Quality in Point of Care Ultrasound:

What you should know in 2025

Matthew Sigakis, MD

Director, POCUS Clinical Service and QA/QI

Associate Professor, Department of Anesthesiology, University of Michigan

The ASPIRE Collaborative Meeting

July 18, 2025

Disclosures

• No personal financial, consulting, or contractual relationships with

any vendor

• Grants paid to University of Michigan from industry sources for

research where I am a PI / Co-I include:

• ImaCor, Inc.

• Apple, Inc.

Agenda

• Background, current state and essential applications of POCUS

• Why invest?

• Competency

• Quality and safety considerations

• Examples

• Measure, maintain and improve

• Future

• Hands on simulation for YOU!

Point of care

ultrasound

“POCUS”

https://www.asra.com

“POCUS”

Goal Directed Exam

https://www.asra.com

Heart

Lungs

Airway

Abdomen

Vascular

Yes, No, or…

I don’t know

Value Proposition of POCUS

Bedside

Non-invasive

Available

Faster Decisions

Fewer

complications

Evolution of POCUS

• Surgical

specialties

• Inpatient wards

• Outpatient care

• Family medicine

Emergency

Medicine

Critical Care

Perioperative

Anesthesiology

Integration

into clinical

practice

Adequate

scientific

evaluation

Acknowledging

advantages

Simple

descriptions

Vascular access

Regional ultrasound

Cardiac TEE

Point of Care

Ultrasound

POCUS applications you should know in 2025

Anesthesiology 2020

Subcostal view

Left ventricular function

Normal systolic function Abnormal systolic function

PLAX

PSAX

A4C

Subcostal

Pericardial

Fluid

Journal of the American Society of Echocardiography 2019

Journal of the American Society of Echocardiography 2014

FoCUS Clinical Utility

• Triage patients

• Determine benefit from fluid loading

• Narrow the differential diagnosis when undifferentiated shock

• During pulseless electrical activity cardiac arrest, FoCUS identifies

patients with myocardial mechanical activity and those with none

• Risk-stratifies patients with pericardial effusion

• Directs the management of patients with LV systolic dysfunction

• Essential part of the initial assessment of patients with

cardiopulmonary instability

FoCUS and Clinical Outcomes

• Cardiac arrest:

• more accurate than EKG for determining mechanical cardiac function

• changes management

• improves the clinician’s ability to predict outcome

• more accurate than the physical examination for diagnosing the cause of cardiac arrest

• more accurate than the physical examination for assessing cardiac function

• Shock and hemodynamic instability:

• accurately assesses global LV systolic function, when compared with comprehensive standard

echocardiography

• narrows the differential diagnosis

• changes management

• improves outcomes

• should be part of the initial assessment of a hemodynamically unstable patient

FoCUS and Clinical Outcomes

• Estimating Central Venous Pressure, Diagnosing Hypovolemia, and Predicting Fluid

Responsiveness:

• accurately identify patients with low central venous pressure

• accurately identify patients who may benefit from fluid loading

• Physical examination:

• more accurate than the physical examination for assessing LV systolic function and detecting valvular disease

• Screening for Cardiovascular Disease:

• useful in screening asymptomatic patients at risk for cardiovascular disease.

• 184 patients presenting to emergency department in non-traumatic, symptomatic,

undifferentiated shock.

Group 1 (88pts) Group 2 (96pts)

• Standard care

• POCUS at time 0

• Standard care

• POCUS delayed

Median

# viable dx:

Correct dx

@ 15min

80%

50%

Crit Care Med 2004

POCUS Lung Exam

Upper

Lower

POCUS Lung Exam

Conditions:

• Acute respiratory failure

• Undifferentiated shock

• Management of fluid resuscitation

• Evaluation of intubation

• Serial evaluations: effusion, edema, functional

lung volume

• Diaphragm function

POCUS Lung Exam

Findings:

• Ultrasound artifacts: normal vs abnormal

• Normal, Edema, COPD, Asthma, PE

• Mainstem intubation

• Pneumothorax

• Alveolar interstitial fluid: Congestive heart failure

• Consolidation: PNA, atelectasis

• Pleural effusion

Dynamic Lung Exam

Pleural line

w/ lung sliding

A line

rib

Pleural line

w/ lung sliding

A line

rib

“Seashore Sign”

Pleural line

Motionless

soft tissues

Sandy beach

• Moving

aerated lung

No Pneumothorax

Motion mode: “M-mode”

Pneumothorax

A’ profile: A lines, no lung sliding

Stratosphere sign

Lung point

M-mode

• 382 trauma patients; Lung US compared to CXR

• 37 of 39 identified by US

• 95% sensitive; 2 unidentified b/c of subcutaneous air

• 100% true negative rate

Acad Emerg Med. 2005

• 176 blunt trauma patients; with CT as gold standard

• US more sensitive than supine CXR (98% vs 75%)

• US allowed differentiation between small, medium, and large PTXs with good agreement

with CT results.

