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Ultrasound in the ICU
Transcript of Ultrasound in the ICU
Journal Club 1/16/13 Conclusions Does it apply to my patient population?
Does it change management?
Does it change mortality? ICU Sound Protocol Optic nerve sheath diameter
In comatose or deeply sedated patients to detect intracranial hypertension
Using different ventral-to-dorsal longitudinal and axial scans to detect pneumothorax, lung consolidation, interstitial syndrome, and alveolar edema
TTE to detect valvular disease, left and right ventricle performance, and pericardial effusion
In different abdominal areas, from epigastrium to right iliac fossa, to detect peritoneal effusion, cholecystitis, hydronephrosis, and parenchymal abnormalities
Upper and lower limbs and neck with a mild compression maneuver to detect deep venous thrombosis. Introduction This study was designed to test the hypothesis that a head-to-toe ultrasound evaluation at ICU admittance could increase diagnostic accuracy.
The results suggest that bedside ultrasound examination by the attending physician at ICU admission can detect significant, unsuspected abnormalities, with a major impact on diagnosis and treatment plans, thus obviating the need to transport patients to other facilities and improving healthcare quality. No correlation was found between number of ultrasonographic findings, mortality, Simplified Acute Physiology Score II, and length of ICU stay.
No procedure related complications occurred.
The time needed to complete scanning ranged from 17 to 54 min (median, 19.5 min).
In 61/125 cases (48.8%), the senior physician ordered a gold standard procedure (CT, MRI, TEE) that confirmed the ultrasonographic findings.
Ultrasound examination missed abnormalities in three cases: Pancreatitis and pneumonia found by CT and severe AI by TEE Methods When: March 2009 – January 2010 (prospective)
Where: Maria Vittoria Hospital, Torino, Italy
Resources: six ICU beds, and six physicians skilled in ultrasound
Who: 262 consecutive patients admitted to the ICU
n = 125
What: Within 12 h of ICU admission, all patients underwent head-to-toe ultrasound examination performed by a different attending physician under the “ICU-sound” protocol developed at the institution. Demographics Exclusions Excluded from the analysis were 121 patients who left the ICU alive within 48 h (usually postoperative or drug-poisoning patients)
Seven because of lack of consent, and nine because of patient and environment related conditions that made U/S difficult
obesity, subcutaneous emphysema, bandages, and digestive gas
brightness of room illumination, space around the patient, noise, and isolation ICU mortality was higher, but not statistically significant, in patients with two or more pathologic findings respect to patients without any findings (SAPS-adjusted OR 2.49, 95% CI: 0.79–7.85) Discussion Previous studies
Large body of evidence that physical exam misses a lot of pathology
Growing body of evidence that for each body part, ultrasonography can improve or confirm diagnosis
Ultrasound was used later and did not change immediate management Future studies
Head to toe vs focused
Larger patient population
US at admission
Study designed to show a mortality difference between using ultrasound vs. convention
Include TEE Criticism
Not blinded to the patient’s clinical picture, which is difficult to entirely eliminate in any use of ultrasound.
Interpretation of the images are very subjective
Nine patients eliminated secondary to patient related conditions. Deep Impact of Ultrasound in the Intensive Care Unit. The “ICU-sound” Protocol. Emilpaolo Manno, M.D., et al. Anesthesiology V117, October 2012, p 801-809
Ultrasonography in the Intensive Care Unit: Looking at the World through Colored Glasses. Paolo Pelosi, M.D., Francesco Corradi, M.D., Ph.D. Anesthesiology V117, October 2012, p696-698
Fedson S, Neithardt G, Thomas P, Lickerman A, Radzienda M, DeCara JM, Lang RM, Spencer KT: Unsuspected clinically important findings detected with a small portable ultrasound device in patients admitted to a general medicine service. J Am Soc Echocardiogr 2003; 16:901–5
Corradi F, Brusasco C, Vezzani A, Palermo S, Altomonte F, Moscatelli P, Pelosi P: Hemorrhagic shock in polytrauma pa- tients: Early detection with renal Doppler resistive index measurements. Radiology 2011; 260:112–8
Bossone E, DiGiovine B, Watts S, Marcovitz PA, Carey L, Watts C, Armstrong WF: Range and prevalence of cardiac abnormalities in patients hospitalized in a medical ICU. Chest 2002; 122:1370–6 Improve quality of healthcare
It is a useful skill to have
It can lower amount of transports of unstable patients