Ultrasound in the ICU Kristine E. W. Breyer, MD Assistant Professor Anesthesia & Critical Care Medicine UCSF DISCLOSURES: NONE Definition The Ultrasound Exam Types & Uses Training Clinical Examples Objectives 1
CRITICAL CARE ULTRASOUND DEFINITION Critical Care Ultrasound Intensivist performs & interprets exam at bedside Immediately integrates results into assessment and plan Repeated as needed, as often as needed Performed within a few minutes Non invasive Schmidt GA; Chest 2012 Clinician Performed Not a study by trained sonographer interpreted by radiologist 2
Focused & Limited Bedside cardiac ultrasound Echocardiogram Cardiac Ultrasound for ICU J Am Soc Echo 2002; 15: 369 Know Your Limits!! Do not comment on findings that are not within your expertise If you see something you do not understand or that concerns you, obtain appropriate imaging performed by a specialist PROMPTLY 3
EXAM TYPES & USES Scope of Critical Care Ultrasound DIAGNOSTIC INTERVENTIONAL INTERVENTIONAL VASCULAR THORACIC ABDOMINAL PERIPHERAL VENOUS CENTRAL VENOUS ARTERIAL THORACENTESIS CHEST TUBE PLACEMENT PARACENTESIS Adapted from: Curr Op Anesth 2014; 27: 123 4
DIAGNOSITC CARDIAC THORACIC VASCULAR ABDOMEN CONTRACTILITY & GROSS FUNCTION EFFUSION PNEUMOTHORAX EFUSSION PULMONARY EDEMA THROMBOSIS FLUID GALL BLADDER Adapted from: Curr Op Anesth 2014; 27: 123 Cardiac Ultrasound Perera; Emerg Med Clin N Am 2010 IVC Dispensability MAX MIN MIN Sens 90% Spec 90% Barbier, Intensive Car Med 2004 5
Charron; Cardiopulm Monit 2006 D IVC predicts volume responsiveness r=0.82, p<0.001 12% D IVC PPV 93% NPV 92% Fiessel; Intensive Care Med 2004 IVC Dispensability MAX MIN MIN Sens 90% Spec 90% Barbier, Intensive Car Med 2004 6
Charron; Cardiopulm Monit 2006 Evidence Data Supports Use Of Cardiac US By Intensivists 10 hour training allowed successful cardiac US by intensivists with 84% correct interpretation Emergency physicians learn cardiac US during 6 hour program ICU trainees can learn cardiac ultrasound in a short course and use it to answer relevant clinical questions Intensivists can accurately assess LV function Manasia. J of CT and CV Anesthesia, 2005; Jones. Academic EM, 2003; Vignon. Intensive Care Med, 2007; Vignon. Crit Care Med, 2011; Melamed. Chest, 2009. Vascular Ultrasound Structures: IJ, carotid, subclavian, axillary, aorta, vena cava, femoral 7
Thoracic Ultrasound Physics not fully understood resonance phenomenon Sonographic artifacts Normal lung has 3 comets per rib space Reach lower edge of screen without fading Move with pleural sliding Erase A lines Normal Lung Findings: B-lines/Comet Tails Physics not fully understood resonance phenomenon Sonographic artifacts Normal lung has 3 comets per rib space Reach lower edge of screen without fading Move with pleural sliding Erase A lines US vs Chest X-ray US can detect as little as 5-50 ml fluid AP film can detect >100 ml of fluid In the ICU finding pleural fluid by chest xray is even more difficult due to positioning and parenchymal lung disease (ARDS, PNA etc) 8
Pleural Effusion Evaluation CT + CT Sens (%) Spec (%) DA (%) L US + 63 0 100 100 100 L US 0 21 CXR + 41 4 65 81 69 CXR 22 17 * Comparison of CXR and LUS with CT as gold standard in 42 Patients Monitoring sequele of fluid administration A lines in anterior lung predicts PAOP <18mmHg Extensive anterior B lines (in combo with smooth pleural line) sensitive and specific for hydrostatic pulmonary edema Copetti R et al US in Med and Bio 2012 Abdominal (FAST exam) Structures: kidneys, Morrison s pouch, liver, gallbladder, diaphragm, spleen, bladder, pouch of Douglas Abnormal findings: free fluid 9
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TRAINING Why train in CCUS? Mounting evidence that CCUS is helpful in the diagnosis and treatment of critically ill patients. The use of cardiothoracic ultrasound seems able to contribute to an early therapeutic decision based on reproducible physiopathological data. 12
Why train in CCUS? Anesthesiology October 2012: Implementation of CCUS led to findings that prompted further testing in 18.4%, led to changes in medical therapy in 17.6%, and to invasive procedures in 21.6%. breyerk@anesthesia.ucsf.edu THANK YOU 13