Sensitivity

• US: 91%

• CXR: 50%

Specificity

• US: 98%

• CXR: 99%

Intralobular septa thickening due to edema

Ground glass pattern due to alveolar edema

Pulmonary Edema

My case: mild to none Example: significant

Pleural Fluid

Liver

Lung

Pleural fluid

Spine

Diaphragm

• 384 Lung regions in 32 ICU pts with

ARDS

• Compared to gold standard of CT

• Lung US better:

• Effusion

• Consolidation

• Edema

Lung POCUS: Putting it all together

• A lines

• B lines

• Lung sliding

• Lung pulse

• Lung point

• Effusion

• Consolidation

BLUE-Protocol and FALLS-Protocol

Two Applications of Lung

Ultrasound in the Critically Ill

Daniel A. Lichtenstein , MD , FCCP

CHEST 2015

Bedside Lung Ultrasound in Emergency (Acute Dyspnea) —the BLUE protocol

(PLAPS: posterior

Effusion/Consolidation)

Deshpande R et al. Curr Opin Anaesthesiol. 2017

FAST / E-Fast exam

Gastric Content: Nature and Volume

• Empty, not empty

• Gas, fluid, or solid

• Gastric antrum

provides the most

reliable quantitative

information for gastric

volume

Perlas A. Anesthesiology 2009

Gastric Content: Nature and Volume

Perlas A. Anesthesiology 2009

Supine

Posterior

Cranial

Caudal

Gastric Exam

Gas while supine

Gas while right lat decub

Perlas et al. Anesthesiology, V 111, No 1, Jul 2009

Solid

Antral cross-sectional: estimate gastric volume

95% confidence interval

• Right lateral decubitus

• 5 cm

< 50cc

• 25 cm

> 300cc

Perlas et al. Anesthesiology, V 111, No 1, Jul 2009

Van de Putte. Br J of Anes 113 (1): 12–22, 2014

gastric volume predicted by gastric

antral CSA, stratified by patient age

Perlas A, Ultrasound assessment of gastric content and volume. Anesthesiology. 2009;111(1):82-9.

Gastricultrasound.org

Solid High risk

Gastricultrasound.org

American Society of Anesthesiologists Consensus-Based

Guidance on Preoperative Management of Patients (Adults and

Children) on Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists

• GLP-1 agonists are associated with adverse gastrointestinal effects

such as nausea, vomiting and delayed gastric emptying

• Risk of regurgitation and aspiration of gastric contents when GLP-1

not held

• If GLP-1 agonists were not held as advised, proceed with ‘full

stomach’ precautions or

consider evaluating gastric volume by

ultrasound, if possible and if proficient with the technique

. If the

stomach is empty, proceed as usual. If the stomach is full or if gastric

ultrasound inconclusive or not possible, consider delaying the

procedure or treat the patient as ‘full stomach’ and manage

accordingly.

https://www.asahq.org/

Oct 2024

POCUS for the airway

• Features predictive of difficult intubation

• Confirmation of endotracheal vs esophageal intubation

• Differentiation between tracheal and bronchial intubation

• Assist with emergent cricothyrotomy

Diagnostics 2023, 13(9), 1541;

Suprahyoid View

Cricothyroid View

Tracheal

dilation

Esophageal intubation

Why develop a POCUS skillset?

• Support clinical assessment

• adjunct to clinical exam and focused sonography

• more timely diagnoses and interventions

Why develop a POCUS skillset?

• Support clinical assessment

• adjunct to clinical exam and focused sonography

• more timely diagnoses and interventions

• Feasible to learn

Ultrasound is not new to Anesthesiology

• Regional anesthesia

• Localization of vasculature before block

• Real-time imaging of anesthetic spread

• Cardiac anesthesia

• Transesophageal Echocardiography: Independent image

acquisition and interpretation

• Core ultrasound skills

• Peripheral and central vascular access

year fellow

Private practice

10 yrs

Experienced

sonographer

r = .76 r = .68

r = .72

Radionuclide ventriculography (gold standard)

Estimated

2 h of didactic instruction on echocardiography

4 h of hands-on training

CHEST /135/6/ JUNE, 2009

Why develop a POCUS skillset?

