The Intensive Care Unit

Transcription

1 Imaging of the ADRS patient: Risk of transportation and alternative to repetitive radiation exposure Jean-Jacques Rouby Pitié-Salpêtrière Hospital The Intensive Care Unit The Intensive Care Unit Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care Medicine,University School of Medicine Pierre and Marie Curie (UPMC) - Paris

2 Lung Computed Tomography in the Critically ill Risk of transportation

3 Risks of transportation outside the ICU Incidents relating to the intra-hospital transfer of critically ill patients An analysis of the reports submitted to the Australian Incident Monitoring Study in Intensive Care Beckmann U et al. Intensive Care Medicine 30: ICUs 176 patients undergoing intra-hospital transportation (operating theatre and department of Radiology), 191 incidents

4 Risks of transportation outside the ICU Monitors Incidents relating to the intra-hospital transfer of critically ill patients An analysis of the reports submitted to the Australian Incident Monitoring Study in Intensive Care Beckmann U et al. Intensive Care Medicine 30: Battery supply problem 8 Not available 2 Faulty monitors 2 Airway equipment Problem with intubation/airway equipment 7 Transport ventilator malfunction 4 Problems with oxygen supply 3 Drugs 93 ICUs 176 patients undergoing intra-hospital transportation (operating theatre and department of Radiology), 191 incidents Delayed administration/failure to deliver drug 14 Infusion interruption 4 Emergency drugs unavailable 2 Infusion pumps Battery supply problem 6 Not available 1 Other Emergency elevator access 18 Bed-related problems

5 Risks of transportation outside the ICU Staff management Incidents relating to the intra-hospital transfer of critically ill patients An analysis of the reports submitted to the Australian Incident Monitoring Study in Intensive Care Beckmann U et al. Intensive Care Medicine 30: Communication/liaison problems 18 Inappropriate staff escort 4 Lack of staff 6 Inadequate notification of arrival 5 Airway/ventilation management Malposition of artificial airway 10 Inadequate securing of airway 6 Unplanned reintubation 4 Accidental extubation 3 Portable ventilator incorrectly set-up 2 Failure to check oxygen supply 2 Vascular line management 93 ICUs 176 patients undergoing intra-hospital transportation (operating theatre and department of Radiology), 191 incidents Other Incorrect moving of patient 10 Incorrect stabilization of injured site 4 Staff back-lifting injury 4 Other 3 Accidental dislodgment 9 Disconnection/loose connection 3 Inadequate securing 7 Monitor use Inadequate monitoring 11 Alarm parameters not used/inadequate 3 Incorrect set-up

6 Lung CT in the critically ill patient Risk resulting from radiation exposure Brenner DJ et al. NEJM :

7 Radiation exposure: respective role of different radiologic tests Number of CT per habitant continuously increases TDM Lung CT 49% % Radiology Radiologie Mammographie Mammography 11% Interventional Radiologie interventionnelle Radiology 14% % Médecine Nuclear nucléaire Medicine 26% % Hricak et al. Radiology : Hall et al. Br J Radiol :

8 Lung CT : irradiation exposure Smith-Bindman R et al. Arch Intern Med 2009;169:

9 Lung CT: Irradiation-induced carcinologic risk Hall EJ and Brenner DJ. Cancer risks from diagnostic radiology Br J Radiol : No epidemiologic study is avaailable (5 are on the way in Europe and United state) 2 Risk is assessed by analogy with the risk measured in survivors from Nagasaki and d Hiroshima, present 3 kms away from the impact and exposed to low irradiations, ranging between 50 and 100 msv). 3 Validity of this method has been partially validated by epidemiologic studies performed in workers exposed to low irradiations in nuclear industry.

