( J C Current ' ~ Concepts in Critical Care

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2 ( J C Current ' ~ Concepts in Critical Care " Already published in the Series: Shock and the Adult Respiratory Distress Syndrome Edited by Wolfgang Kox and David Bihari Forthcoming: Acute Renal Failure in the Intensive Therapy Unit Edited by David Bihari and Guy Nield

3 C I ~ t ) w. Kox, J. Boultbee and R. Donaldson (Eds) " Imaging and Labelling Techniques in the Critically III With 167 Figures Springer-Verlag London Berlin Heidelberg New York Paris Tokyo

4 W. Kox, MD Senior Lecturer/Head of Department, Department of Anaesthesia, Charing Cross and Westminster Medical School; and Honorary Consultant Anaesthetist (Director Intensive Care Unit), Charing Cross Hospital, Fulham Palace Road, London W6 8RF J. Boultbee, FRCP Department of Radiology, Charing Cross Hospital, Fulham Palace Road, London W6 8RF R. Donaldson, MD, MRCP Consultant Cardiologist, National Heart Hospital, Westmoreland Street, London WIM 8BA Cover illustrations are taken from figures within this book British Library Cataloguing in Publication Data Kox, Wolfgang, Imaging and labelling techniques in the critically ill. 1. Medicine. Diagnosis. Imaging I. Title II. Boultbee, J. (Joseph), III. Donaldson, R. (Robert), '54 Library of Congress Cataloging-in-Publication Data Imaging and labelling techniques in the critically ill/w. Kox, J. Boultbee and R. Donaldson (eds.). p. cm. Includes bibliographies and index. ISBN-13: e-isbn-13: DOl: / Diagnostic imaging. 2. Critical care medicine. I. Kox, W. (Wolfgang), II. Boultbee, J. (Joseph), III. Donaldson, R. (Robert) [DNLM: I. Critical Care. 2. Diagnostic Imaging. WN ] RC78.7.D '57--dcl9 DNLM/DLC for Library of Congress CIP This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, re-use of illustrations, recitation, broadcasting, reproduction on microfilms or in other ways, and storage in data banks. Duplication of this publication or parts thereof is only permitted and under the provisions of the German Copyright Law of September 9, 1965, in its version of June 24, 1985, and a copyright fee must always be paid. Violations fall under the prosecution act of the German Copyright Law. Springer-Verlag Berlin Heidelberg 1988 Softcover reprint of the hardcover 1 st edition 1988 The use of registered names, trademarks etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore free for general use. Product liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. 2128/ (Printed on acid-free paper)

5 Foreword It gives me great pleasure to have this opportunity to write a Foreword for this new book. In the past two decades we have witnessed very significant advances in the management of the very ill patient. The great success in this field of medical endeavour is largely due to the establishment of intensive care units, but a great deal of progress can also be attributed to the major developments in technology, which affect patient management and care as well as the many sophisticated techniques of diagnosis and patient monitoring. Imaging and Labelling Techniques in the Critically III covers this new important and difficult field of diagnosis and visual monitoring. By establishing the criteria and algorhythms for the choice of the different methods available for this purpose, defining the diagnostic signs on images and resolving some of the misconceptions and pitfalls, this book will go a long way to help the reader, particularly those involved in the care of patients in the intensive care units. This book brings together many different methods of investigation and discusses the advantages and limitations of these techniques in different clinical circumstances. Some of the techniques are well established and their usefulness in the intensive care unit is in no doubt. Some of the newer techniques such as PET scanning or NMR imaging have not yet found a defined position of usage in the critically ill patient. There is, however, little doubt that in due course this situation will change. After observing, over many years, the development of the various imaging techniques which can be used in diagnosis of the very ill patient, one will appreciate the advantages of having all this diagnostic information put together in one volume. I have no doubt about the success of this book's future. London September 1988 R. E. Steiner Emeritus Professor of Diagnostic Radiology

