5/31/2014 Ultrasound in the ICU Kristine E. W. Breyer, MD Assistant Professor DISCLOSURES: NONE Anesthesia & Critical Care Medicine UCSF Objectives • Definition • Scope & Exam Types • Evidence • Training & Credentialing • Clinical Examples CRITICAL CARE ULTRASOUND DEFINITION 1
5/31/2014 Critical Care Ultrasound • Non-invasive “ Critical Care Ultrasound can supplement • Intensivist performs & Interprets exam at management of critically ill and injured bedside patients and lead to the rapid diagnosis of • Immediately integrates results into the underlying etiology in those suffering cardiopulmonary dysfunction. Providers assessment and plan can also perform many standard bedside • Repeated as needed, as often as needed procedures under ultrasound guidance, • Performed within a few minutes increasing safety and success rates… and also allows critical care providers to obtain • Focused and Limited diagnostic information in a timely manner ” Pustavoitau, SCCM Ultrasound Taskforce Schmidt GA; Chest 2012 Clinician Performed ≠ SCOPE & EXAM TYPES 2
5/31/2014 Scope of Critical Care Ultrasound INTERVENTIONAL VASCULAR THORACIC ABDOMINAL • PERIPHERAL • THORACENTESIS • PARACENTESIS VENOUS • CHEST TUBE • CENTRAL PLACEMENT DIAGNOSTIC INTERVENTIONAL VENOUS • ARTERIAL Adapted from: Curr Op Anesth 2014; 27: 123 Vascular Ultrasound DIAGNOSITC Vascular Access CARDIAC THORACIC VASCULAR ABDOMEN • CONTRACTILITY • PNEUMOTHORAX • THROMBOSIS • FLUID & GROSS • EFUSSION • GALL BLADDER FUNCTION • PULMONARY • EFFUSION EDEMA • IVC Adapted from: Curr Op Anesth 2014; 27: 123 3
5/31/2014 DIAGNOSITC CARDIAC THORACIC VASCULAR ABDOMEN Critical Care Echocardiogram Ultrasound • CONTRACTILITY • PNEUMOTHORAX • THROMBOSIS • FLUID & GROSS • EFUSSION • GALL BLADDER FUNCTION • PULMONARY • EFFUSION EDEMA • IVC Critical Care Echocardiography Pustavoitau, SCCM Ultrasound Taskforce Adapted from: Curr Op Anesth 2014; 27: 123 Cardiac Ultrasound Focused & Limited • Assessments Bedside cardiac ultrasound ≠ Echocardiogram – Contractility • Hyperkinetic/normal • Depressed • Severely depressed ≠ – Effusions 4
5/31/2014 Cardiac Ultrasound Perera; Emerg Med Clin N Am 2010; http://echocardiographer.org/TTE.html IVC IVC Distensibility Size and dispensibility/collapsibility MAX – MIN Sens 90% Spec 90% MIN Barbier, Intensive Car Med 2004 http://www.henryfordultrasounduniversity.com/2education/online-education 5
5/31/2014 DIAGNOSITC • ∆D IVC predicts volume responsiveness CARDIAC THORACIC VASCULAR ABDOMEN – r=0.82, p<0.001 • CONTRACTILITY • PNEUMOTHORAX • THROMBOSIS • FLUID & GROSS • EFUSSION • GALL BLADDER FUNCTION • 12% ∆D IVC • PULMONARY • EFFUSION EDEMA – PPV 93% • IVC – NPV 92% Fiessel; Intensive Care Med 2004 Adapted from: Curr Op Anesth 2014; 27: 123 Lung Exam • Lung parenchyma – Edema – Consolidations • Pleural fluid • Pneumothorax 6
5/31/2014 Cardiogenic Pulmonary Edema Acute Pulmonary Edema After Diuresis Absence of Lung Sliding and PTX Pleural Fluid • US can detect as little as 5-50 ml fluid Population Specificity • AP film can detect >100 ml of fluid General 91% Critically Ill 78%* *Absence of lung sliding is also associated with: • ARDS • Pulmonary contusion • Atelectasis • Severe COPD w/ Blebs • Pleural adhesions • Phrenic nerve palsy • Mainstem intubation CCM 2007; 35: S250-S261 7
