utilization of us in critically ill patients · 2. ama policy on ultrasound acknowledges that broad...

Utilization of US in Critically Ill Patients

Robert Kollpainter, PA-C, FAPACVS, RDMS, CAQ in CVTS

Aspirus Heart & Lung SurgeryAspirus Heart & Vascular Institute

Wausau, Wisconsin

Quandarya state of perplexity or uncertainty over what to do in a difficult situation…

Why I think it makes senseWhat it is

What we can do with itUnder what authority

Credentialing/Certification

Ultrasound Guided Vascular Access

December 17, 2008

Robert Kollpainter, PA-C, FAPACVS, RDMSAspirus Wausau Heart & Vascular Institute

Wausau, Wisconsin

In medicine, we are taught to diagnose utilizing compartmentalized approach…

• We rely on physical exam• Inquiry• Inspection• Palpation• Percussion• Auscultation

• Heart• Lungs

• Order labs• Consult Radiology/Cardiology

• X-Ray• CT Scan• Ultrasound/Echocardiography• MRI• Nucular Medicine

I suck

• Consult Radiology/Cardiology• X-Ray• CT Scan• Ultrasound/Echocardiography• MRI• Nucular Medicine

“It is difficult to find so much diagnostic gain

with so little investment in terms of technology, training, and time”

“When I was treating a young girl suffering from cardiac disease, I hesitated to put my ear directly onto her chest. I made a

cylindrical tube from a piece of paper. One end of the tube was placed on her chest and I put my ear on the other end, making it

possible for me to hear her heart beat”. René Laennec, 1816

stēthos ‘chest, breast’ + skopein ‘look at.’

“when compared to other medical equipment, the stethoscope had the highest positive impact

on the perceived trustworthiness of the practitioner seen with it.”

Is the stethoscope effective…eFast V2eFast V2

453 physicians in training and 88 medical students interpreted “12 important and commonly encountered cardiac events”

via stethoscope.

“Conclusions: Both internal medicine and family practice trainees had a disturbingly low identification rate.”

“Stethoscope Apathy”

When do doctors stopped improving at “auscultation”?

After the third year of medical school.

Is there a better way…eFast V2eFast V2

How about if we look…

“Because US energy is rapidly dissipated in air, is not useful for evaluation of pulmonary parenchyma”

Harrison's Principles of Internal MedicineMcGraw-Hill Education 19th edition (April 8, 2015) - onlinePart 11 Disorders of the Respiratory SystemSection 2307: Diagnostic Procedures in Respiratory DiseaseImaging Studies - Ultrasound

“Lung Ultrasound”We’ve been doing this for some time…

“Ultrasound is often readily available and can help to rapidly diagnose pneumothorax, pleural effusion,

and consolidation of lung parenchyma.”

Harrison's Principles of Internal MedicineMcGraw-Hill Education 20th edition (August 13, 2018) - onlinePart 7, Section 1 Disorders of the Respiratory System278: Approach to the Patient with Disease of the Respiratory System - Chest Imaging - p.1945

This is not the new stethoscope…Ultrasound provides clinically significant

anatomic, functional, and physiologic informationnot obtainable by inspection, palpation, auscultation,

or other components of the physical examination.

but it is better…

Auscultation CXR Lung Ultrasound

Pleural Effusion

Alveolar Consolidation

Alveolar Intersitial Syndrome

61% 47% 93%

36% 75% 97%

55% 72% 95%

The New Normal?

A-Mode

Time (Depth)

Sign

al In

tens

ity

Critical Care Ultrasound

Critical Care Ultrasound

General CCUS

Pleural/Lung Deep venous thrombosis

AbdomenVascular access

CC Echo

Advanced CCEBasic CCE

LV size and systolic function RV size and systolic function

Pericardium for pericardial fluidBasic color Doppler assessment for

severe valvular regurgitation IVC size and respiratory variation

Critical Care Ultrasound(CCUS)

General CCUS

Pleural/Lung Deep venous thrombosis

AbdomenVascular access

CC Echo

Advanced CCEBasic CCE

LV size and systolic function RV size and systolic function

Pericardium for pericardial fluidBasic color Doppler assessment for

severe valvular regurgitation IVC size and respiratory variation

Batwing Sign

a-lines

b-lines

Clot Location

Popliteal10%

Pop - SFV42%

Pop, SFV, CFV5%

All Prox Veins35%

CFV ± SFV8%

Hemostasis and Thrombosis: Basic Principles. 3rd ed., pp1305

The Magic

• Extended Focused Assessment with Sonography in Trauma (eFAST)

• Bedside Lung Ultrasound in Emergency (BLUE)• Rapid Ultrasound for Shock and Hypotension (RUSH)• Fluid Administration Limited by Lung Sonography (FALLS)

Protocol Driven Ultrasound

Acute respiratory failure is one of the most distressing situations for the patient.

An ultrasound approach of this disorder,

The BLUE Protocol,Bedside Lung Ultrasound in Emergency

allows a rapid diagnosis.