6 Foreword Techniques of patient imaging are evolving rapidly. A number have become established in the practice of intensive care medicine, others remain to be evaluated. The contributions of X rays, ultrasound, nuclear imaging and CAT scanning to the diagnosis and management of the many varied problems that beset the very sick patient are well recognised. Critical illness is now dominated by the ravages of trauma and infection, affecting an even older population, and it is the acquisition of detailed structural and functional information, in a noninvasive fashion, that makes imaging such an important and elegant process in the intensive therapy unit. This book, 'Imaging and Labelling Techniques in the Critically Ill'"the second published in the "Current Concepts in Critical Care" series, describes the use of the various imaging methods in an appropriately systematic fashion, highlighting neural, respiratory, cardiovascular and abdominal pathology. A final section is concerned with special techniques and recent advances. Each chapter has been prepared by an expert or experts in the particular field and the whole edited by an intensivist, a cardiologist and a radiologist. The complete work represents a most important addition to the literature of intensive care medicine. It portrays the important integration of different disciplines, a theme so fundamental to the efficient and successful care of the critically ill patient. London September 1988 Jack Tinker Regional Postgraduate Dean, North East Thames R.H.A., British Postgraduate Medical Federation; previously Director, Intensive Therapy Unit, The Middlesex Hospital, London

7 Preface The care of the critically ill patient not only comprises sophisticated monitoring and lifesupporting equipment, but also depends on meaningful diagnostic techniques in order to instigate swift intervention when necessary. This can only be achieved when the choice and use of these diagnostic techniques can be rationalised and those involved in the decision for their application are fully aware of the possibilities and limitations of any such technique. It was the intention of the editors to relate diagnostic imaging and labelling techniques to specific organ systems - the brain and the nervous system, the lungs, the cardiovascular system as well as the abdomen - and to clarify their role in aiding the diagnostic process. In addition, techniques which are at present used as research tools are introduced as possible methods for clinical routine in the near future. Obviously, over the last decade, the imaging developments of the sixties and seventies have become standard investigative procedures in the general hospital environment. Some of these technologies take a large portion of the hospital budget, and they need to be used selectively after careful clinical assessment, particularly when related t9 patients with poor prognosis. Ten years ago a CT (body) scanner was considered beyond the means of most general hospitals, whereas today most large hospitals have installed, or have reasonable access to, this type of technology. The same might be said for the other imaging technologies such as MR scanning in years to come. We realise that some of the techniques described in this book are not always available to the intensivist; we make no apology for including them in this book as we feel we should all be aware of and ready to use them when they become more freely available. Some of the imaging modalities, such as ultrasound and gamma cameras, can be mobile and easily applicable to the severely ill patient in the intensive care ward. However, there are restrictions in the use of other modalities which cannot be brought to the patient's bedside. Sometimes, the benefit achieved by yet another diagnostic procedure may be offset by the deterioration in the patient, due to the move to another department. The ideal - bringing the mountain to Mohammed - has been achieved in the use of portable radiography and mobile ultrasonography. Thus, they are now first-line procedures and should always be freely utilised before embarking on the more complicated and hence expensive techniques. We hope this review will be of value to those involved in the management of critically ill patients. London February 1988 Wolfgang Kox Joe Boultbee Robert Donaldson

8 Contents SECTION I: The Brain and Nervous System Radiography, Angiography and Computed Tomography of the Central Nervous System A. R. Valentine Nuclear Magnetic Imaging of the Nervous System I. Moseley and L. Loh Positron Emission Tomography in the Investigation of Cerebral Disease R. S. J. Frackowiak Jugular Venous Bulb Oxygen Saturation and Cerebral Blood Flow Measurement in Intensive Care R. Garlick SECTION II: Imaging the Lungs 5 The Interpretation of the Portable Chest Film and the Role of Complementary Imaging Techniques W. Kox, J. Boultbee and K. Hillman Computed Tomography in Acute Respiratory Failure L. Gattinoni, A. Pesenti, A. Torresin, S. Vesconi, G. P. Rossi, R. Fumagalli, R. Marcolin, D. Mascheroni, M. Langer, G. Iapichino, F. Rossi and S. Baglioni 67 7 Radionuclide Imaging of the Lungs R. F. Jewkes SECTION III: Cardiovascular Assessment 8 Cardiac Ultrasound R. Donaldson Radionuclide Imaging of the Cardiovascular System S. R. Underwood Magnetic Resonance S. Rees, S. R. Underwood and D. Firmin