5/31/2014 DIAGNOSITC Abdominal: FAST CARDIAC THORACIC VASCULAR ABDOMEN • CONTRACTILITY • PNEUMOTHORAX • THROMBOSIS • FLUID & GROSS • EFUSSION • GALL BLADDER FUNCTION • PULMONARY • EFFUSION EDEMA • IVC http://www.acssurgery.com/acssurgery/institutional/figTabPopup.action?linkId=part07_ch01_fig7&type=fig; Adapted from: Curr Op Anesth 2014; 27: 123 http://www.henryfordultrasounduniversity.com/2education/online-education Positive FAST EVIDENCE 8
5/31/2014 Hussein, J Critical Care 2014 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 TRAINING & CREDENTIALING – ICU trainees can learn cardiac ultrasound in a short course and use it to answer relevant clinical questions 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. 9
5/31/2014 Pustavoitau, SCCM Credentialing • US imaging is within scope of • Follow specialty-specific practice of appropriately guidelines trained physicians • Give separate privileges for • Acknowledges broad & diverse use and application CCUS & Advanced cardiac echo • Privileging should be a • Provide continuous quality function of hospital medical assessment & improvement EXAMPLES staffs • Decide which core ultrasound • Each hospital should review & approve criteria for applications are applicable to credentialing based upon that institution standards by respective specialty AMA H-230.960; Pustavoitau, SCCM 10
5/31/2014 Volume up or down? • 75 year old • Now worsening • PMHx: hypotension • Lactate 3 – Bilateral Lung Transplant ( > 5 years ago) • LOS: + 7 L – ESRD on HD • Admitted to ICU: – Hypercarbic respiratory failure (intubated) – Pneumonia – C. Diff colitis – CRRT Volume up or down? • 75 year old • Now atrial fibrillation • PMHx: (RVR) • Persistent 4-6 L NC – CAD – HTN • LOS: + 3 L – Known PE on heparin • Admitted to ICU: – POD 2 knee tumor resection & free flap 11
5/31/2014 Shock • 35 year old • Now increasing • PMHx: vasopressor requirement – None • UOP 20-30 cc/hr • Admitted to ICU: • Lactate ~ 3 – Acute liver failure – Intubated for hypoxemic respiratory failure • MCVO2 = 47% (PICC) – HLH/autoimmune Insert PL CS video 12
5/31/2014 Shock • 35 year old • Now: • PMHx: – Tachycardic – Tachypneic – Thyroid goiter – Dyspnea • Admitted to ICU: – O2 Saturation 80% ‘s – Thyroidectomy with • CXR ordered (10 upper median sternotomy minutes) – Serial neck circumference checks What do you need? • Ultrasound – 2 D – M- Mode • Probes – Linear (high frequency) – Phased Array (lower frequency) • Image Capture • Quality Assessment and Review 13
5/31/2014 Conclusions Know Your Limits!! • Critical Care Ultrasound is a portable, practitioner • Do not comment on findings that are not within your performed and interpreted exam that establishes expertise diagnoses and guides procedures • If you see something you do not understand or that • Scope includes: Diagnostic & Interventional concerns you, obtain appropriate imaging performed • Exams include: Cardiac, Pulmonary, Vascular & by a specialist PROMPTLY Abdominal • Training is an important and evolving area for critical care trained practitioners & trainees • This technology will make a difference in your critical care practice Cardiac Ultrasound for ICU breyerk@anesthesia.ucsf.edu THANK YOU J Am Soc Echo 2002; 15: 369 14
5/31/2014 15
5/31/2014 http://www.henryfordultrasounduniversity.com/2education/online-education 16
Recommend
More recommend
