appropriate
for some modules.
Training should usually be supervised by a level 2 practitioner. In certain
circumstances it may be appropriate to delegate some of this supervision to an
experienced level 1 practitioner with at least two years of regular practice.
Level 2
This is an advanced level of practice and requires the following abilities:
a. to accept and manage referrals from Level 1 practitioners
b. to recognize and correctly diagnose almost all pathology within the relevant organ
system
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c. to perform all relevant ultrasound-guided invasive procedures
d. to teach ultrasound to trainees and to Level 1 practitioners
e. to conduct some research in ultrasound
The training requisite to this level of practice would be gained during a period of sub-
specialty training, which may either be within or after the completion of a specialist training
program.
This requires at least one year of experience at level 1 with regular ultrasound
clinics.
A significant further number of examinations should have been undertaken in order to
encompass the full range of conditions and procedures encountered in each module.
A log book listing the numbers and types of examinations undertaken by the trainee
should be maintained.
An illustrated log book of specific normal and abnormal findings is appropriate.
Supervision of training should be undertaken by someone who has achieved at least
level 2 competence and has had at least two years experience at that level.
Level 3
This is an expert level of practice, which involves the following abilities:
a. to accept tertiary referrals from Level 1 and 2 practitioners
b. to perform advanced (level 2) ultrasound examinations
c. to perform advanced (level 2) ultrasound-guided invasive procedures
d. to conduct substantial research in ultrasound
e. to teach ultrasound at all levels
f. to be aware of and to pursue developments in ultrasound
This requires practitioners to spend a significant part of their time undertaking
ultrasound examinations and/or teaching, research and development in the field of
ultrasound.
Continuing Medical Education (CME) and Professional Development (CPD)
The minimum amount of on-going experience in ultrasound as outlined in each
syllabus should be maintained.
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CME/CPD should be undertaken which incorporates elements of ultrasound practice.
Regular audit of the individual’s ultrasound practice should be undertaken to
demonstrate that the indications, performance and diagnostic quality of the service is
satisfactory.
1. Anaesthesiological ultrasound
1.1 Introduction The curriculum of anaesthesiological ultrasound is 3-leveled and modular in order to relate
the training to the specialist requirements of the trainee. Within any level of training it may
be appropriate for a trainee to become proficient in some but not all of the individual
modalities and only undertake ultrasound practice in this/these areas. Except level one
which contains the basic common trunk for all specialists of anaesthesiology.
The modalities of anaesthesiological ultrasound are:
- airway
- pleura/lung
- heart
- vascular access
- eFAST
- nerve blocks
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1a. Anaesthesiological ultrasound – airway
1a.1 Introduction
This curriculum is intended for prespecialists and specialists of anaesthesiology who
perform ultrasound guided Airway Management (UGAM). It includes standards for
theoretical knowledge and practical skills.
Introductory level
Performance of supervised basic UGAM prior to Level 1 certification.
Level 1 (basic)
Performance of unsupervised basic UGAM. Basic UGAM: easy and effective ultrasound
guided exams and procedures for airway management. Basic UGAM certification should
be obtained by all specialists in anaesthesiology. It is recommended that all
anaesthesiologists obtain Level 1 competence, preferably during their specialist training.
At least Level 1 competence should be obtained by anyone performing UGAM
unsupervised.
Level 2 (advanced)
Subspecialized anaesthesiologist who performs basic and advanced UGAM most working
days. Advanced UGAM: all UGAM procedures beyond basic UGAM. Advanced UGRA
certification is typically obtained by specialists in anaesthesiology subspecialized in
anaesthesia for otorhinolaryngology.
Level 3 (expert)
Anaesthesiologists who performs basic and advanced UGAM every working day and most
of the day, and who is active with science and teaching. Only very few anaesthesiologists
obtain expert UGAM level. They are typically employed in a few university hospital
centers.
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Typical progression from Introductory level to Level 3
(1) Course pretest
(2) Theory course of basic UGAM
(3) Theory course posttest
(4) Practical hands-on course of basic UGAM
(2) Course exam in theory and practice of basic UGAM
(3) Supervised procedures of basic UGAM
(4) Level 1 certification of basic UGAM
(5) Unsupervised maintenance of basic UGAM
(6) Theory & practice course of advanced UGAM
(7) Course exam of advanced UGAM
(8) Supervised procedures of advanced UGAM
(9) Level 2 certification of advanced UGAM - theory & practice
(10) Level 3 certification of expert UGAM: Level 2 certified + minimum 500 basic and
advanced UGAM procedures per year for at least two years + teaching experience within
advanced UGAM + minimum three scientific publications about UGAM in peer reviewed
papers (PhD level)
1a.2 Level 1
Level 1 Knowledge Base and Recommended Contents of Level 1 Theoretical & Practical
Course
A minimum of 20 hours theoretical and practical teaching is required preferably at the
beginning of the training period. This should include:
Wave, sound wave and ultrasound physics
Ultrasound system controls
Ultrasound user controls
Ultrasound techniques
Ergonomics
Sterility
Safety
Administration (see Appendix 2)
Sonoanatomy
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• Normal airway
o tongue
o thyroid and cricoid cartilages
o cricothyroid membrane
o thyroid rings
o pretracheal soft tissue
• Normal pleura
o lung sliding
o lung pulse
o diaphragm, lever, spleen, vertebral column
Level 1 Competencies to be acquired
To be able to:
• Perform a basic airway US exam • US guided verification of endotracheal intubation • US guided confirmation of endotracheal tube placement • US guided localization of the cricothyroid membrane
• US guided cricothyrotomy • US guided localization of the trachea
Level 1 Theoretical & Practical Course
The course content is equal to the Level 1 knowledge base and the Level 1 competencies
to be acquired listed above. The course should be minimum 20 hours duration at the
beginning of the training period. The theory course should include a pre- and a posttest.
The entire course should be concluded with a course exam covering theory and practice.
The practical sessions should be performed as Hands On Training (HOT):
- HOT 1
o Basic UGAM views on normal models
o Revision of normal findings
- HOT 2
o Basic UGAM views on normal models or patients or sonosimulators
o Revision of pathological findings (tutorial laptops)
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- HOT 3
o Individual reappraisal with interactive in-depth training
The course should be concluded with a course exam in theory and practice of basic
UGAM:
• Theory (30 minutes, 25 MCQ)
• Practice (15 minutes, simulator or model)
Proctored Level 1 practice
• Supervision and recommended number of exams: Within 3 months after the course,
the trainee should collect a minimum of 50 UGAM exams under supervision: 25 fully
supervised basic UGAM exams (TYPE A exams) + 25 autonomously collected (TYPE
B exams, for later validation). The last 25 autonomously performed exams can be
validated either by: a) physical delivery of the electronic logbook + digital clips/images
on a mass storage device (CD/DVD/USB stick) to the assigned tutor once the
collection is completed; b) by internet sharing with a distant tutor. Training should
usually be supervised by a level 2 practitioner. In certain circumstances it may be
appropriate to delegate some of this supervision to an experienced level 1 practitioner
with at least two years of regular practical experience. When local tutors are not
available, the 25 TYPE A exams can be replaced by 25 autonomously collected exams
and internet sharing with a distant tutor where the exams are uploaded and audited
sequentially one-by-one (a dedicated area will be activated on the CECLUS channel,
with reserved access to trainer’s page matched with distance tutor). Lack of information
on single cases, not allowing accurate judgement on trainees competence makes the
case not valid for final certification.
• Documentation: All exams must be video recorded and archived in digital format and
data collected in the electronic logbook (excel file). The documentation should record
time spent, need for supervision and correction, and rating of sonoanatomic skill,
imaging, image quality, and diagnostic performance. During the course of training the
competency assessment sheet should be completed.
• Curriculum: An exam can be a real clinical UGAM exam or a simulated UGAM exam:
Didactic cases (provided from local tutors and from distant tutors) should compensate
for lack of an adequate number of cases on some types of less frequent abnormalities.
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These should not be reported in the logbook but rather listed, indicated separately as
part of exam final documentation. Sequential examinations on the same patients upon
relevant clinical/therapeutical changes are encouraged; provided there’s relevant
change in the findings, they will be counted as individual cases. No more than 10%
exams with normal findings are to be considered for the final certification
Final Level 1 certification of basic UGAM
Different trainees will acquire the necessary skills at different rates and the end point of the
training programme should be judged by an assessment of competencies in the form of
theoretical and practical certification. The theoretical and practical certification should
encompass the full range of the Level 1 knowledge database and competencies to be
acquired listed above.
• Theory (2 hours,100 MCQ)
• Practice (30 minutes, simulator or model)
Areas of competence assessed during certification examination:
• Image generation
• Image acquisition
• Image interpretation
• Image administration
• Clinical and organizational thinking
Tools that may be used for the assessment during certification examination:
• MCQs (overall theoretical assessment)
• Videoclip assessment (assessment of pathological clips interpretation and simulated
clinical integration of findings)
• UGAM exam on a healthy volunteer (assessment of technical skills in machine setting,
image acquisition and storage)
• UGAM on a real patient with relevant morbidity (overall practical assessment)
• Case discussion presented by the trainee
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1a.3 Level 2
The training requisite to this level of practice would be gained during a period of sub-
specialty training, which may either be within or after the completion of a specialist training
programme.
• The training should include a theoretical and practical course of at least 30 hours
(see below) followed by a theoretical and practical examination and the trainee
should read appropriate literature, scientific journals, and textbooks
• Competencies will have been acquired during training for level 1 practice which will
then be refined by performing a minimum of 30 clinic sessions at a centre where
supervision by someone with a Level 2 competence is available.
• Typically a Level 2 practitioner will have undertaken at least 500 ultrasound
examinations within advanced UGAM before Level 2 certification.
• An electronic log book should be kept documenting a minimum of 50 exams which
should include ideally all Level 2 competencies for advanced UGAM. An exam can
be a real clinical UGAM exam or a simulated UGAM exam. A minimum of 25 exams
have to be real clinical UGAM exams. • The theoretical and practical certification should encompass the full range of
procedures listed below.
Level 2 Knowledge Base and Recommended Contents of Level 2 Theoretical and
Practical Course
o new ultrasound modalities (eg. 3D and 4D ultrasound)
o advanced sound and ultrasound physics
o advanced ultrasound system machine controls
o advanced ultrasound system user controls
o advanced ultrasound techniques
o advanced administration (teaching, documentation, organization)
o advanced ultrasound artefacts
o advanced UGAM
o airway anatomy and sonoanatomy
o complications
o safety
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Level 2 Competencies to be acquired
o UGRA
o exams of the tongue, oro-pharynx, hypo-pharynx, hyoid bone, larynx, vocal
cords, cricothyroid membrane, cricoid cartilage, trachea, esophagus
o prediction of difficult laryngoscopy in surgical patients
o evaluation of pathology that may influence the choice of airway management
technique (e.g. subglottic hemangiomas, laryngeal stenosis, laryngeal cysts,
respiratory papillomatosis, pharyngeal pouch, various malignancies)
o prediction of the appropriate diameter of endotracheal-, endobronchial-, or
tracheostomy tube
o localization of the trachea
o localization of the cricothyroid membrane
o confirmation of endotracheal tube placement
1a.4 Level 3
A level 3 practioner is likely to spend the majority of their time undertaking UGAM or
teaching, research and development within their subspecialized field and will be an expert
in this area.
1a.5 Maintenance of Skills
Having been assessed as competent to practice there will be a need for continued
professional development (CPD) and maintenance of practical skills. Recommended
numbers of examinations to be performed annually to maintain skills at each level are
given in the text.
Practitioners should:
• include UGAM in their continued medical education (CME)
• audit their practice
• participate in multidisciplinary meetings
• keep up to date with relevant literature
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1b. Anaesthesiological ultrasound - pleura and lung
1b.1 Introduction
This curriculum is intended for prespecialists and specialists of anesthesiology who
perform lung ultrasound (LUS). It includes standards for theoretical knowledge and
practical skills.
Introductory level
Performance of supervised basic LUS prior to Level 1 certification.
Level 1 (basic)
Performance of unsupervised basic LUS. Basic LUS: easy and effective LUS for
perioperative, emergency and critical care respiratory management. Basic LUS
certification should be obtained by all specialists in anaesthesiology. It is recommended
that all anaesthesiologists obtain Level 1 competence, preferably during their specialist
training. At least Level 1 competence should be obtained by anyone performing basic LUS
unsupervised.
Level 2 (advanced)
Subspecialized anaesthesiologist or critical care specialist who performs basic and
advanced LUS most working days. Advanced LUS certification is typically obtained by
specialists in anaesthesiology or intensive care medicine or lung medicine.
Level 3 (expert)
Expert who performs basic and advanced LUS every working day and most of the day,
and who is active with science and teaching. Only very few clinical specialists obtain
expert LUS level. They are typically employed in a few university hospital centers.
Typical progression from Introduction Level to Level 3
(1) Course pretest
(2) Theory course of basic LUS
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(3) Theory course posttest
(4) Practical hands-on course of basic LUS
(2) Course exam in theory and practice of basic LUS
(3) Supervised procedures of basic LUS
(4) Level 1 certification of basic LUS
(5) Unsupervised maintenance of basic LUS
(6) Theory & practice course of advanced LUS
(7) Course exam of advanced LUS
(8) Supervised procedures of advanced LUS
(9) Level 2 certification of advanced LUS - theory & practice
(10) Level 3 certification of expert LUS: Level 2 certified + minimum 500 basic and
advanced LUS procedures per year for at least two years + teaching experience within
advanced LUS + minimum three scientific publications about LUS in peer reviewed papers
(PhD level)
1b.2 Level 1
Level 1 Knowledge Base and Recommended Contents of Level 1 Theoretical & Practical
Course
Sound and ultrasound physics
Ultrasound system machine controls
Ultrasound system user controls
Ultrasound techniques
Ergonomics
Sterility
Safety
Administration (see Appendix 2)
Sonoanatomy
• Normal pleura
o lung sliding
o lung pulse
o diaphragm, lever, spleen, vertebral column
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Sonopathology
• pneumothorax • pleural effusion
Level 1 Competencies to be acquired
To be able to:
• Perform a basic lung US exam • US guided pleural chest tube insertion
Level 1 Theoretical & Practical Course
The course content is equal to the Level 1 knowledge base and the Level 1 competencies
to be acquired listed above. The course should be minimum 20 hours duration at the
beginning of the training period. The theory course should include a pre- and a posttest.
The entire course should be concluded with a course exam covering theory and practice.
The practical sessions should be performed as Hands On Training (HOT):
- HOT 1
o Basic LUS views on normal models
o Revision of normal findings
- HOT 2
o Basic LUS views on normal models or patients or sonosimulators
o Revision of pathological findings (tutorial laptops)
- HOT 3
o Individual reappraisal with interactive in-depth training
The course should be concluded with a course exam in theory and practice of basic LUS:
• Theory (30 minutes, 25 MCQ)
• Practice (15 minutes, simulator or model)
Proctored Level 1 practice
• Supervision and recommended number of exams: Within 3 months after the course,
the trainee should collect a minimum of 100 LUS exams under supervision: 50 fully
supervised basic LUS exams (TYPE A exams) + 50 autonomously collected (TYPE B
22
exams, for later validation). The last 50 autonomously performed exams can be
validated either by: a) physical delivery of the electronic logbook + digital clips/images
on a mass storage device (CD/DVD/USB stick) to the assigned tutor once the
collection is completed; b) by internet sharing with a distant tutor. Training should
usually be supervised by a level 2 practitioner. In certain circumstances it may be
appropriate to delegate some of this supervision to an experienced level 1 practitioner
with at least two years of regular practical experience. When local tutors are not
available, the 50 TYPE A exams can be replaced by 50 autonomously collected exams
and internet sharing with a distant tutor where the exams are uploaded and audited
sequentially one-by-one (a dedicated area will be activated on the CECLUS channel,
with reserved access to trainer’s page matched with distance tutor). Lack of information
on single cases, not allowing accurate judgement on trainees competence makes the
case not valid for final certification.
• Documentation: All exams must be video recorded and archived in digital format and
data collected in the electronic logbook (excel file). The documentation should record
time spent, need for supervision and correction, and rating of sonoanatomic skill,
imaging, image quality, and diagnostic performance. During the course of training the
competency assessment sheet should be completed.
• Curriculum: All the above mentioned pathology scenarios should be represented. An
exam can be a real clinical LUS exam or a simulated LUS exam: Didactic cases
(provided from local tutors and from distant tutors) should compensate for lack of an
adequate number of cases on some types of less frequent abnormalities. These should
not be reported in the logbook but rather listed, indicated separately as part of exam
final documentation. Sequential examinations on the same patients upon relevant
clinical/therapeutical changes are encouraged; provided there’s relevant change in the
findings, they will be counted as individual cases. No more than 10% exams with
normal findings are to be considered for the final certification
Final Level 1 certification of basic LUS
Different trainees will acquire the necessary skills at different rates and the end point of the
training programme should be judged by an assessment of competencies in the form of
theoretical and practical certification. The theoretical and practical certification should
23
encompass the full range of the Level 1 knowledge database and competencies to be
acquired listed above.
• Theory (2 hours,100 MCQ)
• Practice (30 minutes, simulator or model)
Areas of competence assessed during certification examination:
• Image generation
• Image acquisition
• Image interpretation
• Image administration
• Clinical and organizational thinking
Tools that may be used for the assessment during certification examination:
• MCQs (overall theoretical assessment)
• Videoclip assessment (assessment of pathological clips interpretation and simulated
clinical integration of findings)
• LUS exam on a healthy volunteer (assessment of technical skills in machine setting,
image acquisition and storage)
• LUS on a real patient with relevant morbidity (overall practical assessment)
• Case discussion presented by the trainee
1b.3 Level 2
The training requisite to this level of practice would be gained during a period of sub-
specialty training, which may either be within or after the completion of a specialist training
programme.
• The training should include a theoretical and practical course of at least 30 hours
(see below) followed by a theoretical and practical examination and the trainee
should read appropriate literature, scientific journals, and textbooks
• Competencies will have been acquired during training for level 1 practice which will
then be refined by performing a minimum of 30 clinic sessions at a centre where
supervision by someone with a Level 2 competence is available.
24
• Typically a Level 2 practitioner will have undertaken at least 500 ultrasound
examinations within advanced LUS before Level 2 certification.
• An electronic log book should be kept documenting a minimum of 50 exams which
should include ideally all Level 2 competencies for advanced LUS. An exam can be
a real clinical LUS exam or a simulated LUS exam. A minimum of 25 exams have to
be real clinical LUS exams. • The theoretical and practical certification should encompass the full range of
procedures listed below.
Level 2 Knowledge Base and Recommended Contents of Level 2 Theoretical and
Practical Course
o new ultrasound modalities (eg. image fusion and 4D ultrasound)
o advanced sound and ultrasound physics
o advanced ultrasound system machine controls
o advanced ultrasound system user controls
o advanced ultrasound techniques
o advanced administration (teaching, documentation, organization)
o advanced ultrasound artefacts
o advanced LUS
o anatomy and sonoanatomy
o pathology and sonopathology
o complications
o safety
Level 2 Competencies to be acquired
o LUS
o diagnose pneumothorax
o diagnose pleural effusion
o diagnose rib fractures
o diagnose interstitial syndrome
o diagnose lung edema
o diagnose ARDS
25
o diagnose interstitial lung disease
o diagnose respiratory distress syndrome
o diagnose lung consolidation
o diagnose pneumonia
o diagnose lung embolus
o diagnose lung tumour
o diagnose atelectasis (compression, obstruction)
o examination of acute, severe respiratory insufficiency with the BLUE
(Bedside Lung Ultrasound in Emergency) protocol
o control of lung ventilation after intubation
1b.4 Level 3
A level 3 practioner is likely to spend the majority of their time undertaking LUS or
teaching, research and development within their subspecialized field and will be an expert
in this area.
1b.5 Maintenance of Skills
Having been assessed as competent to practice there will be a need for continued
professional development (CPD) and maintenance of practical skills. Recommended
numbers of examinations to be performed annually to maintain skills at each level
Level 1: the practitioner should perform at least 100 basic LUS exams each year.
Level 2: the practitioner should perform at least 200 basic and advanced LUS exams each
year.
Level 3: the practitioner should perform at least 400 basic and advanced LUS exams each
year.
Practitioners should:
• include LUS in their continued medical education (CME)
• audit their practice
• participate in multidisciplinary meetings
• keep up to date with relevant literature
26
1c1. Anaesthesiological ultrasound - heart
1c1.1 Introduction
This curriculum is intended for CECLUS certification Level 1-3 of prespecialists and
specialists of anaesthesiology who perform focused cardiac ultrasound – also called FATE
(focus assessed transthoracic echocardiography). The FATE curriculum includes
standards for theoretical knowledge and practical skills.
Introductory level (pre-certification)
Performance of supervised basic FATE prior to Level 1 certification.
Level 1 (basic) certification
Performance of unsupervised basic FATE. Basic FATE is easy and effective basic
assessment of haemodynamics with ultrasound. Basic FATE certification should be
obtained by all clinical specialists assessing potentially acute or critically ill patients. It is
especially recommended that all anaesthesiologists obtain Level 1 FATE competence,
preferably prior to or during their specialist training. At least Level 1 competence should be
obtained by anyone performing basic FATE unsupervised.
Level 2 (advanced) certification
Subspecialized clinical specialist who performs focused cardiac assessment with
ultrasound most working days. Advanced FATE is typically obtained by specialists in
anaesthesiology subspecialized in anaesthesia for cardiothoracic surgery or intensive care
medicine or emergency medicine.
Level 3 (expert) certification
Clinical specialists who perform basic and advanced FATE every working day and most of
the day, and who are active with FATE related science and teaching. Only very few clinical
specialists employing FATE obtain the expert FATE level 3 certification. They are typically
employed in university hospital centers.
27
Typical progression from Introductory level to Level 3
(1) Theory course pretest
(2) Theory course of basic FATE
(3) Theory course posttest
(4) Practical hands-on course of basic FATE
(2) Course exam in theory and practice of basic FATE
(3) Proctored practice (supervised procedures) of basic FATE
(4) Level 1 certification of basic FATE
(5) Unsupervised maintenance of basic FATE
(6) Theory & practice course of advanced FATE
(7) Course exam of advanced FATE
(8) Supervised procedures of advanced FATE
(9) Level 2 certification of advanced FATE - theory & practice
(10) Level 3 certification of expert FATE: Level 2 certified + minimum 500 basic and
advanced FATE exams per year for at least two years + teaching experience within
advanced FATE + minimum three FATE related scientific publications in peer reviewed
papers (PhD level)
1c1.2 Level 1
Level 1 Knowledge Base and Recommended Contents of Level 1 Theoretical & Practical
Course
Wave, sound and ultrasound physics
Ultrasound system machine controls
Ultrasound system user controls
Ultrasound techniques
- B mode (2D brightness mode)
- M mode (motion mode)
- Power Doppler
- Pulsed wave Doppler
- Continous wave Doppler
Ergonomics
28
Sterility
Safety
Administration
• Implementation of a focused echocardiography program
Sonoanatomy
• basic TTE (transthoracic echocardiography) 2D views
o subcostal 4-chamber
o apical 4-chamber
o parasternal long axis
o parasternal short axis at the following levels:
aortic valve (base)
mitral leaflet tips
papillary muscles
Cardiac function
systolic ventricular function
diastolic ventricular function
ejection fraction
fractional shortening
mitral septal separation
mitral annular plane systolic excursion (MAPSE)
tricuspid annular plane systolic excursion (TAPSE)
LV dimensions (2D and M-mode)
• Septal thickness at end diastole
• Cavity size at the end diastole
• Posterior wall thickness at end diastole
• Cavity size at end systole
Aortic root dimension
Left atrial dimension
Sonopathology
• Basic cardiac chamber dysfunction
o dilated left atrium o dilated left ventricle
29
o dilated right atrium
o dilated right ventricle o hypertrophy left ventricle
• Mesothelial cavities o pericardial effusion
basic US diagnosis of cardiac tamponade US guided pericardiocentesis
• Pedunculated masses
• Endocarditis and the valves
• Hypovolemia
Level 1 Competencies to be acquired
To be able to perform a basic FATE exam:
• Perform echocardiographic examinations safely and accurately and acquire all
standard views • To recognise and differentiate between normal anatomy/physiology and pathology • To diagnose common abnormalities within the cardiovascular system
• To recognize when a referral for a second opinion is indicated • To understand the relationship between echocardiographic imaging and other
diagnostic imaging techniques • Perform focused point-of-care echocardiographic hemodynamic monitoring of
patient response to interventions and diagnostics:
o Ventricular function Systolic function and wall motion abnormalities Diastolic function
o Hypovolemia and volume responsiveness
o Tamponade and pericardial disease o The sepsis syndromes o Effects of preload and afterload and assessment of filling status o Acute cor pulmonale
o Hypoxemia o Complications of acute MI
30
o Chest trauma
o Assessment of shock o Peri-resuscitation o Failure to wean from mechanical ventilation o Hemodynamic measurements
Level 1 Theoretical & Practical Course
The course content is equal to the Level 1 knowledge base and the Level 1 competencies
to be acquired listed above. The course should be minimum 20 hours duration at the
beginning of the training period. The theory course should include a pre- and a posttest.
The entire course should be concluded with a course exam covering theory and practice.¨
The practical sessions should be performed as Hands On Training (HOT):
- HOT 1
o Basic TTE views on normal models
o Revision of normal findings
- HOT 2
o Basic TTE views on normal models or patients or sonosimulators
o Revision of pathological findings (tutorial laptops)
- HOT 3
- Individual reappraisal with interactive in-depth training
The course should be concluded with a course exam in theory and practice of basic FATE:
• Theory (30 minutes, 25 MCQ)
• Practice (15 minutes, simulator or model)
Proctored Level 1 practice
• Supervision and recommended number of exams: Within 3 months after the course,
the trainee should collect a minimum of 25 basic FATE exams under supervision: 25
fully supervised basic FATE exams (TYPE A exams) + 25 autonomously collected
(TYPE B exams, for later validation). The last 25 autonomously performed exams can
be validated either by: a) physical delivery of the electronic logbook + digital
clips/images on a mass storage device (CD/DVD/USB stick) to the assigned tutor once
the collection is completed; b) by internet sharing with a distant tutor. Training should
31
usually be supervised by a level 2 practitioner. In certain circumstances it may be
appropriate to delegate some of this supervision to an experienced level 1 practitioner
with at least two years of regular practical experience. When local tutors are not
available, the 25 TYPE A exams can be replaced by 25 autonomously collected exams
and internet sharing with a distant tutor where the exams are uploaded and audited
sequentially one-by-one (a dedicated area will be activated on the CECLUS channel,
with reserved access to trainer’s page matched with distance tutor). Lack of information
on single cases, not allowing accurate judgement on trainees competence makes the
case not valid for final certification.
• Documentation: All exams must be video recorded and archived in digital format and
data collected in the electronic logbook (excel file). The documentation should record
time spent, need for supervision and correction, and rating of sonoanatomic skill,
imaging, image quality, and diagnostic performance. During the course of training the
competency assessment sheet should be completed.
• Curriculum: All the above mentioned pathology scenarios should be represented. An
exam can be a real clinical UVS exam or a simulated UVS exam: Didactic cases
(provided from local tutors and from distant tutors) should compensate for lack of an
adequate number of cases on some types of less frequent abnormalities. These should
not be reported in the logbook but rather listed, indicated separately as part of exam
final documentation. Sequential examinations on the same patients upon relevant
clinical/therapeutical changes are encouraged; provided there’s relevant change in the
findings, they will be counted as individual cases. No more than 10% exams with
normal findings are to be considered for the final certification.
Final Level 1 certification of basic FATE
Different trainees will acquire the necessary skills at different rates and the end point of the
training programme should be judged by an assessment of competencies in the form of
theoretical and practical certification. The theoretical and practical certification should
encompass the full range of the Level 1 knowledge database and competencies to be
acquired listed above.
• Theory (2 hours,100 MCQ)
• Practice (30 minutes, simulator or model)
32
Areas of competence assessed during examination:
• Image generation
• Image acquisition
• Image interpretation
• Image administration
• Clinical and organizational thinking
Tools that may be used for the assessment during examination:
• MCQs (overall theoretical assessment)
• Videoclip assessment (assessment of pathological clips interpretation and simulated
clinical integration of findings)
• TTE on a healthy volunteer (assessment of technical skills in machine setting, image
acquisition and storage)
• TTE on a real critical or cardially morbid patient (overall practical assessment,
including ECHO-guided patient management)
• Case discussion presented by the trainee
1c1.3 Level 2
Level 2 Knowledge Base and Recommended Contents of Level 2 Theoretical and
Practical Course
o new ultrasound modalities (eg. 4D ultrasound and image fusion)
o contrast agents
o advanced sound and ultrasound physics
o advanced ultrasound system machine controls
o advanced ultrasound system user controls
o advanced ultrasound techniques
o advanced administration (teaching, documentation, organization)
o advanced ultrasound artefacts
o advanced FATE:
o systolic function
preload (Frank-Starling's law)
afterload (LaPlace's law)
33
contractility (intrinsic myocardial function)
ejection fraction (eyeballing, calculation with M-mode)
hemodynamic parameters (cardiac output (CO) with pulsed wave
Doppler (PWD))
o diastolic function
compliance and relaxation of the left ventricle using transmitral flow
curve visualized with PWD
estimating inotropic effect and/or volume effect
o pericardial effusion
o pleural effusion
o pathology (lung embolus, acute coronary syndrome, papillary muscle
rupture, septic shock, chest trauma, complicated AMI, cardiac tamponade,
pulmonary oedema (cardiogenic and non-cardiogenic), weaning failure from
mechanical ventilation, ARDS, acute valvular dysfunction)
o valvular stenosis using pressure gradients (continuous wave Doppler - CWD)
o insufficiency jets (valvular insufficiency) and atrial septal defect and
ventricular septal defect using colour flow Doppler (CFD)
o assessment of wall thickness and chamber dimensions in M-mode
o assessment of bi-ventricular function
o application of extended FATE views
subcostal vena cava
apical 2-chamber view
apical long-axis view
apical 5-chamber view
parasternal short axis mitral plane view
parasternal aorta short axis view
o diastolic left ventricular function
o Doppler (continuous wave, pulsed wave)
o Measurement of cardiac filling pressures
o Measurement of cardiac output and pulmonary artery pressure
34
Level 2 Competencies to be acquired
Competencies will have been gained during training for Level 1 practice and then refined
during a period of practice
To be able to:
o advanced FATE
o perform the advanced FATE protocol
o estimate chamber dimensions and left ventricular diameter (M-mode)
o estimated contractility (systolic function) of both ventricles
o estimate fractional shortening (FS) and ejection fraction (EF) with M-mode of
the left ventricle
o estimated cardiac output of left ventricle with continuous wave Doppler
o gauge mitral annular plane systolic excursion (MAPSE)
o gauge mitral septal separation (MSS)
o gauge tricuspid annular plane systolic excursion (TAPSE)
o visualize transmitral flow with PWD
o identify important pathology, e.g. left ventricular dilatation, left ventricular
hypertrophy, hypovolemia, left atrial dilatation, right ventricular dilatation,
pericardial effusion, pleural effusion, anatomical defects.
o detect valvular stenosis and/or insufficiency using CWD and CFD.
o correlate sonographic findings to clinical context.
o Color Doppler mapping
o Quantitative spectral Doppler
Pulsed Doppler
Continous wave Doppler
o TDI (Tissue Doppler Imaging)
The training should include a theoretical and practical course of at least 30 hours (see
below) followed by a theoretical and practical examination and the trainee should read
appropriate literature, scientific journals, and textbooks
• Competencies will have been acquired during training for level 1 practice which will
then be refined by performing a minimum of 30 clinical sessions at a centre where
supervision by someone with a Level 2 competence is available.