9 xii Contents SECTION IV: The Abdomen 11 Abdominal Ultrasound in Intensive Care J. Boultbee and W. Kox Computed Tomography of the Abdomen of the Critically III A. Dixon Radioisotopes in the Diagnosis of Abdominal Embarrassment in the Critically III J. P. Lavender SECTION V: Special Techniques and Recent Advances 14 Interventional Radiology and Digital Subtraction Angiography J. McIvor and P. S. Treweeke Radiolabelled Blood Cells in the Investigation of the Critically III C. N. McCollum Imaging and Investigating the Microcirculation in Intensive Care Patients J. R. Weinberg and J. E. Tooke Subject Index

10 Contributors S. Baglioni J. Boultbee Department of Radiology, Charing Cross Hospital, Fulham Palace Road, London W68RF, A.K. Dixon Department of Radiology, University of Cambridge, Addenbrooke's Hospital, Cambridge CB22QQ, R. Donaldson Department of Cardiology, The National Heart Hospital, Westmoreland Street, London W1M8BA, R. S. J. Frackowiak MRC Cyclotron Unit, Hammersmith Hospital, Ducane Road, London W12 OHS, D. Firmin Magnetic Resonance Unit, The National Heart and Chest Hospitals, 30 Britten Street, London SW3 6NN, R. Fumagalli 'L. Gattinoni R. Garlick Department of Neurosurgery, The Royal Free Hospital, Pond Street, Hampstead, London NW32QG, K. Hillman Department of Anaesthetics, Intensive Care and Coronary Care, The Liverpool Hospital, Liverpool 2170, Sidney, NSW, Australia G. Iapichino R. F. Jewkes Department of Nuclear Medicine, Charing Cross, Fulham Palace Road, London W6 8RF,

11 xiv Contributors W.Kox Department of Anaesthesia, Charing Cross and Westminster Medical School and Intensive Care Unit, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, M. Langer J. P. Lavender Department of Nuclear Medicine, Hammersmith Hospital, Ducane Road, London W12 OHS, L. Loh Department of Anaesthesia, John Radcliffe Hospital, Oxford OX3 9DU, R. Marcolin D. Mascheroni Institute of Anaesthesia, University of Milan, Via Francesco Sforza 35,20122 Milan, Italy C. N. McCollum Department of Surgery, Charing Cross and Westminster Medical School, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, J. McIvor Department of Radiology, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, I. Moseley Lyshcilm Department of Radiology, National Hospital for Nervous Diseases, Queen Square, London WCl, A. Pesenti S. Rees, Magnetic Resonance Unit, The National Heart and Chest Hospitals, 30 Britten Street, London SW3 6NN, F. Rossi G. P. Rossi Institute of Anaesthesia. University of Milan, Via Francesco Sforza 35, Milan, Italy J. E. Tooke Department of Physiology, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, K'Torresin. P. S. Treweeke Department of Radiology, Charing Cross Hospital, Fulham Palace Road, London W6 8RF,

12 Imaging and Labelling Techniques in the Critically III xv R. Underwood Department of Nuclear Medicine, The National Heart Hospital, Westmoreland Street, London WIM 8BA, A. R. Valentine Royal Free Hospital, Pond Street, London NW3 2QG, S. Vesconi Institute of Anaesthesia. University of Milan, Via Francesco Sforza 35, Milan, Italy J. R. Weinberg Department of Medicine, Charing Cross Hospital, Fulham Palace Road, London W6 8RF,