• Support clinical assessment

• adjunct to clinical exam and focused sonography

• more timely diagnoses and interventions

• Feasible to learn

• ACGME and ABA expectations

Part B: Technical Skills related to POCUS

• Interpret echocardiograms and ultrasound images

• 2-dimensional and color flow Doppler, and M-mode (lung ultrasound) to identify

relevant anatomy, make qualitative diagnostic assessments, and provide treatment

recommendations.

Scenarios may include the following:

• Biventricular function and wall motion

• Presence or absence of an atrial septal defect

• Volume status assessment- hypovolemia and response to volume therapy

• Pulmonary emboli

• Air emboli

• Basic valvular lesions

• Pericardial effusions

• Aortic dissection

• Pleural effusion

• Pneumothorax

• Pulmonary edema

Lung

• Pleura

• Diaphragm

• Artifacts (A-lines, B-

lines)

Heart

• Parasternal Long Axis

• Parasternal Short Axis (Left Ventricle

Midpapillary)

• Apical Four Chamber

• Subcostal Four Chamber

• Subcostal IVC View

Abdomen (2026)

• Right Upper Quadrant

• Left Upper Quadrant

• Pelvis

• Gastric (content &

volume)

Airway-related structures (Testing to start 2027)

• Trachea

• Tracheal rings

• Cricoid cartilage

• Cricothyroid membrane

• Thyroid cartilage

• Vocal cords

• Hyoid bone

• Epiglottis

• Tongue

• Esophagus

Why develop a POCUS skillset?

• Support clinical assessment

• adjunct to clinical exam and focused sonography

• more timely diagnoses and interventions

• Feasible to learn

• ACGME and ABA expectations

• Many other providers are learning and using

• Trainees

• Other specialties

• CRNAs

• APPs

How do we ensure high quality pocus?

• Competency

How do we ensure high quality pocus?

• Competency

• Ultrasound physics

Fundamental knowledge of ultrasound physics

Piezoelectric crystals

Alternating

current

Thin crystals

High frequency

Thick crystals

Low frequency

How image is generated

Pulse

A mode

B mode

brighter

Structure

Greater reflection

Image artifacts

Optimizing image

- Focus

- Resolution

Fluid -> transmission

Soft tissues -> reflection,

transmission

Stones-> reflection, scatter,

absorption

Isoechoic

Hypoechoic

Hyperechoic

How do we ensure high quality pocus?

• Competency

• Ultrasound physics

• Knobology and equipment

Knobology

https://www.ultrasoundportables.com

https://todopocus.com

Selecting the appropriate machine for

the evaluation:

- Qualitative assessment versus

quantitative measurements

- Resolution

- Portability

High quality POCUS requires appropriate selection of

transducer (“probe”)

Each piezoelectric crystal section is made

of many small individual elements.

Each crystal element is in its own

partition, isolated

“Sequential” = crystals aligned

sequentially in linear or curvilinear

fashion

“Phased” = individual elements activated

in phases, effectively steers the beam

Proper care, maintenance and cleaning

• Care, maintenance and disinfectant

• Recognition of damage

How do we ensure high quality pocus?

• Competency

• Ultrasound physics

• Knobology and equipment

• Documentation and image archiving practices

Demographic information:

• Name

• Age

• Biological sex

• Medical record number

• Date of birth

Exam information:

• Date and time of exam

• Exam performed by

• Exam interpreted by

• Indication for exam

• Clinical assessment/impression

• Main findings

• Detailed findings

• Limitations

• Recommendation for additional studies

• Mode of archiving

ASE elements required for documentation

Qpath (Telexy) image archiving server (QA review)

Medical record

How do we ensure high quality pocus

and patient safety?

• Competency

• Ultrasound physics

• Knobology and equipment

• Documentation and image archiving practices

• Anatomy and standardized images

• Hands-on practice

POCUS Training

• To date, no universally accepted standards for POCUS curriculum and

training

POCUS Training

• To date, no universally accepted standards for POCUS curriculum and

training

• Residency and fellowship trainings vary

• Society trainings and recommendations vary

• Best programs contain these elements:

• Didactics

• Image review

• Hands-on proctored practice

• Portfolio of mentored exams

• Annual CME / maintenance

https://www.asahq.org

140

30 lung ultrasounds

30 gastric ultrasounds

50 focused cardiac ultrasounds

30 AFFBU exam

16 basic POCUS

100 cardiac

20 lung

20 gastric

20 AFFBU exam cases

176

Gastric Point-of-Care Ultrasound (POCUS) Certificate

Part 1: Quality Improvement (QI) Action Plan (optional)

Part 2: Diagnostic POCUS Gastric Training

Part 3: Interpretation Training

Part 4: Image Acquisition

Part 5: Take the Final Exam

https://asra.com/events-education/courses/pocus/program

Related certificates / trainings - high

quality

• Critical Care Ultrasonography Certificate of Completion

• Critical Care Ultrasound: Adult

• Critical Care Ultrasound: Advanced Echocardiography

chestnet.org

sccm.org

How do we ensure high quality pocus?

