Perioperative Ultrasonography Ehab Farag, MD, FRCA Hesham Elsharkawy David G. Anthony, M.D.

Transcription

1 Perioperative Ultrasonography Ehab Farag, MD, FRCA Hesham Elsharkawy David G. Anthony, M.D. Cleveland Clinic, Cleveland OH 1

2 Complications during central venous catheterization (CVC) occur 2% -15% of the time in adults and can be severe 1. Shummer et al cases, critical-care physicians landmark techniques 3.3% complication rate (10 cases pneumothorax/hemothorax and one stroke leading to death) 1 Domino KB, et al. Anesthesiology 2004;100: Shummer W, et al. Intensive Care Medicine 2004;33:

3 ASA closed claims 13 deaths from CVC insertion. Hemothorax from arterial injury & pneumothorax: major contributors to mortality 1. 5 million CVCs are performed every year 2 even low incidence (0.5%) of significant complications would result in 25,000 problems. 1 Bowdle TA. ASA Newsletter 2002;66. 2 Feller-Kopman. Crit Care Med 2005;33:

4 The Agency for Healthcare Research and Quality US 1 of 11 practices to improve the patient safety and outcome*. 2003, a meta-analysis by Hind, 18 RCTs favored US guidance vs landmark techniques reduced failure rates increased first-attempt success, reduced complication rates and faster procedure time (P<0.0001) *Rothschild JM. Agency for Healthcare Research and Quality 2001:

5 Subclavian Vein Approach SV offers ideal size for central access. Close proximity to the lung, subclavian artery, and brachial plexus can lead to significant morbidity. Other challenges for accessing the SV with US are deeper location and the presence of the clavicle. 5

6 Femoral Vein Approach Baum et al reviewed 100 CT scans FV and the femoral artery overlap in the anteroposterior plane 65% of the time 1. Same finding confirmed in US study in 50 ICU patients 2. 1 Baum PA, et al. Radiology 1989;173: Hughes P, et al. Anaesthesia 2000;55:

7 TRANSTHORACIC ECHOCARDIOGRAPHY 7

8 Possibilites with Bedside Ultrasound Etiologies of Hemodynamic Decompensation Vasodilatory/Distributive Shock Cardiogenic Shock Heart Failure Regional wall motion abnormalities Monitor Resuscitation Efforts

9 Limited TTE Exam Types FATE (Focus Assessed Transthoracic Echocardiography), FEEL (Focused Echocardiographic Evaluation in Life Support) FEER (Focused Echocardiographic Evaluation in Resuscitation Management), RUSH (Rapid Ultrasound for Shock and Hypotension), CAUSE (Cardiac Arrest Ultrasound Exam) BLEEP (Bedside Limited Echocardiography by Emergency Physician)

10 Our Exam (FATE) Three Anatomic windows Four clock positions: 10:00, 2:00, 3:00 12:00 Five scanning views In the ideal patient!

11 Proper probe grasp X

12 Probe Orientation

13 Parasternal Long Axis View Parasternal Long Axis Left Upper Sternal Border (3 rd -4 th interspace) Probe Indicator pointed towards right shoulder (10:00) 1

14 Anatomic Correlate Courtesy of Yale University Echocardiography Atlas

15 Parasternal Short Axis View Parasternal Short Axis Left Upper Sternal Border (3 rd -4 th interspace) 2 Probe Indicator pointed towards left shoulder (2:00)

16 Anatomic Correlate Courtesy of Yale University Echocardiography Atlas

17 Apical View Point of Maximal Impulse (PMI) Anterior Axillary Line underneath breast 3 Probe Orientation: 3:00 (patient s left flank)

18 Anatomic Correlate Courtesy of Yale University Echocardiography Atlas

19 Subcostal View Probe in subxiphoid region Probe orientation: 3:00 4 Tilt parallel to back

20 Anatomic Correlate Courtesy of Yale University Echocardiography Atlas

21 IVC View Probe in subxiphoid region Obtain the subcostal view, then rotate the probe Probe orientation: 12:00 5 Tilt towards the back

22 Volume Responsiveness Collapsibility Index = [IVC max (end exhalation) IVC min (end inhalation)] x 100% IVC max (end exhalation) > 50-75% or exhaled diameter < 1 cm suggestive of hypovolemia Distensibility Index = [IVC max (end exhalation) IVC min (end inhalation)] x 100% IVC Mean > 12 % variation: volume responsiveness: 93% PPV; 92% NPV

23 GASTRIC, OPHTHALMIC, AND PULMONARY ULTRASOUND 23

24 Ultrasound for Gastric Content

25 Three outcomes should be assessed: 1-Identify if the stomach is empty or full 2-Identify if the contents is fluid or solid 3-Identify the volume of the content

26 3-Volume of the content (Quantitative) Mathematical models predict GV based on antral CSA. (GV (ml)= right-lateral CSA (cm 2 ) 1.28 age (yr)) Predict volume up to 500 ml. Perlas A, Mitsakakis N, Liu L, et al. Validation of a mathematical model for ultrasound assessment of gastric volume by gastroscopic examination. Anesth Analg 2013;116:

27 Optic nerve sheath Ultrasonography for monitoring intra cranial pressure Optic nerve sheath is a continuation of duramater ICP CSF pressure ONSD Advantages: ICP changes transmitted within minutes Non-invasive No reported complications Disadvantages: Not continuous Cannot quantitate CSF pressure Operator dependent Not widely accepted.

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30 FDA approved ultrasound probe and machine for ocular ultrasonography Requirements: Mechanical index < 0.23 Thermal index < 1.0 Scan 1 : longitudinal B- Scan

31 Scan 2 : transverse B- Scan Scan 3 : transverse and confirmatory A- Scan ONSD greater than 5.0 mm reliably predicts an ICP > 20 mm Hg

32 Normal Lung Sliding Sign

33 B-lines or comet-tail artifacts Absence of lung-sliding and Comet-tail is 96.5% specific to pneumothorax.

34 Power slide A-lines

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36 Pneumothorax stratosphere sign or barcode sign Absent lung sliding and Comet-tail

37 Diaphragmatic Motion

38 Intercostal view Neuromuscular Ultrasound for Evaluation of the Diaphragm, Aarti Sarwal et al

39 Anterior Subcostal View

40 Figure 2 M mode ultrasound trace of normal diaphragm movement. In a normal diaphragm a sharp upstroke is demonstrated when the patient sni ffs Figure 1 M mode ultrasound trace of normal diaphragm movement. N ormal trace of diaphragmatic movement. In inspiration, movement is caudal, with the corresponding M mode trace being upwards as the diaphragm moves toward the probe. In expiration, the M mode trace is downwards as the diaphragm moves away from the probe

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42 Posterior subcostal view Subxiphoid view