Table 5 Final recommendation for point-of-care ultrasound competencies for thoracentesis, paracentesis, and central venous catheterization (CVC)

Mandatory general competencies

 Know which probe(s) to use and probe orientation

 Basic knobology (depth/gain)

 Appropriate infection prevention and control measures

 Appropriate sheathing of transducers for real-time guidance

 Recognizes limitations (e.g. when procedure cannot be performed or should be performed by a more experienced proceduralist)

 Able to correlate findings on ultrasound with surface anatomy

Mandatory thoracentesis competencies

 Can identify the spine sign (e.g. vs. mimickers and false positives of pleural effusion such as drop out artifact)

 Characterization of pleural effusion (septations/etc.)

 Assessment to include probe sliding/two planes

 Assessment to include deep breaths (lung movement) and diaphragm movement

 Can identify location of diaphragm/intra-abdominal organs/lung tip

 Indirect guidance

Mandatory paracentesis

 Can identify abdominal free fluid

 Assessment to include probe sliding/two planes to ensure a sufficient area surveyed

 Assessing for location of structures to avoid (liver, spleen, bladder, kidney, bowel)

 Assessment to include compression to ensure depth of fluid collection remains sufficient

 Ruling out vasculature (e.g. inferior epigastrics/collaterals)

 Indirect guidance

 Recognizes mimickers of free fluid (e.g. intraluminal fluid, perinephric fat)

Mandatory central venous catheterization (CVC)

 Can differentiate between artery vs. vein

Assessment to include ruling out deep vein thrombosis (in the access site vein, not thrombosis in the legs)

 Identify appropriate insertion site based on anatomy (not just where vein is largest, but if location is too low and at high risk of pneumothorax)

 Can identify underlying lung (for internal jugular and subclavian sites)

 Creep technique (to ensure visualization of needle all the way in) for all real-time guidance maneuvers

 Real time guidance for internal jugular CVC

 Internal jugular CVC: either in-plane or out-of-plane

 Femoral CVC: real-time guidance

 Assessment to include confirming location of wire intra-vein with ultrasound

Optional thoracentesis competency

 Assessing for pneumothorax pre- and post-

Optional CVC competencies

 Assessment to include confirming catheter is intra-vein with ultrasound

 Assessing for pneumothorax pre- and post-