Purpose
Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity and mortality, which is largely attributable to secondary complications such as vasospasm and subsequent delayed ...cerebral ischemia. Transcranial Doppler (TCD) is recommended for the screening of vasospasm; however, technicians are not always available. We aimed to see how feasible and reliable bedside transcranial point‐of‐care ultrasound (POCUS) color‐coded duplex sonography was compared with formal non‐imaging TCD in measuring velocities and in diagnosing vasospasm.
Methods
This was a prospective observational study that took place in the neuroscience intensive care unit at a single academic medical center. Patients with aSAH who were undergoing formal TCDs were scanned on days 2–10 of their admission by physicians of ranging ultrasound experience. Absolute velocities were compared as well as the diagnosis of vasospasm via POCUS and formal TCDs.
Results
A total of 226 bedside ultrasound exams were performed and compared with 126 formal TCD studies. Sonographic windows were obtained in 89.4% of patients. Scans took 6.6 minutes to complete on average by the advanced group versus 14.5 minutes in the beginner. Correlation ranged from .52 in the beginner group to .65 in the advanced. When good quality of images obtained at a depth of 4–5 cm were reviewed, correlation of mean velocities increased to .96. Overall sensitivity for diagnosing vasospasm was 75%, with a specificity of 99% and negative predictive value of 99%.
Conclusion
Overall, POCUS TCD cannot replace a formal study performed by expert sonographers. An abbreviated POCUS scan can be performed quickly, however, particularly with more experienced operators. POCUS TCD can also feasibly detect vasospasm, and accurate velocities can be obtained by those with all levels of ultrasound experience. Care must be taken on image interpretation that velocities are obtained at an appropriate depth to ensure appropriate insonation of the MCA as well as in optimal alignment with the vessel to obtain the most accurate velocities.
POCUS in Intensive Care Nephrology Connor-Schuler, Randi; Suarez, Jonathan
POCUS journal,
02/2022, Letnik:
7, Številka:
Kidney
Journal Article
Recenzirano
Odprti dostop
Acute kidney injury (AKI) is a significant problem for patients admitted to the intensive care unit (ICU), both due to the high incidence and associated mortality with rates of AKI requiring renal ...replacement therapy (RRT) of over 5%, and mortality rates with AKI of over 60% 1, 2.Ultrasound can be used to identify those at risk for AKI and assist with AKI management. Risk factors for AKI in the ICU not only include hypoperfusion but also venous congestion and volume overload. Volume overload and vascular congestion are associated with multi-organ dysfunction and worse renal outcomes. Daily and overall fluid balance, daily weights, and physical examination for edema can be inaccurate and belie true systemic venous pressure 3, 4, 5. Bedside ultrasound allows providers to evaluate vascular flow patterns and obtain a more reliable evaluation of volume status to guide and individualize therapies. Cardiac, lung, and vascular patterns on ultrasound can identify preload responsiveness, which should be assessed to safely manage ongoing fluid resuscitation and assess for signs of fluid intolerance. Here we present an overview in the use of point of care ultrasound with particular emphasis on nephro-centric strategies, namely in the identification of the type of renal injury, renal vascular flow assessment, the static measure of volume status, as well as dynamic evaluation for volume optimization in critically ill patients.
Calcium channel blockers are highly protein-bound medications frequently used in the management of hypertension. Overdose results in severe hypotension and is the fourth most common cause of ...toxicity-related deaths in the United States. Management is mostly supportive, with currently no standard role for targeted drug removal. The protein-bound nature of these medications presents the option of utilizing albumin dialysis for their removal and for the reversal of associated shock.
We present two cases of life-threatening intentional amlodipine overdoses successfully treated with albumin dialysis. Both patients experienced profound distributive shock in the setting of preserved cardiac contractility that was refractory to maximal vasoactive agent support.
After initiation of albumin dialysis, the patients showed rapid hemodynamic improvement and were able to be weaned off vasopressor support.
These cases demonstrate the safety and efficacy of albumin dialysis in the management of near-fatal calcium channel blocker overdoses related to amlodipine and offer an additional therapeutic option apart from conventional supportive care. Importantly, these cases were not associated with impaired cardiac contractility, thereby making venoarterial extracorporeal membrane oxygenation a less preferable option. Furthermore, this therapeutic benefit of albumin dialysis can potentially be extended to the management of toxicity related to other highly protein-bound drugs and toxins.
