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Lung ultrasound: The basics

A-line: Sonographic reverberations of the pleural line. These hyperechoic horizontal lines appear at regular intervals deep to the pleural line and between the rib shadows. B-line: Also called a lung rocket, this hyperechoic vertical sonographic artifact arises from the inferior aspect of the pleural line and extends to the edge of the screen without fading. B-lines obscure A-lines and move with lung sliding. Barcode sign: Also…

Ultrasound-guided placement of inferior vena cava filters: (CONSULTANT-LEVEL EXAMINATION)

Venous thromboembolism (VTE) is a major problem in patients in the intensive care unit (ICU), as previously analyzed ( Chapter 9 ). VTE will develop in approximately 12% of ICU patients despite appropriate prophylaxis. Furthermore, pulmonary embolism (PE) is common and underrecognized in critically ill patients. Inferior vena cava (IVC) filter placement is indicated in a small group of patients with VTE who have a contraindication…

Intravascular ultrasound: (CONSULTANT-LEVEL EXAMINATION)

Overview Since its advent in 1977, percutaneous coronary intervention (PCI) has become a dominant treatment modality for ischemic coronary artery disease, especially unstable angina and acute myocardial infarction. During the last 2 decades, intravascular ultrasound (IVUS), a catheter-based technique that provides tomographic images perpendicular to the length of the coronary arteries, has been used widely in clinical research and has contributed to technologic improvements in interventional…

Ultrasound-guided arterial catheterization

Overview Arterial catheterization is a frequent and essential procedure that is used in the intensive care unit (ICU) for accurate hemodynamic monitoring and repeated sampling of blood for analysis. Blind or palpated catheter insertion can be difficult because pulsations and landmarks are often obscured by edema, obesity, hypotension, hypovolemia, and small-caliber vasculature. Repeated attempts at catheterization are often less successful because of arterial spasm. In addition,…

Ultrasound-guided placement of peripherally inserted central venous catheters

Overview The concept of achieving central venous access by cannulation of a peripheral arm vein is old, although only in the last decade has the peripherally inserted central catheter (PICC) emerged as a safe and cost-effective option. In the last century, PICCs were positioned by catheterization of visible or palpable superficial veins in the antecubital area (mostly the cephalic or the antecubital vein) or less often…

Ultrasound-guided peripheral intravenous access

Ultrasound guidance to obtain vascular access has become increasingly more popular over the past decade. Advances in ultrasound technology have enhanced its ability to detect and interrogate smaller vascular structures for cannulation purposes. Given the potential complications that can develop when accessing central veins, practitioners have turned to ultrasound-guided peripheral access. Although no invasive procedure is without risks, the relative array of complications potentially produced by…

Pediatric ultrasound-guided vascular access

General considerations and ultrasound evaluation of peripheral and central veins in pediatric patients (preprocedural scanning) Ultrasound offers the advantage of preprocedural evaluation of all possible venipuncture sites as detailed in previous chapters. This is an essential feature of the ultrasound method when applied in the pediatric intensive care unit (PICU). A thorough ultrasound examination allows the identification of vessels that may be difficult to puncture (e.g.,…

How to choose the most appropriate ultrasound-guided approach for central line insertion: Introducing the rapid central venous assessment protocol

Overview Standard central venous access performed with the “blind” technique was historically based on the puncture of two central veins (the subclavian vein and the internal jugular vein), but ultrasound (US) guidance has expanded the spectrum to at least four sites: the internal jugular vein, the brachiocephalic (or “innominate”) vein, the subclavian vein, and the axillary vein. In many patients, two additional, centrally located venous segments…

Ultrasound-guided vascular access: Trends and perspectives

Ultrasound-guided vascular access (UGVA) was introduced in the preceding chapter. This chapter highlights a few tips for novices as well as additional techniques and innovations that would assist skilled operators in definitively identifying the target vessel and improving catheterization in the intensive care unit (ICU). Many randomized controlled trials and meta-analyses have associated UGVA with a considerable reduction in complications and increased first-attempt success when compared…

Ultrasound-guided central venous access: The basics

Overview Central venous access is a core skill for anesthesiologists, intensivists, acute care physicians, and surgeons. It is indicated for fluid and drug administration, dialysis, and cardiovascular monitoring. More than 5 million central venous catheters (CVCs) are inserted annually in the United States. Because central venous access often remains poorly taught and left out of training curricula, inexperienced and less skilled practitioners frequently experience significant difficulties.…