• Competency

• Ultrasound physics

• Knobology and equipment

• Documentation and image archiving practices

• Anatomy and standardized images

• Hands-on practice

• Repetition – mentored portfolio and deliberate practice

Type of Ultrasound

Application

Minimum Number

Interpreted

Minimum Number

Personally Performed

Diagnostic

Basic Critical Care Echo

50 30

Pleural/pulmonary

ultrasound

30 20

Focused abdominal

ultrasound

30 20

Vascular ultrasound

30 20

Requirements for Competence in Critical Care Ultrasound

Core Applications – SCCM

Mastery of two cognitive processes

www.sonosite.com

Physical manipulation of the probe to generate the desired image

Ability to interpret the image in the clinical context

High Quality POCUs requires stereotactic

skillset to appropriately maneuver the

Transducer

American Institute of Ultrasound Medicine: J Ultrasound Med 1999

Image interpretation

Mentored feedback:

- Optimal image orientations “windows” that allow appropriate

assessment

- Interpretation in clinical context

Trainee self assessment form

Monthly POCUS presentation by fellows providing image review, QA

review and literature reference – fellows and faculty

How do we ensure high quality pocus?

• Competency

• Ultrasound physics

• Knobology and equipment

• Documentation and image archiving practices

• Anatomy and standardized images

• Hands-on practice

• Repetition – mentored portfolio and deliberate practice

• Scope of practice

UM Policy defines scope of practice

• The cardiac portion of core POCUS application, also referred to as

Focused Cardiac Ultrasound (FoCUS), is not a substitute for a formal

diagnostic echocardiogram performed by the consulting

echocardiography service. The perioperative POCUS exam is limited in

scope and does NOT include:

• Detailed qualitative or quantitative valvular pathology

• Confirmation of the presence or absence of vegetations or

intracardiac/valvular masses

• Evaluation for congenital abnormalities

• Quantitative assessment of systolic or diastolic function

Competency vs certification vs credentialing

• Competency: having knowledge, skills, judgment to perform.

Competency vs certification vs credentialing

• Competency: having knowledge, skills, judgment to perform.

• Certification

: regulatory body recognition of competence.

Certificate vs certification vs credentialing

• Certification:

• Special Competency in Critical Care Echocardiography exam (CCEeXAM)

• National Board of Echocardiography (NBE).

• January, 2019, the first formal exam

• Passing this exam leads to Testamur status, a prerequisite for certification.

• Certification requires:

• 150 full TTE exams w/ all obtainable elements

• Supervised Training vs Practice Experience Pathway

Competency vs certification vs credentialing

• Competency: having knowledge, skills, judgment to perform.

• Certification

: regulatory body recognition of competence.

• Credentialing: assessment of qualifications to practice.

UM Credentialing

• ABA board certification – basic POCUS is core privilege

• Recommend all Anesthesiologists obtain ASA POCUS certificate to

improve skill set given the variability and challenges within residency

and fellowship programs.

• Critical care divisions in some institutions requiring NBE Critical Care

Echo certification to practice.

Quality and Safety concerns

Lack of standardization

• Terminology

• Training and competency standards

• Workflow and documentation practices

Diverse terminologies

• 1999 American Medical

Association policy

statement H-230.960

• ultrasound imaging within

the scope of practice of

appropriately trained

physicians – not a specific

specialty

Example: “Cardiac POCUS”

• Focused-assessed transthoracic echocardiography

• Focused cardiac ultrasound

• cardiopulmonary limited ultrasound

• informal transthoracic echocardiogram

• limited transthoracic echocardiogram

• bedside echocardiogram

• basic echocardiography

UM QA event

• “bedside echocardiogram” performed on patient with infectious signs

in the ED

• Qualitative exam

• “Echo was done” in progress note.

