 Good afternoon, everyone. Thank you, Dr. Coulter, for this invitation. I feel absolutely honored being here with you today. I want to thank Dr. Cesar Castillo for nominating me. And I always think that Dr. Castillo is the most noble colleague I ever have met in my career. I'm a proud Brown immigrant of Columbia and American citizen. And I absolutely bless in our institution, including the Baylor Correctional Medicine, Baylor Sundance Medical Center, and THI. I was born in Cartagena, beautiful city. One day you can visit, please do so. The only thing I want to remind you for your cultural awareness, you should actually write it as, it's Columbia, not Columbia. That would be a good tip whenever you visit my lovely city. So I'm inspired to present this lecture because I do believe that the patients and health care improvement need timely delivery of valuable clinical knowledge and prevention of errors at the point of care. And you will see how critical care ecocardiography fits in that category. My interest includes that I actually, the anesthesiology designated seed within the Society of Critical Care Medicine, I do represent the society with the National Board of Ecocardiography, as well as the SCM at the American Society of Ecocardiography and the Joint Commission for Cardiac Center Certifications. I have been challenged over the last decade and it's this picture you see how actually engaged in a serious discussion with a very prominent surgical intensities in the United States because he was probably skeptical about the value of critical care ecocardiography. So I'm pretty comfortable doing this lecture and engage any of my colleagues within Baylor Sundance Medical Center to discuss more about this. I will gonna be using my favorite book that I have read over the last five years to justify why critical care ecocardiography should be a priority for each of you, especially the cardiology trainees. I will gonna explain first what is critical care ecocardiography when you use it and more importantly, half of the presentation I will justify why it is important. So this is the first definition for critical care ecocardiography. Back in 2013, by the person who trained me at the Beth Israel Deaconess Medical Center in Boston, Dr. Aki Orengrimber. And as you can see in this definition, it's pretty much the utilization of ecocardiography and in cardiovascular and respiratory failure. You can't repeat it. And as you can see here, it's very clear that this is for emerging problems in a critical care setting. The same year, there was this controversial publication by the American study of ecocardiography. This publication actually was led by cardiologists. They were trying to make a contrast between limited TTE and focused cardiac ultrasound. I have several presentations in Europe specifically and oh my God, I encounter very tough discussion with the Europeans because they disagree with this. And basically they were undermining the utilization of pocus at the bedside and pretty much living then apart. So over the last decade, with those two definitions and the previous one by Dr. Aki Orengrimber, we have been using all these wide range of devices. And in this picture was my previous institution. She was a cardiology fellow and pulmonary critical care fellow. I was educating both of them. It doesn't matter which device you have. It doesn't matter the definition. What matters is how you're gonna be using at the bedside. And that's what I will make emphasis now. So within the society of critical care medicine, we really were committed to see how this concept of critical care ecocardiography try to equate at least the level of cardiology with limited TTE. That was the goal. So those definition of focused cardiac ultrasound or even focused cardiac critical care ecocardiography were left behind. And now we were more focused how we really can raise the standard. So you can see IN and STL is intensives. And you can see here all my applications for the tool. I can be called from the AD to evaluate a patient that's going to the OR in the anesthesia office. It can be in the PAC, it can be in the CVICU or even the general soldier award inside the OR. So early in my career, I was very interested in seeing how the tool can be utilized across the board. So in this study, I was able to demonstrate that regardless you are a cardiovascular anesthesia fellow, critical care physician, even nurse practitioner or general anesthesiologist, you still can actually learn basic skills in focused cardiac ultrasoundography. Later in 2018, we actually were trying even to propose that even one view might equate the three conventional views with transthoracic echo, we were able actually to see up to 80% of the patients when we were evaluating them with only the sucostal view. And that's the reason this nemonic came up at the ecocardiographic assessment using suicide for only view, the easy exam. And just this year, we were able actually to publish with the Canadian Journal of Anesthesiology that it's going that direction, that we need to identify what is that entry point for any novice in our specialty. So you can see how all of these definitions, all this transition, trying to facilitate the learning and the teaching to the trainee has been important for us over the last decade. Perhaps this might be a moment to have a pause. What is the situation? We have two distinct scope of practice here. We have