35
• Typically a Level 2 practitioner will have undertaken at least 800 ultrasound
examinations within advanced FATE before Level 2 certification.
• An electronic log book should be kept documenting a minimum of 50 procedures
which should include ideally all Level 2 competencies for advanced FATE.
• The theoretical and practical certification should encompass the full range of
sonopathology listed above.
1c1.4 Level 3
A Level 3 practioner is likely to spend the majority of their time undertaking FATE or
teaching, research and development within their subspecialized field and will be an expert
in this area.
1c1.5 Maintenance of Skills
Having been assessed as competent to practice there will be a need for continued
professional development (CPD) and maintenance of practical skills. Recommended
numbers of examinations to be performed annually to maintain skills at each level
Level 1: the practitioner should perform at least 100 basic UVS exams each year.
Level 2: the practitioner should perform at least 200 basic and advanced UVS exams each
year.
Level 3: the practitioner should perform at least 400 basic and advanced UVS exams each
year.
Practitioners should:
• include FATE in their continued medical education (CME)
• audit their practice
• participate in multidisciplinary meetings
• keep up to date with relevant literature
36
Certification for physicians already holding national/international TTE certifications
Physicians holding national or international echocardiography accreditation are considered
technically competent in the execution of a Focused Echo exam. Their clinical competence
in image integration into the critical or acute cardiac patient management should though
be certified by provision of minimum 30 documented exams (Logbook) + exam on a critical
patient + case discussion
1c2. Anaesthesiological ultrasound – vascular access 1c2.1 Introduction
This curriculum is intended for CECLUS certification Level 1-3 of prespecialist and
specialist anesthesiologists who perform ultrasound guided vascular access (UGVA).
UGVA includes standards for theoretical knowledge and practical skills.
Introductory level (pre-certification)
Performance of supervised basic UGVA prior to Level 1 certification.
Level 1 (basic) UGVA certification
Performance of unsupervised basic UGVA. Basic UGVA certification should be obtained
by all specialists of anesthesiology, preferably prior to or during their specialist training. At
least Level 1 competence should be obtained by anyone performing basic UGVA
unsupervised.
Level 2 (advanced) UGVA certification
Subspecialized specialist of anaesthesiology who performs basic and advanced UGVA
most working days.
Level 3 (expert) UGVA certification
Subspecialized experts of anaesthesiology who perform basic and advanced UGVA every
working day, and who are active with UGVA related science and teaching. Only very few
anaesthesiologists employing UGVA obtain the expert UGVA level 3 certification – if any.
They would typically be employed in a few university hospital centers.
Typical progression from introductory level to Level 3
(1) Theory course pretest
(2) Theory course of basic UGVA
(3) Theory course posttest
(4) Practical hands-on course of basic UGVA
38
(2) Course exam in theory and practice of basic UGVA
(3) Proctored practice (supervised procedures) of basic UGVA
(4) Level 1 certification of basic UGVA
(5Unsupervised maintenance of basic UGVA
(6) Theory & practice course of advanced UGVA
(7) Course exam of advanced UGVA
(8) Supervised procedures of advanced UGVA
(9) Level 2 certification of advanced UGVA - theory & practice
(10) Level 3 certification of expert UGVA: Level 2 certified + minimum 300 basic and
advanced UGVA exams per year for at least two years + teaching experience within
advanced UGVA + minimum three UGVA related scientific publications in peer reviewed
papers (PhD level)
1c2.2 Level 1
Level 1 Knowledge Base and Recommended Contents of Level 1 Theoretical & Practical
Course
Wave, sound and ultrasound physics
Ultrasound system machine controls
Ultrasound system user controls (knobbology)
Ultrasound techniques
- B mode (2D brightness mode)
- Doppler (color)
- In-plane/out-of-plane
Ergonomics
Sterility
Safety
Administration
• Implementation of an UGVA program
Sonoanatomy
• Superficial cubital and antebrachial veins
• Brachial veins
39
• Major saphenous vein
• Femoral vein
• Internal jugular vein
• Subclavian vein/axillary vein
• Radial artery
• Femoral artery
Sonopathology
• Thrombosis
• Complications
Pitfalls and limitations
Level 1 Competencies to be acquired
To be able to perform basic UGVA:
• Perform UGVA safely and accurately • To recognise and differentiate between normal anatomy/physiology and pathology • To recognize when a referral for a second opinion is indicated
Level 1 Theoretical & Practical Course
The course content is equal to the Level 1 knowledge base and the Level 1 competencies
to be acquired listed above. The course should be minimum 20 hours duration at the
beginning of the training period. The theory course should include a pre- and a posttest.
The entire course should be concluded with a course exam covering theory and practice.
The practical sessions should be performed as Hands On Training (HOT):
- HOT 1
o Basic UGVA views on normal models
o Revision of normal findings
- HOT 2
o Basic UGVA views on normal models or patients or sonosimulators
o Revision of pathological findings (tutorial laptops)
- HOT 3
o Individual reappraisal with interactive in-depth training
40
Level 1 theoretical and practical course exam on basic UGVA
• Theory (30 minutes, 25 MCQ)
• Practice (15 minutes, simulator or model)
The course should be concluded with a course exam in theory and practice of basic UVS:
• Theory (30 minutes, 25 MCQ)
• Practice (15 minutes, simulator or model)
Proctored Level 1 practice
• Supervision and recommended number of exams: Within 3 months after the course,
the trainee should collect a minimum of 50 UGVA exams under supervision: 25 fully
supervised basic UGVA exams (TYPE A exams) + 25 autonomously collected (TYPE
B exams, for later validation). The last 25 autonomously performed exams can be
validated either by: a) physical delivery of the electronic logbook + digital clips/images
• on a mass storage device (CD/DVD/USB stick) to the assigned tutor once the
collection is completed; b) by internet sharing with a distant tutor. Training should
usually be supervised by a level 2 practitioner. In certain circumstances it may be
appropriate to delegate some of this supervision to an experienced level 1 practitioner
with at least two years of regular practical experience. When local tutors are not
available, the 25 TYPE A exams can be replaced by 25 autonomously collected exams
and internet sharing with a distant tutor where the exams are uploaded and audited
sequentially one-by-one (a dedicated area will be activated on the CECLUS channel,
with reserved access to trainer’s page matched with distance tutor). Lack of information
on single cases, not allowing accurate judgement on trainees competence makes the
case not valid for final certification.
• Documentation: All exams must be video recorded and archived in digital format and
data collected in the electronic logbook (excel file). The documentation should record
time spent, need for supervision and correction, and rating of sonoanatomic skill,
imaging, image quality, and diagnostic performance. During the course of training the
competency assessment sheet should be completed.
• Curriculum: All the above mentioned pathology scenarios should be represented. An
exam can be a real clinical UGVA exam or a simulated UGVA exam: Didactic cases
(provided from local tutors and from distant tutors) should compensate for lack of an
adequate number of cases on some types of less frequent abnormalities. These should
41
not be reported in the logbook but rather listed, indicated separately as part of exam
final documentation. Sequential examinations on the same patients upon relevant
clinical/therapeutical changes are encouraged; provided there’s relevant change in the
findings, they will be counted as individual cases. No more than 10% exams with
normal findings are to be considered for the final certification
Final Level 1 certification of basic UGVA
Different trainees will acquire the necessary skills at different rates and the end point of the
training programme should be judged by an assessment of competencies in the form of
theoretical and practical certification. The theoretical and practical certification should
encompass the full range of the Level 1 knowledge database and competencies to be
acquired listed above.
• Theory (30 minutes, 25 MCQ)
• Practice (15 minutes, simulator or model)
Areas of competence assessed during examination
• Image generation
• Image acquisition
• Image interpretation
• Image administration
• Clinical and organizational thinking
Tools that may be used for the assessment during examination
• MCQs (overall theoretical assessment)
• Videoclip assessment (assessment of pathological clips interpretation and simulated
clinical integration of findings)
• UGVA imaging on a healthy volunteer (assessment of technical skills in machine
setting, image acquisition and storage)
• Case discussion presented by the trainee
42
1c2.3 Level 2
The training requisite to this level of practice would be gained during a period of sub-
specialty training, which may either be within or after the completion of a specialist training
programme.
• The training should include a theoretical and practical course of at least 5 hours
(see below) followed by a theoretical and practical examination and the trainee
should read appropriate literature, scientific journals, and textbooks
• Competencies will have been acquired during training for level 1 practice which will
then be refined by performing a minimum of 50 clinical sessions at a centre where
supervision by someone with a Level 2 competence is available.
• Typically a Level 2 practitioner will have undertaken at least 100 ultrasound
examinations within advanced UGVA before Level 2 certification.
• An electronic log book should be kept documenting a minimum of 50 procedures
which should include ideally all Level 2 competencies for advanced UGVA.
• To maintain competence at Level 2 practitioners should perform at least 50
advanced UGVA each year.
Level 2 Knowledge Base and Recommended Contents of Level 2 Theoretical and
Practical Course
o advanced sound and ultrasound physics (eg. 3D ultrasound and image fusion)
o advanced ultrasound system machine controls
o advanced ultrasound system user controls
o advanced ultrasound techniques
o advanced administration (teaching, documentation, organization)
o advanced ultrasound artefacts
o advanced UGVA:
o Central venous catheters
Umbilical vein catheter
Femoral vein catheter
Subclavian vein catheter
o Umbilical artery catheter
43
o Radial artery catheter
Level 2 Competencies to be acquired
o perform the advanced UGVA procedures
o apply color Doppler
A minimum of 30 hours theoretical and practical teaching is required. Prior to the theory
course the practitioner performs a pretest. The theory course should be concluded with a
posttest with a minimum level of performance before entering the practical hands-on
course.
1c2.4 Level 3
A level 3 practioner is likely to spend a substantial amount of their time undertaking UGVA
and teaching, research and development within their subspecialized field and will be an
expert in this area.
1c2.5 Maintenance of Skills
Having been assessed as competent to practice there will be a need for continued
professional development (CPD) and maintenance of practical skills. Recommended
numbers of procedures to be performed annually to maintain skills at each level are given
in the text.
Practitioners should:
• include UGVA in their continued medical education (CME)
• audit their practice
• participate in multidisciplinary meetings
• keep up to date with relevant literature
Maintenance requirements
Having been assessed as competent to practice there will be a need for continued
professional development (CPD) and maintenance of practical skills. Recommended
numbers of examinations to be performed annually to maintain skills at each level
Level 1: the practitioner should perform at least 50 basic UGVA exams each year.
Level 2: the practitioner should perform at least 100 basic and advanced UGVA exams
each year.
Level 3: the practitioner should perform at least 200 basic and advanced UGVA exams
each year.
Certification for physicians already holding national/international UGVA certifications
Physicians holding national or international UGVA accreditation are considered technically
competent in the execution of basic UGVA. Their clinical competence in UGVA should
45
though be certified by provision of minimum 5 documented exams (Logbook) + exam on a
model + case discussion.
1c3. Anaesthesiological ultrasound – eFAST (extended Focused Assessment with Sonography in Trauma) 1c3. 1 Introduction This protocol is intended for CECLUS certification Level 1 of prespecialists and specialists
of anaesthesiology who perform focused assessment with sonography in trauma – also
called FAST. The FAST protocol includes standards for theoretical knowledge and
practical skills.
The extended version of FAST (eFAST) is presented which includes assessment of:
- pleural effusion
- pericardial effusion
- peritoneal effusion
- abdominal aorta
- inferior vena cava
- urinary bladder
Typical progression to eFAST certification
(1) Theory course pretest
(2) Theory course of eFAST
(3) Theory course posttest
(4) Practical hands-on course of eFAST
(2) Course exam in theory and practice of eFAST
(3) Proctored practice (supervised procedures) of eFAST
(4) Certification of eFAST - theory (30 minutes, 25 MCQ) & practice (15 minutes, simulator
or model)
(5) Unsupervised maintenance of eFAST
1c3.2 Level 1
Level 1 Knowledge Base and Recommended Contents of Level 1 Theoretical & Practical Course
Wave, sound and ultrasound physics
47
Ultrasound system machine controls
Ultrasound system user controls
Ultrasound techniques
- B mode (2D brightness mode)
- M mode (motion mode)
Ergonomics
Sterility
Safety
Administration
• Implementation of an eFAST program
Sonoanatomy
• eFAST 2D and M-mode views
o Pleura
Anterior, bilateral
Posterior, bilateral
o Pericardium
o Peritoneum
Liver/right kidney
Spleen/left kidney
Rectovesical/vesicouterine pouch
Urinary bladder
Abdominal aorta
Inferior vena cava
Sonopathology
• Pneumothorax
• Pleura effusion • Cardiac tamponade • Peritoneal effusion • Distended urinary bladder
• Abdominal aortic enlargement • Hypovolemia
48
eFAST Competencies to be acquired
To be able to perform an eFAST exam:
• Perform the eFAST examinations safely and accurately and acquire all standard
views • To recognise and differentiate between normal anatomy/physiology and pathology
• To diagnose common abnormalities • To recognize when a referral for a second opinion is indicated • To understand the relationship between ultrasound imaging and other diagnostic
imaging techniques
Level 1 Theoretical & Practical Course
The course content is equal to the Level 1 knowledge base and the Level 1 competencies
to be acquired listed above. The course should be minimum 20 hours duration at the
beginning of the training period. The theory course should include a pre- and a posttest.
The entire course should be concluded with a course exam covering theory and practice.
The practical sessions should be performed as Hands On Training (HOT):
- HOT 1
o eFAST views on normal models
o Revision of normal findings
- HOT 2
o eFAST views on normal models or patients or sonosimulators
o Revision of pathological findings (tutorial laptops)
- HOT 3
o Individual reappraisal with interactive in-depth training
The course should be concluded with a course exam in theory and practice of basic UVS:
• Theory (30 minutes, 25 MCQ)
• Practice (15 minutes, simulator or model)
• Proctored eFAST practice
• Supervision and recommended number of exams: Within 3 months after the course,
the trainee should collect a minimum of 25 fully supervised eFAST exams (TYPE A
49
exams) + 25 autonomously collected (TYPE B exams, for later validation). All exams
must be archived in digital format and data collected in the logbook (excel file).
• When local tutors are not available, for the 25 fully supervised exams the 5 TYPE A
exams can be replaced by 25 autonomously collected exams and internet sharing with
a distant tutor where the exams are uploaded and audited sequentially one-by-one (a
dedicated area will be activated on the CECLUS channel, with reserved access to the
trainees page matched with distance tutor). Lack of information on single cases, not
allowing accurate judgement on trainees competence makes the case not valid for final
certification.
• Documentation: All exams must be video recorded and archived in digital format and
data collected in the electronic logbook (excel file). The documentation should record
time spent, need for supervision and correction, and rating of sonoanatomic skill,
imaging, image quality, and diagnostic performance. During the course of training the
competency assessment sheet should be completed.
• Curriculum: All the above mentioned pathology scenarios should be represented. An
exam can be a real clinical UVS exam or a simulated UVS exam: Didactic cases
(provided from local tutors and from distant tutors) should compensate for lack of an
adequate number of cases on some types of less frequent abnormalities. These should
not be reported in the logbook but rather listed, indicated separately as part of exam
final documentation. Sequential examinations on the same patients upon relevant
clinical/therapeutical changes are encouraged; provided there’s relevant change in the
findings, they will be counted as individual cases. No more than 10% exams with
normal findings are to be considered for the final certification
• The last 25 autonomously performed exams can be validated either by: a) physical
delivery of logbook + digital clips/images on a mass storage device (CD/DVD/USB
stick) to the assigned tutor once the collection is completed; b) by internet sharing with
a distant tutor (see above). The FAST exams should be preferrably performed in
patients with pathological hemodynamics.
• Case mix should include: Pneumothorax, pleura effusion, cardiac tamponade,
peritoneal effusion, distended urinary bladder, abdominal aortic enlargement, and
hypovolemia.
50
• Didactic cases (provided from local tutors and from distant tutors) should compensate
for lack of an adequate number of cases on some types of less frequent abnormalities.
These should not be reported in the logbook but rather listed, indicated separately as
part of exam final documentation. Sequential examinations on the same patients upon
relevant clinical/therapeutical changes are encouraged; provided there’s relevant
change in the findings, they will be counted as individual cases.
• No more than 10% exams with normal findings are to be considered for the final
certification
Final Level 1 certification of basic UVS
Different trainees will acquire the necessary skills at different rates and the end point of the
training programme should be judged by an assessment of competencies in the form of
theoretical and practical certification. The theoretical and practical certification should
encompass the full range of the Level 1 knowledge database and competencies to be
acquired listed above.
• Theory (2 hours,100 MCQ)
• Practice (30 minutes, simulator or model)
Areas of competence assessed during examination
• Image generation
• Image acquisition
• Image interpretation
• Image administration
• Clinical and organizational thinking
Tools that may be used for the assessment during examination
• MCQs (overall theoretical assessment)
• Videoclip assessment (assessment of pathological clips interpretation and simulated
clinical integration of findings)
• eFAST on a healthy volunteer (assessment of technical skills in machine setting, image
acquisition and storage)
51
• eFAST on a real patient (overall practical assessment, including FAST-guided patient
management)
• Case discussion presented by the trainee
1c3.3 Maintenance of Skills
Having been assessed as competent to practice there will be a need for continued
professional development (CPD) and maintenance of practical skills. Recommended
numbers of examinations to be performed annually to maintain skills at each level
Level 1: the practitioner should perform at least 100 eFAST exams each year.
Practitioners should:
• include eFAT in their continued medical education (CME)
• audit their practice
• participate in multidisciplinary meetings
• keep up to date with relevant literature
1d. Anaesthesiological ultrasound – nerve blocks
1d.1 Introduction
This curriculum is intended for CECLUS certification Level 1-3 of pre-specialists and
specialists of anaesthesiology who perform ultrasound guided regional anaesthesia
(UGRA). It includes standards for theoretical knowledge and practical skills.
Introductory level
Performance of supervised basic UGRA prior to Level 1 certification.
Level 1 (basic)
Performance of unsupervised basic UGRA. Basic UGRA is easy and effective single shot
peripheral nerve blocks for perioperative, emergency and critical care analgesia -
interscalene, infraclavicular, femoral, popliteal sciatic, and TAP blocks. Basic UGRA
certification should be obtained by all specialists in anaesthesiology. It is recommended
that all anaesthesiologists obtain Level 1 competence, preferably during their specialist
training. At least Level 1 competence should be obtained by anyone performing UGRA
unsupervised.
Level 2 (advanced)
Subspecialized anaesthesiologists who perform basic and advanced nerve blocks most
working days. Advanced UGRA: all single shot peripheral nerve blocks beyond basic
blocks, all continuous nerve blocks with catheter technique, and neuraxial UGRA.
Advanced UGRA certification is typically obtained by specialists in anaesthesiology
subspecialized in orthopedic surgery anaesthesiology.
Level 3 (expert)
Anesthesiologists who perform basic and advanced UGRA every working day and most of
the day, and who is active with science and teaching. Only very few anaesthesiologists
obtain expert UGRA level. They are typically employed in university hospital centers.
53
Typical progression from Introduction Level to Level 3
(1) Theory course pretest
(2) Theory course of basic UGRA
(3) Theory course posttest
(4) Practical hands-on course of basic UGRA
(2) Course exam in theory and practice of basic UGRA
(3) Supervised procedures of basic UGRA
(4) Level 1 certification of basic UGRA
(5) Unsupervised maintenance of basic UGRA
(6) Theory & practice course of advanced UGRA
(7) Course exam of advanced UGRA
(8) Supervised procedures of advanced UGRA
(9) Level 2 certification of advanced UGRA - theory & practice
(10) Level 3 certification of expert UGRA: Level 2 certified + minimum 500 basic and
advanced UGRA procedures per year for at least two years + teaching experience within
advanced UGRA + minimum three scientific publications about UGRA in peer reviewed
papers (PhD level)
1d.2 Level 1
Level 1 Knowledge Base and Recommended Contents of Level 1 Theoretical & Practical
Course
Sound and ultrasound physics
Ultrasound system machine controls
Ultrasound system user controls
Ultrasound techniques
Ergonomics
Sterility
Safety
Administration (see Appendix 2)
Sonoanatomy
• Normal peripheral nerves
54
o cervical plexus
o brachial plexus
spinal nerve roots
trunks
transition zone
fascicles
terminal nerves
• radial nerve
• median nerve
• ulnar nerve
• musculocutaneous nerve
o lumbar plexus
femoral nerve, inguinal crease
• saphenous nerve, adductor canal
obturator nerve
• anterior branch
• posterior branch
lateral femoral cutaneous nerve
o sacral plexus
sciatic nerve
sciatic nerve, popliteal fossa
tibial nerve, popliteal fossa
common peroneal nerve, popliteal fossa
o trunkal innervation
Specific nerve blocks: Imaging, image recognition (still images and video clips), needle
dexterity
• interscalene brachial plexus block • infraclavicular brachial plexus block • femoral nerve block including saphenuous nerve block
• popliteal sciatic nerve block • transverse abdominis plane (TAP) block
55
Level 1 Competencies to be acquired
To be able to:
• Perform the five nerve blocks in basic UGRA o interscalene brachial plexus block o infraclavicular brachial plexus block
o femoral nerve block including saphenuous nerve block o popliteal sciatic nerve block o transverse abdominis plane (TAP) block
Level 1 Theoretical & Practical Course
The course content is equal to the Level 1 knowledge base and the Level 1 competencies
to be acquired listed above. The course should be minimum 20 hours duration at the
beginning of the training period. The theory course should include a pre- and a posttest.
The entire course should be concluded with a course exam covering theory and practice.
The practical sessions should be performed as Hands On Training (HOT):
- HOT 1
o interscalene block
- HOT 2
o infraclavicular block
- HOT 3
o femoral nerve block (incl. saphenous block)
- HOT 4
o popliteal sciatic nerve block
- HOT 5
o TAP block
- HOT 6
o needle dexterity training in phantoms
The course should be concluded with a course exam in theory and practice of basic
UGRA:
• Theory (30 minutes, 25 MCQ)
• Practice (15 minutes, simulator or model)
56
Proctored Level 1 practice
• Supervision and recommended number of exams: Within 3 months after the course,
the trainee should collect a minimum of 100 UGRA exams under supervision: 50 fully
supervised basic UGRA exams (TYPE A exams) + 50 autonomously collected (TYPE
B exams, for later validation). The last 50 autonomously performed exams can be
validated either by: a) physical delivery of the electronic logbook + digital clips/images
on a mass storage device (CD/DVD/USB stick) to the assigned tutor once the
collection is completed; b) by internet sharing with a distant tutor. Training should
usually be supervised by a level 2 practitioner. In certain circumstances it may be
appropriate to delegate some of this supervision to an experienced level 1 practitioner
with at least two years of regular practical experience. When local tutors are not
available, the 50 TYPE A exams can be replaced by 50 autonomously collected exams
and internet sharing with a distant tutor where the exams are uploaded and audited
sequentially one-by-one (a dedicated area will be activated on the CECLUS channel,
with reserved access to trainer’s page matched with distance tutor). Lack of information
on single cases, not allowing accurate judgement on trainees competence makes the
case not valid for final certification.
• Documentation: All exams must be video recorded and archived in digital format and
data collected in the electronic logbook (excel file). The documentation should record
time spent, need for supervision and correction, and rating of sonoanatomic skill,
imaging, image quality, and diagnostic performance. During the course of training the
competency assessment sheet should be completed.
• Curriculum: All the above mentioned pathology scenarios should be represented. An
exam can be a real clinical UGRA exam or a simulated UGRA exam: Didactic cases
(provided from local tutors and from distant tutors) should compensate for lack of an
adequate number of cases on some types of less frequent abnormalities. These should
not be reported in the logbook but rather listed, indicated separately as part of exam
final documentation. Sequential examinations on the same patients upon relevant
clinical/therapeutical changes are encouraged; provided there’s relevant change in the
findings, they will be counted as individual cases. No more than 10% exams with
normal findings are to be considered for the final certification
57
Final Level 1 certification of basic UGRA
Different trainees will acquire the necessary skills at different rates and the end point of the
training programme should be judged by an assessment of competencies in the form of
theoretical and practical certification. The theoretical and practical certification should
encompass the full range of the Level 1 knowledge database and competencies to be
acquired listed above.
• Theory (2 hours,100 MCQ)
• Practice (30 minutes, simulator or model)
Areas of competence assessed during certification examination:
• Image generation
• Image acquisition
• Image interpretation
• Image administration
• Clinical and organizational thinking
Tools that may be used for the assessment during certification examination:
• MCQs (overall theoretical assessment)
• Videoclip assessment (assessment of pathological clips interpretation and simulated
clinical integration of findings)
• UGRA exam on a healthy volunteer (assessment of technical skills in machine setting,
image acquisition and storage)
• Case discussion presented by the trainee
1d.3 Level 2
The training requisite to this level of practice would be gained during a period of sub-
specialty training, which may either be within or after the completion of a specialist training
programme.
• The training should include a theoretical and practical course of at least 30 hours
(see below) followed by a theoretical and practical examination and the trainee
should read appropriate literature, scientific journals, and textbooks
58
• Competencies will have been acquired during training for level 1 practice which will
then be refined by performing a minimum of 30 clinic sessions at a centre where
supervision by someone with a Level 2 competence is available.
• Typically a Level 2 practitioner will have undertaken at least 2.000 ultrasound
examinations within advanced ultrasound guided regional anaesthesia (UGRA)
before Level 2 certification.
• An electronic log book should be kept documenting a minimum of 50 procedures
which should include ideally all Level 2 competencies for advanced UGRA. A
procedure can be a real clinical UGRA procedure or a simulated UGRA procedure.
A minimum of 25 procedures have to be real clinical UGRA procedures. • The theoretical and practical certification should encompass the full range of
procedures listed below.
• To maintain competence at Level 2 practitioners should perform at least 500 clinical
examinations each year within their Level 2 subspecialty of advanced UGRA. Level 2 Knowledge Base and Recommended Contents of Level 2 Theoretical and
Practical Course
o new ultrasound modalities (eg. 4D ultrasound, biplane ultrasound and image fusion)
o contrast agents
o advanced sound and ultrasound physics
o advanced ultrasound system machine controls
o advanced ultrasound system user controls
o advanced ultrasound techniques
o advanced administration (teaching, documentation, organization)
o advanced ultrasound artefacts
o advanced UGRA
o anatomy and sonoanatomy
o peripheral nerve pathology
o neurophysiology and neuropathophysiology
o complications
o safety
o histology of peripheral nerves
59
o pharmacology of local anaesthetics and adjuvants
o peripheral nerve stimulators and electrophysiology
o continuous nerve blocks
o UGRA in children
Level 2 Competencies to be acquired
o UGRA
o US guided insertion of catheters for continuous peripheral nerve blockade
(subspecialty: orthopedic surgery anaesthesia - OSA)
o trigeminal (Gasserian) nerve block (subspecialty: neuroanaesthesia - NA)
o occipital nerve block (subspecialty: NA)
o cervical plexus block (superficial, deep) (subspecialty: OSA)
o suprascapular nerve block (subspecialty: OSA)
o supraclavicular brachial plexus block (subspecialty: OSA)
o axillary brachial plexus block (subspecialty: OSA)
o lumbar plexus block (subspecialty: OSA)
o fascia transversalis block (subspecialty: OSA)
o quadratus lumborum block (subspecialty: OSA)
o obturator nerve block (anterior and posterior branch) (subspecialty: OSA)
o lateral femoral cutaneous nerve block (subspecialty: OSA)
o genitofemoral nerve block (femoral branch) (subspecialty: OSA)
o sacral plexus block (subspecialty: OSA)
o sciatic nerve block (transgluteal, subgluteal, anterior approach)
(subspecialty: OSA)
o posterior tibial nerve block, ankle (subspecialty: OSA)
o sural nerve block, ankle (subspecialty: OSA)
o superficial peroneal nerve, ankle (subspecialty: OSA)
o deep peroneal nerve, ankle (subspecialty: OSA)
o intercostal block (subspecialty: OSA)
o spinal anaesthesia (subspecialty: OSA)
o caudal anaesthesia (subspecialty: OSA)
o combined spinal-epidural anaesthesia (subspecialty: OSA)
60
o epidural blockade (cervical, thoracic, lumbar) (subspecialty: gastroenterology
anaesthesia - GEA, OSA)
o thoracic paravertebral block (subspecialty: GEA)
o iliohypogastric/ilioinguinal block (subspecialty: GEA)
o stellate ganglion block (subspecialty: pain medicine)
o ganglion impar block (subspecialty: pain medicine)
o facet joint block (subspecialty: pain medicine)
1d.4 Level 3
A level 3 practioner is likely to spend the majority of their time undertaking UGRA or
teaching, research and development within their subspecialized field and will be an expert
in this area.