• Interpreted by providers as formal comprehensive echocardiogram

• Delayed evaluation of endocarditis and appropriate management

UM – Department specific solution

Point of Care Ultrasound Study

Department of Anesthesia

• Disclaimer: This study may contain a focused cardiac ultrasound performed by a clinician to guide

management at the bedside. This study should NOT be considered definitive- please order a comprehensive

echocardiography study if appropriate, especially for (but not limited to

) questions related to the following-

• Valvular pathology

• Presence of vegetations or intracardiac/ valvular masses

• Mechanical and bioprosthetic valves, other devices and foreign bodies

• Quantification of systolic or diastolic chamber function

• Hemodynamic measurements

• Chamber size

• Congenital abnormalities

2024 ASE consensus recommendation

• American College of Chest Physicians (CHEST)

• American College of Emergency Physicians (ACEP)

• American Institute of Ultrasound in Medicine (AIUM)

• American Society of Anesthesiologists (ASA)

• American Thoracic Society (ATS)

• Society of Cardiovascular Anesthesiologists (SCA)

• Society of Critical Care Medicine (SCCM)

• Society of Critical Care Anesthesiology (SCCA)

• World Interactive Network Focused on Critical Ultrasound (WINFOCUS)

2024 ASE consensus recommendation

Journal of the American Society of Echocardiography

September 2024

Patient Safety related to training

Should we practice on patients?

QA events:

1. Practice exam performed in PACU

2. Ask patients to look “for fun” or “to practice”

UM solution:

1. Only true practice exams are on a model

2. If performing POCUS on patients, always have a clinical question in mind and perform exams with

more experienced faculty

Patient Safety related to training

POCUS practice on models:

Signed agreement:

- Benefits

- Risks – ALARA principle,

pregnancy

- Incidental findings

- Exposure

- Ability to stop

Chaperone policy:

- Never 1:1

- Always 3

person

Quality events

• Phantom exams: exams performed that influence clinical decision making

without documentation or image archiving

• Risk: Unable to confirm exam accuracy or perform QA review

UM solution and ASE recommendation:

• Structured image archiving system

• Formal reporting requirements – document in medical record

• Cultural expectations with dedicated departmental oversight

• Engage established vendors and a hospital level appointed gate-keeper

Emerging technology

• Real-time / off-site virtual support

• Artificial intelligence

• Wearable sonography

Emerging technology

• Extensive video tutorials and

real-time virtual support on

vendor machines and websites

(Sonosite, Philips)

• Voice-assist / hands-free

knobology (Sonosite)

Sonosite.com

Emerging technology

• Artificial intelligence-

Deep learning algorithms and automated

calculations

• Current limitations:

• insufficient datasets for training AI systems

• limited generalizability

• lack of standardized POCUS protocols, algorithms, and devices

Diagnostics 2024 Aug 1;14(15):1669

AI-assisted FoCUS

Nature, Cardiovasc Health 2, 27 (2025).

Nature Biotechnology volume 42, pages448–457 (2024)

Summary

• POCUS is an impactful tool for clinical assessments

• Increased multidisciplinary engagement and consensus definitions

will improve clarity around POCUS scope of practice and training

standards

• Reduced operator dependence and AI assisted ultrasound will

increase the opportunities for POCUS in patient care

msigakis@med.umich.edu

Supplements

CMUTs – capacitive micromachined

ultrasonic transducers

Portable Point of Care Ultrasound (PPOCUS): An

Emerging Technology for Improving Patient Safety

• Discuss the indications and limitations of POCUS

• Barriers to adoption:

• fear of missed diagnoses and medical/legal ramifications

• lack of formal training or certification

• Utility demonstrated

• Rapid assessments of acute conditions, before formal echo service mobilized

• Avoiding transfer of patients to higher levels of care such as the ICU

• Describe approaches to learning and integration into practice

Circulation 122,210 • Volume 35, No. 1 • February 2020

Summary of "Role of Point-of-Care Ultrasound in

Emergency Airway Management Outside the Operating

Room"

• Non-OR intubations in critically ill patients

• 42.6% hemodynamic instability, 9.3% severely hypoxic, 3.1% cardiac arrest

• POCUS pre-intubation to decrease severity of physiologic

consequences of intubation

• Screen for decreased LV or RV function and pericardial effusion

• Intravascular volume status and screen for vascular abnormalities

• Screen for pneumothorax and lung consolidation

• Assess gastric volume

• Predict difficult airway

Oct 21, 2023; Anesth Analg. 2023 Jul 1;137(1):124-136

Perioperative Patients With Hemodynamic

Instability: Consensus Recommendations of the

Anesthesia Patient Safety Foundation

• recommendations to guide the clinician in identifying risk, using

essential monitoring, understanding thresholds for specific patients,

and effective and timely interventions for improvement.

• Formalize teaching of new types of monitoring, including point of care

ultrasound

, in postgraduate training programs that enable early

detection of hemodynamic instability and precise diagnosis of the

underlying cause.

• Availability

of point of care ultrasound

Anesthesia & Analgesia, April 2024.

Billing