cardiologists, ecocardiographies that mainly work in the echo lab. They are experts in structural assessment and it's disease oriented approach. And they don't need to have that immediate integration to the clinical context. In contrast, we have intensities, which actually has to be at the bedside all the time. We need to incorporate those physiologic parameters and other even diagnostic modalities. And we are using the tool, even for screening diagnostic or monitoring purpose. But the most important thing is that we need to take immediate decisions. And actually that was what inspired me to put in the first three lines of this review article with the New England Journal of Medicine, stating that the immediate clinical integration is actually what contrasts that a scope of practice on intensities and radiologists or cardiologists. And I think this is a good first step to have that mutual respect and recognition that the tool can be applicable for both scenarios, but they are not actually exclusive. And this is my personal conceptual framework of critical care echocardiography. I do believe overall ultrasonography in clinical medicine, you have application of ultrasonography in other areas in obstetrics or even a space medicine, et cetera. Then my scope of practice as an intensities being at the bedside is important. So the point of care ultrasonography is a necessary skill set for me as an intensities. Inside that point of care ultrasonography, we acknowledge that critical care echocardiography will include that advanced level of skills to actually do the proper assessment. As you can see here, I include both TTE and TEY. Well, I will tell you later why, but it's an expectation that we are forming half a dozen of individuals with the Bayeru Salute Medical Center for the LVAD and the Heart Transplant Service with one six anesthesiologist intensities who actually can have both diplomats, you know, certifications with the National Board of ECHO because the complexity of the patient we deal with in a daily basis. So when you're gonna do that? Well, this is kind of the new paradigm. You can see here how you can start using Pocus just to do an screening. Have a sense what's going on. Sometimes even it can be urgent to the physical exam, whenever we want to do a diagnosis, whenever we want a diagnostic application, then we need to incorporate here critical care echocardiography and comprehensive echo. This actually has been documented in the literature. And then lastly, whenever you want to use as a monitor, this is a different level because when you are using a monitor, you will gonna need quantitation. You need quantitation. You need to be exceedingly experienced in this specific skill. So you can see here, whenever I'm applying critical care echocardiography as a monitoring tool, it's the maximal usefulness because you probably even, you can do the same monitoring you do with a swan guns with echocardiography. But then that's the maximal usefulness. You are avoiding an invasive procedure, but you need maximal experience and I'm very serious about this. So I was exposed early in my career to see this huge frame in my previous institute, my first institute at Cleveland Clinic. And you can see here, it was a high state situation. They really are a high reputable team in the entire world. I was absolutely blessed being there as well. And I was in a nine, they build this new, actually, hospital that was only dedicated to cardiovascular medicine and lung transplantation. And I was very active in this unit. And I will tell you, I was lucky because that beginning in my career was actually who put me in the spot. I'm not a cardiologist, okay? I'm not an anesthesiologist. And I'm naturally associated with, cardiology fellows that most of them were chief residents elsewhere and have prominent cardiologists, prominent cardiothoracic surgeons. What does it mean? Well, it means that that year in 2009, my second kid was born, but at the same time the nurses said, I have little Jose. I was beginning my career, I started going to examine each of my patients with CX-50 machine that I loved. And then one night at 3 a.m. in the morning, I actually was able to rescue a patient that I couldn't do a T. T was kind of the standard with whatever badness in the ICU was. But in this case, using trans-thoracic echo actually saved this patient that have a colisnesin procedure. As you know, I cannot put a T. Pro if you have this case. And Dr. Rice was Thomas Rice who's a very prominent thoracic surgeon in America. Actually was very grateful that we saved this patient's life. So during that year, that was so much fun. This was a patient that was transferred from the MICU to the CVICU 2 a.m. in the morning. That was a year 2010. They needed an ACMO, all the ACMOs were in our unit. So guess what? And I'm saving this clip because at the time I was not able actually to put my clips in the medical record. I was not allowed. This is actually a clip that was recorded with my iPhone. And for those that are not that familiar with this kind of ultrasoundography, you can see how there is a fusion around the loan and then end of the story. We drained that 1.7 liters sequentially in both hemitorics. And within five hours, the patient is back in the MICU. Of course, next day, everybody has to be saying like, wow, how does this happen? In my opinion, you put this morbid obis patient in an ACMO where you were able to abort