1d.5 Maintenance of Skills
Having been assessed as competent to practice there will be a need for continued
professional development (CPD) and maintenance of practical skills. Recommended
numbers of examinations to be performed annually to maintain skills at each level are
given in the text.
Recommended numbers of examinations to be performed annually to maintain skills at
each level
Level 1: the practitioner should perform at least 100 basic UGRA exams each year.
Level 2: the practitioner should perform at least 200 basic and advanced UGRA exams
each year.
Level 3: the practitioner should perform at least 400 basic and advanced UGRA exams
each year.
Practitioners should:
• include UGRA in their continued medical education (CME)
• audit their practice
• participate in multidisciplinary meetings
• keep up to date with relevant literature
2. Obstetric (fetal medicine) ultrasound
2.1 Introduction DSOG (Dansk Selskab for Obstetrik og Gynækologi = the Danish Society of Obstetrics
and Gynecology) has established a system of education and certification for fetal medicine
ultrasound (FMU) that is mandatory for all Danish practioners of FMU.
This curriculum is intended for CECLUS certification Level 1-3 of pre-specialists and
specialists of obstetrics who perform fetal medicine ultrasound (FMU). The curriculum
includes standards for theoretical knowledge and practical skills.
Introductory level (pre-certification)
Performance of supervised basic FMU prior to Level 1 certification. All trainees of
gynecology and obstetrics in Denmark complete 3 weeks (1+2) of supervised focused
FMU in the departments of Fetal Medicine of the university hospitals.
Level 1 (basic) certification
Performance of unsupervised basic FMU. Basic FMU is easy and effective basic
assessment of basic fetal medicine conditions with ultrasound. Basic FMU certification
should be obtained by all specialists of obstetrics. At least Level 1 competence should be
obtained by anyone performing basic FMU unsupervised.
Level 2 (advanced) certification
Subspecialized specialists who perform advanced FMU most working days. Level 2
certification is only obtained by few specialists of obstetrics.
Level 3 (expert) certification
Subspecialized experts who perform advanced FMU every working day and most of the
day, and who are active with FMU related science and teaching. Only very few clinical
experts employing FMU obtain the expert FMU level 3 certification. They are typically
employed in university hospital centers.
62
Typical progression from introductory level to Level 3
(1) Theory course pretest
(2) Theory course of basic FMU
(3) Theory course posttest
(4) Practical hands-on course of basic FMU
(2) Course exam in theory and practice of basic FMU
(3) Proctored practice (supervised procedures) of basic FMU
(4) Level 1 certification of basic FMU
(5) Unsupervised maintenance of basic FMU
(6) Theory & practice course of advanced FMU
(7) Course exam of advanced FMU
(8) Supervised procedures of advanced FMU
(9) Level 2 certification of advanced FMU - theory & practice
(10) Level 3 certification of expert FMU: Level 2 certified + minimum 400 advanced FMU
exams per year for at least two years + teaching experience within advanced FMU +
minimum three FMU related scientific publications in peer reviewed papers (PhD level)
2.2 Level 1 Level 1 Knowledge Base and Recommended Contents of Level 1 Theoretical & Practical
Course
Sound and ultrasound physics
Ultrasound system machine controls
Ultrasound system user controls
Ultrasound techniques
Ergonomics
Sterility
Safety
Administration
Sonoanatomy (including common variants)
• estimation of date of pregnancy
• estimation of the weight and growth of the fetus
63
• Normal fetal anatomy
• Multiple pregnancy
• Placenta, amniotic fluid
Sonopathology (pathology and results of treatment in relation to ultrasound)
• common fetal malformations
• Screening for fetal chromosomal aberrations – eg. nuchal fold scans
Level 1 Competencies to be acquired
To be able to:
General
• systematics (abdominal/vaginal)
• image optimization
• cleaning the ultrasound system
Scan
• gestational sac
• CRL
• BPD
• head structure
• insertion site
• extremities
• estimation of due date
• missed abortion counselling
Nuchal fold scans
• nuchal fold
• nasal bone
• gastric ventricle
• urinary bladder
• risc counselling
Counselling of increased risk of combination tests
• counselling about big nuchal fold
• counselling about chorionic villus sampling and amniocentesis
64
Scans of malformations
• BPD
• cerebral structures
• thorax/abdomen – position of cor and gastric ventricle
• 4 chamber view of the heart
• gastric ventricle
• abdominal wall
• renal pelvis and bladder
• limbs
• sex determination
• position of placenta
• profile/photo
• Down stigmata
• normal MD
• counselling about placenta previa
• common malformations
• counselling about common malformations
3. semester scans
• weight • fluid • flow (umbilicus) • flow (cerebri media artery)
• cervix scan • counselling about short cervix • estimation of the state of the fetus • general overview of the status of the fetus
Gemelli
• classification 1/2 a/b
• classification of choriosity
• monochoric gemelli
• dichoric gemelli
• deepest sea
65
• weight
• flow
• TTTS
Level 1 Theoretical & Practical Course
The course content is equal to the Level 1 knowledge base and the Level 1 competencies
to be acquired listed above. The course should be minimum 20 hours duration at the
beginning of the training period. The theory course should include a pre- and a posttest.
The entire course should be concluded with a course exam covering theory and practice.
The practical sessions should be performed as Hands On Training (HOT):
- HOT 1
o Basic FMU views on normal non-pregnant models
o Revision of normal findings
- HOT 2
o Basic UVS views on normal non-pregnant models or pregnant women or
sonosimulators
o Revision of pathological findings (tutorial laptops)
- HOT 3
o Individual reappraisal with interactive in-depth training
The course should be concluded with a course exam in theory and practice of basic
FMU:
• Theory (30 minutes, 25 MCQ)
• Practice (15 minutes, simulator or model)
Proctored Level 1 practice
• Supervision and recommended number of exams: Within 3 months after the course,
the trainee should collect a minimum of 400 FMU exams under supervision: 200 fully
supervised basic FMU exams (TYPE A exams) + 200 autonomously collected (TYPE B
exams, for later validation). The last 200 autonomously performed exams can be
validated either by: a) physical delivery of the electronic logbook + digital clips/images
on a mass storage device (CD/DVD/USB stick) to the assigned tutor once the
collection is completed; b) by internet sharing with a distant tutor. Training should
66
usually be supervised by a level 2 practitioner. In certain circumstances it may be
appropriate to delegate some of this supervision to an experienced level 1 practitioner
with at least two years of regular practical experience. When local tutors are not
available, the 200 TYPE A exams can be replaced by 200 autonomously collected
exams and internet sharing with a distant tutor where the exams are uploaded and
audited sequentially one-by-one (a dedicated area will be activated on the CECLUS
channel, with reserved access to trainer’s page matched with distance tutor). Lack of
information on single cases, not allowing accurate judgement on trainees competence
makes the case not valid for final certification.
• Documentation: All exams must be video recorded and archived in digital format and
data collected in the electronic logbook (excel file). The documentation should record
time spent, need for supervision and correction, and rating of sonoanatomic skill,
imaging, image quality, and diagnostic performance. During the course of training the
competency assessment sheet should be completed.
• Curriculum: All the above mentioned pathology scenarios should be represented. An
exam can be a real clinical FMU exam or a simulated FMU exam: Didactic cases
(provided from local tutors and from distant tutors) should compensate for lack of an
adequate number of cases on some types of less frequent abnormalities. These should
not be reported in the logbook but rather listed, indicated separately as part of exam
final documentation. Sequential examinations on the same patients upon relevant
clinical/therapeutical changes are encouraged; provided there’s relevant change in the
findings, they will be counted as individual cases. No more than 10% exams with
normal findings are to be considered for the final certification
Final Level 1 certification of basic FMU
Different trainees will acquire the necessary skills at different rates and the end point of the
training programme should be judged by an assessment of competencies in the form of
theoretical and practical certification. The theoretical and practical certification should
encompass the full range of the Level 1 knowledge database and competencies to be
acquired listed above.
• Theory (2 hours,100 MCQ)
• Practice (30 minutes, simulator or model)
67
Areas of competence assessed during certification examination:
• Image generation
• Image acquisition
• Image interpretation
• Image administration
• Clinical and organizational thinking
Tools that may be used for the assessment during certification examination:
• MCQs (overall theoretical assessment)
• Videoclip assessment (assessment of pathological clips interpretation and simulated
clinical integration of findings)
• FMU exam on a healthy volunteer (assessment of technical skills in machine setting,
image acquisition and storage)
• FMU on a real pregnant woman or patient with relevant morbidity (overall practical
assessment)
• Case discussion presented by the trainee
2.3 Level 2
The training requisite to this level of practice would be gained during a period of sub-
specialty training, which may either be within or after the completion of a specialist training
programme.
• The training should include a theoretical and practical course of at least 30 hours
(see below) followed by a theoretical and practical examination and the trainee
should read appropriate literature, scientific journals, and textbooks
• Competencies will have been acquired during training for level 1 practice which will
then be refined by performing a minimum of 30 clinic sessions at a centre where
supervision by someone with a Level 2 competence is available.
• Typically a Level 2 practitioner will have undertaken at least 800 ultrasound
examinations within basic and advanced FMU before Level 2 certification.
68
• An electronic log book should be kept documenting a minimum of 50 exams which
should include ideally all Level 2 competencies for advanced FMU. An exam can be
a real clinical FMU exam or a simulated FMU exam. A minimum of 25 exams have
to be real clinical FMU exams. • The theoretical and practical certification should encompass the full range of
procedures listed below.
Level 2 Knowledge Base and Recommended Contents of Level 2 Theoretical and
Practical Course
o new ultrasound modalities (eg. 4D ultrasound, MRI and image fusion)
o advanced sound and ultrasound physics
o advanced ultrasound system machine controls
o advanced ultrasound system user controls
o advanced ultrasound techniques
o fetal echocardiography
o fetal Doppler
o soft markers
o advanced administration (teaching, documentation, organization)
o advanced ultrasound artefacts
o advanced sonoanatomy (including common variants)
o advanced UVS sonopathology (pathology and results of treatment in relation to
ultrasound)
o fetal malformations
o syndromes
o complications
o safety
Level 2 competencies to be acquired
Competencies will have been gained during training for Level 1 practice and then refined
during a period of practice
To be able to:
• perform a complete imaging ultrasound scan and identify all abnormalities detailed
69
in Level 1
• diagnose all fetal malformations and knowledge about the treatment
• diagnose intrauterine growth inhibition and knowledge about treatment
• diagnose complications related to twin pregnancy and knowledge about treatment
2.4 Level 3
A Level 3 practioner is likely to spend the majority of their time undertaking advanced FMU
and teaching, research and development within their subspecialized field and will be an
expert in this area. A Level 3 practitioner will accept tertiary referrals from Level 1 and 2
practioners. He/she should have the capability to utilise developing technologies and
ultrasound techniques, develop research and teaching skills and the performance of
specialised examinations including the use ultrasound guided interventional procedures.
DSOG has established an expert education of fetal medicine leading to Level 3 in FMU.
2.5 Maintenance of skills
Having been assessed as competent to practice there will be a need for continued
professional development (CPD) and maintenance of practical skills. Recommended
numbers of examinations to be performed annually to maintain skills at each level
Level 1: the practitioner should perform at least 400 basic FMU exams each year.
Level 2: the practitioner should perform at least 800 basic and advanced FMU exams each
year.
Level 3: the practitioner should perform at least 1.200 basic and advanced FMU exams
each year.
Practitioners should:
• include FMU in their continued medical education (CME)
• audit their practice
• participate in multidisciplinary meetings
• keep up to date with relevant literature
3. Gynecological ultrasound
3.1 Introduction This curriculum is intended for CECLUS certification Level 1-3 of pre-specialists and
specialists of vascular surgery who perform gynecological ultrasound (GUS). The
curriculum includes standards for theoretical knowledge and practical skills.
The curriculum includes standards for theoretical knowledge and practical skills.
Introductory level (pre-certification)
Performance of supervised basic GUS prior to Level 1 certification.
Level 1 (basic) certification
Performance of unsupervised basic GUS. Basic GUS is easy and effective assessment of
basic gynecological conditions with ultrasound. Basic GUS certification should be obtained
by all specialists in gynecology and obstetrics. It is recommended that all gynecologists
obtain Level 1 competence, preferably during their specialist training. At least Level 1
competence should be obtained by anyone performing GUS unsupervised.
Level 2 (advanced)
Subspecialized gynecologist who performs basic and advanced GUS most working days.
Advanced GUS: all gynecological ultrasound procedures beyond basic level. Advanced
gynecological ultrasound certification is typically obtained by subspecialized specialists in
gynecology.
Level 3 (expert)
Subspecialized experts who perform basic and advanced GUS every working day and
most of the day, and who is active with GUS related science and teaching. Only very few
gynecologists obtain expert GUS level 3 certification. They would typically be employed in
a few university hospital centers.
71
Typical progression from Introductory level to Level 3
(1) Course pretest
(2) Theory course of basic GUS
(3) Theory course posttest
(4) Practical hands-on course of basic GUS
(2) Course exam in theory and practice of basic GUS
(3) Supervised procedures of basic GUS
(4) Level 1 certification of basic GUS
(5) Unsupervised maintenance of basic GUS
(6) Theory & practice course of advanced GUS
(7) Course exam of advanced GUS
(8) Supervised procedures of advanced GUS
(9) Level 2 certification of advanced GUS - theory & practice
(10) Level 3 certification of expert GUS: Level 2 certified + minimum 400 basic and
advanced GUS procedures per year for at least two years + teaching experience within
advanced GUS + minimum three scientific publications about gynecological ultrasound in
peer reviewed papers
3.2 Level 1
Level 1 Knowledge Base and Recommended Contents of Level 1 Theoretical & Practical
Course
Wave, sound wave and ultrasound physics
Ultrasound system controls
Ultrasound user controls
Ultrasound techniques
Ergonomics
Sterility
Safety
Administration
Sonoanatomy
Sonopathology
72
Level 1 Competencies to be acquired
To be able to:
• Perform a basic GUS exam
Level 1 Theoretical & Practical Course
The course content is equal to the Level 1 knowledge base and the Level 1 competencies
to be acquired listed above. The course should be minimum 20 hours duration at the
beginning of the training period. The theory course should include a pre- and a posttest.
The entire course should be concluded with a course exam covering theory and practice.
The practical sessions should be performed as Hands On Training (HOT):
- HOT 1
o Basic GUS views on sonosimulators
o Revision of normal findings
- HOT 2
o Basic UVS views on patients or sonosimulators
o Revision of pathological findings (tutorial laptops)
- HOT 3
o Individual reappraisal with interactive in-depth training
The course should be concluded with a course exam in theory and practice of basic
GUS:
• Theory (30 minutes, 25 MCQ)
• Practice (15 minutes, simulator or model)
Proctored Level 1 practice
• Supervision and recommended number of exams: Within 3 months after the course,
the trainee should collect a minimum of 100 GUS exams under supervision: 50 fully
supervised basic GUS exams (TYPE A exams) + 50 autonomously collected (TYPE B
exams, for later validation). The last 50 autonomously performed exams can be
validated either by: a) physical delivery of the electronic logbook + digital clips/images
on a mass storage device (CD/DVD/USB stick) to the assigned tutor once the
collection is completed; b) by internet sharing with a distant tutor. Training should
73
usually be supervised by a level 2 practitioner. In certain circumstances it may be
appropriate to delegate some of this supervision to an experienced level 1 practitioner
with at least two years of regular practical experience. When local tutors are not
available, the 50 TYPE A exams can be replaced by 50 autonomously collected exams
and internet sharing with a distant tutor where the exams are uploaded and audited
sequentially one-by-one (a dedicated area will be activated on the CECLUS channel,
with reserved access to trainer’s page matched with distance tutor). Lack of information
on single cases, not allowing accurate judgement on trainees competence makes the
case not valid for final certification.
• Documentation: All exams must be video recorded and archived in digital format and
data collected in the electronic logbook (excel file). The documentation should record
time spent, need for supervision and correction, and rating of sonoanatomic skill,
imaging, image quality, and diagnostic performance. During the course of training the
competency assessment sheet should be completed.
• Curriculum: All the above mentioned pathology scenarios should be represented. An
exam can be a real clinical GUS exam or a simulated GUS exam: Didactic cases
(provided from local tutors and from distant tutors) should compensate for lack of an
adequate number of cases on some types of less frequent abnormalities. These should
not be reported in the logbook but rather listed, indicated separately as part of exam
final documentation. Sequential examinations on the same patients upon relevant
clinical/therapeutical changes are encouraged; provided there’s relevant change in the
findings, they will be counted as individual cases. No more than 10% exams with
normal findings are to be considered for the final certification
Final Level 1 certification of basic UVS
Different trainees will acquire the necessary skills at different rates and the end point of the
training programme should be judged by an assessment of competencies in the form of
theoretical and practical certification. The theoretical and practical certification should
encompass the full range of the Level 1 knowledge database and competencies to be
acquired listed above.
• Theory (2 hours,100 MCQ)
• Practice (30 minutes, simulator or model)
74
Areas of competence assessed during certification examination:
• Image generation
• Image acquisition
• Image interpretation
• Image administration
• Clinical and organizational thinking
Tools that may be used for the assessment during certification examination:
• MCQs (overall theoretical assessment)
• Videoclip assessment (assessment of pathological clips interpretation and simulated
clinical integration of findings)
• UVS exam on a healthy volunteer (assessment of technical skills in machine setting,
image acquisition and storage)
• UVS on a real patient with relevant morbidity (overall practical assessment)
• Case discussion presented by the trainee
3.3 Level 2
The training requisite to this level of practice would be gained during a period of sub-
specialty training, which may either be within or after the completion of a specialist training
programme.
• The training should include a theoretical and practical course of at least 30 hours
(see below) followed by a theoretical and practical examination and the trainee
should read appropriate literature, scientific journals, and textbooks
• Competencies will have been acquired during training for level 1 practice which will
then be refined by performing a minimum of 30 clinic sessions at a centre where
supervision by someone with a Level 2 competence is available.
• Typically a Level 2 practitioner will have undertaken at least 800 ultrasound
examinations within advanced GUS before Level 2 certification.
• An electronic log book should be kept documenting a minimum of 50 exams which
should include ideally all Level 2 competencies for advanced GUS. A procedure
75
can be a real clinical GUS procedure or a simulated procedure. A minimum of 25
procedures have to be real clinical GUS procedures. • The theoretical and practical certification should encompass the full range of
procedures listed below.
• To maintain competence at Level 2 practitioners should perform at least 400 clinical
examinations each year within their Level 2 subspecialty of advanced gynecological
ultrasound.
Level 2 Knowledge Base and Recommended Contents of Level 2 Theoretical and
Practical Course
o new ultrasound modalities (eg. 4D ultrasound, MRI and image fusion)
o advanced sound and ultrasound physics
o advanced ultrasound system machine controls
o advanced ultrasound system user controls
o advanced ultrasound techniques
o advanced administration (teaching, documentation, organization)
o advanced ultrasound artefacts
o advanced GUS
o anatomy and sonoanatomy
o complications
o safety
Level 2 Competencies to be acquired
o gynecological ultrasound
3.4 Level 3
A level 3 practioner is likely to spend the majority of their time undertaking GUS or
teaching, research and development within their subspecialized field and will be an expert
in this area.
76
3.5 Maintenance of skills Having been assessed as competent to practice there will be a need for continued
professional development (CPD) and maintenance of practical skills. Recommended
numbers of examinations to be performed annually to maintain skills at each level
Level 1: the practitioner should perform at least 100 basic GUS exams each year.
Level 2: the practitioner should perform at least 200 basic and advanced GUS exams each
year.
Level 3: the practitioner should perform at least 400 basic and advanced GUS exams each
yeaGU
Practitioners should:
• include GUS in their continued medical education (CME)
• audit their practice
• participate in multidisciplinary meetings
• keep up to date with relevant literature
4. Endocrinological ultrasound
4.1 Introduction
This curriculum is intended for CECLUS certification Level 1-3 of pre-specialists and
specialists of endocrinology who perform endocrinological ultrasound (EUS). It includes
standards for theoretical knowledge and practical skills.
Introductory level
Performance of supervised basic EUS prior to Level 1 certification.
Level 1 (basic)
Performance of unsupervised basic EUS. Basic EUS is easy and effective basic
assessment of endocrinological conditions with ultrasound. Basic EUS certification should
be obtained by all specialists in endocrinology. It is recommended that all endocrinologists
obtain Level 1 competence, preferably during their specialist training. At least Level 1
competence should be obtained by anyone performing EUS unsupervised.
Level 2 (advanced)
Subspecialized experts who perform basic and advanced EUS most working days.
Advanced EUS is all EUS procedures beyond basic level. Advanced EUS certification is
typically obtained by specialists in endocrinology subspecialized in thyroid diseases.
Level 3 (expert)
Subspecialized experts who perfors basic and advanced EUS every working day and most
of the day, and who is active with science and teaching. Only very few endocrinologists
obtain expert EUS level 3 certification. They would typically be employed in a few
university hospital centers.
Typical progression from Introductory level to Level 3
(1) Theory course pretest
(2) Theory course of basic EUS
78
(3) Theory course posttest
(4) Practical hands-on course of basic EUS
(2) Course exam in theory and practice of basic EUS
(3) Supervised procedures of basic EUS
(4) Level 1 certification of basic EUS
(5) Unsupervised maintenance of basic EUS
(6) Theory & practice course of advanced EUS
(7) Course exam of advanced EUS
(8) Supervised procedures of advanced EUS
(9) Level 2 certification of advanced EUS - theory & practice
(10) Level 3 certification of expert EUS: Level 2 certified + minimum 500 basic and
advanced EUS procedures per year for at least two years + teaching experience within
advanced EUS + minimum three scientific publications about EUS in peer reviewed
papers (PhD level)
4.2 Level 1
Level 1 Knowledge Base and Recommended Contents of Level 1 Theoretical & Practical
Course
Wave, sound wave and ultrasound physics
Ultrasound system controls
Ultrasound user controls
Ultrasound techniques
Ergonomics
Sterility
Safety
Administration
Sonoanatomy
• Basic 2D and Color Doppler views in longitudinal and cross sectional scans
o thyroid gland
o parathyroid glands
o lymph nodes
79
Sonopathology
• Thyroid gland
o Measure size
o Estimate color (dark/light +/- thyroiditis/sequelae)
o Estimate homogeneity/inhomogeneity
If inhomogeneity
• Solitary nodus
• Multiple nodi
• Dominating nodus
• Calcifications/microcalcifications
If nodus
• Simple cyst
• Semisolid cyst
• Calcifications in the cystic wall
• Parathyroid glands - Identify parathyroid glands (pathological)
• Lymph nodes
- normal - reactive - pathological
Level 1 Competencies to be acquired
To be able to:
• Perform a basic EUS exam Level 1 Theoretical & Practical Course
The course content is equal to the Level 1 knowledge base and the Level 1 competencies
to be acquired listed above. The course should be minimum 20 hours duration at the
beginning of the training period. The theory course should include a pre- and a posttest.
The entire course should be concluded with a course exam covering theory and practice.
The practical sessions should be performed as Hands On Training (HOT):
- HOT 1
o Basic EUS views on normal models
o Revision of normal findings
80
- HOT 2
o Basic EUS views on normal models or patients or sonosimulators
o Revision of pathological findings (tutorial laptops)
- HOT 3
o Individual reappraisal with interactive in-depth training
The course should be concluded with a course exam in theory and practice of basic UVS:
• Theory (30 minutes, 25 MCQ)
• Practice (15 minutes, simulator or model)
Proctored Level 1 practice
• Supervision and recommended number of exams: Within 3 months after the course,
the trainee should collect a minimum of 50 EUS exams under supervision: 25 fully
supervised basic EUS exams (TYPE A exams) + 25 autonomously collected (TYPE B
exams, for later validation). The last 25 autonomously performed exams can be
validated either by: a) physical delivery of the electronic logbook + digital clips/images
on a mass storage device (CD/DVD/USB stick) to the assigned tutor once the
collection is completed; b) by internet sharing with a distant tutor. Training should
usually be supervised by a level 2 practitioner. In certain circumstances it may be
appropriate to delegate some of this supervision to an experienced level 1 practitioner
with at least two years of regular practical experience. When local tutors are not
available, the 25 TYPE A exams can be replaced by 25 autonomously collected exams
and internet sharing with a distant tutor where the exams are uploaded and audited
sequentially one-by-one (a dedicated area will be activated on the CECLUS channel,
with reserved access to trainer’s page matched with distance tutor). Lack of information
on single cases, not allowing accurate judgement on trainees competence makes the
case not valid for final certification.
• Documentation: All exams must be video recorded and archived in digital format and
data collected in the electronic logbook (excel file). The documentation should record
time spent, need for supervision and correction, and rating of sonoanatomic skill,
imaging, image quality, and diagnostic performance. During the course of training the
competency assessment sheet should be completed.
81
• Curriculum: All the above mentioned pathology scenarios should be represented. An
exam can be a real clinical EUS exam or a simulated EUS exam: Didactic cases
(provided from local tutors and from distant tutors) should compensate for lack of an
adequate number of cases on some types of less frequent abnormalities. These should
not be reported in the logbook but rather listed, indicated separately as part of exam
final documentation. Sequential examinations on the same patients upon relevant
clinical/therapeutical changes are encouraged; provided there’s relevant change in the
findings, they will be counted as individual cases. No more than 10% exams with
normal findings are to be considered for the final certification
Final Level 1 certification of basic EUS
Different trainees will acquire the necessary skills at different rates and the end point of the
training programme should be judged by an assessment of competencies in the form of
theoretical and practical certification. The theoretical and practical certification should
encompass the full range of the Level 1 knowledge database and competencies to be
acquired listed above.
• Theory (2 hours,100 MCQ)
• Practice (30 minutes, simulator or model)
Areas of competence assessed during certification examination:
• Image generation
• Image acquisition
• Image interpretation
• Image administration
• Clinical and organizational thinking
Tools that may be used for the assessment during certification examination:
• MCQs (overall theoretical assessment)
• Videoclip assessment (assessment of pathological clips interpretation and simulated
clinical integration of findings)
• EUS exam on a healthy volunteer (assessment of technical skills in machine setting,
image acquisition and storage)
82
• EUS on a real patient with relevant morbidity (overall practical assessment)
• Case discussion presented by the trainee
4.3 Level 2
The training requisite to this level of practice would be gained during a period of sub-
specialty training, which may either be within or after the completion of a specialist training
programme.
• The training should include a theoretical and practical course of at least 10 hours
(see below) followed by a theoretical and practical examination and the trainee
should read appropriate literature, scientific journals, and textbooks
• Competencies will have been acquired during training for level 1 practice which will
then be refined by performing a minimum of 30 clinic sessions at a centre where
supervision by someone with a Level 2 competence is available.
• Typically a Level 2 practitioner will have undertaken at least 200 ultrasound
examinations within advanced EUS before Level 2 certification.
• An electronic log book should be kept documenting a minimum of 50 exams which
should include ideally all Level 2 competencies for advanced EUS. A procedure can
be a real clinical EUS procedure or a simulated procedure. A minimum of 25
procedures have to be real clinical EUS procedures. • The theoretical and practical certification should encompass the full range of
procedures listed below.
• To maintain competence at Level 2 practitioners should perform at least 400 clinical
examinations each year within their Level 2 subspecialty of advanced
endocrinological ultrasound.
Level 2 Knowledge Base and Recommended Contents of Level 2 Theoretical and
Practical Course
o new ultrasound modalities (eg. 4D ultrasound, MRI and image fusion)
o advanced sound and ultrasound physics
o advanced ultrasound system machine controls
o advanced ultrasound system user controls
o advanced ultrasound techniques
83
o advanced administration (teaching, documentation, organization)
o advanced ultrasound artefacts
o advanced EUS
o anatomy and sonoanatomy focusing on the thyroid gland
o complications
o safety
Level 2 Competencies to be acquired
o ultrasound guided thyroid gland biopsies
4.4 Level 3
A level 3 practioner is likely to spend the majority of their time undertaking ultrasound
including EUS and teaching, research and development within their subspecialized field
and will be an expert in this area. Typically a level 3 EUS expert would be a radiologist
rather than an endocrinologist.
4.5 Maintenance of skills
Having been assessed as competent to practice there will be a need for continued
professional development (CPD) and maintenance of practical skills. Recommended
numbers of examinations to be performed annually to maintain skills at each level
Level 1: the practitioner should perform at least 100 basic EUS exams each year.
Level 2: the practitioner should perform at least 200 basic and advanced EUS exams each
year.
Level 3: the practitioner should perform at least 400 basic and advanced EUS exams each
year.
Practitioners should:
• include EUS in their continued medical education (CME)
• audit their practice
• participate in multidisciplinary meetings
• keep up to date with relevant literature
84
5. Pediatric ultrasound
5.1 Introduction This curriculum is intended for CECLUS certification Level 1-3 of pre-specialists and
specialists of pediatrics who perform pediatric ultrasound (PUS).The curriculum of PUS is
modular in order to relate the training to the specialist requirements of the trainee. Within
any one level of training it may be appropriate for a trainee to become proficient in some
but not all of the individual modules and only undertake ultrasound practice in this/these
areas. Except level one which contains the basic common trunk for all specialists of
pediatrics.
The level 1 modules of pediatric ultrasound are:
• FATE protocol • eFAST protocol
o (including pleura/lung, urinary bladder and internal jugular vein)
• vascular access • brain
The level 2 and level 3 modules of pediatric ultrasound are:
• cardiology • neurology • rheumatology • nephrourology
• gastroenterology • emergency medicine/infectious diseases • neonatology
5c1. Pediatric FATE (focus assessed transthoracic echocardiography)
5c1.1 Introduction This curriculum is intended for CECLUS certification Level 1-3 of pediatrics who perform
focused cardiac ultrasound – also called FATE (focus assessed transthoracic
echocardiography). FATE includes standards for theoretical knowledge and practical skills.
