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Echocardiography: Beyond the basics: (CONSULTANT-LEVEL EXAMINATION)

Overview Echocardiography is one of the most powerful diagnostic and monitoring tools available to the modern intensivist. Although its potential was first recognized more than 20 years ago, only recently has it become a mainstream imaging application in the intensive care unit (ICU). However, the widespread application of advanced echocardiographic techniques in the ICU remains disappointingly limited to isolated experts across the world, and the huge…

Echocardiography for intensivists

Overview Since its early use in intensive care unit (ICU) settings by pioneers, echocardiography has been increasingly performed in critically ill patients because it provides unparalleled information on central hemodynamics. Initially, real-time morphologic and hemodynamic information, ease of use, portability, and safety constituted definite advantages of echocardiography over more invasive techniques, such as right heart catheterization. Subsequently, ultrasound systems have become smaller, higher quality, and less…

Transthoracic echocardiography: An overview

Overview The first reported use of ultrasound to assess cardiac function was almost 60 years ago. Technologic advances have now placed echocardiography as the intensivist’s only option for bedside visualization of cardiac anatomy and function in real time. Although echocardiography began as the domain of the specialist cardiologist, a number of factors have contributed to increasing interest and training among critical care physicians. These include, a…

Endobronchial ultrasound: (CONSULTANT-LEVEL EXAMINATION)

Overview Convex probe endobronchial ultrasound-guided transbronchial needle aspiration is used for diagnosing (and staging) intrathoracic lymphadenopathy in lung cancer, other intrathoracic tumors, and lymphadenopathy from extrathoracic malignancies. The aspiration yield for benign causes of intrathoracic lymphadenopathy is less than with cancer, mostly because of lack of tissue architecture in cytology specimens, but sarcoidosis, and bacterial, mycobacterial, and fungal infections can be diagnosed. High-frequency endobronchial ultrasound (EBUS),…

Lung ultrasound: Protocols in acute dyspnea

Overview Lung ultrasound is becoming a standard diagnostic and therapeutic tool in the management of intensive care unit (ICU) patients, as analyzed extensively in this section of the book. It helps the clinician to rapidly evaluate thoracic pathologies and guide many bedside procedures. Thoracic ultrasound and the findings that follow are described in detail in previous chapters. This chapter aims to offer protocols and review specific…

Lung ultrasound in mechanically ventilated patients

Overview Mechanically ventilated patients often have contraindications to transport outside a monitored setting. Ultrasound is an alternative to traditional imaging techniques in the critical care environment because of its portability, absence of radiation, and real-time image acquisition. This chapter will highlight the utility of bedside ultrasound in the day-to-day management of mechanically ventilated patients. Recruitment/positive end-expiratory pressure (PEEP) Recruitment maneuvers play an integral role in the…

Lung ultrasound in acute respiratory distress syndrome (ARDS)

Overview Acute respiratory distress syndrome (ARDS) is a clinical entity characterized by acute inflammatory lung injury, increased pulmonary vascular permeability and lung weight, as well as loss of aerated lung tissue. The clinical hallmarks of ARDS are hypoxemia, bilateral opacities detected by chest radiograph or computed tomography (CT) scan, decreased lung compliance, and increased dead space. ARDS has different etiologies, among which the most common ones…

Lung ultrasound in trauma

Overview The great potential of ultrasound in the study of lung parenchyma lies in its ability to detect alterations in parenchymal density resulting from loss of alveolar air with or without increase of interstitial fluids. Moreover, pleural disorders can be studied by direct visualization or indirect detection of abnormal fluids or air collected in the pleural space. Ultrasound abilities are based not only on the capacity…

Pleural ultrasound

Overview Pleural ultrasound is influenced particularly by the presence of ribs and aerated lung. Ribs provide a shadowing artifact that completely blocks the transmission of ultrasound waves. Aerated lung is a powerful reflector of ultrasound waves and creates a typical artifact pattern. The pleura is well visualized by ultrasound, given that it is a boundary between two tissue densities (the lung and subcutaneous tissue) that have…

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…