it. So these are anecdotes. But the anecdotes actually might be really well-justified by studies like this one. That, by the way, was published in our necessarily journals since 2004. And you can see how the chess radiography underperforms when you compare that with loan ultrasoundography. No question. So I can always challenge most of my colleagues regarding the identification of prior fusion with loan ultrasoundography. There is no question about that. Later on, I'm being in the past doing some percentage of neurocritical care. And even the neurointensives, they still believe that the tool doesn't have actually a role in the management of the patients. Think about it. People who have a stroke have cardiovascular disease. It's very prevalent. So I have these patients that are coming for care and thrombectomies in acute ischemic stroke, but they had the comorbidity. So the one has to manage those patients just with concius edation and they don't have a clue whether the patient have a yes of 20% bilateral prior fusion. Those patients were crashing in the angel suite. So I engaged, you know, strong leader like Paul Bespa from UCLA in this regard and inspired the neurointensives to do that. And this other study, I team up with a very respected young cardiologist intensives at Mayo Clinic in Rochester and now starting integrating loan ultrasound with cardiac ultrasound for the cardiac ICU because the cardiologists were not that actually, you know, updated on loan ultrasoundography, especially integrating that with the echocardiography. Or even now we have nephrologists that are intensives and I'm just demonstrating the value of critical care echocardiography. In this case, actually they are telling them, hey, listen, we can do advanced critical care echocardiography. Look at all these parameters in echocardiography. They are proposing to do, this is advanced critical care echo and this is actually coming from an nephrologist intensives. So, and this is to distinguish the different kind of shocks. Show me in any of the current classification for shock how a person who's not a cardiologist is proposing this. So the last three examples are showing you that the tool is not inherent to any specific specialty or any specific patient population. The tool actually is for any medical specialist or even generalists who wants to use it. Regardless is even in the field, it can be even in rural area, it can be a paramedic that is recent evidence of that. So I'm now showing you how over the last decade we have made a significant progress in the utilization of critical care echo. In this review that I participated with colleagues from different continents, we came out with this A and this sequential at the most important one on the top, the number one, you can see every new trainee should be able to perform a basic critical care echo. But the second one that there is no excuse for any patient who becomes high-potency to not have this evaluation. And then we go so on and you can see even here, we're just even saying that the TE pro should be in the ICU. So this is a consensus. This is a consensus on mounting evidence for critical care echo choreography. But now is the most important part of the lecture. I want to engage you, what is the reason I became so, so reluctant to change my practice. And I do believe that any intensities moving forward must always have the skill set in critical care echo choreography. This is one of our leaders in the country, Dr. Fink stated this in 2015. The technical skill set that is required to be a fully competent intensities has expanded as well. We expect proficiency, proficiency in ultrasound and echo careography and diagnostic and interventional tools. You are seeing a way management and you are seeing a stack portfolio support. Dr. Fink actually is a surgical intensities and that actually inspired me five years ago. I do believe that's what you have to be able to look with our group in our critical care section. So we are committed to have advanced beginner, everybody in my team, everybody in our team, including the North practitioners should be at this level in critical care echo choreography. However, as a program director of the fellowship in anesthesia critical care, our fellows want to be at least competent, most likely proficient. And if somebody wants to go to the next level, they should be experts. But this is a commitment from the leadership perspective that our trainees has to be at that level. So we want to really take better care of our patients. It cannot be only one person. And the competence actually includes having the right technology, having that political alignment and have the collective learning. And that's the reason we need to be inclusive and we need to actually train anybody from any specific background, including even respiratory therapies. What if I have in the future respiratory therapy is telling me I have failed to actually win this patient from the ventilator, but I'm seeing here we're ultrasound, you have a major electrolysis. So we created a certification pathway and we are very, very fortunate to be successful a few years back. But what does it mean that you are critical care echocardiography certifying in this specific field? Well, that means that you know how to obtain, you know how to obtain the images and you interpret them. I'm not talking about just passing the test. I have seen people who have passed the test, they