Introductory level (pre-certification)
Performance of supervised basic pediatric FATE prior to Level 1 certification.
Level 1 (basic) pediatric FATE certification
Performance of unsupervised basic pediatric FATE. Basic pediatric FATE is easy and
effective basic assessment of haemodynamics. Basic pediatric FATE certification should
be obtained by all clinical specialists assessing potentially acute or critically ill pediatric
patients. It is especially recommended that all pediatrics obtain Level 1 pediatric FATE
competence, preferably prior to or during their specialist training. At least Level 1
competence should be obtained by anyone performing basic pediatric FATE
unsupervised.
Level 2 (advanced) pediatric FATE certification
Subspecialized clinical specialist of pediatrics who perform focused cardiac assessment
with ultrasound most working days. Advanced pediatric FATE is typically obtained by
specialists in pediatrics subspecialized in neonatology, pediatric emergency
medicine/infectious diseases or pediatric cardiology.
Level 3 (expert) pediatric FATE certification
Clinical specialists who perform basic and advanced pediatric FATE every working day
and most of the day, and who are active with pediatric FATE related science and teaching.
Only very few clinical specialists employing pediatric FATE obtain the expert pediatric
FATE level 3 certification. They are typically employed in a few university hospital centers.
86
Typical progression from introduction level to level 3
(1) Theory course pretest
(2) Theory course of basic pediatric FATE
(3) Theory course posttest
(4) Practical hands-on course of basic pediatric FATE
(2) Course exam in theory and practice of basic pediatric FATE
(3) Proctored practice (supervised procedures) of basic pediatric FATE
(4) Level 1 certification of basic pediatric FATE
(5) Unsupervised maintenance of basic pediatric FATE
(6) Theory & practice course of advanced pediatric FATE
(7) Course exam of advanced pediatric FATE
(8) Supervised procedures of advanced pediatric FATE
(9) Level 2 certification of advanced pediatric FATE - theory & practice
(10) Level 3 certification of expert pediatric FATE: Level 2 certified + minimum 400 basic
and advanced pediatric FATE exams per year for at least two years + teaching experience
within advanced pediatric FATE + minimum three pediatric FATE related scientific
publications in peer reviewed papers (PhD level)
5c1.2 Level 1
Level 1 Knowledge Base and Recommended Contents of Level 1 Theoretical & Practical
Course
Wave, sound and ultrasound physics
Ultrasound system machine controls
Ultrasound system user controls
Ultrasound techniques
- B mode (2D brightness mode)
- M mode (motion mode)
Ergonomics
Sterility
Safety
87
Administration
• Implementation of a focused echocardiography program
Sonoanatomy
• basic TTE (transthoracic echocardiography) 2D views
o subcostal 4-chamber
o apical 4-chamber
o parasternal long axis
o parasternal short axis at the following levels:
aortic valve (base)
mitral leaflet tips
papillary muscles
Cardiac function
systolic ventricular function
diastolic ventricular function
ejection fraction
fractional shortening
mitral septal separation
mitral annular plane systolic excursion (MAPSE)
tricuspid annular plane systolic excursion (TAPSE)
LV dimensions (2D and M-mode)
• Septal thickness at end diastole
• Cavity size at the end diastole
• Posterior wall thickness at end diastole
• Cavity size at end systole
Aortic root dimension
Left atrial dimension
Sonopathology
• Basic cardiac chamber dysfunction o dilated left atrium o dilated left ventricle
o dilated right atrium o dilated right ventricle
88
o hypertrophy left ventricle
• Mesothelial cavities o pericardial effusion
basic US diagnosis of cardiac tamponade US guided pericardiocentesis
• Pedunculated masses
• Endocarditis and the valves
• Hypovolemia
Level 1 Competencies to be acquired
To be able to perform a basic pediatric FATE exam:
• Perform echocardiographic examinations safely and accurately and acquire all
standard views
• To recognise and differentiate between normal anatomy/physiology and pathology • To diagnose common abnormalities within the cardiovascular system • To recognize when a referral for a second opinion is indicated • To understand the relationship between echocardiographic imaging and other
diagnostic imaging techniques • Perform focused point-of-care echocardiographic hemodynamic monitoring of
patient response to interventions and diagnostics: o Ventricular function
Systolic function and wall motion abnormalities
Diastolic function o Hypovolemia and volume responsiveness o Tamponade and pericardial disease o The sepsis syndromes
o Effects of preload and afterload and assessment of filling status o Acute cor pulmonale o Hypoxemia o Chest trauma
o Assessment of shock o Peri-resuscitation
89
o Failure to wean from mechanical ventilation
o Patent Ductus arteriosus o Hemodynamic measurements
Level 1 Theoretical & Practical Course
The course content is equal to the Level 1 knowledge base and the Level 1 competencies
to be acquired listed above. The course should be minimum 20 hours duration at the
beginning of the training period. The theory course should include a pre- and a posttest.
The entire course should be concluded with a course exam covering theory and practice.
The practical sessions should be performed as Hands On Training (HOT):
- HOT 1
o Basic TTE views on normal models
o Revision of normal findings
- HOT 2
o Basic TTE views on normal models or patients or sonosimulators
o Revision of pathological findings (tutorial laptops)
- HOT 3
o Individual reappraisal with interactive in-depth training
The course should be concluded with a course exam in theory and practice of basic
pediatric FATE:
• Theory (30 minutes, 25 MCQ)
• Practice (15 minutes, simulator or model)
Proctored Level 1 practice
• Within 6 months after the course, the trainee should collect a minimum of 25 fully
supervised basic pediatric FATE exams (TYPE A exams) + 25 autonomously collected
(TYPE B exams, for later validation). All exams must be archived in digital format and
data collected in the logbook (excel file). When digital storage (strongly encouraged) is
not available, detailed printouts of exams must be collected in a way to allow for
understanding of dynamic phenomena (end-diastole/end-systole; end-expiration/end-
inspiration; M-mode)
90
• When local tutors are not available, for the 25 fully supervised exams a period in a
CECLUS certified International Training Center is required. Alternatively the 25 TYPE A
exams can be replaced by 25 autonomously collected exams and internet sharing with
a distant tutor where the exams are uploaded and audited sequentially one-by-one (a
dedicated area will be activated on the CECLUS channel, with reserved access to the
trainees page matched with distance tutor). Lack of information on single cases, not
allowing accurate judgement on trainees competence makes the case not valid for final
certification.
• The last 25 autonomously performed exams can be validated either by: a) physical
delivery of logbook + digital clips/images on a mass storage device (CD/DVD/USB
stick) to the assigned tutor once the collection is completed; b) by internet sharing with
a distant tutor (see above). Training in Cardiological Echo Labs is encouraged,
especially to acquire confidence with main TTE views. Focused Echo should be
preferrably performed in patients with pathological hemodynamics.
• Case mix should include: LV dysfunction, RV dysfunction (acute cor pulmonale),
hypovolemia, vasoplegia, cardiac tamponade, cardiac standstill, valvular disease.
• The following scenarios may be represented: PEA, cardiac arrest, septic shock,
trauma, congenital cardiac disease.
• Didactic cases (provided from local tutors and from distant tutors) should compensate
for lack of an adequate number of cases on some types of less frequent abnormalities.
These should not be reported in the logbook but rather listed, indicated separately as
part of exam final documentation. Sequential examinations on the same patients upon
relevant clinical/therapeutical changes are encouraged; provided there’s relevant
change in the findings, they will be counted as individual cases.
• No more than 10% exams with normal findings are to be considered for the final
certification
Final Level 1 certification of basic pediatric FATE
Different trainees will acquire the necessary skills at different rates and the end point of the
training programme should be judged by an assessment of competencies in the form of
theoretical and practical certification. The theoretical and practical certification should
91
encompass the full range of the Level 1 knowledge database and competencies to be
acquired listed above.
• Theory (2 hours,100 MCQ)
• Practice (30 minutes, simulator or model)
Areas of competence assessed during examination
• Image generation
• Image acquisition
• Image interpretation
• Image administration
• Clinical and organizational thinking
Tools that may be used for the assessment during examination
• MCQs (overall theoretical assessment)
• Videoclip assessment (assessment of pathological clips interpretation and simulated
clinical integration of findings)
• TTE on a healthy volunteer (assessment of technical skills in machine setting, image
acquisition and storage)
• TTE on a real critical or cardially morbid patient (overall practical assessment,
including ECHO-guided patient management)
• Case discussion presented by the trainee
Certification for physicians already holding national/international TTE certifications
Physicians holding national or international echocardiography accreditation are considered
technically competent in the execution of a Focused Echo exam. Their clinical competence
in image integration into the critical or acute cardiac patient management should though
be certified by provision of minimum 25 documented exams (Logbook) + exam on a critical
patient + case discussion.
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5c1.3 Level 2 The training requisite to this level of practice would be gained during a period of sub-
specialty training, which may either be within or after the completion of a specialist training
programme.
• The training should include a theoretical and practical course of at least 30 hours
(see below) followed by a theoretical and practical examination and the trainee
should read appropriate literature, scientific journals, and textbooks
• Competencies will have been acquired during training for level 1 practice which will
then be refined by performing a minimum of 30 clinical sessions at a centre where
supervision by someone with a Level 2 competence is available.
• Typically a Level 2 practitioner will have undertaken at least 800 ultrasound
examinations within advanced pediatric FATE before Level 2 certification.
• An electronic log book should be kept documenting a minimum of 50 procedures
which should include ideally all Level 2 competencies for advanced FATE.
• The theoretical and practical certification should encompass the full range of
sonopathology listed below.
• To maintain competence at Level 2 practitioners should perform at least 400
advanced pediatric FATE examinations each year.
Level 2 Knowledge Base and Recommended Contents of Level 2 Theoretical and
Practical Course
o new ultrasound modalities (eg. 4D ultrasound, MRI, image fusion)
o contrast agents
o advanced sound and ultrasound physics
o advanced ultrasound system machine controls
o advanced ultrasound system user controls
o advanced ultrasound techniques
o advanced administration (teaching, documentation, organization)
o advanced ultrasound artefacts
o advanced pediatric FATE:
o systolic function
93
preload (Frank-Starling's law)
afterload (LaPlace's law)
contractility (intrinsic myocardial function)
ejection fraction (eyeballing, calculation with M-mode)
hemodynamic parameters (cardiac output (CO) with pulsed wave
Doppler (PWD))
o diastolic function
compliance and relaxation of the left ventricle using transmitral flow
curve visualized with PWD
estimating inotropic effect and/or volume effect
o pericardial effusion
o pleural effusion
o pathology (septic shock, chest trauma, tamponade, pulmonary oedema
(cardiogenic and non-cardiogenic), weaning failure from mechanical
ventilation, ARDS, acute valvular dysfunction)
o valvular stenosis using pressure gradients (continuous wave Doppler - CWD)
o insufficiency jets (valvular insufficiency) and atrial septal defect and
ventricular septal defect using colour flow Doppler (CFD)
o assessment of wall thickness and chamber dimensions in M-mode
o assessment of bi-ventricular function
o application of extended FATE views
subcostal vena cava
apical 2-chamber view
apical long-axis view
apical 5-chamber view
parasternal short axis mitral plane view
parasternal aorta short axis view
o diastolic left ventricular function
o Doppler (continuous wave, pulsed wave)
o Measurement of cardiac filling pressures
o Measurement of cardiac output and pulmonary artery pressure
94
Level 2 Competencies to be acquired
o advanced pediatric FATE
o perform the advanced pediatric FATE protocol
o estimate chamber dimensions and left ventricular diameter (M-mode)
o estimated contractility (systolic function) of both ventricles
o estimate fractional shortening (FS) and ejection fraction (EF) with M-mode of
the left ventricle
o estimated cardiac output of left ventricle with continuous wave Doppler
o gauge mitral annular plane systolic excursion (MAPSE)
o gauge mitral septal separation (MSS)
o gauge tricuspid annular plane systolic excursion (TAPSE)
o visualize transmitral flow with PWD
o identify important pathology, e.g. left ventricular dilatation, left ventricular
hypertrophy, hypovolemia, left atrial dilatation, right ventricular dilatation,
pericardial effusion, pleural effusion, anatomical defects.
o detect valvular stenosis and/or insufficiency using CWD and CFD.
o correlate sonographic findings to clinical context.
o Color Doppler mapping
o Quantitative spectral Doppler
Pulsed Doppler
Continous wave Doppler
o TDI (Tissue Doppler Imaging)
5c1.4 Level 3
A level 3 practioner is likely to spend the majority of their time undertaking pediatric FATE
or teaching, research and development within their subspecialized field and will be an
expert in this area. A Level 3 practitioner will accept tertiary referrals from Level 1 and 2
practioners. He/she should have the capability to utilise developing technologies and
ultrasound techniques, develop research and teaching skills and the performance of
specialised examinations including the use of ultrasound guided interventional procedures.
95
5c1.5 Maintenance of skills
Having been assessed as competent to practice there will be a need for continued
professional development (CPD) and maintenance of practical skills. Recommended
numbers of examinations to be performed annually to maintain skills at each level
Level 1: the practitioner should perform at least 100 basic pediatric FATE exams each
year.
Level 2: the practitioner should perform at least 200 basic and advanced pediatric FATE
exams each year.
Level 3: the practitioner should perform at least 400 basic and advanced pediatric FATE
exams each year.
Practitioners should:
• include pediatric FATE in their continued medical education (CME)
• audit their practice
• participate in multidisciplinary meetings
• keep up to date with relevant literature
Maintenance requirements
• Practicioners should perform at least 50 basic pediatric FATE examinations annually. • Recertification every 2 years, by submission of logbook.
• Refresher course (4 hours).
5c2. Pediatric extended FAST (focused assessment with sonography in trauma)
5c2.1 Introduction This protocol is intended for CECLUS certification Level 1 of pediatrics who perform
pediatric focused assessment with sonography in trauma – also called FAST. Pediatric
FAST includes standards for theoretical knowledge and practical skills.
The extended version of FAST is presented which includes assessment of:
- pericardial effusion
- peritoneal effusion
- pleural effusion
- abdominal aorta
- inferior vena cava
- urinary bladder
Typical progression to extended pediatric FAST certification
(1) Theory course pretest
(2) Theory course of extended pediatric FAST
(3) Theory course posttest
(4) Practical hands-on course of extended pediatric FAST
(2) Course exam in theory and practice of extended pediatric FAST
(3) Proctored practice (supervised procedures) of extended pediatric FAST
(4) Certification of extended pediatric FAST
5c2.2 Level 1 Knowledge Base and Recommended Contents of Theoretical & Practical Course
A minimum of 10 hours theoretical and practical teaching is required preferably at the
beginning of the training period. Prior to the theory course the practitioner performs a
pretest. The theory course should be concluded with a posttest with a minimum level of
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performance before entering the practical hands-on course. The theoretical and practical
courses should cover:
Wave, sound and ultrasound physics
Ultrasound system machine controls
Ultrasound system user controls (knobbology)
Ultrasound techniques
- B mode (2D brightness mode)
- M mode (motion mode)
Ergonomics
Sterility
Safety
Administration
• Implementation of an extended program
Sonoanatomy
• Extended FAST 2D and M-mode views
o Pleura
Anterior, bilateral
Posterior, bilateral
o Pericardium
o Peritoneum
Liver/right kidney
Spleen/left kidney
Rectovesical/vesicouterine pouch
Urinary bladder
Abdominal aorta
Inferior vena cava
Sonopathology
• Pneumothorax
• Pleura effusion • Cardiac tamponade • Peritoneal effusion
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• Distended urinary bladder
• Abdominal aortic enlargement • Hypovolemia
Extended Pediatric FAST Competencies to be acquired
To be able to perform an extended pediatric FAST exam:
• Perform the extended pediatric FAST examinations safely and accurately and
acquire all standard views • To recognise and differentiate between normal anatomy/physiology and pathology
• To diagnose common abnormalities • To recognize when a referral for a second opinion is indicated • To understand the relationship between ultrasound imaging and other diagnostic
imaging techniques
Practical course: Organisation of practical sessions
The practical sessions should be performed as Hands On Training (HOT):
- HOT 1
o Extended FAST views on normal models
o Revision of normal findings
- HOT 2
o Extended FAST views on normal models or patients or sonosimulators
o Revision of pathological findings (tutorial laptops)
- HOT 3
o Individual reappraisal with interactive in-depth training
Theoretical and practical course exam on extended pediatric FAST
• Theory (30 minutes, 25 MCQ)
• Practice (15 minutes, simulator or model)
Proctored extended pediatric FAST practice
• Within 3 months after the course, the trainee should collect a minimum of 25 fully
supervised extended pediatric FAST exams (TYPE A exams) + 25 autonomously
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collected (TYPE B exams, for later validation). All exams must be archived in digital
format and data collected in the logbook (excel file). When digital storage (strongly
encouraged) is not available, detailed printouts of exams must be collected in a way to
allow for understanding of dynamic phenomena.
• When local tutors are not available, for the 25 fully supervised exams a period in a
CECLUS certified International Training Center is required. Alternatively the 25 TYPE A
exams can be replaced by 25 autonomously collected exams and internet sharing with
a distant tutor where the exams are uploaded and audited sequentially one-by-one (a
dedicated area will be activated on the CECLUS channel, with reserved access to the
trainees page matched with distance tutor). Lack of information on single cases, not
allowing accurate judgement on trainees competence makes the case not valid for final
certification.
• The last 25 autonomously performed exams can be validated either by: a) physical
delivery of logbook + digital clips/images on a mass storage device (CD/DVD/USB
stick) to the assigned tutor once the collection is completed; b) by internet sharing with
a distant tutor (see above). The FAST exams should be preferrably performed in
patients with pathological hemodynamics.
• Case mix should include: Pneumothorax, pleura effusion, cardiac tamponade,
peritoneal effusion, distended urinary bladder, abdominal aortic enlargement, and
hypovolemia.
• The following scenarios may be represented: PEA, cardiac arrest, septic shock,
trauma, congenital cardiac disease.
• Didactic cases (provided from local tutors and from distant tutors) should compensate
for lack of an adequate number of cases on some types of less frequent abnormalities.
These should not be reported in the logbook but rather listed, indicated separately as
part of exam final documentation. Sequential examinations on the same patients upon
relevant clinical/therapeutical changes are encouraged; provided there’s relevant
change in the findings, they will be counted as individual cases.
• No more than 10% exams with normal findings are to be considered for the final
certification
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Final certification of extended pediatric FAST
• Theory (30 minutes, 25 MCQ)
• Practice (15 minutes, simulator or model)
Areas of competence assessed during examination
• Image generation
• Image acquisition
• Image interpretation
• Image administration
• Clinical and organizational thinking
Tools that may be used for the assessment during examination
• MCQs (overall theoretical assessment)
• Videoclip assessment (assessment of pathological clips interpretation and simulated
clinical integration of findings)
• Extended FAST on a healthy volunteer (assessment of technical skills in machine
setting, image acquisition and storage)
• Extended FAST on a real patient (overall practical assessment, including FAST-guided
patient management)
• Case discussion presented by the trainee
Maintenance requirements
• Practicioners should perform at least 50 extended pediatric FAST examinations
annually. • Recertification every 2 years, by submission of logbook. • Refresher course (4 hours).
Certification for physicians already holding national/international TTE certifications
Physicians holding national or international estende FAST accreditation are considered
technically competent in the execution of an estended pediatric FAST exam. Their clinical
competence in image integration into the critical or acute cardiac patient management
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should though be certified by provision of minimum 10 documented exams (Logbook) +
exam on a critical patient + case discussion.
5c3. Pediatric ultrasound guided vascular access
5c3.1 Introduction This curriculum is intended for CECLUS certification Level 1-3 of pediatrics who perform
pediatric ultrasound guided vascular access (UGVA). Pediatric UGVA includes standards
for theoretical knowledge and practical skills.
Introductory level (pre-certification)
Performance of supervised basic pediatric UGVA prior to Level 1 certification.
Level 1 (basic) pediatric UGVA certification
Performance of unsupervised basic pediatric UGVA. Basic pediatric UGVA certification
should be obtained by all clinical specialists managing pediatric patients. It is especially
recommended that all pediatrics obtain Level 1 pediatric UGVA competence, preferably
prior to or during their specialist training. At least Level 1 competence should be obtained
by anyone performing basic pediatric UGVA unsupervised.
Level 2 (advanced) pediatric UGVA certification
Subspecialized clinical specialist of pediatrics who perform pediatric UGVA most working
days. Advanced pediatric UGVA is typically obtained by specialists in pediatrics
subspecialized in neonatology.
Level 3 (expert) pediatric UGVA certification
Clinical specialists who perform basic and advanced UGVA every working day, and who
are active with UGVA related science and teaching. Only very few clinical specialists
employing pediatric UGVA obtain the expert pediatric UGVA level 3 certification – if any.
They would typically be employed in a few university hospital centers.
Typical progression from introduction level to level 3
(1) Theory course pretest
(2) Theory course of basic pediatric UGVA
(3) Theory course posttest
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(4) Practical hands-on course of basic pediatric UGVA
(2) Course exam in theory and practice of basic pediatric UGVA
(3) Proctored practice (supervised procedures) of basic pediatric UGVA
(4) Level 1 certification of basic pediatric UGVA
(5) Unsupervised maintenance of basic pediatric UGVA
(6) Theory & practice course of advanced pediatric UGVA
(7) Course exam of advanced pediatric UGVA
(8) Supervised procedures of advanced pediatric UGVA
(9) Level 2 certification of advanced pediatric UGVA - theory & practice
(10) Level 3 certification of expert pediatric UGVA: Level 2 certified + minimum 400 basic
and advanced pediatric UGVA exams per year for at least two years + teaching
experience within advanced pediatric UGVA + minimum three pediatric UGVA related
scientific publications in peer reviewed papers (PhD level)
5c3.2 Level 1
Level 1 Knowledge Base and Recommended Contents of Level 1 Theoretical & Practical
Course
Wave, sound and ultrasound physics
Ultrasound system machine controls
Ultrasound system user controls (knobbology)
Ultrasound techniques
- B mode (2D brightness mode)
- Doppler (color)
- In-plane/out-of-plane
Ergonomics
Sterility
Safety
Administration
• Implementation of an UGVA program
Sonoanatomy
• Superficial cubital and antebrachial veins
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• Brachial veins
• Major saphenous vein
• Femoral vein
• Internal jugular vein
• Subclavian vein/axillary vein
• Radial artery
• Femoral artery
Sonopathology
• Thrombosis
• Complications
Pitfalls and limitations
Level 1 Competencies to be acquired
To be able to perform basic pediatric UGVA:
• Perform UGVA safely and accurately • To recognise and differentiate between normal anatomy/physiology and pathology • To recognize when a referral for a second opinion is indicated
Level 1 Theoretical & Practical Course
The course content is equal to the Level 1 knowledge base and the Level 1 competencies
to be acquired listed above. The course should be minimum 10 hours duration at the
beginning of the training period. The theory course should include a pre- and a posttest.
The entire course should be concluded with a course exam covering theory and practice.
The practical sessions should be performed as Hands On Training (HOT):
- HOT 1
o Basic UGVA views on normal models
o Revision of normal findings
- HOT 2
o Basic UGVA views on normal models or patients or sonosimulators
o Revision of pathological findings (tutorial laptops)
- HOT 3
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o Individual reappraisal with interactive in-depth training
Level 1 theoretical and practical course exam on basic UGVA
• Theory (30 minutes, 25 MCQ)
• Practice (15 minutes, simulator or model)
Proctored Level 1 practice
• Within 3 months after the course, the trainee should collect a minimum 5f 20 fully
supervised basic pediatric UGVA procedures (TYPE A exams) + 25 autonomously
collected (TYPE B exams, for later validation). All exams must be archived in digital
format and data collected in the logbook (excel file). When digital storage (strongly
encouraged) is not available, detailed printouts of exams must be collected in a way to
allow for understanding of dynamic phenomena
• When local tutors are not available, for the 25 fully supervised procedures they can be
replaced by 25 autonomously collected exams and internet sharing with a distant tutor
where the exams are uploaded and audited sequentially one-by-one (a dedicated area
will be activated on the CECLUS channel, with reserved access to the trainees page
matched with distance tutor). Lack of information on single cases, not allowing accurate
judgement on trainees competence makes the case not valid for final certification.
• The last 25 autonomously performed exams can be validated either by: a) physical
delivery of logbook + digital clips/images on a mass storage device (CD/DVD/USB
stick) to the assigned tutor once the collection is completed; b) by internet sharing with
a distant tutor (see above).
• Case mix should include UGVA into all abovementioned veins and arteries.
• Didactic cases (provided from local tutors and from distant tutors) should compensate
for lack of an adequate number of cases on some types of less frequent UGVA
procedures. These should not be reported in the logbook but rather listed, indicated
separately as part of exam final documentation.
Final Level 1 certification of basic pediatric FATE
• Theory (30 minutes, 25 MCQ)
• Practice (15 minutes, simulator or model)
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Areas of competence assessed during examination
• Image generation
• Image acquisition
• Image interpretation
• Image administration
• Clinical and organizational thinking
Tools that may be used for the assessment during examination
• MCQs (overall theoretical assessment)
• Videoclip assessment (assessment of pathological clips interpretation and simulated
clinical integration of findings)
• UGVA imaging on a healthy volunteer (assessment of technical skills in machine
setting, image acquisition and storage)
• Case discussion presented by the trainee
Maintenance requirements
• Practicioners should perform at least 50 basic pediatric FATE examinations annually. • Recertification every 2 years, by submission of logbook. • Refresher course (1 hour).
Certification for physicians already holding national/international TTE certifications
Physicians holding national or international UGVA accreditation are considered technically
competent in the execution of basic UGVA. Their clinical competence in UGVA should
though be certified by provision of minimum 25 documented exams (Logbook) + exam on
a model + case discussion.
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5c3.3 Level 2
The training requisite to this level of practice would be gained during a period of sub-
specialty training, which may either be within or after the completion of a specialist training
programme.
• The training should include a theoretical and practical course of at least 5 hours
(see below) followed by a theoretical and practical examination and the trainee
should read appropriate literature, scientific journals, and textbooks
• Competencies will have been acquired during training for level 1 practice which will
then be refined by performing a minimum of 50 clinical sessions at a centre where
supervision by someone with a Level 2 competence is available.
• Typically a Level 2 practitioner will have undertaken at least 100 ultrasound
examinations within advanced pediatric UGVA before Level 2 certification.
• An electronic log book should be kept documenting a minimum of 50 procedures
which should include ideally all Level 2 competencies for advanced UGVA.
• To maintain competence at Level 2 practitioners should perform at least 100
advanced pediatric UGVA each year. Level 2 Knowledge Base and Recommended Contents of Level 2 Theoretical and
Practical Course
A minimum of 30 hours theoretical and practical teaching is required. Prior to the theory
course the practitioner performs a pretest. The theory course should be concluded with a
posttest with a minimum level of performance before entering the practical hands-on
course. The theoretical and practical courses should cover:
o advanced sound and ultrasound physics
o advanced ultrasound system machine controls
o advanced ultrasound system user controls
o advanced ultrasound techniques
o advanced administration (teaching, documentation, organization)
o advanced ultrasound artefacts
o advanced pediatric UGVA:
o Central venous catheters
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Umbilical vein catheter
Femoral vein catheter
Subclavian vein catheter
o Umbilical artery catheter
o Radial artery catheter
Level 2 Competencies to be acquired
o perform the advanced pediatric UGVA procedures
o apply color Doppler
5c3.4 Level 3 A level 3 practioner is likely to spend a substantial amount of their time undertaking
pediatric UGVA or teaching, research and development within their subspecialized field
and will be an expert in this area.
5c3.5 Maintenance of skills Having been assessed as competent to practice there will be a need for continued
professional development (CPD) and maintenance of practical skills. Recommended
numbers of examinations to be performed annually to maintain skills at each level
Level 1: the practitioner should perform at least 50 basic UVS exams each year.
Level 2: the practitioner should perform at least 100 basic and advanced UVS exams each
year.
Level 3: the practitioner should perform at least 200 basic and advanced UVS exams each
year.
Practitioners should:
• include pediatric UGVA in their continued medical education (CME)
• audit their practice
• participate in multidisciplinary meetings
• keep up to date with relevant literature
5d. Pediatric neurology ultrasound 5d.1 Introduction This curriculum is intended for CECLUS certification Level 1-3 of pediatrics who perform
pediatric neurology ultrasound. Pediatric neurology ultrasound (NUS) includes standards
for theoretical knowledge and practical skills.
Introductory level (pre-certification)
Performance of supervised basic pediatric NUS prior to Level 1 certification.
Level 1 (basic) pediatric neurology ultrasound certification
Performance of unsupervised basic pediatric NUS. Basic pediatric NUS certification should
be obtained by all clinical specialists managing pediatric patients. It is especially
recommended that all pediatrics obtain Level 1 pediatric neurology ultrasound
competence, preferably prior to or during their specialist training. At least Level 1
competence should be obtained by anyone performing basic pediatric NUS unsupervised.
Level 2 (advanced) pediatric NUS certification
No Level 2.
Level 3 (expert) pediatric neurology ultrasound certification
No Level 3.
5d.2 Level 1 Level 1 Knowledge Base and Recommended Contents of Level 1 Theoretical & Practical
Course
Wave, sound and ultrasound physics
Ultrasound system machine controls
Ultrasound system user controls (knobbology)
Ultrasound techniques
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- B mode (2D brightness mode)
Ergonomics
Sterility
Safety
Administration
• Implementation of an neurology ultrasound program
Sonoanatomy
• Normal brain
Sonopathology
• Cerebral bleeding
o Parenchymal
o Ventricular
• Cerebral midline shift
Pitfalls and limitations
Level 1 Competencies to be acquired
• To be able to perform basic pediatric neurology ultrasound exam • To recognise and differentiate between normal anatomy/physiology and pathology • To recognize when a referral for a second opinion is indicated
Level 1 Theoretical & Practical Course
The course content is equal to the Level 1 knowledge base and the Level 1 competencies
to be acquired listed above. The course should be minimum 20 hours duration at the
beginning of the training period. The theory course should include a pre- and a posttest.
