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El Ultrasonido y el Anestesiólogo, más allá de la anestesia

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ezequiel vidal

on 23 September 2016

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Transcript of El Ultrasonido y el Anestesiólogo, más allá de la anestesia

El Ultrasonido y el Anestesiólogo, más allá de la anestesia regional.
Evaluacion de la VA y IOT
Estomago Ocupado y Ayuno
A. Perlas et Al.
Valida un protocolo para Predecir el Contenido Gastrico mediante un modelo ecografico y
matematico.
EVALUACION CARDIACA y FAST
Anestesia Regional Ecoguiada
BLOQUEOS NERVIOSOS
Miembro Superior
Miembro Inferior
Compartimental del Psoas
Bloqueos Periféricos o Únicos.
Nuevos Bloqueos
-1978, Grange et al describen por primera vez el uso de los ultrasonidos para facilitar el
bloqueo del plexo supraclavicular.

-1994 Kapral et primer estudio
sobre anestesia regional utilizando visualización
directa con ecografía 2D.
Paravertebrales
Neuroaxiales
Bloqueos Nervios Sensitivos
Protocolos BLUE y FALLS
TAP Block

Bloqueos de Pared
Abdominal

PECs Block

Bloqueos oftalmicos

Bloqueos Facetarios
Luego de 2 modelos previos, genera un nuevo protocolo que logra Predecir el Contenido Gastrico hasta con 6 ml. de diferencia Vs Contenido Aspirado por Sonda.
Evidencia Presencia de Estomago Ocupado en 2 posiciones (supina y lateral Derecha).
Otros procedimientos:

Canulación Venosa Central o Arterial
Puncion de Estructuras o Colecciones (Derrames, tumores, quistes)
Visualizacion y Medición de estructura de Columna LumboSacra
EVALUACION CARDIACA FUNCIONAL
Y TRAUMA

FAST y FoCUS
Anaesth Intensive Care. 2010 Sep;38(5):823-36.

Focused transthoracic echocardiography in the perioperative period.

Cowie BS. Department of Anaesthesia, St. Vincent's Hospital, Melbourne, Victoria, Australia.

Abstrac:
Ultrasound applications in perioperative medicine have expanded enormously over the past decade. Transoesophageal echocardiography has been performed by anaesthetists during cardiac surgery for over 20 years. With the increasing availability of portable ultrasound systems, the use of ultrasound to assist in vascular cannulation and regional anaesthesia has been well described. Portable ultrasound systems come with a range of probes for different applications, including transthoracic echocardiography.
While transthoracic echocardiography has traditionally been the domain of cardiologists, its use has been increasing in critical care, the emergency room and, recently, by anaesthetists in the perioperative period. Unlike formal cardiology-based transthoracic echocardiography, focused, goal-directed transthoracic echocardiography is often more appropriate in the perioperative period to address a particular question and can be performed in just a few minutes.

Transthoracic echocardiography allows rapid, noninvasive, point-of-care assessment of ventricular function, valvular integrity volume status and fluid responsiveness. It can help distinguish undifferentiated systolic murmurs preoperatively, give valuable information on the aetiology of unexplained hypotension and cardiovascular collapse and assess response to therapeutic interventions such as vasoactive drugs and volume resuscitation.

Focused transthoracic echocardiography should include qualitative assessment of left and right ventricular function, an estimate of aortic valve gradient, right ventricular systolic pressure and intravascular volume status as minimum requirements.

Transthoracic echocardiography is a valuable tool in the perioperative period and ideally the equipment and expertise should be available in all operating rooms.



A FAVOR DEL RECLUTAMIENTO:

Furthermore, US examinations enable the evaluation of the effects of the mode of mechanical ventilation on lung aeration.
Konstantinos and colleagues, who studied lung aeration in patients with ARDS using US imaging, showed that increases in PEEP from 5 to 15 cm H2O led to increased aerated lung areas and correlated with improved arterial blood oxygenation
Anaesthesia. 2011 Apr;66(4):268-73.