Ultrasonography for deep venous thrombosis

Background Venous thromboembolism (VTE) is a spectrum of disease that encompasses both deep venous thrombosis (DVT) and pulmonary embolism (PE). It is a serious and often underrecognized condition in critically ill patients that can lead to significant morbidity and mortality. PE remains one of the leading causes of unexpected death in hospitalized patients. , In the intensive care unit (ICU), the Virchow triad of “stasis, endothelial…

Overview of the arterial system

Procedural and diagnostic vascular ultrasound applications are essential in the intensive care unit (ICU). This chapter presents a synopsis of arterial disorders, whereas evaluation of venous thrombosis and ultrasound-guided vascular procedures are presented in Chapter 9, Chapter 10, Chapter 11, Chapter 12, Chapter 13, Chapter 14, Chapter 15, Chapter 16, Chapter 17, Chapter 18 . The arterial system The left-sided aorta couples the left ventricle to…

General chest ultrasound in neurocritical care

Overview Neurocritical care patients often require hemodynamic monitoring to optimize cerebral blood flow and brain tissue oxygen delivery. Hemodynamic monitoring also aids in the management of usual coexisting disorders, such as acute lung injury and acute respiratory distress syndrome (ARDS), as well as shock states. General chest ultrasound (see Chapter 1 ), which consists of cardiovascular and lung ultrasound, is a noninvasive bedside tool that facilitates…

Ocular ultrasound in the intensive care unit: (CONSULTANT LEVEL EXAMINATION)

Overview Multipurpose ultrasound systems offer a variety of eye and orbit imaging techniques relevant to critical care. Bedside ocular ultrasound can be used for the following purposes: (1) timely identification of threats to ocular health and vision and prevention of vision-related disability in trauma, (2) assessment of nontraumatic acute change in vision and the need for immediate ophthalmologic consultation, (3) measurement of the diameter of the…

Use of transcranial doppler ultrasonography in the pediatric intensive care unit: (CONSULTANT LEVEL EXAMINATION)

Overview As mentioned in preceding chapters, transcranial Doppler (TCD) ultrasonography is a noninvasive technique that uses low-frequency transducers for real-time evaluation of cerebral arteries in adults and in children with a closed anterior fontanelle. TCD has been increasingly used for cerebral circulation monitoring in the pediatric intensive care unit (PICU), and it has become an essential tool for managing sickle cell disease in children. , Two…

Transcranial doppler in the diagnosis of cerebral circulatory arrest: (CONSULTANT LEVEL EXAMINATION)

Overview The role of transcranial color coded Doppler (TCCD) in neurocritical monitoring has been illustrated in previous chapters. We will here focus on its use as a confirmatory test in the diagnosis of brain death (BD). The concept of death in Western civilization has been linked to the cessation of breathing and heart beat, irrespective of cultural and religious variability. Advances in medical technology after the…

Transcranial doppler in aneurysmal subarachnoid hemorrhage : (CONSULTANT LEVEL EXAMINATION)

Overview The management of aneurysmal subarachnoid hemorrhage (aSAH) and its accompanying sequelae integrates transcranial Doppler (TCD) ultrasonography for the surveillance of the emergence and course of vasospasm (VS) and delayed cerebral ischemia. TCD surveillance of patients after aSAH has been advocated by the two most recent aSAH treatment guidelines, and practice standards for its use are published. This disease is complex to manage, and TCD has…

Transcranial doppler ultrasound in neurocritical care

Overview In 1982, Aaslid et al authored a paper with the title “Noninvasive transcranial Doppler ultrasound recording of flow velocity in basal cerebral arteries,” describing the successful insonation and blood flow velocity (FV) measurement of the basal cerebral arteries with a range-gated Doppler transducer. These authors located an “ultrasonic window” above the zygomatic arch and 1 to 5 cm anterior to the ear, through which a…

Fundamentals: Essential technology, concepts, and capability

Christian Doppler was born in Salzburg, Austria on November 29, 1803 and lived a short and deprived life, like many scientists of his time. In an 1842 session of the Science Section of the Royal Bohemian Society in Prague, he presented a thesis entitled “Concerning the colored light of double stars and other celestial constellations.” Other milestones relevant to this chapter include the discovery of piezoelectric…

Radiomics and artificial intelligence

Introduction Positron emission tomography/magnetic resonance imaging (PET/MRI) is an innovative imaging technology that simultaneously acquires PET and MRI, allowing the integration of sensitive metabolic and functional information with precise structural and anatomical characterization of tissues ( ). PET/MRI has shown great potential in tumor diagnosis, treatment planning, and follow-up ( ). In addition to the qualitative image evaluation, PET/MRI may potentially provide several imaging biomarkers for…