The entire course should be concluded with a course exam covering theory and practice.
The practical sessions should be performed as Hands On Training (HOT):
- HOT 1
o Basic neurology ultrasound views on normal models
o Revision of normal findings
- HOT 2
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o Basic neurology ultrasound views on normal models or patients or
sonosimulators
o Revision of pathological findings (tutorial laptops)
- HOT 3
o Individual reappraisal with interactive in-depth training
The course should be concluded with a course exam in theory and practice of basic
pediatric neurology ultrasound
• Theory (30 minutes, 25 MCQ)
• Practice (15 minutes, simulator or model)
Proctored Level 1 practice
• Within 3 months after the course, the trainee should collect a minimum of 25 fully
supervised basic pediatric NUS procedures (TYPE A exams) + 25 autonomously
collected (TYPE B exams, for later validation). All exams must be archived in digital
format and data collected in the logbook (excel file). When digital storage (strongly
encouraged) is not available, detailed printouts of exams must be collected in a way to
allow for understanding of dynamic phenomena
• When local tutors are not available, for the 25 fully supervised procedures they can be
replaced by 25 autonomously collected exams and internet sharing with a distant tutor
where the exams are uploaded and audited sequentially one-by-one (a dedicated area
will be activated on the CECLUS channel, with reserved access to the trainees page
matched with distance tutor). Lack of information on single cases, not allowing accurate
judgement on trainees competence makes the case not valid for final certification.
• The last 25 autonomously performed exams can be validated either by: a) physical
delivery of logbook + digital clips/images on a mass storage device (CD/DVD/USB
stick) to the assigned tutor once the collection is completed; b) by internet sharing with
a distant tutor (see above).
• Case mix should include neurology ultrasound exam of all the abovementioned types.
• Didactic cases (provided from local tutors and from distant tutors) should compensate
for lack of an adequate number of cases on some types of less frequent NUS exams.
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These should not be reported in the logbook but rather listed, indicated separately as
part of exam final documentation.
• Final Level 1 certification of basic NUS
• Different trainees will acquire the necessary skills at different rates and the end point of
the training programme should be judged by an assessment of competencies in the
form of theoretical and practical certification. The theoretical and practical certification
should encompass the full range of the Level 1 knowledge database and competencies
to be acquired listed above.
• Theory (30 minutes, 25 MCQ)
• Practice (15 minutes, simulator or model)
Areas of competence assessed during examination
• Image generation
• Image acquisition
• Image interpretation
• Image administration
• Clinical and organizational thinking
Tools that may be used for the assessment during examination
• MCQs (overall theoretical assessment)
• Videoclip assessment (assessment of pathological clips interpretation and simulated
clinical integration of findings)
• Neurology ultrasound imaging on a healthy volunteer (assessment of technical skills in
machine setting, image acquisition and storage)
• Case discussion presented by the trainee
Certification for physicians already holding national/international neurology ultrasound
certifications
Physicians holding national or international neurology ultrasound accreditation are
considered technically competent in the execution of basic pediatric neurology ultrasound .
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Their clinical competence in neurology ultrasound should though be certified by provision
of minimum 5 documented exams (Logbook) + exam on a model + case discussion.
5d.3 Maintenance • Practicioners should perform at least 50 basic pediatric neurology ultrasound
examinations annually. • Recertification every 2 years, by submission of logbook.
• Refresher course (1 hour).
6. Oto-rhino-laryngeal ultrasound
6.1 Introduction
This curriculum is intended for CECLUS certification Level 1-3 of oto-rhino-laryngologists
who perform oto-rhino-laryngeal ultrasound – also called ORLUS. ORLUS includes
standards for theoretical knowledge and practical skills.
The curriculum of oto-rhino-laryngeal ultrasound (ORLUS) is 3-leveled and modular in
order to relate the training to the specialist requirements of the trainee. Within any one
level of training it may be appropriate for a trainee to become proficient in some but not all
of the individual modules and only undertake ultrasound practice in this/these areas.
Except level one which contains the basic common trunk for all specialists of oto-rhino-
laryngology.
Introductory level (pre-certification)
Performance of supervised ORLUS prior to Level 1 certification.
Level 1 (basic) ORLUS certification
Performance of unsupervised basic ORLUS. Basic ORLUS is easy and effective basic
assessment of oto-rhino-laryngeal anatomy and pathology relevant for all oto-rhino-
laryngologists. Basic ORLUS certification should be obtained by all specialists of oto-rhino-
laryngology, preferably prior to or during their specialist training. At least Level 1
competence should be obtained by anyone performing basic ORLUS unsupervised.
Level 2 (advanced) ORLUS certification
Subspecialized clinical specialist of oto-rhino-laryngology. Advanced ORLUS is typically
obtained by specialists subspecialized in neck surgery.
Level 3 (expert) ORLUS certification
Clinical specialists who perform basic and advanced ORLUS every working day and most
of the day, and who are active with ORLUS related science and teaching. Only very few
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clinical specialists employing ORLUS obtain the expert ORLUS level 3 certification. They
are typically employed in a few university hospital centers.
Typical progression from introduction level to level 3
(1) Theory course pretest
(2) Theory course of basic ORLUS
(3) Theory course posttest
(4) Practical hands-on course of basic ORLUS
(2) Course exam in theory and practice of basic ORLUS
(3) Proctored practice (supervised procedures) of basic ORLUS
(4) Level 1 certification of basic ORLUS
(5) Unsupervised maintenance of basic ORLUS
(6) Theory & practice course of advanced ORLUS
(7) Course exam of advanced ORLUS
(8) Supervised procedures of advanced ORLUS
(9) Level 2 certification of advanced ORLUS - theory & practice
(10) Level 3 certification of expert ORLUS: Level 2 certified + minimum 500 basic and
advanced ORLUS exams per year for at least two years + teaching experience within
advanced ORLUS + minimum three ORLUS related scientific publications in peer
reviewed papers (PhD level)
6.2 Level 1
Level 1 Knowledge Base and Recommended Contents of Level 1 Theoretical & Practical
Course
Wave, sound and ultrasound physics
Ultrasound system machine controls
Ultrasound system user controls (knobbology)
Ultrasound techniques
- B mode (2D brightness mode)
- M mode (motion mode)
- Sonoelastography (knowledge about)
Ergonomics
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Sterility
Safety
Administration
• Implementation of a basic ORLUS programme
Sonoanatomy
• basic sonographic 2D views of normal neck anatomy
Sonopathology
• thyroid gland
o measure size
o evaluate colour (dark/light +/- thyroiditis/sequelae)
o evaluate whether the gland is homogenous/in-homogenous
if inhomogenous
• solitary node
• multiple noduli
• dominating node
• calcifications/microcalcifications
if node
• simple cyst
• semisolid cyst
• calcifications in the cystic wall
• Parathyroid gland o identify the parathyroid gland (pathological) o knowledge about parathyroid sonopathology
• Lymph nodes
o describe size and shape normal, reactive, pathological
o hilum o blood flow o levels
• Salivary glands (parotid, submandibular, sublingual)
o describe size o describe echo pattern o cysts o stones o adenomas o dilated gland ducts
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o tumours
• Carotid artery and internal jugular vein o aneyrisms o thrombosis o knowledge about sonographic features of atherosclerosis
• Median and lateral neck cysts
o identification o measure size
• Neck abscesses
Level 1 Competencies to be acquired
To be able to perform a basic ORLUS exam:
• Perform examinations and procedures safely and accurately and acquire all
standard views • To recognise and differentiate between normal anatomy/physiology and pathology
• To diagnose common abnormalities within the neck • To recognize when a referral for a second opinion is indicated • To understand the relationship between sonographic imaging and other diagnostic
imaging techniques
Perform focused point-of-care ORLUS guided interventions with monitoring of patient
response to interventions and diagnostics
• fine needle aspiration from lymph nodes • fine needle aspiration from the thyroid gland
• fine needle aspiration of neck cysts in adults Level 1 Theoretical & Practical Course
The course content is equal to the Level 1 knowledge base and the Level 1 competencies
to be acquired listed above. The course should be minimum 20 hours duration at the
beginning of the training period. The theory course should include a pre- and a posttest.
The entire course should be concluded with a course exam covering theory and practice.
The practical sessions should be performed as Hands On Training (HOT):
- HOT 1
o Basic ORLUS views on normal models
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o Revision of normal findings
- HOT 2
o Basic ORLUS views on normal models or patients or sonosimulators
o Revision of pathological findings (tutorial laptops)
- HOT 3
o Individual reappraisal with interactive in-depth training
The course should be concluded with a course exam in theory and practice of basic UVS:
• Theory (30 minutes, 25 MCQ)
• Practice (15 minutes, simulator or model)
Proctored Level 1 practice
• Within 3 months after the course, the trainee should collect a minimum of 25 fully
supervised basic ORLUS exams (TYPE A exams) + 25 autonomously collected (TYPE
B exams, for later validation). All exams must be archived in digital format and data
collected in the logbook (excel file). When digital storage (strongly encouraged) is not
available, detailed printouts of exams must be collected in a way to allow for
understanding of dynamic phenomena (end-diastole/end-systole; end-expiration/end-
inspiration; M-mode)
• When local tutors are not available, for the 25 fully supervised exams a period in a
CECLUS certified International Training Center is required. Alternatively the 25 TYPE A
exams can be replaced by 25 autonomously collected exams and internet sharing with
a distant tutor where the exams are uploaded and audited sequentially one-by-one (a
dedicated area will be activated on the CECLUS channel, with reserved access to the
trainees page matched with distance tutor). Lack of information on single cases, not
allowing accurate judgement on trainees competence makes the case not valid for final
certification.
• The last 25 autonomously performed exams can be validated either by: a) physical
delivery of logbook + digital clips/images on a mass storage device (CD/DVD/USB
stick) to the assigned tutor once the collection is completed; b) by internet sharing with
a distant tutor (see above). Focused ORLUS should be preferrably performed in
patients with relevant pathology.
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• Case mix should include all the pathological conditions mentioned above.
• Didactic cases (provided from local tutors and from distant tutors) should compensate
for lack of an adequate number of cases on some types of less frequent abnormalities.
These should not be reported in the logbook but rather listed, indicated separately as
part of exam final documentation. Sequential examinations on the same patients upon
relevant clinical/therapeutical changes are encouraged; provided there’s relevant
change in the findings, they will be counted as individual cases.
• No more than 10% exams with normal findings are to be considered for the final
certification
Final Level 1 certification of basic ORLUS
Different trainees will acquire the necessary skills at different rates and the end point of the
training programme should be judged by an assessment of competencies in the form of
theoretical and practical certification. The theoretical and practical certification should
encompass the full range of the Level 1 knowledge database and competencies to be
acquired listed above.
• Theory (2 hours,100 MCQ)
• Practice (30 minutes, simulator or model)
Areas of competence assessed during examination
• Image generation
• Image acquisition
• Image interpretation
• Image administration
• Clinical and organizational thinking
Tools that may be used for the assessment during examination
• MCQs (overall theoretical assessment)
• Videoclip assessment (assessment of pathological clips interpretation and simulated
clinical integration of findings)
• ORLUS on a healthy volunteer (assessment of technical skills in machine setting,
image acquisition and storage)
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• ORLUS on a patient with relevant pathological condition (overall practical assessment)
• Case discussion presented by the trainee
Certification for physicians already holding national/international ORLUS certifications
Physicians holding national or international ORLUS accreditation are considered
technically competent in the execution of a Focused ORLUS exam. Their clinical
competence in image integration into the oto-rhino-laryngeal patient management should
though be certified by provision of minimum 30 documented exams (Logbook) + exam on
a patient + case discussion
6.3 Level 2
The training requisite to this level of practice would be gained during a period of sub-
specialty training, which may either be within or after the completion of a specialist training
programme.
• The training should include a theoretical and practical course of at least 30 hours
(see below) followed by a theoretical and practical examination and the trainee
should read appropriate literature, scientific journals, and textbooks
• Competencies will have been acquired during training for level 1 practice which will
then be refined by performing a minimum of 30 clinical sessions at a centre where
supervision by someone with a Level 2 competence is available.
• Typically a Level 2 practitioner will have undertaken at least 1.000 ultrasound
examinations within advanced ORLUS before Level 2 certification.
• An electronic log book should be kept documenting a minimum of 50 procedures
which should include ideally all Level 2 competencies for advanced ORLUS for the
particular modality.
• The theoretical and practical certification should encompass the full module-specific
range of sonopathology listed below.
• To maintain competence at Level 2 practitioners should perform at least 500
module-specific advanced ORLUS examinations each year.
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Level 2 Knowledge Base and Recommended Contents of Level 2 Theoretical and
Practical Course
A minimum of 30 hours theoretical and practical teaching is required. Prior to the theory
course the practitioner performs a pretest. The theory course should be concluded with a
posttest with a minimum level of performance before entering the practical hands-on
course. The theoretical and practical courses should cover:
• new ultrasound modalities (eg. 3D and 4D ultrasound)
• contrast agents
• advanced sound and ultrasound physics
• advanced ultrasound system machine controls
• advanced ultrasound system user controls
• advanced ultrasound techniques
• advanced administration (teaching, documentation, organization)
• advanced ultrasound artefacts
• advanced module-specific ORLUS pathology
Level 2 Competencies to be acquired
Perform the advanced module-specific ORLUS examinations and procedures.
o Sonoelastography
6.4 Level 3
A level 3 practioner is likely to spend the majority of their time undertaking advanced
ORLUS or teaching, research and development within their subspecialized field and will be
an expert in this area.
6.5 Maintenance of skills
Having been assessed as competent to practice there will be a need for continued
professional development (CPD) and maintenance of practical skills. Recommended
numbers of examinations to be performed annually to maintain skills at each level
122
Level 1: the practitioner should perform at least 50 basic ORLUS exams each year.
Level 2: the practitioner should perform at least 100 basic and advanced ORLUS exams
each year.
Level 3: the practitioner should perform at least 200 basic and advanced ORLUS exams
each year.
Practitioners should:
• include ORLUS in their continued medical education (CME)
• audit their practice
• participate in multidisciplinary meetings
• keep up to date with relevant literature
7. Orthopedic surgery ultrasound
7.1 Introduction
This curriculum is intended for CECLUS certification Level 1-3 of orthopedic surgeons who
perform orthopedic surgery ultrasound – also called OSUS. OSUS includes standards for
theoretical knowledge and practical skills.
The curriculum of orthopedic surgery ultrasound (OSUS) is 3-leveled and modular in order
to relate the training to the specialist requirements of the trainee. Within any one level of
training it may be appropriate for a trainee to become proficient in some but not all of the
individual modules and only undertake ultrasound practice in this/these areas. Except level
one which contains the basic common trunk for all specialists of orthopedic ultrasound.
The level 1 modules of OSUS are:
• general OSUS • basic OSUS
o shoulder and elbow
o wrist and hand
o hip
o knee
o ankle and foot
The level 2 and level 3 modules of OSUS are:
• advanced shoulder and elbow OSUS • advanced wrist and hand OSUS
• advanced hip OSUS
• advanced knee OSUS
• advanced ankle and foot OSUS
Introductory level (pre-certification)
Performance of supervised OSUS prior to Level 1 certification.
Level 1 (basic) OSUS certification
Performance of unsupervised basic OSUS. Basic OSUS is easy and effective basic
assessment of musculoskeletal anatomy and pathology relevant for all orthopedic
surgeons. Basic OSUS certification should be obtained by all specialists of orthopedic
surgery, preferably prior to or during their specialist training. At least Level 1 competence
should be obtained by anyone performing basic OSUS unsupervised.
Level 2 (advanced) OSUS certification
Subspecialized clinical specialist of orthopedic surgery . Advanced OSUS is typically
obtained by specialists subspecialized in either shoulder/elbow, wrist/hand, hip, knee, or
ankle/foot orthopedic surgery.
Level 3 (expert) OSUS certification
Clinical specialists who perform basic and advanced OSUS every working day and most of
the day, and who are active with OSUS related science and teaching. Only very few
clinical specialists employing OSUS obtain the expert OSUS level 3 certification. They are
typically employed in a few university hospital centers.
Typical progression from introduction level to level 3
(1) Theory course pretest
(2) Theory course of basic OSUS
(3) Theory course posttest
(4) Practical hands-on course of basic OSUS
(2) Course exam in theory and practice of basic OSUS
(3) Proctored practice (supervised procedures) of basic OSUS
(4) Level 1 certification of basic OSUS
(5) Unsupervised maintenance of basic OSUS
(6) Theory & practice course of advanced OSUS
125
(7) Course exam of advanced OSUS
(8) Supervised procedures of advanced OSUS
(9) Level 2 certification of advanced OSUS - theory & practice
(10) Level 3 certification of expert OSUS: Level 2 certified + minimum 500 basic and
advanced OSUS exams per year for at least two years + teaching experience within
advanced OSUS + minimum three OSUS related scientific publications in peer reviewed
papers (PhD level)
7.2 Level 1
Level 1 Knowledge Base and Recommended Contents of Level 1 Theoretical & Practical
Course
Wave, sound and ultrasound physics
Ultrasound system machine controls
Ultrasound system user controls (knobbology)
Ultrasound techniques
- B mode (2D brightness mode)
- M mode (motion mode)
Ergonomics
Sterility
Safety
Administration
• Implementation of a basic OSUS programme
Sonoanatomy
• basic sonographic 2D views of normal muscles and joints
Sonopathology
• shoulder
o complete rotator cuff lesion
o rotator cuff calcification (different types)
o shoulder joint effusion and synovitis
o subacromial-subdeltoid bursitis
o biceps tendon (tendinopathy, luxation, rupture)
126
o Hill-Sachs lesion
o acromioclavicular joint pathology
o rheumatoid erosions
• elbow
o lateral and medial epicondylitis
o elbow joint effusion and synovitis
o rheumatoid lesions
• wrist and hand
o ganglionic cyst
o tenosynovitis
o tendon rupture
o joint effusion and synovitis
o median nerve
o rheumatoid erosions
• hip
o hip joint effusion and synovitis
o trochanteric bursitis
o rheumatoid erosions
• knee
o knee joint effusion and synovitis
o Baker’s cyst (and rupture)
o patella ligament tendinopathy
o Quadriceps femoris tendon rupture
o identification of meniscs
o large meniscal cysts
o Osgood-Schlatter
o Collateral ligament lesion
o all cysts, bursiti, ganglions
o rheumatoid erosions
• ankle and foot
o joint effusion and synovitis
o Achilles tendinopathy and rupture
127
o tenosynovitis
o exostoses
o fasciitis plantaris
o rheumatoid erosions
• muscles, general
o large muscle ruptures
o abscesses
o myositis ossificans
• varia
o identification of bone pathology
o fluid in relation to prostheses/osteosyntheses
o detection of foreign bodies
Level 1 Competencies to be acquired
To be able to perform a basic OSUS exam:
• Perform examinations and procedures safely and accurately and acquire all
standard views
• To recognise and differentiate between normal anatomy/physiology and pathology • To diagnose common abnormalities within the musculoskeletal system • To recognize when a referral for a second opinion is indicated • To understand the relationship between sonographic imaging and other diagnostic
imaging techniques
• Perform focused point-of-care OSUS guided interventions with monitoring of patient
response to interventions and diagnostics Level 1 Theoretical & Practical Course
The course content is equal to the Level 1 knowledge base and the Level 1 competencies
to be acquired listed above. The course should be minimum 20 hours duration at the
beginning of the training period. The theory course should include a pre- and a posttest.
The entire course should be concluded with a course exam covering theory and practice.
The practical sessions should be performed as Hands On Training (HOT):
128
- HOT 1
o Basic OSUS views on normal models
o Revision of normal findings
- HOT 2
o Basic OSUS views on normal models or patients or sonosimulators
o Revision of pathological findings (tutorial laptops)
- HOT 3
o Individual reappraisal with interactive in-depth training
The course should be concluded with a course exam in theory and practice of basic UVS:
• Theory (30 minutes, 25 MCQ)
• Practice (15 minutes, simulator or model)
Proctored Level 1 practice
• Within 3 months after the course, the trainee should collect a minimum of 50 fully
supervised basic OSUS exams (TYPE A exams) + 50 autonomously collected (TYPE
B exams, for later validation). All exams must be archived in digital format and data
collected in the logbook (excel file). When digital storage (strongly encouraged) is not
available, detailed printouts of exams must be collected in a way to allow for
understanding of dynamic phenomena (end-diastole/end-systole; end-expiration/end-
inspiration; M-mode)
• When local tutors are not available, for the 50 fully supervised exams a period in a
CECLUS certified International Training Center is required. Alternatively the 50 TYPE A
exams can be replaced by 50 autonomously collected exams and internet sharing with
a distant tutor where the exams are uploaded and audited sequentially one-by-one (a
dedicated area will be activated on the CECLUS channel, with reserved access to the
trainees page matched with distance tutor). Lack of information on single cases, not
allowing accurate judgement on trainees competence makes the case not valid for final
certification.
• The last 50 autonomously performed exams can be validated either by: a) physical
delivery of logbook + digital clips/images on a mass storage device (CD/DVD/USB
stick) to the assigned tutor once the collection is completed; b) by internet sharing with
129
a distant tutor (see above). Focused OSUS should be preferrably performed in
patients with relevant pathology.
• Case mix should include all the pathological conditions mentioned above.
• Didactic cases (provided from local tutors and from distant tutors) should compensate
for lack of an adequate number of cases on some types of less frequent abnormalities.
These should not be reported in the logbook but rather listed, indicated separately as
part of exam final documentation. Sequential examinations on the same patients upon
relevant clinical/therapeutical changes are encouraged; provided there’s relevant
change in the findings, they will be counted as individual cases.
• No more than 10% exams with normal findings are to be considered for the final
certification
• Final Level 1 certification of basic OSUS
• Different trainees will acquire the necessary skills at different rates and the end point of
the training programme should be judged by an assessment of competencies in the
form of theoretical and practical certification. The theoretical and practical certification
should encompass the full range of the Level 1 knowledge database and competencies
to be acquired listed above.
• Theory (2 hours,100 MCQ)
• Practice (30 minutes, simulator or model)
Areas of competence assessed during examination
• Image generation
• Image acquisition
• Image interpretation
• Image administration
• Clinical and organizational thinking
Tools that may be used for the assessment during examination
• MCQs (overall theoretical assessment)
• Videoclip assessment (assessment of pathological clips interpretation and simulated
clinical integration of findings)
130
• OSUS on a healthy volunteer (assessment of technical skills in machine setting, image
acquisition and storage)
• OSUS on a patient with pathological condition relevant for orthopedic surgery (overall
practical assessment)
• Case discussion presented by the trainee
Maintenance requirements
• Practicioners should perform at least 50 basic OSUS examinations annually. • Recertification every 2 years, by submission of logbook.
• Refresher course (4 hours).
Certification for physicians already holding national/international OSUS certifications
Physicians holding national or international OSUS accreditation are considered technically
competent in the execution of a Focused OSUS exam. Their clinical competence in image
integration into the orthopedic surgery patient management should though be certified by
provision of minimum 30 documented exams (Logbook) + exam on a patient + case
discussion.
7.3 Level 2
The training requisite to this level of practice would be gained during a period of sub-
specialty training, which may either be within or after the completion of a specialist training
programme.
• The training should include a theoretical and practical course of at least 30 hours
(see below) followed by a theoretical and practical examination and the trainee
should read appropriate literature, scientific journals, and textbooks
• Competencies will have been acquired during training for level 1 practice which will
then be refined by performing a minimum of 30 clinical sessions at a centre where
supervision by someone with a Level 2 competence is available.
• Typically a Level 2 practitioner will have undertaken at least 1.000 ultrasound
examinations within advanced OSUS before Level 2 certification.
131
• An electronic log book should be kept documenting a minimum of 50 procedures
which should include ideally all Level 2 competencies for advanced OSUS for the
particular modality.
• The theoretical and practical certification should encompass the full module-specific
range of sonopathology listed below.
• To maintain competence at Level 2 practitioners should perform at least 500
module-specific advanced OSUS examinations each year. Level 2 Knowledge Base and Recommended Contents of Level 2 Theoretical and
Practical Course
A minimum of 30 hours theoretical and practical teaching is required. Prior to the theory
course the practitioner performs a pretest. The theory course should be concluded with a
posttest with a minimum level of performance before entering the practical hands-on
course. The theoretical and practical courses should cover:
• new ultrasound modalities (eg. 3D and 4D ultrasound)
• contrast agents
• advanced sound and ultrasound physics
• advanced ultrasound system machine controls
• advanced ultrasound system user controls
• advanced ultrasound techniques
• advanced administration (teaching, documentation, organization)
• advanced ultrasound artefacts
• advanced module-specific OSUS pathology
• shoulder
o partial rotator cuff lesion
o dynamic examination for impingement
o ganglions
o rotator cuff interval pathology
o frozen shoulder
o nerve entrapment
o identification of posterior and anterior glenoid labrum
o ultrasound guided interventions
132
• elbow
o biceps and triceps tendinopathy and rupture
o nerve entrapment
o ultrasound guided interventions
• wrist and hand
o Carpal tunnel syndrome
o tendon adherences
o ligament and pulley lesions
o other tumors than ganglions
o ultrasound guided interventions
• hip
o other bursitis than trochanteric
o osteoarthritis
o identification of anterior labrum
o identification of iliopsoas tendon
o snapping hip
o inguinal hernia
o groin pain
o pathology of the infant hip
o ultrasound guided interventions
• knee
o meniscus tear
o meniscus cyst
o Runner’s knee
o pathology of small muscle tendons
o osteoarthritis
o cartilage lesions
o ultrasound guided interventions
• ankle and foot
o Morton’s neuroma
o tarsal tunnel syndrome
133
o ligament strain
o ultrasound guided interventions
• muscles, general
o small muscle rupture
o late complications of muscle rupture
o identification of common muscle tumors
• varia
o withdrawal of foreign bodies
o bone pathology (fractures, tumors)
o Doppler examination of tendons and joints
o entesopathy
o identification of common nerves
o ultrasound guided interventions
Level 2 Competencies to be acquired
Perform the advanced module-specific OSUS examinations and procedures.
7.4 Level 3
A level 3 practioner is likely to spend the majority of their time undertaking advanced
OSUS or teaching, research and development within their subspecialized field and will be
an expert in this area.
7.5 Maintenance of skills
Having been assessed as competent to practice there will be a need for continued
professional development (CPD) and maintenance of practical skills. Recommended
numbers of examinations to be performed annually to maintain skills at each level
Level 1: the practitioner should perform at least 100 basic OSUS exams each year.
Level 2: the practitioner should perform at least 200 basic and advanced OSUS exams
each year.
134
Level 3: the practitioner should perform at least 400 basic and advanced OSUS exams
each year.
Practitioners should:
• include OSUS in their continued medical education (CME)
• audit their practice
• participate in multidisciplinary meetings
• keep up to date with relevant literature
8. Rheumatological ultrasound
8.1 Introduction This curriculum is intended for CECLUS certification Level 1-3 of rheumatologists who
perform rheumatological ultrasound – also called RUS. RUS includes standards for
theoretical knowledge and practical skills.
The curriculum of rheumatological ultrasound (RUS) is 3-leveled and modular in order to
relate the training to the specialist requirements of the trainee. Within any one level of
training it may be appropriate for a trainee to become proficient in some but not all of the
individual modules and only undertake ultrasound practice in this/these areas. Except level
one which contains the basic common trunk for all specialists of rheumatology.
The level 1 modules of RUS are:
• general RUS • basic RUS
o shoulder joint o elbow joint
o wrist joint
o finger joints
o hip joint
o knee joint
o ankle joint
o toe joints
The level 2 and level 3 modules of RUS are:
• advanced shoulder and elbow RUS • advanced wrist and hand RUS
• advanced hip RUS
• advanced knee RUS
• advanced ankle and foot RUS
Introductory level (pre-certification)
Performance of supervised RUS prior to Level 1 certification.
Level 1 (basic) RUS certification
Performance of unsupervised basic RUS. Basic RUS is easy and effective basic
assessment of musculoskeletal anatomy and pathology relevant for all rheumatologists.
Basic RUS certification should be obtained by all specialists of rheumatology, preferably
prior to or during their specialist training. At least Level 1 competence should be obtained
by anyone performing basic RUS unsupervised.
Level 2 (advanced) RUS certification
Subspecialized clinical specialist of rheumatology. Advanced RUS is typically obtained by
specialists subspecialized in sports medicine.
Level 3 (expert) RUS certification
Clinical specialists who perform basic and advanced RUS every working day and most of
the day, and who are active with RUS related science and teaching. Only very few clinical
specialists employing RUS obtain the expert RUS level 3 certification. They are typically
employed in a few subspecialized hospital centers.
