Intensive Care Ultrasound
Critical Care Ultrasound
Echocardiography Lung Abdominal Venous
Recommended reading
Intensive Care Ultrasound is very topical at the moment with the increasing availability and affordability of good quality portable machines. Not may people know how to use them at the moment and obtaining adequate training is challenging but this is rapidly changing.
It’s not good enough to just start having a go with the machine the ‘League of Friends’ bought you and that’s standing in the corner looking shiny. You need some training first. Go on a course and then practice what they teach you. Make sure you know what to clean the machine with that will not degrade the probe (don’t use chlorhexidine). Be strict about infection control. Ultrasound will not benefit your patients if it is transferring pathogenic organisms between them.
Like anything else, US is easy once you know how and critical care has the widest applications for its use anywhere in the hospital. Ultrasound will become an integral part of the management of every critically ill patient from comprehensive scanning on admission for diagnosis and then using it for monitoring of pathology thereafter as well as identifying new pathology.
Echocardiography is indicated for any haemodynamically compromised patient and will provide a diagnosis and allow monitoring of response to treatment. There are now 2 studies demonstrating that performing an echo on a critically ill patient changes management about 50% of the time.
Lung scanning diagnoses the cause of acute respiratory failure 90.5% of the time in less than 5 minutes (without including any history, clinical examination or other investigations). It has a sensitivity and specificity for most conditions approaching that of CT and will virtually replace x-rays over the coming years. It allows safe insertion of drains and guides thoracocentesis.
Venous scanning allows the diagnosis and exclusion of thrombosis and combined with echo and lung scanning can rule out thromboembolism. It also facilitates line placement for internal jugular, subclavian and femoral routes.
FAST scanning identifies intra-abdominal fluid.
Renal ultrasound will identify hydronephrosis, renal size, cysts and some stones in a few minutes.
Liver ultrasound will identify fatty liver, cirrhosis (including portal hypertension), tumours, hepatic or portal vein thrombosis, billiary obstruction and gallbladder pathology.
Additional abdominal scanning will identify ascites and allow ultrasound guided drain placement.
Identification of peristalsis is easy - this is useful for guiding enteral feeding and its presence makes abdominal catastrophe much less likely.
Ultrasound guided regional anaesthesia provides analgesia.
A slightly fanciful example would be:
A trauma patient is admitted and has an anterior pneumothorax diagnosed with US by absent anterior sliding and identification of the lung point. A FAST scan identifies intra-abdominal bleeding with an abnormal looking spleen. A focussed echo reveals hypovolaemia. Lines are placed with US. The patient requires a laparotomy for splenectomy and has bilateral TAP blocks with US guidance to aid weaning. A US guided femoral nerve catheter is inserted for femoral fracture analgesia. He later develops large pleural effusions and consolidation, both identified and sized by US and drained under US guidance to improve oxygenation and aid weaning. When a swollen arm is noted a few days later a subclavian vein thrombosis is diagnosed with US. He complains of RUQ abdominal pain after extubation and has signs of sepsis. Acalculous cholecystitis is diagnosed with US allowing drainage.
All of the above applications are easily achievable for a critical care physician with a bit of dedication.
All the images and video clips have been obtained by me from critically ill patients.
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