Background
In teaching hospitals, the majority of central venous lines (CVL) are placed by trainees, resulting in little opportunity for attending critical care physicians to maintain this procedural ...skill. Additionally, not all attending critical care physicians have been trained in the most up-to-date method of dynamic ultrasound (US) guided CVL placement. Furthermore, there is no standardized method to assess procedural competency of attending critical care physicians or to train them in the evolving practice of CVL placement. Despite these limitations, attending critical care physicians are ultimately responsible for supervision of CVL placement by trainees.
Objective
To assess the utility of an instructional video to impact attending critical care physicians’ competency and confidence in dynamic US guided CVL placement.
Methods
A pre-post intervention study was conducted at an academic medical center. Attending critical care physicians were first asked to obtain CVL access on a gelatin model using US guidance. They then participated in the intervention, which consisted of watching a short instructional video demonstrating a method of dynamic US guided CVL placement. They were then asked to obtain access again, this time using the described method. All CVL placements were video recorded to assess competency in dynamic US guided CVL placement as well as the time required to obtain CVL access. Two blinded and independent reviewers evaluated each video with discrepancies resolved by a third reviewer. Participants were also surveyed pre and post intervention to assess their confidence in performing and supervising CVL placement.
Results
A total of 21 attending critical care physicians were included. Pre-intervention, four used dynamic US guidance compared to 16 post-intervention (P < .001). Confidence in both CVL placement and supervision improved post-intervention (P = .03 each). Time required to obtain CVL access did not differ significantly pre and post intervention. The majority (20/21) believed there should be required competency testing for CVL placement.
Conclusions
Pre-intervention dynamic US guided CVL competency was poor in this sample of attending critical care physicians but improved significantly with an instructional video intervention. This study suggests there is a role for procedural competency testing among attending critical care physicians, and that significant improvement is achievable with relatively minimal instruction.
The cardiovascular system is a major target of thyroid hormone action and the two systems are closely interlinked. It can be greatly impacted even with subtle alterations in thyroid function. Caution ...is needed when implementing thyroid hormone replacement in patients with severe hypothyroidism, especially in the setting of ischemic coronary artery disease. If not properly treated, myxedema may ensue. Given the high mortality of myxedema coma, supportive care may not always suffice and patients may require more invasive interventions. We present a challenging case of a patient with overt hypothyroidism with concurrent acute coronary syndrome which subsequently lead to myxedema coma and cardiogenic shock. A transcaval approach for the delivery of an Impella 5.0 (Abiomed Inc., Danvers, MA) was utilized in supporting this patient. To our knowledge, this is the first reported case that describes the use of a mechanical circulatory support in treating myxedema-induced cardiovascular collapse.
Portal venous gas has mainly been studied in pediatrics and seen in cases of necrotizing enterocolitis. It is a rare finding in adults and is typically associated with underlying intestinal ischemia ...or other malignant intra-abdominal pathology. Portal venous gas is seen more readily on ultrasound compared to radiographs in both pediatric and adult patients. Findings include lucencies extending to the periphery of the liver, echogenic bubbles flowing centrifugally throughout the portal venous system, and bidirectional spikes interrupting the monophasic portal venous waveform on spectral analysis.
We present a case of a 36-year-old female who presented with abdominal pain. She had findings consistent with portal venous gas on point-of-care ultrasound, prompting computed tomography of her abdomen and surgical consultation. She was ultimately found to have cecal ischemia from cecal volvulus, had surgical resection and anastomosis, and was able to be discharged from the hospital following recovery.
With the ever-increasing use of point-of-care ultrasound, emergency physicians should be aware of the findings consistent with portal venous gas as well as its implications. Emergency physicians should know portal venous gas is associated with intestinal ischemia and other malignant pathologies and should prompt more advanced imaging or surgical consultation when observed. Emergency physicians should also understand the distinctions between portal venous gas and pneumobilia found on point-of-care ultrasound, given that portal venous gas is typically a malignant finding and pneumobilia is most frequently benign.
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