Typical progression from introduction level to level 3
(1) Theory course pretest
(2) Theory course of basic RUS
(3) Theory course posttest
(4) Practical hands-on course of basic RUS
(5) Course exam in theory and practice of basic RUS
(6) Proctored practice (supervised procedures) of basic RUS
(7) Level 1 certification of basic RUS
(8) Unsupervised maintenance of basic RUS
(9) Theory & practice course of advanced RUS
(10) Course exam of advanced RUS
(11) Supervised procedures of advanced RUS
137
(9) Level 2 certification of advanced RUS - theory & practice
(10) Level 3 certification of expert RUS: Level 2 certified + minimum 500 basic and
advanced RUS exams per year for at least two years + teaching experience within
advanced RUS + minimum three RUS related scientific publications in peer reviewed
papers (PhD level)
8.2 Level 1
Level 1 Knowledge Base and Recommended Contents of Level 1 Theoretical & Practical
Course
Wave, sound and ultrasound physics
Ultrasound system machine controls
Ultrasound system user controls (knobbology)
Ultrasound techniques
- B mode (2D brightness mode)
- M mode (motion mode)
Ergonomics
Sterility
Safety
Administration
• Implementation of a basic RUS programme
Sonoanatomy
• basic sonographic 2D views of normal muscles and joints
Sonopathology
• shoulder
o rotator cuff lesion
o rotator cuff calcification (different types)
o shoulder joint effusion and synovitis
o subacromial-subdeltoid bursitis
o biceps tendon (tendinopathy, luxation, rupture)
o Hill-Sachs lesion
o acromioclavicular joint pathology
138
o joint destruction
• elbow
o lateral and medial epicondylitis
o elbow joint effusion and synovitis
o joint destruction
• wrist and hand
o ganglionic cyst
o tenosynovitis
o tendon rupture
o joint effusion and synovitis
o median nerve in carpal tunnel syndrome
o joint destruction
• hip
o hip joint effusion and synovitis
o trochanteric bursitis
o joint destruction
• knee
o knee joint effusion and synovitis
o Baker’s cyst (and rupture)
o patella ligament tendinopathy
o Osgood-Schlatter
o Collateral ligament lesion
o all cysts, bursiti, ganglions
o joint destruction
• ankle and foot
o joint effusion and synovitis
o Achilles tendinopathy and rupture
o tenosynovitis
o exostoses
o fasciitis plantaris
o joint destruction
• muscles, general
139
o large muscle ruptures
o abscesses
o myositis ossificans
• varia
o identification of bone pathology
o fluid in relation to prostheses/osteosyntheses
o detection of foreign bodies
Level 1 Competencies to be acquired
To be able to perform a basic RUS exam:
• Perform examinations and procedures safely and accurately and acquire all
standard views • To recognise and differentiate between normal anatomy/physiology and pathology
• To diagnose common abnormalities within the musculoskeletal system • To recognize when a referral for a second opinion is indicated • To understand the relationship between sonographic imaging and other diagnostic
imaging techniques
• Perform focused point-of-care RUS guided interventions with monitoring of patient
response to interventions and diagnostics Level 1 Theoretical & Practical Course
The course content is equal to the Level 1 knowledge base and the Level 1 competencies
to be acquired listed above. The course should be minimum 20 hours duration at the
beginning of the training period. The theory course should include a pre- and a posttest.
The entire course should be concluded with a course exam covering theory and practice.
The practical sessions should be performed as Hands On Training (HOT):
- HOT 1
o Basic RUS views on normal models
o Revision of normal findings
- HOT 2
o Basic RUS views on normal models or patients or sonosimulators
o Revision of pathological findings (tutorial laptops)
140
- HOT 3
o Individual reappraisal with interactive in-depth training
The course should be concluded with a course exam in theory and practice of basic UVS:
• Theory (30 minutes, 25 MCQ)
• Practice (15 minutes, simulator or model)
Proctored Level 1 practice
• Within 3 months after the course, the trainee should collect a minimum of 50 fully
supervised basic RUS exams (TYPE A exams) and 25 fully supervised intraarticular
injections + 50 autonomously collected (TYPE B exams, for later validation) and 25
autonomously collected intraarticular injections. All exams must be archived in digital
format and data collected in the logbook (excel file). When digital storage (strongly
encouraged) is not available, detailed printouts of exams must be collected.
• When local tutors are not available, for the fully supervised exams and procedures a
period in a CECLUS certified International Training Center is required. Alternatively the
TYPE A exams can be replaced by autonomously collected exams and internet sharing
with a distant tutor where the exams are uploaded and audited sequentially one-by-one
(a dedicated area will be activated on the CECLUS channel, with reserved access to
the trainees page matched with distance tutor). Lack of information on single cases,
not allowing accurate judgement on trainees competence makes the case not valid for
final certification.
• The last autonomously performed exams can be validated either by: a) physical
delivery of logbook + digital clips/images on a mass storage device (CD/DVD/USB
stick) to the assigned tutor once the collection is completed; b) by internet sharing with
a distant tutor (see above). Focused RUS should be preferrably performed in patients
with relevant pathology.
• Case mix should include all the pathological conditions mentioned above.
• Didactic cases (provided from local tutors and from distant tutors) should compensate
for lack of an adequate number of cases on some types of less frequent abnormalities.
These should not be reported in the logbook but rather listed, indicated separately as
part of exam final documentation. Sequential examinations on the same patients upon
141
relevant clinical/therapeutical changes are encouraged; provided there’s relevant
change in the findings, they will be counted as individual cases.
• No more than 10% exams with normal findings are to be considered for the final
certification
Final Level 1 certification of basic RUS
Different trainees will acquire the necessary skills at different rates and the end point of the
training programme should be judged by an assessment of competencies in the form of
theoretical and practical certification. The theoretical and practical certification should
encompass the full range of the Level 1 knowledge database and competencies to be
acquired listed above.
• Theory (2 hours,100 MCQ)
• Practice (30 minutes, simulator or model)
Areas of competence assessed during examination
• Image generation
• Image acquisition
• Image interpretation
• Image administration
• Clinical and organizational thinking
Tools that may be used for the assessment during examination
• MCQs (overall theoretical assessment)
• Videoclip assessment (assessment of pathological clips interpretation and simulated
clinical integration of findings)
• RUS on a healthy volunteer (assessment of technical skills in machine setting, image
acquisition and storage)
• RUS on a patient with pathological condition relevant for rheumatology (overall
practical assessment)
• Case discussion presented by the trainee
142
Maintenance requirements
• Practicioners should perform at least 50 basic RUS examinations and 25 intraarticular
injections annually. • Recertification every 2 years, by submission of logbook. • Refresher course (4 hours).
Certification for physicians already holding national/international RUS certifications
Physicians holding national or international RUS accreditation are considered technically
competent in the execution of a Focused RUS exam. Their clinical competence in image
integration into the rheumatology patient management should though be certified by
provision of minimum 30 documented exams (Logbook) + exam on a patient + case
discussion.
8.3 Level 2
The training requisite to this level of practice would be gained during a period of sub-
specialty training, which may either be within or after the completion of a specialist training
programme.
• The training should include a theoretical and practical course of at least 30 hours
(see below) followed by a theoretical and practical examination and the trainee
should read appropriate literature, scientific journals, and textbooks
• Competencies will have been acquired during training for level 1 practice which will
then be refined by performing a minimum of 30 clinical sessions at a centre where
supervision by someone with a Level 2 competence is available.
• Typically a Level 2 practitioner will have undertaken at least 1.000 ultrasound
examinations within advanced RUS before Level 2 certification.
• An electronic log book should be kept documenting a minimum of 50 procedures
which should include ideally all Level 2 competencies for advanced RUS for the
particular modality.
• The theoretical and practical certification should encompass the full module-specific
range of sonopathology listed below.
• To maintain competence at Level 2 practitioners should perform at least 500
module-specific advanced RUS examinations each year.
143
Level 2 Knowledge Base and Recommended Contents of Level 2 Theoretical and
Practical Course
A minimum of 30 hours theoretical and practical teaching is required. Prior to the theory
course the practitioner performs a pretest. The theory course should be concluded with a
posttest with a minimum level of performance before entering the practical hands-on
course. The theoretical and practical courses should cover:
• new ultrasound modalities (eg. 3D and 4D ultrasound)
• contrast agents
• advanced sound and ultrasound physics
• advanced ultrasound system machine controls
• advanced ultrasound system user controls
• advanced ultrasound techniques
• advanced administration (teaching, documentation, organization)
• advanced ultrasound artefacts
• advanced module-specific RUS pathology
• shoulder
o partial rotator cuff lesion
o dynamic examination for impingement
o ganglions
o rotator cuff interval pathology
o frozen shoulder
o nerve entrapment
o identification of posterior and anterior glenoid labrum
o ultrasound guided interventions
• elbow
o biceps and triceps tendinopathy and rupture
o nerve entrapment
o ultrasound guided interventions
• wrist and hand
o tendon adherences
o ligament and pulley lesions
144
o other tumors than ganglions
o ultrasound guided interventions
• hip
o other bursitis than trochanteric
o osteoarthritis
o identification of anterior labrum
o identification of iliopsoas tendon
o snapping hip
o inguinal hernia
o groin pain
o pathology of the infant hip
o ultrasound guided interventions
• knee
o meniscus tear
o meniscus cyst
o Runner’s knee
o pathology of small muscle tendons
o osteoarthritis
o cartilage lesions
o ultrasound guided interventions
• ankle and foot
o Morton’s neuroma
o tarsal tunnel syndrome
o ligament strain
o ultrasound guided intervention
• muscles, general
o small muscle rupture
o late complications of muscle rupture
o identification of common muscle tumors
• varia
o withdrawal of foreign bodies
o bone pathology (fractures, tumors)
145
o Doppler examination of tendons and joints
o entesopathy
o identification of common nerves
o ultrasound guided interventions
Level 2 Competencies to be acquired
Perform the advanced module-specific RUS examinations and procedures.
8.4 Level 3
A level 3 practioner is likely to spend the majority of their time undertaking advanced RUS
or teaching, research and development within their subspecialized field and will be an
expert in this area.
8.5 Maintenance of skills
Having been assessed as competent to practice there will be a need for continued
professional development (CPD) and maintenance of practical skills. Recommended
numbers of examinations to be performed annually to maintain skills at each level are
given in the text.
Practitioners should:
• include RUS in their continued medical education (CME)
• audit their practice
• participate in multidisciplinary meetings
• keep up to date with relevant literatur
9. Infectious Diseases Ultrasound
9.1 Introduction The curriculum of infectious diseases ultrasound (IDUS) is modular in order to relate the
training to the specialist requirements of the trainee. Level one which contains the basic
common trunk for all specialists of infectious medicine. At the present time it is not
appropriate to define Level 2 and 3 curricula for IDUS.
The modules of IDUS are:
- Vascular access (see 1c2.2)
- Cardiac (see 1c1.2)
- Abdomen (see 12.2)
- Musculoskeletal (see 8.2)
147
10. Cardiology
10.1 Introduction This curriculum is intended for CECLUS certification Level 1-3 of pre-specialists and
specialists of cardiology who perform echocardiography. The curriculum includes
standards for theoretical knowledge and practical skills.
Introductory level (pre-certification)
Performance of supervised basic echocardiography prior to Level 1 certification.
Level 1 (basic) certification
Performance of unsupervised basic echocardiography. Basic echocardiography is easy
and effective basic assessment of haemodynamics. Basic echocardiography certification
should be obtained by all pre-specialists working in cardiology wards with assessment of
potentially acute or critically ill patients. At least Level 1 competence should be obtained
by anyone performing basic echocardiography unsupervised.
Level 2 (advanced) certification
Specialists of cardiology who perform advanced echocardiography routinely. Level 2
certification should be obtained by all specialists of cardiology.
Level 3 (expert) certification
Specialists of cardiology who perform advanced echocardiography every working day and
most of the day, and who are active with echocardiography related science and teaching.
Only very few clinical specialists employing echocardiography obtain the expert
echocardiography level 3 certification. They are typically employed in university hospital
centers.
Typical progression from introduction level to level 3
(1) Theory course pretest
(2) Theory course of basic echocardiography
(3) Theory course posttest
148
(4) Practical hands-on course of basic echocardiography
(2) Course exam in theory and practice of basic echocardiography
(3) Proctored practice (supervised procedures) of basic echocardiography
(4) Level 1 certification of basic echocardiography
(5) Unsupervised maintenance of basic echocardiography
(6) Theory & practice course of advanced echocardiography
(7) Course exam of advanced echocardiography
(8) Supervised procedures of advanced echocardiography
(9) Level 2 certification of advanced echocardiography - theory & practice
(10) Level 3 certification of expert echocardiography: Level 2 certified + minimum 500
advanced echocardiography exams per year for at least two years + teaching experience
within advanced echocardiography + minimum three echocardiography related scientific
publications in peer reviewed papers (PhD level)
10.2 Level 1 Level 1 Knowledge Base and Recommended Contents of Level 1 Theoretical & Practical
Course
Wave, sound and ultrasound physics
Ultrasound system machine controls
Ultrasound system user controls (knobbology)
Ultrasound techniques
- B mode (2D brightness mode)
- M mode (motion mode)
Ergonomics
Sterility
Safety
Administration
• Implementation of a basic echocardiography program
Sonoanatomy
• basic TTE (transthoracic echocardiography) 2D views
o subcostal 4-chamber
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o apical 4-chamber
o parasternal long axis
o parasternal short axis at the following levels:
aortic valve (base)
mitral leaflet tips
papillary muscles
Cardiac function
systolic ventricular function
diastolic ventricular function
ejection fraction
fractional shortening
mitral septal separation
mitral annular plane systolic excursion (MAPSE)
tricuspid annular plane systolic excursion (TAPSE)
LV dimensions (2D and M-mode)
• Septal thickness at end diastole
• Cavity size at the end diastole
• Posterior wall thickness at end diastole
• Cavity size at end systole
Aortic root dimension
Left atrial dimension
Sonopathology
• Basic cardiac chamber dysfunction o dilated left atrium
o dilated left ventricle o dilated right atrium o dilated right ventricle o hypertrophy left ventricle
• Mesothelial cavities o pericardial effusion
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basic US diagnosis of cardiac tamponade
US guided pericardiocentesis • Pedunculated masses
• Endocarditis and the valves
• Hypovolemia
Level 1 Competencies to be acquired
To be able to perform a basic echocardiography exam:
• Perform echocardiographic examinations safely and accurately and acquire all
standard views • To recognise and differentiate between normal anatomy/physiology and pathology • To diagnose common abnormalities within the cardiovascular system • To recognize when a referral for a second opinion is indicated
• To understand the relationship between echocardiographic imaging and other
diagnostic imaging techniques • Perform basic echocardiographic hemodynamic monitoring of patient response to
interventions and diagnostics:
o Ventricular function Systolic function and wall motion abnormalities Diastolic function
o Hypovolemia and volume responsiveness o Tamponade and pericardial disease
o The sepsis syndromes o Effects of preload and afterload and assessment of filling status o Acute cor pulmonale o Hypoxemia
o Complications of acute MI o Chest trauma o Assessment of shock o Peri-resuscitation
o Failure to wean from mechanical ventilation o Hemodynamic measurements
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Level 1 Theoretical & Practical Course
The course content is equal to the Level 1 knowledge base and the Level 1 competencies
to be acquired listed above. The course should be minimum 30 hours duration at the
beginning of the training period. The theory course should include a pre- and a posttest.
The entire course should be concluded with a course exam covering theory and practice.
The practical sessions should be performed as Hands On Training (HOT):
- HOT 1
o Basic TTE views on normal models
o Revision of normal findings
- HOT 2
o Basic TTE views on normal models or patients or sonosimulators
o Revision of pathological findings (tutorial laptops)
- HOT 3
o Individual reappraisal with interactive in-depth training
The course should be concluded with a course exam in theory and practice of basic UVS:
• Theory (30 minutes, 25 MCQ)
• Practice (15 minutes, simulator or model)
Proctored Level 1 practice
• Within 3 months after the course, the trainee should collect a minimum of 25 fully
supervised basic echocardiography exams (TYPE A exams) + 25 autonomously
collected (TYPE B exams, for later validation). All exams must be archived in digital
format and data collected in the logbook (excel file). When digital storage (strongly
encouraged) is not available, detailed printouts of exams must be collected in a way to
allow for understanding of dynamic phenomena (end-diastole/end-systole; end-
expiration/end-inspiration; M-mode)
• When local tutors are not available, for the 25 fully supervised exams a period in a
CECLUS certified International Training Center (ITC) is required. Alternatively the 25
TYPE A exams can be replaced by 25 autonomously collected exams and internet
sharing with a distant tutor where the exams are uploaded and audited sequentially
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one-by-one (a dedicated area will be activated on the CECLUS channel, with reserved
access to trainer’s page matched with distance tutor). Lack of information on single
cases, not allowing accurate judgement on trainees competence makes the case not
valid for final certification.
• The last 25 autonomously performed exams can be validated either by: a) physical
delivery of logbook + digital clips/images on a mass storage device (CD/DVD/USB
stick) to the assigned tutor once the collection is completed; b) by internet sharing with
a distant tutor. Training in Cardiological Echo Labs is encouraged, especially to acquire
confidence with main TTE views. The basic echocardiographic exams should be
preferrably performed in patients with pathological hemodynamics.
• Case mix should include: LV dysfunction (ischemic and non ischemic), RV dysfunction
(acute cor pulmonale and ischemic), hypovolemia, vasoplegia, tamponade, cardiac
standstill, severe valvular disease.
• The following scenarios may be represented: PEA, cardiac arrest, septic shock,
trauma, AMI, pulmonary embolism, chronic cardiac disease (myocardial, valvular,
chronic cor pulmonale).
• Didactic cases (provided from local tutors and from distant tutors) should compensate
for lack of an adequate number of cases on some types of less frequent abnormalities.
These should not be reported in the logbook but rather listed, indicated separately as
part of exam final documentation. Sequential examinations on the same patients upon
relevant clinical/therapeutical changes are encouraged; provided there’s relevant
change in the findings, they will be counted as individual cases.
• No more than 10% exams with normal findings are to be considered for the final
certification
Final Level 1 certification of basic echocardiography
• Theory (2 hours,100 MCQ)
• Practice (30 minutes, simulator or model)
Areas of competence assessed during examination
• Image generation
• Image acquisition
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• Image interpretation
• Image administration
• Clinical and organizational thinking
Tools that may be used for the assessment during examination
• MCQs (overall theoretical assessment)
• Videoclip assessment (assessment of pathological clips interpretation and simulated
clinical integration of findings)
• TTE on a healthy volunteer (assessment of technical skills in machine setting, image
acquisition and storage)
• TTE on a real critical or cardially morbid patient (overall practical assessment, including
echocardiography-guided patient management)
• Case discussion presented by the trainee
Certification for physicians already holding national/international TTE certifications
Physicians holding national or international echocardiography accreditation are considered
technically competent in the execution of a basic echocardiography exam. Their clinical
competence in image integration into the critical or acute cardiac patient management
should though be certified by provision of minimum 30 documented exams (Logbook) +
exam on an acute cardiac patient + case discussion
10.3 Level 2
The training requisite to this level of practice would be gained during a period of cardiology
specialist training programme.
• The training should include a theoretical and practical course of at least 30 hours
(see below) followed by a theoretical and practical examination and the trainee
should read appropriate literature, scientific journals, and textbooks
• Competencies will have been acquired during training for level 1 practice which will
then be refined by performing a minimum of 30 clinical sessions at a centre where
supervision by someone with a Level 2 competence is available.
• Typically a Level 2 practitioner will have undertaken at least 500 ultrasound
examinations within advanced echocardiography before Level 2 certification.
• An electronic log book should be kept documenting a minimum of 50 procedures
which should include ideally all Level 2 competencies for advanced
echocardiography.
• The theoretical and practical certification should encompass the full range of
sonopathology listed below.
• To maintain competence at Level 2 practitioners should perform at least 500
advanced echocardiography examinations each year.
Level 2 Knowledge Base and Recommended Contents of Level 2 Theoretical and
Practical Course
A minimum of 30 hours theoretical and practical teaching is required. Prior to the theory
course the practitioner performs a pretest. The theory course should be concluded with a
posttest with a minimum level of performance before entering the practical hands-on
course. The theoretical and practical courses should cover:
o new ultrasound modalities (eg. 3D and 4D ultrasound)
o contrast agents
o advanced sound and ultrasound physics
o advanced ultrasound system machine controls
o advanced ultrasound system user controls
o advanced ultrasound techniques
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o advanced administration (teaching, documentation, organization)
o advanced ultrasound artefacts
o advanced echocardiography:
o systolic function
preload (Frank-Starling's law)
afterload (LaPlace's law)
contractility (intrinsic myocardial function)
ejection fraction (eyeballing, calculation with M-mode)
hemodynamic parameters (cardiac output (CO) with pulsed wave
Doppler (PWD))
o diastolic function
compliance and relaxation of the left ventricle using transmitral flow
curve visualized with PWD
estimating inotropic effect and/or volume effect
o pericardial effusion
o pathology (lung embolus, acute coronary syndrome, papillary muscle
rupture, septic shock, chest trauma, complicated AMI, cardiac tamponade,
weaning failure from mechanical ventilation, acute valvular dysfunction)
o valvular stenosis using pressure gradients (continuous wave Doppler - CWD)
o insufficiency jets (valvular insufficiency) and atrial septal defect and
ventricular septal defect using colour flow Doppler (CFD)
o assessment of wall thickness and chamber dimensions in M-mode
o assessment of bi-ventricular function
o application of extended echocardiographic views
subcostal vena cava
apical 2-chamber view
apical long-axis view
apical 5-chamber view
parasternal short axis mitral plane view
parasternal aorta short axis view
suprasternal view
o diastolic left ventricular function
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o Doppler (continuous wave, pulsed wave)
o Measurement of cardiac filling pressures
o Measurement of cardiac output and pulmonary artery pressure
Left ventricle (LV) size
-‐ measured in PLAX view on frozen 2D or M-mode image
-‐ LV diastolic diameter (LVDd, cm)
-‐ LV diastolic diameter indexed for body surface area (BSA) (LVIDd, cm/m2)
-‐ LV systolic diameter (LVSd, cm)
-‐ LV mass (LVM, g)
-‐ LV mass indexed for body surface area (BSA) (LVMi, g/m2)
-‐ LV diastolic posterior wall thickness (PWTd, mm)
-‐ LV diastolic septal wall thickness (SWTd, mm)
Left ventricle geometry
-‐ normal geometry
-‐ concentric remodelling
-‐ excentric hypertrophy
-‐ concentric hypertrophy
-‐ Relative wall thickness (RWT)
Left ventricle systolic function
-‐ LV ejection fraction (LVEF)
-‐ Wall Motion Score Index (WMSI)
o normal
o hypokinesia
o akinesia
o dyskinesia
o ventricular aneyrism
-‐ Planimetry
Left ventricle diastolic function
-‐ measured in apical 4-chamber view with Pulsed Wave (PW) Doppler of mitral inflow
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o PW tissue Doppler e’ lateral (cm/s)
o E/A ratio
o E/e’ ratio
o mitral deceleration time (ms)
Left atrium size
-‐ measured in PLAX end-systole
-‐ left atrial volume (ml)
-‐ left atrium volume index (ml/m2)
-‐ left atrium diameter (mm)
-‐ left atrium diameter index (mm/m2)
Right ventricle size
-‐ measured in apical 4-chamber view or RVOT (right ventricular outlet tract)
measured in PSAX (parasternal short axis view)
-‐ Right ventricular diastolic diameter (mm)
-‐ RVOT diameter (mm)
Right ventricle systolic function
-‐ measured in M-mode
-‐ Tricuspid annulus plane systolic excursion (TAPSE) (mm)
Aorta/truncus pulmonalis
-‐ aorta: measured in PLAX view in end-diastole (cm)
-‐ truncus pulmonalis: measured in PSAX (cm)
Inferior Vena Cava (IVC)
-‐ measured in the subcostal view
-‐ exspiratory diameter IVC (cm)
-‐ inspiratory collapse (%)
Aortic valve stenosis
-‐ Aortic valve area (AVA) (cm2)
-‐ Aortic valve peak velocity (m/s)
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-‐ mean gradient (mmHg)
-‐ AVA indexed bsa (cm2/m2)
Mitral valve insufficiency
-‐ effective regurgitation orificium (ERO, cm2)
-‐ regurgitation volume (RV, ml)
Level 2 Competencies to be acquired
o advanced echocardiography
o perform an advanced echocardiography exam
o estimate chamber dimensions and left ventricular diameter (M-mode)
o estimate contractility (systolic function) of both ventricles
o estimate fractional shortening (FS) and ejection fraction (EF) with M-mode of
the left ventricle
o estimated cardiac output of left ventricle with continuous wave Doppler
o gauge mitral annular plane systolic excursion (MAPSE)
o gauge mitral septal separation (MSS)
o gauge tricuspid annular plane systolic excursion (TAPSE)
o visualize transmitral flow with PWD
o identify important pathology, e.g. left ventricular dilatation, left ventricular
hypertrophy, hypovolemia, left atrial dilatation, right ventricular dilatation,
pericardial effusion, pleural effusion, anatomical defects.
o detect valvular stenosis and/or insufficiency using CWD and CFD.
o correlate sonographic findings to clinical context.
o Color Doppler mapping
o Quantitative spectral Doppler
Pulsed Doppler
Continous wave Doppler
o TDI (Tissue Doppler Imaging)
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10.4 Level 3
A level 3 practioner is likely to spend the majority of their time undertaking advanced
echocardiography and teaching, research and development within their subspecialized
field and will be an expert in this area.
10.5 Maintenance of Skills
Having been assessed as competent to practice there will be a need for continued
professional development (CPD) and maintenance of practical skills. Recommended
numbers of examinations to be performed annually to maintain skills at each level
Level 1: the practitioner should perform at least 100 basic TTE exams each year.
Level 2: the practitioner should perform at least 200 basic and advanced TTE exams each
year.
Level 3: the practitioner should perform at least 400 basic and advanced TTE exams each
year.
Practitioners should:
• include echocardiography in their continued medical education (CME)
• audit their practice
• participate in multidisciplinary meetings
• keep up to date with relevant literature
11. Lung Medicine Ultrasound 11.1 Introduction
This curriculum is intended for clinicians who perform lung medicine ultrasound (LMUS). It
includes standards for theoretical knowledge and practical skills.
Introductory level
Performance of supervised basic LMUS prior to Level 1 certification.
Level 1 (basic)
Performance of unsupervised basic LMUS. Basic LMUS: easy and effective LMUS for
management of acute pleural conditions. Basic LMUS certification (Level 1) should be
obtained by all specialists in lung medicine, preferably during their specialist training. At
least Level 1 competence should be obtained by anyone performing basic LMUS
unsupervised.
Level 2 (advanced)
Subspecialized lung medicine specialists who perform basic and advanced LMUS most
working days. Advanced LMUS: all LMUS procedures beyond basic LUS.
Level 3 (expert)
Expert who performs basic and advanced LMUS every working day and most of the day,
and who is active with science and teaching. Only very few clinical lung medicine
specialists obtain expert LMUS level. They are typically employed in a few university
hospital centers.
Typical progression from Introduction Level to Level 3
(1) Course pretest
(2) Theory course of basic LMUS
(3) Theory course posttest
(4) Practical hands-on course of basic LMUS
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(2) Course exam in theory and practice of basic LMUS
(3) Supervised procedures of basic LMUS
(4) Level 1 certification of basic LMUS
(5) Unsupervised maintenance of basic LMUS
(6) Theory & practice course of advanced LMUS
(7) Course exam of advanced LMUS
(8) Supervised procedures of advanced LMUS
(9) Level 2 certification of advanced LMUS - theory & practice
(10) Level 3 certification of expert LMUS: Level 2 certified + minimum 500 basic and
advanced LMUS procedures per year for at least two years + teaching experience within
advanced LMUS + minimum three scientific publications about LMUS in peer reviewed
papers
11.2 Level 1 Level 1 Knowledge Base and Recommended Contents of Level 1 Theoretical & Practical
Course
Sound and ultrasound physics
Ultrasound system machine controls
Ultrasound system user controls
Ultrasound techniques
Ergonomics
Sterility
Safety
Administration
Sonoanatomy
• Normal pleura
o lung sliding
o lung pulse
o diaphragm, lever, spleen, vertebral column
Sonopathology
• pneumothorax
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• pleural effusion
• pleural empyema Level 1 Competencies to be acquired
To be able to:
• Perform a basic lung US exam • US guided pleural chest tube insertion
Level 1 Theoretical & Practical Course
The course content is equal to the Level 1 knowledge base and the Level 1 competencies
to be acquired listed above. The course should be minimum 20 hours duration at the
beginning of the training period. The theory course should include a pre- and a posttest.
The entire course should be concluded with a course exam covering theory and practice.
The practical sessions should be performed as Hands On Training (HOT):
- HOT 1
o Basic LMUS views on normal models
o Revision of normal findings
- HOT 2
o Basic LMUS views on normal models or patients or sonosimulators
o Revision of pathological findings (tutorial laptops)
- HOT 3
o Individual reappraisal with interactive in-depth training
- The course should be concluded with a course exam in theory and practice of basic
LMUS:
• Theory (30 minutes, 25 MCQ)
• Practice (15 minutes, simulator or model)
Proctored Level 1 practice
• Within 3 months after the course, the trainee should collect a minimum of 25 fully
supervised basic LMUS exams (TYPE A exams) + 25 autonomously collected (TYPE B
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exams, for later validation). All exams must be archived in digital format and data
collected in the logbook (excel file).
• When local tutors are not available, the 25 TYPE A exams can be replaced by 25
autonomously collected exams and internet sharing with a distant tutor where the
exams are uploaded and audited sequentially one-by-one (a dedicated area will be
activated on the CECLUS channel, with reserved access to trainer’s page matched
with distance tutor). Lack of information on single cases, not allowing accurate
judgement on trainees competence makes the case not valid for final certification.
• The last 25 autonomously performed exams can be validated either by: a) physical
delivery of logbook + digital clips/images on a mass storage device (CD/DVD/USB
stick) to the assigned tutor once the collection is completed; b) by internet sharing with
a distant tutor.
• The following scenarios must be represented: Pneumothorax, pleural effusion, pleural
empyema, and ultrasound-guided insertion of a pleural chest tube.
• Didactic cases (provided from local tutors and from distant tutors) should compensate
for lack of an adequate number of cases on some types of less frequent abnormalities.
These should not be reported in the logbook but rather listed, indicated separately as
part of exam final documentation. Sequential examinations on the same patients upon
relevant clinical/therapeutical changes are encouraged; provided there’s relevant
change in the findings, they will be counted as individual cases.
• No more than 10% exams with normal findings are to be considered for the final
certification
• Final Level 1 certification of basic LMUS
• Different trainees will acquire the necessary skills at different rates and the end point of
the training programme should be judged by an assessment of competencies in the
form of theoretical and practical certification. The theoretical and practical certification
should encompass the full range of the Level 1 knowledge database and competencies
to be acquired listed above.