struggle obtaining the views. But when you had the critical care echocardiography certification, that implies that you should be able to actually acquire the images and interpret the image in the clinical context. Why this was needed? Because we needed a formal assessment to prove that expertise in every domain that requires that integration of the cognitive and the motor skills. And by the way, that includes the wide breadth of pathophysiology in critical care medicine. So if I work in a unit that has patients with LBADS transplantation, I better make sure that actually that is included in this certification. So these are the purpose of the critical care echocardiography certification. Once again, establish that domain. We need to really demonstrate the level of knowledge. And we really want to enhance over time the quality and individual professional growth in this field. And we want to recognize those individuals who are doing this very seriously. And lastly, we need to continue serving the public but encouraging high quality patient care in the practice of critical care echocardiography. So here I'm making a contrast between basic knowledge and advanced knowledge. The critical care echocardiography certification includes advanced knowledge. And you can see here how actually is defined as comprehensive hemodynamic and cardiac evaluation. You need to demonstrate that competency in all ICU patients. You should be able to do differential diagnosis. You should be able to do quantitative measurement. You actually will be introduced to TEE. So that's when you consider yourself that you are competent in critical care echocardiography. How to apply to this certification? Well, first of all, you should be able to demonstrate that you are practicing as a critical care provider. So this is for individuals that are able to demonstrate they have a certain amount of hours working in an ICU. Even if you are a general cardiologist or even if you are a general anesthesiologist, as long as you are able to demonstrate you spend hours with critical little patients. The legibility, you can see here, you pass the exam and you have done the ASCII exam in the past. You need a medical license. You have your certification and your specialty and training as I told you, as I told you, experiencing critical care. And then some training or experiencing critical care echo. More importantly, you need these numbers for studies. And this is a good opportunity to thank all cardiology fellows and cardiac sonographers under the leadership of Nofel and Dr. Steinbach for allowing my anesthesia critical care fellows to be there. And you have been extremely helpful to them. Both of my fellows are actually over 100 studies now. And it is our goal, by June, they have 150 studies. I want them to lead by example, whatever they go. So going to which evidence, because this is the problem, I'm being stopped by people. What's the evidence for that Jose? I haven't seen all of you guys have been doing this, but what is the evidence? Well, if I take this study from almost like a decade ago, they just basically were scanning people from head to toe. And of course, when you scan, you're gonna have findings. But I will tell you, almost 80% of the new findings were cardiothoracic abnormalities. You can see here how long the sonority and cardiothoracic were important. And of course, that will lead to changes in the medical therapy. And in terms of invasive procedures, the more prevalent was actually the drainage of purer refusions. So thing has been changing in regard of which specialty are becoming more active on the academic productivity. You can see here how over the last five years has been a tremendous revolution, tremendous explosion in the number of publications related to critical care echography or cardiac point of care ultrasound. And you can see here all the domains including cardiovascular structure and function, technique, volume status, cardiac arrest, and medical education, for instance. But look at this, just this past year, we were able to see how my background specialty of critical care and anesthesiologist actually kind of increased in comparison than a decade ago. So a decade ago was more prominent actually with your specialty of cardiology. And then now there are more anesthesiologists, more intensive, more emergency medicine physicians being more prolific and that this is important because you need to be aware of that application outside your cardiovascular floors. Furthermore, CMS now includes ultrasound therapy evaluation, even in the management of patients with septic shock and sepsis is there. It's actually an alternative to the physical exam. In addition to it, some institution has developed robust database and the MIMIC-3 actually is a database and associated with the hardware system. It's a tremendously resource for critical care echocardiography. I have to say that Antoabela Arbaron, I will speak about him later, participated actually and I was quite surprised because they brought people from the different parts in the world but look at what happened here. Patients with sepsis, septic shock, when they did this propensity score, matched the mortality rates for TTE and not TTE in the first 24 hours of admission to the hospital. Actually, the mortality was lower whenever you do a TTE. So we have been trying to facilitate how we can apply this in septic shock. And then here we created that