Daniel Lichtenstein

The “BLUE Points”

• Upper BLUE point• Lower BLUE point

– Allows avoiding the heart

• Phrenic Line– Defines the anterior margin of the diaphragm

• Phrenic point– Used for assessing the diaphragm laterally

• PLAPS Point– Posterolateral alveolar &/or Pleural Syndrome = Morrison’s pouch of the lung

Lung Sliding?

present absent (‘)

B profile A profile B’ profile A’ profile

Pulmonary Edema SequentialVenous Analysis

Thrombosed vein Free veins

Pulmonary Embolism Stage 3(PLAPS-point)

A-V-PLAPS profile Nude Profile

Pneumonia COPD or Asthma

PneumoniaPneumonia

Any

A/B or C-profile

pluslung point

withoutlung point

Pneumothorax Need for otherdiagnostic modalities

Detailed performance of the BLUE protocol

Mechanism of dyspnea

Profiles of BLUE-protocol Sensitivity Specificity Positive

predictive valueNegative

predictive value

Acute pulmonary edema B-profile 97% 95% 87% 99%

COPD/Acute asthma Nude profile 89% 97% 93% 95%

Pulmonary embolism A-profile (with DVT) 81% 99% 94% 98%

Pneumothorax A’-profile (with lung point) 88% 100% 100% 99%

Pneumonia B’-profile 11% 100% 100% 70%

A/B profile 14.5% 100% 100% 71.5%

C-profile 21.5% 99% 90% 73%

A-V-PLAPS profile 42% 96% 83% 78%

The four profiles 89% 94% 88% 95%

Rapid Ultrasound for Shock and Hypotension

• Heart • IVC• Morison’s Pouch (FAST)

• RUQ• LUQ• Bladder

• Aorta• Pulmonary

HI-MAP

In Cardiac Surgery…

• Hypovolemia• Hypoxia• Hydrogen ion excess • Hypoglycemia• Hypo/Hyperkalemia• Hypothermia

• Tension pneumothorax• Tamponade • Toxins• Thrombosis

• Pulmonary embolus• Myocardial infarction

Rapid Ultrasound for Shock and Hypotension

• Heart • Pulmonary• IVC

HPI

Other things we can do…• Evaluation of dyspnea/hypoxia

– ETT placement– Sniff Test– Routine post-op management

• Evaluation of renal failure • Evaluation of free fluid• Evaluate the gall bladder

• Procedural Ultrasound– Line placement– Thoracentesis– Chest tube placement

Endoscopic Vessel Harvesting

Whenever possible, perform vein mapping with ultrasound to locate and evaluate the vessel.

October 4, 2010

Who says???

American Medical AssociationPrivileging for Ultrasound Imaging H-230.960

1. AMA affirms that ultrasound imaging is within the scope of practice of appropriately trained physicians;

2. AMA policy on ultrasound acknowledges that broad and diverse use and application of ultrasound imaging technologies exist in medical practice;

American Society of Echocardiography/ American College of Emergency Physicians

Consensus Statement

“the ability to assess global left ventricular function, to detect pericardial effusions, and to assess for right heart

dilatation (chamber sizes) are within the scope of clinicians and can help answer critical patient management questions.”

Journal of the American Society of Echocardiography December 2010

International Evidence-Based Recommendations for Focused Cardiac Ultrasound Journal of the

American Society of Echocardiography

• LV dimensions and systolic function• Right ventricular systolic function • Volume status• Pericardial effusion and tamponade physiology

• Imaging of basic signs of compression of right-sided chambers rather than Doppler-based study of intra-cardiac flows

• Detection of gross signs of chronic cardiac disease• LV or left atrial dilatation, right atrial dilatation, marked LV or RV

hypertrophy• Detection of morphologic clues toward gross valvular disease

• Without the use of Doppler-based techniques• Detection of gross intra-cardiac masses

Journal of the American Society of Echocardiography July 2014

Here’s the difference…

“Comprehensive” ultrasound examinations seek to completely evaluate an organ system or anatomic area.

“Point-of-Care” ultrasound answers a specific questions to make patient care decisions in real time.

Credentialing vs. Certification

CredentialingPrivileging for Ultrasound Imaging H-230.960

1. AMA affirms that ultrasound imaging is within the scope of practice of appropriately trained physicians;

2. AMA policy on ultrasound acknowledges that broad and diverse use and application of ultrasound imaging technologies exist in medical practice;

3. AMA policy on ultrasound imaging affirms that privileging of the physician to perform ultrasound imaging procedures in a hospital setting should be a function of hospital medical staffs and should be specifically delineated on the Department's Delineation of Privileges form; and

4. AMA policy on ultrasound imaging states that each hospital medical staff should review and approve criteria for granting ultrasound privileges based upon background and training for the use of ultrasound technology and strongly recommends that these criteria are in accordance with recommended training and education standards developed by each physician's respective specialty.

Certification“Demonstration, proof, confirm, assure, make certain”

CONCLUSIONS

The purpose of this document is to define explicitly the competencies of CCUS. This statement has two important uses:

1. It may be used as a practical guide for physicians who seek training and for those who provide training in the field. With this standard statement of competence, the goals of training are now clearly defined.

2. It may be used as a foundation for developing training methods and standards, as well as providing a framework for developing a formal system of certification in the field of CCUS.

Certification“Demonstration, proof, confirm, assure, make certain”

• Standardizes the necessary knowledge, skills and training in the specific point-of-care ultrasound imaging procedure to be performed

• Proves acquisition of the necessary knowledge, skills and training in the specific point-of-care ultrasound imaging procedure to be performed

• Communicates a commitment to patient care and safety• Reassure patients and employers that you are committed to

excellence in Ultrasound• Gain visibility and credibility in the field • Broaden eligibility for reimbursement?• Enhance your career opportunities

– Job change/promotion/$

The doctors of tomorrow may still listen with a stethoscope to their patient’s lung…

but they will certainly be seeing it with ultrasound…

utilization of us in critically ill patients · 2. ama policy on ultrasound acknowledges that broad...

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