Three years' experience of focused cardiovascular ultrasound in the peri-operative period.

Cowie B. Department of Anaesthesia, St. Vincent's Hospital, Melbourne, Australia.

Abstract
Ultrasound applications in peri-operative medicine have become common place in modern anaesthesia practice. Anaesthetists have performed transoesophageal echocardiography in cardiac and selected non-cardiac surgery for over two decades. We aimed to assess the indications, impact on clinical management and accuracy of focused cardiovascular ultrasound performed by anaesthetists in the peri-operative period.
One hundred and seventy patients over a 3-year period had a focused transthoracic echocardiogram. Adequate images to answer the clinical question were obtained in 167 out of 170 patients (98%).
The undifferentiated systolic murmur was the commonest indication (98 out of 170, 58%). Some degree of aortic stenosis was present in 47 out of 170 (26%) of patients; mitral valve disease (30 out of 170 (18%)) and pulmonary hypertension (25 out of 170 (14%)) were also common.

Changes in peri-operative management occurred in 140 out of 170 (82%) patients and major findings correlated with a formal cardiology transthoracic echocardiogram in 52 out of 57 (92%) patients.

Focused cardiovascular ultrasound performed by anaesthetists in the peri-operative period accurately detects major cardiac pathology and significantly alters peri-operative management.
Br J Anaesth. 2009 Sep;103(3):352-8.

Audit of anaesthetist-performed echocardiography on perioperative management decisions for non-cardiacsurgery.

Canty DJ, Royse CF. Department of Anaesthesia, Royal Hobart Hospital, Tasmania 7000, Australia.

Abstract:
Intraoperative transoesophageal echocardiography is increasingly used for guiding intraoperative management decisions during non-cardiac surgery. Transthoracic echocardiography (TTE) equipment and training is becoming more available to anaesthetists, and its point-of-care application may facilitate real-time haemodynamic management and preoperative screening.

METHODS:
We conducted an audit of transthoracic and transoesophageal echocardiograms, performed by an anaesthetist at a tertiary referral centre over a 9-month period, to identify the effect of echocardiography on clinical decision-making in patients undergoing non-cardiac surgery. The indications for echocardiography followed published guidelines.
RESULTS:
Echocardiographic examinations of 97 patients included 87 transthoracic, and 14 transoesophageal studies. Of 36 studies conducted in the preoperative clinic, eight revealed significant cardiac pathology, necessitating cardiology referral or admission before surgery.
Preoperative transthoracic echocardiograms performed on the day of surgery (n=39) led to two cancellations of surgery owing to end-stage cardiac disease, the institution of two unplanned surgical procedures (drainage of pleural and pericardial effusions), and to significant changes in anaesthetic and haemodynamic management, or both in 18 patients.
Greater influence on management occurred with emergency surgery (75%) than elective surgery (43%). Intraoperative transthoracic (n=10) and transoesophageal (n=14) echocardiography also altered management (altered surgery in two patients, cancellation in one, and altered haemodynamic management in 18 patients).

CONCLUSIONS:
Anaesthetist-performed point-of-care TTE and thoracic ultrasound may have a high clinical impact on the perioperative management of patients scheduled for non-cardiac surgery.


Chest. 2008 Jul;134(1):117-25.

Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol.

Lichtenstein DA, Mezière GA. Service de Réanimation Médicale, Hôpital Ambroise-Paré, F-92100 Boulogne, Faculté Paris-Ouest, France.

Abstract
This study assesses the potential of lung ultrasonography to diagnose acute respiratory failure.

METHODS:
This observational study was conducted in university-affiliated teaching-hospital ICUs. We performed ultrasonography on consecutive patients admitted to the ICU with acute respiratory failure, comparing lung ultrasonography results on initial presentation with the final diagnosis by the ICU team. Uncertain diagnoses and rare causes (frequency<2%) were excluded.
We included 260 dyspneic patients with a definite diagnosis. Three items were assessed: artifacts (horizontal A lines or vertical B lines indicating interstitial syndrome), lung sliding, and alveolar consolidation and/or pleural effusion. Combined with venous analysis, these items were grouped to assess ultrasound profiles.