son specific phenotypes that was from the work in 2018 with anesthesiology residents. Well, the following year, Antoabela Arbaron again was a cardiologist intensivist who worked in Paris and he was trained in cardiography in the United States, had been working in this field for two decades now. He actually did the study very well done but utilizing TTE and now he has these phenotypes and these phenotypes will have different management in your septic once again, a very active, very active field in the research of a critical care echocardiography. So I put this book chapter because once again, the amount of evidence that is available related to ribenticular function and critical care choreography is not that much but I'm being absolutely fascinated to kind of make a correlation between whatever quantitation and qualitative assessment because the importance of do the proper screening. So I have the opportunity to work with Antoabela Arbaron and couple of full locations in M mode and then in this specific role, I consider him the most respected individual in the planet when it's related to ribenticular dysfunction. So we came up with actually these qualitative assessment and I know that some echocardiologists do not believe in the moderate dysfunction of the ribentical, even if you want to do that, it's fine but even just distinguish, being able to distinguish or contrast normal form severe ribenticular dysfunction that will be important. I haven't stopped that there. I think in the coming year, you will see a high profile publication that we are working on with Dr. Raymond Stainbach and another national respected cardiac sonographer. So more to follow regarding the ribenticular dysfunction. So what I'm going now to show you is how things become more complex. So we have oftentimes patients with LBOD or heart transplantation and we know the ribenticular dysfunction is there, underlying, but why did they become septic? And then I have seen a little bit of, it's sometimes hard to really come together as a team when you have some beliefs and the other especially has another belief but let me tell you why sometimes we cannot be in the same page. You see how you are presenting this data. So and Traveller Barone recently presented this data on ribenticular failure in septic shock. You can see here how he has three groups. He had this group of people that actually, there was not ribenticular enlargement but the CVP was all over the place. And this group too, there was an enlargement and the CVP was trying to probably not be in the high side but more importantly, the only group that actually he was able to demonstrate that that group of patients did not need more fluids were patients who have a CVP higher than A with RB enlargement. But this graphic is telling you how you have been trained. If you have been trained only on CVP and following so on numbers is one thing. My suggestion is we might be open to actually have both modalities together. We will serve better our patients with that approach. As you can see here, once again, we do this test oftentimes the passive layer race test. And you can see here how as you become more enlarged in the ribenticular, you are not that actually responsive to passive leg race. And this is the right way to do it. We have, we published this past year, please try to take a look of this review article on dosing fluids in early septic shock, how to do it. They will explain you there. It's very important because something I've been advocating to the team is before you just give empirically 500 ccs of albumin, whatever, why don't do a passive leg racing? Of course, we have been able to demonstrate that indiscriminate amount of fluids is harmful to the patient. In that study, by the way, there was no evidence of the taxi being discriminatory and patients were gonna respond or not to fluids. That's an important finding. So, what are those active areas of research right now? Well, there is a lot going on on the cardiac arrest prognostication. They wanna see whether if we do a critical care in cardiac arrest, I can prognosticate that's something you have to be vigilant of. Second, very popular, there is interest to de-resuscitate patients, meaning after we have been so good resuscitating them, how we can take out fluids. And lastly, this is our area of mechanical circulatory support, how we can manage those patients better with critical care echocardiography. Now, this paper last year, like 95%, 98% of the authors were from Europe, only Paul Mayo was there. It's showing you how we're becoming more strict when it's coming to conducting critical care echocardiography studies. So, this panel is proposing now that these are actually the parameters has to be included in the evaluation of LBC Stoic function. Okay. And for ribo integral function, same thing they will tell you. And for diastolic dysfunction and for fluid management. What I mentioned in this, it's very possible that you submit a study regarding the management of patients with critical care echo, they were gonna make this paper as a reference, how your methodology can be better validated if you follow those parameters that I was including here. So, I just wanted you to have a reference this paper because I'm seeing how even though it's a panel, as per panel opinion, it may sense because we are trying to elevate the importance of the methodology on this studies. And I welcome that for sure. So, regarding