10 Carcinologic effects of exposure to low dose radiation in survivors of Nagasaki and Hiroshima More than survivors (adults and children), exposed to radiation ranging between 5 and 500 MsV (corresponding to one or several CTs) had a 60-year follow-up for mortality and cancer Hall et al. Br J Radiol : gray (Gy) = 1 Sivert (sv) Brenner DJ et al. NEJM :

11 Carcinologic effects of exposure to low dose radiation in survivors of Nagasaki and Hiroshima Increased risk of cancer is expressed as the number of additional cancers for inhabitants exposed to 100 msv (= 3 CTs) Shuryak I et al. J Natl Cancer Inst 2010;102:

12 Lung CT: How to decrease irradiation? 1 Reduce the number of useless tests (20 à 30 %...) 2 Automatic modulation of radiation dose

13 For reducing irradiation exposure, «new generation» scanners automatically adapt irradiation dose to the density of each organ Irradiation dose can be reduced by 20-50% whereas preserving image quality Hricak et al. Radiology :

14 Lung CT: How to decrease irradiation? 1 Reduce the number of useless tests (20 à 30 %...) 2 Automatic modulation of radiation dose 3 Introduce alternative and non invasive techniques Bedside lung ultrasound

15 Lung diseases where Lung Ultrasound = Lung CT Alveolar-interstitial syndrome Lichtenstein et al. Anesthesiology : 9-15 Lung consolidation Lichtenstein et al. Anesthesiology : 9-15 Ventilator-associated pneumonia Bouhemad et al. Critical Care Medicine : Lung abscess Lichtenstein et al. Intensive Care Medicine : Pulmonary embolism Mathis et al. Chest : Pneumothorax Zhang et al. Critical Care ; R112 Pleural effusion Remérand et al. Intensive Care Medicine :

16 Multiple B-lines - «comet-tails» - interstitial edema (B 1 ) 7 mm apart «B lines» thickened interlobular septa JJR D Lichtenstein et al AJRCCM 156 : ,

17 Coalescent B lines - «comet-tails» - alveolar edema 3 mm apart «B lines» ground-glass areas D Lichtenstein et al AJRCCM 156 : , 1997

18 Coalescent B lines issued from juxtapleural consolidations confluent bronchopneumonia B Bouhemad, JJ Rouby Critical Care Medicine 2009 A Reissig et al Respiration 74 : 537, 2007

19 Pulmonary consolidations: ultrasound characteristics Presence of punctiform or tubular images resulting from static or dynamic aeric bronchogram Pleural effusion Lower lobe

20 Pulmonary consolidations: ultrasound characteristics Presence of punctiform or tubular images resulting from static or dynamic aeric bronchogram

21 Inflammatory or infectious consolidations are characterized by persistent regional blood flow

22 Multiple abscesses of the left lower lobe

23 Multiple abscesses of the right lower lobe

24 Multiple lung abscesses are not detected by lung ultrasound when located centrally within aerated lung regions

25 Quantification of pleural effusion which volume is 500 ml Interpleural distance at the lung base (PLD base ) Between 3 et 5 cms, inconclusive limits Roch A et al Chest 2005; 127:

26 : 656 PE volume US = PE area midlength x PE axial length

27 Quantification of small and large pleural effusions: The multiplane ultrasound approach Rémérand F et al Intensive Care Medicine 2010, 36:

28 Prospective evaluation of pulmonary auscultation, bedside chest radiography and lung ultrasound for the diagnosis of pleural effusion, alveolar-interstitial syndrome and lung consolidation in 31 patients with early ARDS The same day : Auscultation 6 quadrants in the anterior, lateral and posterior planes Bedside chest radiography 4 quadrants in the anterior and lateral planes and the «silhouette sign» for diagnosing posterior opacities Ultrasound 6 quadrants in the anterior, lateral and posterior planes Gold standard : CT of the whole lung D Lichtentsein and JJ Rouby., Annesthesiology 2004, 100 : 9-15

29 Diagnostic accuracy of Chest Radiography vs Lung Ultrasound in 32 patients with ARDS Pleural Effusion Alveolar-interstitial Consolidation syndrome sensitivity specificity Diagnostic accuracy D Lichtentsein and JJ Rouby, Annesthesiology 2004, 100 : 9-15

30 CONCLUSIONS The routine use of lung ultrasound in critically ill patients drastically reduces the indications of bedside chest radiography and thoracic CT. Simultaneously, radiation exposure and ICU costs should decrease whereas, at the same time, very accurate information on the lung status of patients with ARDS should become available at the bedside.