RESULTS:
Predominant A lines plus lung sliding indicated asthma (n=34) or COPD (n=49) with 89% sensitivity and 97% specificity. Multiple anterior diffuse B lines with lung sliding indicated pulmonary edema (n=64) with 97% sensitivity and 95% specificity. A normal anterior profile plus deep venous thrombosis indicated pulmonary embolism (n=21) with 81% sensitivity and 99% specificity. Anterior absent lung sliding plus A lines plus lung point indicated pneumothorax (n=9) with 81% sensitivity and 100% specificity. Anterior alveolar consolidations, anterior diffuse B lines with abolished lung sliding, anterior asymmetric interstitial patterns, posterior consolidations or effusions without anterior diffuse B lines indicated pneumonia (n=83) with 89% sensitivity and 94% specificity. The use of these profiles would have provided correct diagnoses in 90.5% of cases.
CONCLUSIONS:
Lung ultrasound can help the clinician make a rapid diagnosis in patients with acute respiratory failure, thus meeting the priority objective of saving time.
-Predominant A lines plus lung sliding indicated asthma (n=34) or COPD (n=49) with 89% sensitivity and 97% specificity.
(LINEAS A + DESLIZAMIENTO = ASMA o EPOC)

-Multiple anterior diffuse B lines with lung sliding indicated pulmonary edema (n=64) with 97% sensitivity and 95% specificity. A normal anterior profile plus deep venous thrombosis indicated pulmonary embolism (n=21) with 81% sensitivity and 99% specificity.
(LINEAS B + DESLIZAMIENTO = EDEMA PULM)
-Anterior absent lung sliding plus A lines plus lung point indicated pneumothorax (n=9) with 81% sensitivity and 100% specificity.
(AUSENCIA DE DESLIZAMIENTO + LINEAS A + PUNTO PULMON = NEUMOTORAX)

-Anterior alveolar consolidations, anterior diffuse B lines with abolished lung sliding, anterior asymmetric interstitial patterns, posterior consolidations or effusions without anterior diffuse B lines indicated pneumonia (n=83) with 89% sensitivity and 94% specificity.
(CONSOLIDACIONES o LINEAS B DIFUSAS + AUSENCIA DE DESLIZAMIENTO = NEUMONIA CONSOLIDADA)

The use of these profiles would have provided correct diagnoses in 90.5% of cases.
CONCLUSIONS:
Lung ultrasound can help the clinician make a rapid diagnosis in patients with acute respiratory failure, thus meeting the priority objective of saving time.
Bedside Lung Ultrasound
in Emergency (BLUE)
Confirmación de IOT
Evaluacion de VAS
Capacidad de Visualizar la Via Aerea Superior Transversal y longitudinalmente
Intubacion Selectiva
Capacidad de Aprendizaje
EVALUACION PULMONAR
RECLUTAMIENTO PULMONAR
PREDICCTOR DE VA DIFUCTOSA Y TUMORES
Anaesthesiol Intensive Ther. 2012 Oct-Dec;44(4):226-31.

MODERN METHODS OF ASSESSMENT OF LUNG AERATION DURING MECHANICAL VENTILATION

Wierzejski W, Department of Anaesthesiology and Intensive Therapy, Praga Hospital, Warsaw

ANALIZAN LA UTILIDAD DE NUEVOS METODOS DIAGNOSTICOS PARA RECLUTAMIENTO PULMONAR:
TAC, USG PULMONAR y ELECTROBIOIMPEDANCIA TOMOGRAFICA.
USG COMO METODO PORTATIL Y FIABLE:

Ultrasonography is widely used in intensive care medicine, which is a noninvasive and bedside method.
It gives the opportunity to assess an investigated organ in real time. Its clinical utility in patients with ARDS was proved by Lichtenstein at.al.
PARA DIFERENCIAR EL NEUMOTORAX:

To differentiate them, the sliding phenomenon (the movement of the pulmonary
pleura in relation to the parietal pleura) is used.