• Theory (2 hours,100 MCQ)
• Practice (30 minutes, simulator or model)
164
Areas of competence assessed during examination
• Image generation
• Image acquisition
• Image interpretation
• Image administration
• Clinical and organizational thinking
Tools that may be used for the assessment during examination
• MCQs (overall theoretical assessment)
• Videoclip assessment (assessment of pathological clips interpretation and simulated
clinical integration of findings)
• LMUS exam on a healthy volunteer (assessment of technical skills in machine setting,
image acquisition and storage)
• LMUS on a real patient with pleural morbidity (overall practical assessment)
• Case discussion presented by the trainee
11.3 Level 2
The training requisite to this level of practice would be gained during a period of sub-
specialty training, which may either be within or after the completion of a specialist training
programme.
• The training should include a theoretical and practical course of at least 30 hours
(see below) followed by a theoretical and practical examination and the trainee
should read appropriate literature, scientific journals, and textbooks
• Competencies will have been acquired during training for level 1 practice which will
then be refined by performing a minimum of 30 clinic sessions at a centre where
supervision by someone with a Level 2 competence is available.
• Typically a Level 2 practitioner will have undertaken at least 500 ultrasound
examinations within advanced LMUS before Level 2 certification.
• An electronic log book should be kept documenting a minimum of 50 exams which
should include ideally all Level 2 competencies for advanced LMUS. An exam can
165
be a real clinical LMUS exam or a simulated LMUS exam. A minimum of 25 exams
have to be real clinical LMUS exams. • The theoretical and practical certification should encompass the full range of
procedures listed below.
• To maintain competence at Level 2 practitioners should perform at least 100 clinical
examinations each year within advanced LMUS.
Level 2 Knowledge Base and Recommended Contents of Level 2 Theoretical and
Practical Course
o new ultrasound modalities (eg. 3D and 4D ultrasound)
o advanced sound and ultrasound physics
o advanced ultrasound system machine controls
o advanced ultrasound system user controls
o advanced ultrasound techniques
o advanced administration (teaching, documentation, organization)
o advanced ultrasound artefacts
o advanced LMUS
o anatomy and sonoanatomy
o pathology and sonopathology
pneumothorax
pleural effusion
rib fractures
interstitial syndrome
lung edema
ARDS
interstitial lung disease
respiratory distress syndrome
lung consolidation
pneumonia
lung embolus
atelectasis (compression, obstruction)
lung tumour
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mediastinal staging of lung cancer
o complications
o safety
Level 2 Competencies to be acquired
o basic and advanced LMUS exam
o Endobronchial ultrasound (EBUS) exam
o Endoscopic ultrasound (EUS) exam via esophagus
11.4 Level 3
A level 3 practioner is likely to spend the majority of their time undertaking LMUS and
teaching, research and development within their subspecialized field and will be an expert
in this area.
11.5 Maintenance of skills
Having been assessed as competent to practice there will be a need for continued
professional development (CPD) and maintenance of practical skills. Recommended
numbers of examinations to be performed annually to maintain skills at each level are
given in the text.
Practitioners should:
• include LMUS in their continued medical education (CME)
• audit their practice
• participate in multidisciplinary meetings
• keep up to date with relevant literature
12. Ultrasound in Surgical Gastroenterology 12.1 Introduction This curriculum is intended for CECLUS certification Level 1-3 of pre-specialists and
specialists of gastroenterology surgery who perform ultrasound in surgical
gastroenterology (USSG). The curriculum includes standards for theoretical knowledge
and practical skills.
Introductory level (pre-certification)
Performance of supervised basic USSG prior to Level 1 certification.
Level 1 (basic) certification
Performance of unsupervised basic USSG. Basic USSG is easy and effective basic
assessment of basic acute gastroenterology conditions with ultrasound. Basic USSG
certification should be obtained by all specialists of gastroenterology surgery. At least
Level 1 competence should be obtained by anyone performing basic USSG unsupervised.
Level 2 (advanced) certification
Subspecialized specialists who perform advanced USSG most working days. Level 2
certification is only obtained by few specialists in surgical gastroenterology.
Level 3 (expert) certification
Subspecialized experts who perform advanced USSG every working day and most of the
day, and who are active with endoscopic and laparoscopic ultrasound related science and
teaching. Only very few clinical experts employing USSG obtain the expert USSG level 3
certification. They are typically employed in university hospital centers.
Typical progression from introduction level to level 3
(1) Theory course pretest
(2) Theory course of basic USSG
(3) Theory course posttest
(4) Practical hands-on course of basic USSG
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(2) Course exam in theory and practice of basic USSG
(3) Proctored practice (supervised procedures) of basic USSG
(4) Level 1 certification of basic USSG
(5) Unsupervised maintenanc of basic USSG
(6) Theory & practice course of advanced USSG
(7) Course exam of advanced USSG
(8) Supervised procedures of advanced USSG
(9) Level 2 certification of advanced USSG - theory & practice
(10) Level 3 certification of expert USSG: Level 2 certified + minimum 500 advanced
USSG exams per year for at least two years + teaching experience within advanced
USSG + minimum three USSG related scientific publications in peer reviewed papers
(PhD level)
12.2 Level 1 Level 1 Knowledge Base and Recommended Contents of Level 1 Theoretical & Practical
Course
Sound and ultrasound physics
Ultrasound system machine controls
Ultrasound system user controls
Ultrasound techniques
- B mode (2D brightness mode)
- M mode (motion mode)
Ergonomics
Sterility
Safety
Administration
Sonoanatomy
• Extended FAST 2D and M-mode views
o Pleura
Anterior, bilateral
Posterior, bilateral
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o Pericardium
o Peritoneum
Liver/right kidney
Spleen/left kidney
Rectovesical/vesicouterine pouch
Urinary bladder
Abdominal aorta
Inferior vena cava
renal pelvis
gall bladder
Sonopathology
• pneumothorax
• pleural effusion • pericardial effusion • peritoneal effusion • urinary retention
• abdominal aortic aneyrism
• hydronephrosis
• gall bladder stones
• hypovolemia
Level 1 Competencies to be acquired
To be able to:
• Perform an eFAST exam • US guided pleural chest tube insertion
• US guided peritoneal catheter insertion • US guided suprapubic catheter insertion • US guided peripheral venous access
170
Level 1 Theoretical & Practical Course
The course content is equal to the Level 1 knowledge base and the Level 1 competencies
to be acquired listed above. The course should be minimum 20 hours duration at the
beginning of the training period. The theory course should include a pre- and a posttest.
The entire course should be concluded with a course exam covering theory and practice.
The practical sessions should be performed as Hands On Training (HOT):
- HOT 1
o Basic USSG views on normal models
o Revision of normal findings
- HOT 2
o Basic USSG views on normal models or patients or sonosimulators
o Revision of pathological findings (tutorial laptops)
- HOT 3
o Individual reappraisal with interactive in-depth training
The course should be concluded with a course exam in theory and practice of basic
USSG:
• Theory (30 minutes, 25 MCQ)
• Practice (15 minutes, simulator or model)
Proctored Level 1 practice
• Within 3 months after the course, the trainee should collect a minimum of 25 fully
supervised basic USSG exams (TYPE A exams) + 25 autonomously collected (TYPE
B exams, for later validation). All exams must be archived in digital format and data
collected in the logbook (excel file).
• When local tutors are not available, the 25 TYPE A exams can be replaced by 25
autonomously collected exams and internet sharing with a distant tutor where the
exams are uploaded and audited sequentially one-by-one (a dedicated area will be
activated on the CECLUS channel, with reserved access to trainer’s page matched
with distance tutor). Lack of information on single cases, not allowing accurate
judgement on trainees competence makes the case not valid for final certification.
171
• The last 25 autonomously performed exams can be validated either by: a) physical
delivery of logbook + digital clips/images on a mass storage device (CD/DVD/USB
stick) to the assigned tutor once the collection is completed; b) by internet sharing with
a distant tutor.
• The following scenarios must be represented: Pneumothorax, pleural effusion,
pericardial effusion, peritoneal effusion, urinary retention, abdominal aortic aneyrism,
hydronephrosis, gall bladder stones, pleural chest tube insertion, peritoneal catheter
insertion, and suprapubic catheter insertion.
• Didactic cases (provided from local tutors and from distant tutors) should compensate
for lack of an adequate number of cases on some types of less frequent abnormalities.
These should not be reported in the logbook but rather listed, indicated separately as
part of exam final documentation. Sequential examinations on the same patients upon
relevant clinical/therapeutical changes are encouraged; provided there’s relevant
change in the findings, they will be counted as individual cases.
• No more than 10% exams with normal findings are to be considered for the final
certification
• Final Level 1 certification of basic USSG
• Different trainees will acquire the necessary skills at different rates and the end point of
the training programme should be judged by an assessment of competencies in the
form of theoretical and practical certification. The theoretical and practical certification
should encompass the full range of the Level 1 knowledge database and competencies
to be acquired listed above.
• Theory (2 hours,100 MCQ)
• Practice (30 minutes, simulator or model)
Areas of competence assessed during examination
• Image generation
• Image acquisition
• Image interpretation
• Image administration
• Clinical and organizational thinking
172
Tools that may be used for the assessment during examination
• MCQs (overall theoretical assessment)
• Videoclip assessment (assessment of pathological clips interpretation and simulated
clinical integration of findings)
• USSG exam on a healthy volunteer (assessment of technical skills in machine setting,
image acquisition and storage)
• USSG on a real patient with relevant morbidity (overall practical assessment)
• Case discussion presented by the trainee
12.3 Level 2
The training requisite to this level of practice would be gained during a period of sub-
specialty training, which may either be within or after the completion of a specialist training
programme.
• The training should include a theoretical and practical course of at least 30 hours
(see below) followed by a theoretical and practical examination and the trainee
should read appropriate literature, scientific journals, and textbooks
• Competencies will have been acquired during training for level 1 practice which will
then be refined by performing a minimum of 30 clinic sessions at a centre where
supervision by someone with a Level 2 competence is available.
• Typically a Level 2 practitioner will have undertaken at least 500 ultrasound
examinations within advanced USSG before Level 2 certification.
• An electronic log book should be kept documenting a minimum of 50 exams which
should include ideally all Level 2 competencies for advanced USSG. An exam can
be a real clinical USSG exam or a simulated USSG exam. A minimum of 25 exams
have to be real clinical USSG exams. • The theoretical and practical certification should encompass the full range of
procedures listed below.
• To maintain competence at Level 2 practitioners should perform at least 100 clinical
examinations each year within advanced USSG.
173
Level 2 Knowledge Base and Recommended Contents of Level 2 Theoretical and
Practical Course
o new ultrasound modalities (eg. 3D and 4D ultrasound)
o advanced sound and ultrasound physics
o advanced ultrasound system machine controls
o advanced ultrasound system user controls
o advanced ultrasound techniques
o endoscopic US (EUS) examinations
o EUS guided celiacus blockade
o EUS guided cystogastrostomy
o EUS guided fine needle aspiration
o laparoscopic US (LUS) examination
o advanced administration (teaching, documentation, organization)
o advanced ultrasound artefacts
o advanced USSG
o anatomy and sonoanatomy
o pathology and sonopathology
o complications
o safety
Level 2 competencies to be acquired
To be able to perform:
o Perform endoscopic US (EUS) examinations safely and accurately and acquire all
standard views
o Perform EUS guided celiacus blockade safely and accurately and acquire all
standard views
o Perform EUS guided cystogastrostomy safely and accurately and acquire all
standard views
o Perform EUS guided fine needle aspiration safely and accurately and acquire all
standard views
o Perform laparoscopic US (LUS) examinations safely and accurately and acquire all
standard views
174
• To recognise and differentiate between normal anatomy/physiology and pathology
• To diagnose common abnormalities • To recognize when a referral for a second opinion is indicated • To understand the relationship between ultrasound imaging and other diagnostic
imaging techniques
12.4 Level 3
A level 3 practioner is likely to spend the majority of their time undertaking advanced
USSG and teaching, research and development within their subspecialized field and will
be an expert in this area. 12.5 Maintenance of skills
Having been assessed as competent to practice there will be a need for continued
professional development (CPD) and maintenance of practical skills. Recommended
numbers of examinations to be performed annually to maintain skills at each level
Level 1: the practitioner should perform at least 50 basic USSG exams each year.
Level 2: the practitioner should perform at least 200 basic and advanced USSG exams
each year.
Level 3: the practitioner should perform at least 400 basic and advanced USSG exams
each year.
Practitioners should:
• include USSG in their continued medical education (CME)
• audit their practice
• participate in multidisciplinary meetings
• keep up to date with relevant literature
13. Ultrasound of vascular surgery
13.1 Introduction This curriculum is intended for CECLUS certification Level 1-3 of pre-specialists and
specialists of vascular surgery who perform ultrasound of vascular surgery (UVS). The
curriculum includes standards for theoretical knowledge and practical skills.
Introductory level (pre-certification)
Performance of supervised basic UVS prior to Level 1 certification.
Level 1 (basic) certification
Performance of unsupervised basic UVS. Basic UVS is easy and effective basic
assessment of basic vascular surgery conditions with ultrasound. Basic UVS certification
should be obtained by all specialists of vascular surgery. At least Level 1 competence
should be obtained by anyone performing basic UVS unsupervised.
Level 2 (advanced) certification
Subspecialized specialists who perform advanced UVS many working days. Level 2
certification is only obtained by few specialists of vascular surgery.
Level 3 (expert) certification
Subspecialized experts who perform advanced UVS many working days, and who are
active with UVS related science and teaching. Only very few clinical experts employing
UVS obtain the expert UVS level 3 certification. They are typically employed in university
hospital centers.
Typical progression from introduction level to level 3
(1) Theory course pretest
(2) Theory course of basic UVS
(3) Theory course posttest
(4) Practical hands-on course of basic UVS
(2) Course exam in theory and practice of basic UVS
176
(3) Proctored practice (supervised procedures) of basic UVS
(4) Level 1 certification of basic UVS
(5) Unsupervised maintenance of basic UVS
(6) Theory & practice course of advanced UVS
(7) Course exam of advanced UVS
(8) Supervised procedures of advanced UVS
(9) Level 2 certification of advanced UVS - theory & practice
(10) Level 3 certification of expert UVS: Level 2 certified + minimum 100 advanced UVS
exams per year for at least two years + teaching experience within advanced UVS +
minimum three UVS related scientific publications in peer reviewed papers (PhD level)
13.2 Level 1 Level 1 Knowledge Base and Recommended Contents of Level 1 Theoretical & Practical
Course
Sound and ultrasound physics
Ultrasound system machine controls
Ultrasound system user controls
• Scale
• Gain
• Filter
• Priority
• Angle correction
• Electronic steering
• Invert
• Sample gating
• Power output
• Colour amplitude
• Velocity measurement
• Spectral changes
Ultrasound techniques
• 2D ultrasound
• Power Doppler
177
• Pulsed wave Doppler
• Color wave Doppler
• Duplex
Ergonomics
Sterility
Safety
Administration
Sonoanatomy (including common variants)
• peripheral extremity and pelvic arteries and veins
o Upper limb: subclavian, axillary, brachial, ulnar, radial
o Pelvic and lower limb: inferior vena cava, iliac, femoral, popliteal, major and
minor saphenous
Sonopathology (pathology and results of treatment in relation to ultrasound)
• peripheral extremity arteries: patency, stenosis, occlusion, aneurismal dilatation
• peripheral extremity veins: patency, occlusion, deep venous thrombosis, reflux and
incompetence
Level 1 Competencies to be acquired
To be able to:
• perform continuous wave hand-held Doppler and segmental pressures (ABPI)
• Upper and lower extremity peripheral arteries and grafts
• perform a complete imaging ultrasound examination of the axillary, brachial, radial,
and ulnar arteries
• perform a complete imaging ultrasound examination of the common iliac to femoral
and popliteal and calf arteries
• recognise and assess patency, occlusion, stenosis and aneurysmal dilatation, and
measure approximate extent of abnormality in lower extremity peripheral arteries
and grafts
• diagnose > 50% stenosis and assess the lenght of stenosis in lower extremity
peripheral arteries and grafts
• follow-up patients after surgical and endovascular procedures, recognise common
complications like arterio-venous (AV) fistulas and pseudoaneurysm formation
178
• recognise, diagnose and locate reflux
• identify the saphenofemoral and saphenopopliteal junctions
• recognise and locate clinically relevant venous reflux, incompetence and perforators
Level 1 Theoretical & Practical Course
The course content is equal to the Level 1 knowledge base and the Level 1 competencies
to be acquired listed below. The course should be minimum 24 hours duration at the
beginning of the training period. The theory course should include a pre- and a posttest.
The entire course should be concluded with a course exam covering theory and practice.
The practical sessions should be performed as Hands On Training (HOT):
- HOT 1
o Basic UVS views on normal models
o Revision of normal findings
- HOT 2
o Basic UVS views on normal models or patients or sonosimulators
o Revision of pathological findings (tutorial laptops)
- HOT 3
o Individual reappraisal with interactive in-depth training
The course should be concluded with a course exam in theory and practice of basic UVS:
• Theory (30 minutes, 25 MCQ)
• Practice (15 minutes, simulator or model)
Proctored Level 1 practice
• Supervision and recommended number of exams: Within 3 months after the course,
the trainee should collect a minimum of 100 UVS exams under supervision: 50 fully
supervised basic UVS exams (TYPE A exams) + 50 autonomously collected (TYPE B
exams, for later validation). The last 50 autonomously performed exams can be
validated either by: a) physical delivery of the electronic logbook + digital clips/images
on a mass storage device (CD/DVD/USB stick) to the assigned tutor once the
collection is completed; b) by internet sharing with a distant tutor. Training should
usually be supervised by a level 2 practitioner. In certain circumstances it may be
appropriate to delegate some of this supervision to an experienced level 1 practitioner
179
with at least two years of regular practical experience. When local tutors are not
available, the 50 TYPE A exams can be replaced by 50 autonomously collected exams
and internet sharing with a distant tutor where the exams are uploaded and audited
sequentially one-by-one (a dedicated area will be activated on the CECLUS channel,
with reserved access to trainer’s page matched with distance tutor). Lack of information
on single cases, not allowing accurate judgement on trainees competence makes the
case not valid for final certification.
• Documentation: All exams must be video recorded and archived in digital format and
data collected in the electronic logbook (excel file). The documentation should record
time spent, need for supervision and correction, and rating of sonoanatomic skill,
imaging, image quality, and diagnostic performance. During the course of training the
competency assessment sheet should be completed.
• Curriculum: All the above mentioned pathology scenarios should be represented. An
exam can be a real clinical UVS exam or a simulated UVS exam: Didactic cases
(provided from local tutors and from distant tutors) should compensate for lack of an
adequate number of cases on some types of less frequent abnormalities. These should
not be reported in the logbook but rather listed, indicated separately as part of exam
final documentation. Sequential examinations on the same patients upon relevant
clinical/therapeutical changes are encouraged; provided there’s relevant change in the
findings, they will be counted as individual cases. No more than 10% exams with
normal findings are to be considered for the final certification
Final Level 1 certification of basic UVS
Different trainees will acquire the necessary skills at different rates and the end point of the
training programme should be judged by an assessment of competencies in the form of
theoretical and practical certification. The theoretical and practical certification should
encompass the full range of the Level 1 knowledge database and competencies to be
acquired listed above.
• Theory (2 hours,100 MCQ)
• Practice (30 minutes, simulator or model)
Areas of competence assessed during certification examination:
180
• Image generation
• Image acquisition
• Image interpretation
• Image administration
• Clinical and organizational thinking
Tools that may be used for the assessment during certification examination:
• MCQs (overall theoretical assessment)
• Videoclip assessment (assessment of pathological clips interpretation and simulated
clinical integration of findings)
• UVS exam on a healthy volunteer (assessment of technical skills in machine setting,
image acquisition and storage)
• UVS on a real patient with relevant morbidity (overall practical assessment)
• Case discussion presented by the trainee
13.3 Level 2
The training requisite to this level of practice would be gained during a period of sub-
specialty training, which may either be within or after the completion of a specialist training
programme.
• The training should include a theoretical and practical course of at least 32 hours
(see below) followed by a theoretical and practical examination and the trainee
should read appropriate literature, scientific journals, and textbooks
• Competencies will have been acquired during training for level 1 practice which will
then be refined by performing a minimum of 30 clinic sessions at a centre where
supervision by someone with a Level 2 competence is available.
• Typically a Level 2 practitioner will have undertaken at least 500 ultrasound
examinations within advanced UVS before Level 2 certification.
• An electronic log book should be kept documenting a minimum of 50 exams which
should include ideally all Level 2 competencies for advanced UVS. An exam can be
a real clinical UVS exam or a simulated UVS exam. A minimum of 25 exams have
to be real clinical UVS exams.
181
• The theoretical and practical certification should encompass the full range of
procedures listed below.
Level 2 Knowledge Base and Recommended Contents of Level 2 Theoretical and
Practical Course
o new ultrasound modalities (eg. 3D and 4D ultrasound)
o advanced sound and ultrasound physics
o advanced ultrasound system machine controls
o advanced ultrasound system user controls
o advanced ultrasound techniques
o contrast enhanced ultrasound physics and examination
o advanced administration (teaching, documentation, organization)
o advanced ultrasound artefacts
o advanced sonoanatomy (including common variants)
o abdominal aorta visceral arteries
o extracranial vessels
o advanced UVS sonopathology (pathology and results of treatment in relation to
ultrasound)
o abdominal vessels: patency, occlusion, aneurysmal dilatation of aorta
o extracranial vessels: patency, occlusion, stenosis
o appearances and sequelae of common surgical or endovascular interventions
including angioplasty, stenting, grafts, Miller vein cuffs, dissections, and neointimal
hyperplasia
o complications
o safety
Level 2 competencies to be acquired
Competencies will have been gained during training for Level 1 practice and then refined
during a period of practice
To be able to:
• perform a complete imaging ultrasound scan and identify all abnormalities detailed
in Level 1
182
• in the upper and lower extremities, from common iliac to pedal vessels and
subclavian to radial and ulnar arteries and veins and to identify all kinds of non-
atherosclerotic diseases (vasculitides, compression syndromes, etc), as well as all
kinds of vascular malformation
• recognise and locate patency and occlusion of the abdominal aorta and large
visceral arteries (including renal arteries, superior mesenteric artery and celiac
trunk)
• recognise and size aneurysmal dilatation of the abdominal aorta large visceral
arteries
• recognise common normal variants, aneurysmal dilatation, patency, stenosis and
occlusion of the major abdominal and iliac vessels, including the mesenteric and
renal vessels
• recognise and locate patency, occlusion, plaque and stenoses in the carotid
vessels and vertebral arteries
• recognise and diagnose patency, occlusion, stenosis, reverse flow and steal in the
carotid and vertebral vessels
• grade degrees of carotid stenosis and plaque type in accordance with local criteria
and standards, and to follow-up patients after endarterectomy, carotid artery
stenting, and angioplasty
• perform vein mapping and marking
13.4 Level 3
A Level 3 practioner is likely to spend the majority of their time undertaking advanced UVS
and teaching, research and development within their subspecialized field and will be an
expert in this area. A Level 3 practitioner will accept tertiary referrals from Level 1 and 2
practioners. He/she should have the capability to utilise developing technologies and
ultrasound techniques, develop research and teaching skills and the performance of
specialised examinations including the use of non-invasive physiological studies, contrast
agents, intravascular or intra-operative ultrasound and ultrasound guided interventional
procedures (like US guide treatment of pseudonaeurysms, US guided RFA of varicose
veins, etc).
183
13.5 Maintenance of skills
Having been assessed as competent to practice there will be a need for continued
professional development (CPD) and maintenance of practical skills. Recommended
numbers of examinations to be performed annually to maintain skills at each level
Level 1: the practitioner should perform at least 50 basic UVS exams each year.
Level 2: the practitioner should perform at least 100 basic and advanced UVS exams each
year.
Level 3: the practitioner should perform at least 200 basic and advanced UVS exams each
year.
Practitioners should:
• include UVS in their continued medical education (CME)
• audit their practice
• participate in multidisciplinary meetings
• keep up to date with relevant literature
14. Ultrasound of neurology
14.1 Introduction This curriculum is intended for CECLUS certification Level 1-3 of pre-specialists and
specialists of neurology who perform neurology ultrasound (NUS). The curriculum includes
standards for theoretical knowledge and practical skills.
Introductory level (pre-certification)
Performance of supervised basic NUS prior to Level 1 certification.
Level 1 (basic) certification
Performance of unsupervised basic NUS. Basic NUS is easy and effective basic
assessment of basic neurologic conditions with ultrasound. Basic NUS certification should
be obtained by all specialists of neurology. At least Level 1 competence should be
obtained by anyone performing basic NUS unsupervised.
Level 2 (advanced) certification
Subspecialized specialists who perform advanced NUS most working days. Level 2
certification is only obtained by few specialists of neurology.
Level 3 (expert) certification
Subspecialized experts who perform advanced NUS every working day and most of the
day, and who are active with NUS related science and teaching. Only very few clinical
experts employing NUS obtain the expert UVS level 3 certification. They are typically
employed in university hospital centers.
Typical progression from introduction level to level 3
(1) Theory course pretest
(2) Theory course of basic NUS
(3) Theory course posttest
(4) Practical hands-on course of basic NUS
(2) Course exam in theory and practice of basic NUS
185
(3) Proctored practice (supervised procedures) of basic NUS
(4) Level 1 certification of basic NUS - theory and practice
(5) Unsupervised maintenance of basic NUS
(6) Theory & practice course of advanced NUS
(7) Course exam of advanced NUS
(8) Supervised procedures of advanced NUS
(9) Level 2 certification of advanced NUS - theory & practice
(10) Level 3 certification of expert NUS
14.2 Level 1 Level 1 Knowledge Base and Recommended Contents of Level 1 Theoretical & Practical
Course
Sound and ultrasound physics
Ultrasound system machine controls
Ultrasound system user controls
• Scale
• Gain
• Filter
• Priority
• Angle correction
• Electronic steering
• Invert
• Sample gating
• Power output
• Colour amplitude
• Velocity measurement
• Spectral changes
Ultrasound techniques
• 2D ultrasound
• Power Doppler
• Pulsed wave Doppler
186
• Color wave Doppler
• Duplex
Ergonomics
Sterility
Safety
Administration
Sonoanatomy (including common variants)
o extracranial vessels
o common carotid artery
o internal carotid artery
o external carotid artery
o vertebral artery
o intracranial vessels
o middle cerebral artery
o anterior cerebral artery
o posterior cerebral artery
o vertebral artery
o basilary artery
o internal carotid artery
Sonopathology (pathology and results of treatment in relation to ultrasound)
o arterial stenosis
o arterial occlusion
o subclavian steal syndrome
o arterial plaques
Level 1 Competencies to be acquired
To be able to:
o extracranial vessels:
o identify the vessels mentioned above
o identify patency, occlusion, stenosis
o grading of stenoses and evaluate pre- and post-stenotic flow
o subclavian steal syndrome
187
o intracranial vessels:
o identify the vessels mentioned above
o identify patency, occlusion, stenosis
o identify normal variants
o evaluate plaque morphology
o use contrast enhanced transcranial ultrasound
Level 1 Theoretical & Practical Course
The course content is equal to the Level 1 knowledge base and the Level 1 competencies
to be acquired listed below. The course should be minimum 20 hours duration at the
beginning of the training period. The theory course should include a pre- and a posttest.
The entire course should be concluded with a course exam covering theory and practice.
The practical sessions should be performed as Hands On Training (HOT):
- HOT 1
o Basic NUS views on normal models
o Revision of normal findings
- HOT 2
o Basic NUS views on normal models or patients or sonosimulators
o Revision of pathological findings (tutorial laptops)
- HOT 3
o Individual reappraisal with interactive in-depth training
The course should be concluded with a course exam in theory and practice of basic
NUS:
• Theory (30 minutes, 25 MCQ)
• Practice (15 minutes, simulator or model)
Proctored Level 1 practice
• Supervision and recommended number of exams: Within 3 months after the course,
the trainee should collect a minimum of 200 intra- and extracranial NUS exams under
supervision: 100 fully supervised basic NUS exams (TYPE A exams) + 100
autonomously collected (TYPE B exams, for later validation). The last 100
autonomously performed exams can be validated either by: a) physical delivery of the
188
electronic logbook + digital clips/images on a mass storage device (CD/DVD/USB
stick) to the assigned tutor once the collection is completed; b) by internet sharing with
a distant tutor. Training should usually be supervised by a level 2 practitioner. In certain
circumstances it may be appropriate to delegate some of this supervision to an
experienced level 1 practitioner with at least two years of regular practical experience.
When local tutors are not available, the 100 TYPE A exams can be replaced by
autonomously collected exams and internet sharing with a distant tutor where the
exams are uploaded and audited sequentially one-by-one (a dedicated area will be
activated on the CECLUS channel, with reserved access to trainer’s page matched
with distance tutor). Lack of information on single cases, not allowing accurate
judgement on trainees competence makes the case not valid for final certification.
• Documentation: All exams must be video recorded and archived in digital format and
data collected in an electronic logbook (excel file). The documentation should record
time spent, need for supervision and correction, and rating of sonoanatomic skill,
imaging, image quality, and diagnostic performance. During the course of training a
competency assessment sheet should be completed.
• Curriculum: All the above mentioned pathology scenarios should be represented. An
exam can be a real clinical NUS exam or a simulated NUS exam: Didactic cases
(provided from local tutors and from distant tutors) should compensate for lack of an
adequate number of cases on some types of less frequent abnormalities. These should
not be reported in the logbook but rather listed, indicated separately as part of exam
final documentation. Sequential examinations on the same patients upon relevant
clinical/therapeutical changes are encouraged; provided there’s relevant change in the
findings, they will be counted as individual cases. No more than 10% exams with
normal findings are to be considered for the final certification
Final Level 1 certification of basic NUS
Different trainees will acquire the necessary skills at different rates and the end point of the
training programme should be judged by an assessment of competencies in the form of
theoretical and practical certification. The theoretical and practical certification should
encompass the full range of the Level 1 knowledge database and competencies to be
acquired listed above.