the fluid resuscitation, you can see here all the consequences for fluid overload. I'm pretty sure most of you as cardiologists are probably very aware of this, but for those who are working in surgical ICU, we know actually how we can create problems in the GI tract or even patients who have abdominal wall defect as well. And respiratory for us is a big deal regarding difficult weaning, work of breathing. So, this is something that is very important. So, what's happened? Well, I will tell you, this is just a very schematic representation how when you become fluid overloaded, your re-ethyl pressure increases, but this actually are the Doppler imaging in the hepatic vein, the poral vein, and the inter-renal vein vessels just to see how you actually have evidence that that's happening. I applaud those efforts. I think this will be something that should be appreciated. Indeed, this publication has shown you here how to do it. And guess what? We actually are doing it. This is actually one of my wonderful fellows, very skillful pulmonary arithmetical care fellow. And actually, without disclosing any patient information here, you can look at and I have to thank Dr. Senuzzi for, because he's advocacy in this regard. It's all good. This is the first step creating studies, potential studies that might actually be a good hypothesis for the future. So, we're already doing this at Baylor San Luis Medical Center. But what is the problem? The problem is that I have people who can ask me, what is the evidence? Well, the honest answer is, we don't have that much evidence yet. So, this is good, starting point. I want you just to be aware of this progress. And the research agenda, I think the fluidity tolerance is up there. We're gonna continue producing that. I want to show you here that actually, in the past, I used to utilize big hearts to really demonstrate the trainees how actually don't sound being dissect the heart. Okay? And then now, and even I needed to use the ASE videos, like in this case, so they can understand. This is one of my former fellows that was actually a previous attending here at Baylor San Luis, and he's under intensive, he's now University of Florida. But the purpose now, I just recently started a collaboration with a dear Colombian friend, the University of Minnesota. And now, this is a case of a patient actually who have a hypertrophic fibromyalpathy and needed heart transplantation. So when that patient actually, under when heart transplantation, they were able actually to do these ex vivo MRI, and based on this MRI, and ex vivo, you actually can have a 3D printer and have those models from pathologic hearts for the education. What that means? Look at now, they have it actually here at home. I have it with me here right now. See? So I don't have now to do any dissection of big hearts. I have actually hearts with pathology. And with that, I will be able to even teach much better my trainees. They actually can see these in modules online. So this is a wonderful collaboration. And I hope they come in and wash up what we do with the cardiovascular anesthesia fellowship and the critical care medicine fellowship. I might bring my colleagues from the University of Minnesota and we'll do something fun with this technology. So what is our current stewardship? So I committed to call it the guidelines for the proper use of cardiac ultrasonography for critically ill patients. As you can see here in 2016, this were the last guidelines. And I can tell you with all this research agenda, the landscape is very transformational. So this is time the society tried every five years to do a new guidance. And I feel absolutely honored to lead this guidance with my dear friend and colleague Dr. Saranicka with University of Washington in Seattle. From the personal perspective, I'm pursuing right now my healthcare quality master with John Hopkins. And I was very lucky to interact with Dr. Neumann Tocher who was one of the professors. And I'm very interested in really mitigate those diagnostic errors with Palkus. I think we even can change the terminology and talk about diagnostic difficulties. But this is a new framework, a new understanding about how you have diagnostics, a process failure, diagnostic label failure. And this is probably complex at this time for you to understand, but definitely the medication errors were the importance for preventing hormone patients in the last decade, but moving forward, the diagnostic errors are becoming more important. And in fact, there is a society in diagnostic medicine. So this is right now one of my priorities in my career. And I collaborated with another colleague from Cleveland Clinic, Dr. Asig Dugar. And I hope we can have something out there published by next year. So I want to thank you for the invite. This is a picture of mine in 1974. My man said that I always was fascinated with medicine. That picture in 2001 was my first fellowship in critical care medicine. I repeated both my fellowship by my residence in the United States. And the picture in 2017 is because I really worked hard to empower the intensivist to have the TE Pro in the ICU and we develop advanced course in TE within the SCCM. So I just showing with these three pictures that once again, nobody will change my mind regarding the importance of serving our patients better, having higher standards of qualification in critical care echoreography. Thank you so much.