In pneumothorax, the sliding phenomenon is absent, and the additional confirmation is the lung point i.e. the place on the thoracic wall where the US image of Neumothorax
is replaced by the lung expanding during inspiration
AUMENTO DEL LIQUIDO INTRA/EXTRA ALVEOLAR:

Increased water content in the lung tissue results in vertical
artefacts (B lines), caused by reflection of ultrasounds from the fluid filling the interstitial space and/or pulmonary alveoli. The concentration of these lines defines the severity of interstitial oedema
PRECARGA Y VOLEMIA

En condiciones normales, en un paciente con respiración
espontánea sin asistencia respiratoria mecánica,
la vena cava inferior disminuye su calibre en inspiración
presentando mayor diámetro en espiración.
En pacientes con asistencia respiratoria mecánica, el
diámetro de la vena cava inferior aumenta en inspiración
y disminuye en espiración. En pacientes ventilados
la medición del diámetro en mm de la vena
cava inferior se realiza al final de la espiración, y en
pacientes no ventilados se realiza al final de la inspiración

La medición del diámetro de la vena cava
inferior por ecografía puede servir como indicador de PVC, en
el paciente internado en el servicio de emergencias,
en UTI y como parte del ECOFAST.

la VCI se ha medido en diferentes planos y en diferentes áreas anatómicas desde el atrio derecho hasta el área suprarenal

Sin importar el lugar que se utilice, lo que se observa a través del US, es la colapsabilidad de la VCI durante el ciclo respiratorio.
Este indice de colapsabalidad se conoce como el "Indice Caval" (IC). Este se expresa como un porcentaje de
colapso

Indice Caval (IC) =
100 * (diámetro VCImax – diámetro VCImin) / diámetro VCImax

Ezequiel Vidal
MD. Anestesiologo. Hospital de Clinicas GJSM
Buenos Aires,Argentina.

PROTOCOLO FALLS
Fluid Administration Limited by Lung Protocol
solo nosotros lo sabemos...
muchas,
muchas Gracias
ANESTESIOLOGOS HACIENDO ETT:
-De 36 Eval PreOP/ 8 Dx Enf Cardiaca Significativa
-De 39 ETT EVal el mismo dia de la Cirugia :
2 CANCELACIONES por Enf Card Terminal
2 Internaciones
18 CAMBIOS DE MANEJO ANEST
LOS CAMBIOS FUERON MAYORES EN LA GUARDIA (75 % vs 43%).
EVALUARON 167 Pac. en 3 añ0s
Se Dx 98% patologías:
Cambio la Cdta Anestesica en 82%
Dx Patologías Cardiacas en 92%
ULTRASONOGRAFÍA, OTROS USOS
Dra. María Carolina Cabrera Schulmeyer
Médica Anestesióloga, Profesora Adjunta de la Universidad de Valparaíso, Chile.
Directora del Curso Internacional, Ecocardiografía Perioperatoria y de Cuidados Críticos, de modalidad semipresencial, compuesta por un Curso Semestral E-learning + 1 semana de estadía en Hospital para el aprendizaje de ETE y las funciones básicas de doppler. También participa en un taller de ETT, para aprender un examen básico focalizado.
-PARA EL DIAGNOSTICO DE FRACTURAS NO EVIDENCIADAS

-CONFIRMACION DE LADO Y COMPROMISO DE PARTES BLANDAS.

-EVALUAR EVOLUCION O PSEUDOARTROSIS
USO DE LA ECOGRAFIA EN TRAUMATOLOGIA
DEVIDENCIAS ECOGRAFICAS DE RECLUTAMIENTO:

On the US scan of properly aerated lungs, horizontal artefacts (A lines), arising from the pleural line are visible as the multiple repetitions of this line at regular intervals They can indicate both proper lung aeration and the presence of air in the pleural cavity
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