189
• Theory (2 hours,100 MCQ)
• Practice (30 minutes, simulator or model)
Areas of competence assessed during certification examination:
• Image generation
• Image acquisition
• Image interpretation
• Image administration
• Clinical and organizational thinking
Tools that may be used for the assessment during certification examination:
• MCQs (overall theoretical assessment)
• Videoclip assessment (assessment of pathological clips interpretation and simulated
clinical integration of findings)
• NUS exam on a healthy volunteer (assessment of technical skills in machine setting,
image acquisition and storage)
• NUS on a real patient with relevant morbidity (overall practical assessment)
• Case discussion presented by the trainee
14.3 Level 2
The training requisite to this level of practice would be gained during a period of sub-
specialty training, which may either be within or after the completion of a specialist training
programme.
• The training should include a theoretical and practical course of at least 30 hours
(see below) followed by a theoretical and practical examination and the trainee
should read appropriate literature, scientific journals, and textbooks
• Competencies will have been acquired during training for level 1 practice which will
then be refined by performing a minimum of 30 clinic sessions at a centre where
supervision by someone with a Level 2 competence is available.
• Typically a Level 2 practitioner will have undertaken at least 1.000 ultrasound
examinations within advanced UVS before Level 2 certification.
190
• An electronic log book should be kept documenting a minimum of 50 exams which
should include ideally all Level 2 competencies for advanced NUS.
• The theoretical and practical certification should encompass the full range of
procedures listed below.
Level 2 Knowledge Base and Recommended Contents of Level 2 Theoretical and
Practical Course
o new ultrasound modalities (eg. 3D and 4D ultrasound)
o advanced sound and ultrasound physics
o advanced ultrasound system machine controls
o advanced ultrasound system user controls
o advanced ultrasound techniques
o advanced administration (teaching, documentation, organization)
o advanced ultrasound artefacts
o advanced sonoanatomy (including common variants)
o advanced UVS sonopathology (pathology and results of treatment in relation to
ultrasound)
o identify advanced patterns of occlusion and stenosis
o advanced grading of stenoses and pre- and post-stenotic flow
o identify indirect signs of dissection of extracranial vessels
o evaluate complex flow abnormalities
o evaluate complex collateral formation
o complications
o safety
Level 2 competencies to be acquired
Competencies will have been gained during training for Level 1 practice and then refined
during a period of practice
To be able to:
• perform a complete imaging ultrasound scan and identify all abnormalities detailed
in Level 1 and 2.
191
14.4 Level 3
A Level 3 practioner is likely to spend the majority of their time undertaking advanced NUS
and teaching, research and development within their subspecialized field and will be an
expert in this area. A Level 3 practitioner will accept tertiary referrals from Level 1 and 2
practioners. He/she should have the capability to utilise developing technologies and
ultrasound techniques, develop research and teaching skills and the performance of
specialised examinations.
Level 3 certification requirements
Level 2 certified + minimum 400 advanced NUS exams per year for at least two years +
teaching experience within advanced NUS + minimum three NUS related scientific
publications in peer reviewed papers (PhD level)
14.5 Maintenance of skills
Having been assessed as competent to practice there will be a need for continued
professional development (CPD) and maintenance of practical skills. Recommended
numbers of examinations to be performed annually to maintain skills at each level
Level 1: the practitioner should perform at least 100 basic UVS exams each year.
Level 2: the practitioner should perform at least 200 basic and advanced UVS exams each
year.
Level 3: the practitioner should perform at least 400 basic and advanced UVS exams each
year.
Practitioners should:
• include UVS in their continued medical education (CME)
• audit their practice
• participate in multidisciplinary meetings
• keep up to date with relevant literature
15. Ultrasound of general medicine
15.1 Introduction This curriculum is intended for CECLUS certification Level 1 of specialists of general
medicine who perform basic clinical ultrasound (BCU). The curriculum includes standards
for theoretical knowledge and practical skills. CECLUS has so far not defined Level 2 and
Level 3 of clinical ultrasound for general medicine.
Introductory level (pre-certification)
Performance of supervised BCU prior to Level 1 certification.
Level 1 (basic) certification
Performance of unsupervised BCU. BCU is easy and effective basic assessment of basic
conditions in general medicine with ultrasound. BCU certification should be obtained by all
specialists of general medicine. At least Level 1 competence should be obtained by
anyone performing basic BCU unsupervised.
Typical progression from introduction level to level 1
(1) Theory course pretest
(2) Theory course of BCU
(3) Theory course posttest
(4) Practical hands-on course of BCU
(2) Course exam in theory and practice of BCU
(3) Proctored practice (supervised procedures) of BCU
(4) Level 1 certification of BCU - theory and practice
(5) Performance of unsupervised BCU - maintenance
193
15.2 Level 1 Level 1 Knowledge Base and Recommended Contents of Level 1 Theoretical & Practical
Course
Sound and ultrasound physics
Ultrasound system machine controls
Ultrasound system user controls
Ultrasound techniques
• 2D ultrasound
• M mode
• Colour wave Doppler
Ergonomics
Sterility
Safety
Administration
Sonoanatomy (including common variants)
• pleura/lung
• heart
• arteries
o aorta
o femoral artery
• veins
o inferior vena cava
o femoral vein
• diaphragm
• liver/gallbladder
• spleen
• kidneys
• intestines
• urinary bladder
• uterus
• musculoskeletal
o muscles/tendons
194
o bones
o joints
o subcutaneous tissue
Sonopathology (pathology and results of treatment in relation to ultrasound)
• pleural effusion
• pneumothorax
• basic FATE (Focused Assessment with Transthoracic echocardiography)
• gallstones
• abdominal aortic aneyrism
• urinary bladder retention
• hydronephrosis
• peritoneal effusion
• hepatomegaly
• splenomegaly
• joint effusion
• joint aspiration
• joint injection
• abscess vs. phlegmon
• Deep venous thrombois (DVT) in the lower limb above the knee
• tendinitis
Other sonodiagnostics
• intrauterine pregnancy
• intrauterine device (IUD)
Level 1 Competencies to be acquired
To be able to perform the following procedures with ultrasound guidance:
• diagnose pleural effusion
• diagnose pneumothorax
• the FATE protocol
• diagnose abdominal aortic aneurism (AAA)
• diagnose gallstones
• diagnose hydronephrosis
• diagnose joint effusion
195
• aspirate joint effusion
• joint injection
• differentiate subcutaneous abscess and phlegmon
• incision of abscess
• diagnose DVT above the knee
• diagnose tendinitis
• diagnose intrauterine pregnancy
• control IUD
• intravenous access
Level 1 Theoretical & Practical Course
The course content is equal to the Level 1 knowledge base and the Level 1 competencies
to be acquired listed below. The course should be minimum 20 hours duration at the
beginning of the training period. The theory course should include a pre- and a posttest.
The entire course should be concluded with a course exam covering theory and practice.
The practical sessions should be performed as Hands On Training (HOT):
- HOT 1
o BCU views on normal models
o Revision of normal findings
- HOT 2
o BCU views on normal models or patients or sonosimulators
o Revision of pathological findings (tutorial laptops)
- HOT 3
o Individual reappraisal with interactive in-depth training
The course should be concluded with a course exam in theory and practice of BCU:
• Theory (30 minutes, 25 MCQ)
• Practice (15 minutes, simulator or model)
Proctored Level 1 practice
• Supervision and recommended number of exams: Within 3 months after the course,
the trainee should collect a minimum of 100 BCU exams under supervision: 50 fully
supervised basic BCU exams (TYPE A exams) + 50 autonomously collected (TYPE B
exams, for later validation). The last 50 autonomously performed exams can be
196
validated either by: a) physical delivery of the electronic logbook + digital clips/images
on a mass storage device (CD/DVD/USB stick) to the assigned tutor once the
collection is completed; b) by internet sharing with a distant tutor. Training should
usually be supervised by an experienced level 1 practitioner with at least two years of
regular practical experience. When local tutors are not available, the 50 TYPE A exams
can be replaced by 50 autonomously collected exams and internet sharing with a
distant tutor where the exams are uploaded and audited sequentially one-by-one (a
dedicated area will be activated on the CECLUS channel, with reserved access to
trainer’s page matched with distance tutor). Lack of information on single cases, not
allowing accurate judgement on trainees competence makes the case not valid for final
certification.
• Documentation: All exams must be video recorded and archived in digital format and
data collected in the electronic logbook (excel file). The documentation should record
time spent, need for supervision and correction, and rating of sonoanatomic skill,
imaging, image quality, and diagnostic performance. During the course of training the
competency assessment sheet should be completed.
• Curriculum: All the above mentioned pathology scenarios should be represented. An
exam can be a real BCU exam or a simulated BCU exam: Didactic cases (provided
from local tutors and from distant tutors) should compensate for lack of an adequate
number of cases on some types of less frequent abnormalities. These should not be
reported in the logbook but rather listed, indicated separately as part of exam final
documentation. Sequential examinations on the same patients upon relevant
clinical/therapeutical changes are encouraged; provided there’s relevant change in the
findings, they will be counted as individual cases. No more than 10% exams with
normal findings are to be considered for the final certification
Final Level 1 certification of BCU
Different trainees will acquire the necessary skills at different rates and the end point of the
training programme should be judged by an assessment of competencies in the form of
theoretical and practical certification. The theoretical and practical certification should
encompass the full range of the Level 1 knowledge database and competencies to be
acquired listed above.
197
• Theory (2 hours,100 MCQ)
• Practice (30 minutes, simulator or model)
Areas of competence assessed during certification examination:
• Image generation
• Image acquisition
• Image interpretation
• Image administration
• Clinical and organizational thinking
Tools that may be used for the assessment during certification examination:
• MCQs (overall theoretical assessment)
• Videoclip assessment (assessment of pathological clips interpretation and simulated
clinical integration of findings)
• BCU exam on a healthy volunteer (assessment of technical skills in machine setting,
image acquisition and storage)
• BCU on a real patient with relevant morbidity (overall practical assessment)
• Case discussion presented by the trainee
15.3 Maintenance of skills
Having been assessed as competent to practice there will be a need for continued
professional development (CPD) and maintenance of practical skills. Recommended
numbers of examinations to be performed annually to maintain skills certified at Level 1
are: the practitioner should perform at least 100 basic UVS exams each year.
Practitioners should:
• include BCU in their continued medical education (CME)
• audit their practice
• participate in multidisciplinary meetings
• keep up to date with relevant literature
16. Ultrasound of geriatric medicine
16.1 Introduction This curriculum is intended for CECLUS certification Level 1 of specialists of geriatric
medicine who perform basic geriatric ultrasound (GUS). The curriculum includes standards
for theoretical knowledge and practical skills. CECLUS has so far not defined Level 2 and
Level 3 of clinical ultrasound for geriatric medicine.
Introductory level (pre-certification)
Performance of supervised basic GUS prior to Level 1 certification.
Level 1 (basic) certification
Performance of unsupervised basic GUS. Basic GUS is easy and effective basic
assessment of basic conditions in geriatric medicine with ultrasound. Basic GUS
certification should be obtained by all specialists of geriatric medicine. Level 1 competence
should be obtained by anyone performing basic GUS unsupervised.
Typical progression from introduction level to level 1
(1) Theory course pretest
(2) Theory course of basic GUS
(3) Theory course posttest
(4) Practical hands-on course of basic GUS
(2) Course exam in theory and practice of basic GUS
(3) Proctored practice (supervised procedures) of basic GUS
(4) Level 1 certification of basic GUS - theory and practice
(5) Performance of unsupervised basic GUS - maintenance
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16.2 Level 1 Level 1 Knowledge Base and Recommended Contents of Level 1 Theoretical & Practical
Course
Sound and ultrasound physics
Ultrasound system machine controls
Ultrasound system user controls
Ultrasound techniques
• 2D ultrasound
• M mode
• Colour wave Doppler
Ergonomics
Sterility
Safety
Administration
Sonoanatomy (including common variants)
• pleura/lung
• heart
• arteries
o aorta
o femoral artery
• veins
o IVC
o femoral vein
• diaphragm
• liver/gallbladder
• spleen
• kidneys
• intestines
• urinary bladder
• musculoskeletal
o muscles/tendons
o bones
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o joints
o subcutaneous tissue
Sonopathology (pathology and results of treatment in relation to ultrasound)
• pleural effusion
• pneumothorax
• basic FATE
• gallstones
• abdominal aortic aneyrism
• urinary bladder retention
• hydronephrosis
• FAST (focused assessment with sonography in trauma)
• peritoneal effusion
• hepatomegaly
• splenomegaly
• abscess vs. phlegmon
Level 1 Competencies to be acquired
To be able to perform the following procedures with ultrasound guidance:
• diagnose pleural effusion
• diagnose pneumothorax
• the FATE protocol
• the FAST protocol
• diagnose AAA
• diagnose gallstones
• diagnose hydronephrosis
• differentiate subcutaneous abscess and phlegmon
• incision of abscess
• intravenous access
Level 1 Theoretical & Practical Course
The course content is equal to the Level 1 knowledge base and the Level 1 competencies
to be acquired listed below. The course should be minimum 20 hours duration at the
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beginning of the training period. The theory course should include a pre- and a posttest.
The entire course should be concluded with a course exam covering theory and practice.
The practical sessions should be performed as Hands On Training (HOT):
- HOT 1
o Basic GUS views on normal models
o Revision of normal findings
- HOT 2
o Basic GUS views on normal models or patients or sonosimulators
o Revision of pathological findings (tutorial laptops)
- HOT 3
o Individual reappraisal with interactive in-depth training
The course should be concluded with a course exam in theory and practice of basic GUS
• Theory (30 minutes, 25 MCQ)
• Practice (15 minutes, simulator or model)
Proctored Level 1 practice
• Supervision and recommended number of exams: Within 3 months after the course,
the trainee should collect a minimum of 100 basic GUS exams under supervision: 50
fully supervised basic GUS exams (TYPE A exams) + 50 autonomously collected
(TYPE B exams, for later validation). The last 50 autonomously performed exams can
be validated either by: a) physical delivery of the electronic logbook + digital
clips/images on a mass storage device (CD/DVD/USB stick) to the assigned tutor once
the collection is completed; b) by internet sharing with a distant tutor. Training should
usually be supervised by an experienced level 1 practitioner with at least two years of
regular practical experience. When local tutors are not available, the 50 TYPE A exams
can be replaced by 50 autonomously collected exams and internet sharing with a
distant tutor where the exams are uploaded and audited sequentially one-by-one (a
dedicated area will be activated on the CECLUS channel, with reserved access to
trainer’s page matched with distance tutor). Lack of information on single cases, not
allowing accurate judgement on trainees competence makes the case not valid for final
certification.
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• Documentation: All exams must be video recorded and archived in digital format and
data collected in the electronic logbook (excel file). The documentation should record
time spent, need for supervision and correction, and rating of sonoanatomic skill,
imaging, image quality, and diagnostic performance. During the course of training the
competency assessment sheet should be completed.
• Curriculum: All the above mentioned pathology scenarios should be represented. An
exam can be a real basic GUS exam or a simulated basic GUS exam: Didactic cases
(provided from local tutors and from distant tutors) should compensate for lack of an
adequate number of cases on some types of less frequent abnormalities. These should
not be reported in the logbook but rather listed, indicated separately as part of exam
final documentation. Sequential examinations on the same patients upon relevant
clinical/therapeutical changes are encouraged; provided there’s relevant change in the
findings, they will be counted as individual cases. No more than 10% exams with
normal findings are to be considered for the final certification
Final Level 1 certification of basic GUS
Different trainees will acquire the necessary skills at different rates and the end point of the
training programme should be judged by an assessment of competencies in the form of
theoretical and practical certification. The theoretical and practical certification should
encompass the full range of the Level 1 knowledge database and competencies to be
acquired listed above.
• Theory (2 hours,100 MCQ)
• Practice (30 minutes, simulator or model)
Areas of competence assessed during certification examination:
• Image generation
• Image acquisition
• Image interpretation
• Image administration
• Clinical and organizational thinking
Tools that may be used for the assessment during certification examination:
203
• MCQs (overall theoretical assessment)
• Videoclip assessment (assessment of pathological clips interpretation and simulated
clinical integration of findings)
• Basic GUS exam on a healthy volunteer (assessment of technical skills in machine
setting, image acquisition and storage)
• Basic GUS on a real patient with relevant morbidity (overall practical assessment)
• Case discussion presented by the trainee
16.3 Maintenance of skills
Having been assessed as competent to practice there will be a need for continued
professional development (CPD) and maintenance of practical skills. Recommended
numbers of examinations to be performed annually to maintain skills certified at Level 1
are: the practitioner should perform at least 100 basic GUS exams each year.
Practitioners should:
• include basic GUS in their continued medical education (CME)
• audit their practice
• participate in multidisciplinary meetings
• keep up to date with relevant literature
17. Medical Gastroenterology Ultrasound 17.1 Introduction This curriculum is intended for CECLUS certification Level 1-3 of pre-specialists and
specialists of medical gastroenterology who perform medical gastroenterology ultrasound
(MGUS). The curriculum includes standards for theoretical knowledge and practical skills.
Introductory level (pre-certification)
Performance of supervised basic MGUS prior to Level 1 certification.
Level 1 (basic) certification
Performance of unsupervised basic MGUS. Basic MGUS is easy and effective basic
assessment of basic gastroenterology conditions with ultrasound. Basic MGUS
certification should be obtained by all specialists of medical gastroenterology. At least
Level 1 competence should be obtained by anyone performing basic MGUS unsupervised.
Level 2 (advanced) certification
Subspecialized specialists who perform advanced MGUS most working days. Level 2
certification is only obtained by few specialists of medical gastroenterology.
Level 3 (expert) certification
Subspecialized experts who perform advanced MGUS every working day and most of the
day, and who are active with MGUS related science and teaching. Only very few clinical
experts employing MGUS obtain the expert MGUS level 3 certification. They are typically
employed in university hospital centers.
Typical progression from introduction level to level 3
(1) Theory course pretest
(2) Theory course of basic MGUS
(3) Theory course posttest
(4) Practical hands-on course of basic MGUS
(2) Course exam in theory and practice of basic MGUS
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(3) Proctored practice (supervised procedures) of basic MGUS
(4) Level 1 certification of basic MGUS
(5) Unsupervised maintenanc of basic MGUS
(6) Theory & practice course of advanced MGUS
(7) Course exam of advanced MGUS
(8) Supervised procedures of advanced MGUS
(9) Level 2 certification of advanced MGUS - theory & practice
(10) Level 3 certification of expert MGUS: Level 2 certified + minimum 500 advanced
MGUS exams per year for at least two years + teaching experience within advanced
MGUS + minimum three MGUS related scientific publications in peer reviewed papers
(PhD level)
17.2 Level 1 Level 1 Knowledge Base and Recommended Contents of Level 1 Theoretical & Practical
Course
Sound and ultrasound physics
Ultrasound system machine controls
Ultrasound system user controls
Ultrasound techniques
- B mode (2D brightness mode)
- M mode (motion mode)
Ergonomics
Sterility
Safety
Administration
Sonoanatomy
• Extended FAST 2D and M-mode views
o Pleura
Anterior, bilateral
Posterior, bilateral
o Pericardium
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o Peritoneum
Liver/right kidney
Spleen/left kidney
Rectovesical/vesicouterine pouch
Urinary bladder
adrenal glands
Abdominal aorta
Inferior vena cava
renal pelvis
gall bladder/bile ducts
pancreas
Sonopathology
• pneumothorax • pleural effusion • pericardial effusion • peritoneal effusion
• urinary retention
• abdominal aortic aneyrism
• hydronephrosis
• renal enlargement
• renal processes
• gall bladder stones
• cholecystitis
• gall bladder tumours
• bile duct obstruction
• liver cysts
• liver processes
• fatty liver change
• liver cirrhosis
• pancreatitis
• pancreatic duct stones
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• pancreatic duct dilatation
• pancreatic processes
• splenic enlargement
• portal venous distension
• portal venous thrombosis
• uterine processes
• intrauterine pregnancy
• hypovolemia
Level 1 Competencies to be acquired
To be able to:
• Perform an eFAST exam • Recognize normal sonoanatomy (see above)
• Diagnose relevant sonopathology (see above) • US guided pleural chest tube insertion • US guided peritoneal catheter insertion • US guided suprapubic catheter insertion
• US guided vascular access Level 1 Theoretical & Practical Course
The course content is equal to the Level 1 knowledge base and the Level 1 competencies
to be acquired listed above. The course should be minimum 20 hours duration at the
beginning of the training period. The theory course should include a pre- and a posttest.
The entire course should be concluded with a course exam covering theory and practice.
The practical sessions should be performed as Hands On Training (HOT):
- HOT 1
o Basic MGUS views on normal models
o Revision of normal findings
- HOT 2
o Basic MGUS views on normal models or patients or sonosimulators
o Revision of pathological findings (tutorial laptops)
- HOT 3
208
o Individual reappraisal with interactive in-depth training
The course should be concluded with a course exam in theory and practice of basic
MGUS:
• Theory (30 minutes, 25 MCQ)
• Practice (15 minutes, simulator or model)
Proctored Level 1 practice
• Within 3 months after the course, the trainee should collect a minimum of 25 fully
supervised basic MGUS exams (TYPE A exams) + 25 autonomously collected (TYPE
B exams, for later validation). All exams must be archived in digital format and data
collected in the logbook (excel file).
• When local tutors are not available, the 25 TYPE A exams can be replaced by 25
autonomously collected exams and internet sharing with a distant tutor where the
exams are uploaded and audited sequentially one-by-one (a dedicated area will be
activated on the CECLUS channel, with reserved access to trainer’s page matched
with distance tutor). Lack of information on single cases, not allowing accurate
judgement on trainees competence makes the case not valid for final certification.
• The last 25 autonomously performed exams can be validated either by: a) physical
delivery of logbook + digital clips/images on a mass storage device (CD/DVD/USB
stick) to the assigned tutor once the collection is completed; b) by internet sharing with
a distant tutor.
• The following scenarios must be represented: all the sonopathological conditions listed
above.
• Didactic cases (provided from local tutors and from distant tutors) should compensate
for lack of an adequate number of cases on some types of less frequent abnormalities.
These should not be reported in the logbook but rather listed, indicated separately as
part of exam final documentation. Sequential examinations on the same patients upon
relevant clinical/therapeutical changes are encouraged; provided there’s relevant
change in the findings, they will be counted as individual cases.
• No more than 10% exams with normal findings are to be considered for the final
certification
209
• Final Level 1 certification of basic MGUS
• Different trainees will acquire the necessary skills at different rates and the end point of
the training programme should be judged by an assessment of competencies in the
form of theoretical and practical certification. The theoretical and practical certification
should encompass the full range of the Level 1 knowledge database and competencies
to be acquired listed above.
• Theory (2 hours,100 MCQ)
• Practice (30 minutes, simulator or model)
Areas of competence assessed during examination
• Image generation
• Image acquisition
• Image interpretation
• Image administration
• Clinical and organizational thinking
Tools that may be used for the assessment during examination
• MCQs (overall theoretical assessment)
• Videoclip assessment (assessment of pathological clips interpretation and simulated
clinical integration of findings)
• MGUS exam on a healthy volunteer (assessment of technical skills in machine setting,
image acquisition and storage)
• MGUS on a real patient with relevant morbidity (overall practical assessment)
• Case discussion presented by the trainee
17.3 Level 2
The training requisite to this level of practice would be gained during a period of sub-
specialty training, which may either be within or after the completion of a specialist training
programme.
210
• The training should include a theoretical and practical course of at least 30 hours
(see below) followed by a theoretical and practical examination and the trainee
should read appropriate literature, scientific journals, and textbooks
• Competencies will have been acquired during training for level 1 practice which will
then be refined by performing a minimum of 30 clinic sessions at a centre where
supervision by someone with a Level 2 competence is available.
• Typically a Level 2 practitioner will have undertaken at least 500 ultrasound
examinations within advanced MGUS before Level 2 certification.
• An electronic log book should be kept documenting a minimum of 50 exams which
should include ideally all Level 2 competencies for advanced MGUS. An exam can
be a real clinical MGUS exam or a simulated MGUS exam. A minimum of 25 exams
have to be real clinical MGUS exams. • The theoretical and practical certification should encompass the full range of
procedures listed below.
• To maintain competence at Level 2 practitioners should perform at least 100 clinical
examinations each year within advanced MGUS.
Level 2 Knowledge Base and Recommended Contents of Level 2 Theoretical and
Practical Course
o new ultrasound modalities (eg. 3D and 4D ultrasound)
o advanced sound and ultrasound physics
o advanced ultrasound system machine controls
o advanced ultrasound system user controls
o advanced ultrasound techniques
o endoscopic US (EUS) examinations
o EUS guided celiacus blockade
o EUS guided fine needle aspiration
o advanced administration (teaching, documentation, organization)
o advanced ultrasound artefacts
o advanced MGUS
o anatomy and sonoanatomy
o pathology and sonopathology
211
o complications
o safety
Level 2 competencies to be acquired
To be able to perform:
o Perform endoscopic US (EUS) examinations safely and accurately and acquire all
standard views
o Perform EUS guided celiacus blockade safely and accurately and acquire all
standard views
o Perform EUS guided fine needle aspiration safely and accurately and acquire all
standard views
• To recognise and differentiate between normal anatomy/physiology and pathology • To diagnose common abnormalities
• To recognize when a referral for a second opinion is indicated • To understand the relationship between ultrasound imaging and other diagnostic
imaging techniques
17.4 Level 3
A level 3 practioner is likely to spend the majority of their time undertaking advanced
MGUS and teaching, research and development within their subspecialized field and will
be an expert in this area. 17.5 Maintenance of skills
Having been assessed as competent to practice there will be a need for continued
professional development (CPD) and maintenance of practical skills. Recommended
numbers of examinations to be performed annually to maintain skills at each level
Level 1: the practitioner should perform at least 50 basic MGUS exams each year.
Level 2: the practitioner should perform at least 200 basic and advanced MGUS exams
each year.
Level 3: the practitioner should perform at least 400 basic and advanced MGUS exams
each year.
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Practitioners should:
• include MGUS in their continued medical education (CME)
• audit their practice
• participate in multidisciplinary meetings
• keep up to date with relevant literature
18. Contacts
Specialty Name Department E-mail CECLUS Lars Bolvig Dep. Radiology, AUH larshans@rm.dk CECLUS Thomas F Bendtsen Dep. Anesthesiology, AUH tfb@dadlnet.dk CECLUS Peder Charles Center of Medical Education charles@medu.au.dk Exp. & Clin. Research Kristjar Skajaa Clinical Institute, FH, AU jcd@ki.au.dk Medico-technology Carsten Riis Dep. medico-technology, AUH carrii@rm.dk Skill training Kurt Nielsen Skill training lab., AUH Medical imaging Hans Nygaard Clinical Institute, FH, AU nygaard@ki.au.dk Anesthesiology Erik Sloth Dep. Cardiothor Anesth, AUH sloth@dadlnet.dk Anesthesiology Lars Knudsen Dep. Anesthesiology, AUH lars.knudsen.dk@gmail.com Cardiology US Steen H Poulsen Dep. Cardiology, AUH steepoul@rm.dk Cardiology US Susanne Aagaard Dep. Cardiology, AUH afdBmail@yahoo.dk Dermatology US Karsten Fogh Dep. Dermatology, AUH karsfogh@rm.dk Endocrinology US Eva Ebbehøj Dep. Endocrinology, AUH evaebb@rm.dk Endocrinology US Søren Gregersen Dep. Endocrinology, AUH s.gregersen@dadlnet.dk Gastroenterol medicine US Jens Dahlerup Dep. gastroenterol med, AUH jensdahl@rm.dk Gastroenterol medicine US Søren Lyhne Dep. gastroenterol med, RHR soelyh@rm.dk Gastroenterol medicine US Martin Eivindson Dep. gastroenterol med, RHH mareiv@aarhus.rm.dk Gastroenterol surg US - - - Geriatric medicine US Bjørn Mathiassen Dep. Geriatrics, AUH bjomat@rm.dk Geriatric medicine US Anne B Pedersen Dep. Geriatrics, AUH annepede@rm.dk General medecine US Martin Bach Jensen Institute of Public Health, AUH mbj@rn.dk General medecine US Søren Olsson MEDU, AUH s.olsson@dadlnet.dk Gynecological US Olav Bjørn Petersen Dep. Obstetrics & Gynaecology olavpete@rm.dk Infectious Diseases US Peter Leutscher Dep. Infectious Medicine, AUH peteleut@rm.dk Infectious Diseases US Hanne Arildsen Dep. Infectious Medicine, AUH hannaril@rm.dk Lung medicine US Birgitte Folkersen Dep. Lung Medicine, AUH birgfolk@rm.dk Lung medicine US Ole Hilberg Dep. Lung Medicine, AUH olehilbe@rm.dk Neurology US Paul von Weitzel Dep. Neurology, AUH paul.vonweitzel@aarhus.rm.dk Orthopedic surgery US Svend E Christiansen Dep. Orthopedic Surgery, AUH svechr@rm.dk Orthopedic surgery US Kjeld Søballe Dep. Orthopedic Surgery, AUH soballe@ki.au.dk Orthopedic surgery US Claus Möger Dep. Orthopedic Surgery, AUH claumoeg@rm.dk Orthopedic surgery US Peter Faunø Dep. Orthopedic Surgery, AUH petefaun@rm.dk Orthopedic surgery US Hans V Johansen Dep. Orthopedic Surgery, AUH hansjoha@rm.dk Otorhinolaryngology US Sten Schytte Dep. otorhinolaryngol., AUH stenschy@rm.dk Otorhinolaryngology US Thomas Barrett Dep. otorhinolaryngol., AUH thobar@rm.dk Pediatrics US Tine B Henriksen Dep. Pediatrics, AUH tine.brink.henriksen@ki.au.dk Plastic surgery US Tine Damsgaard Dep. Plastic Surgery, AUH tinedams@rm.dk Rheumatology US Ulrik Fredberg Dep. Rheumatology, RHS mogjen@rm.dk Thoracic surgery US Mariann Tang Dep. Thoracic Surgery, AUH mataje@rm.dk Urology US - - - Vascular surgery US Nikolaj Eldrup Dep. Vascular Surgery, AUH eldrup@ki.au.dk
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