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Pediatric Point-of-Care Ultrasound: Soft Tissue

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Pediatric Point-of-Care Ultrasound: Soft Tissue

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Thu, 01/10/2019 - 12:00

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- Hello, and welcome to this webinar by Fujifilm Sonosite.
My name is Stephanie Doniger,
and I'm a pediatric emergency medicine physician.
I'll be speaking with you today
about pediatric point-of-care ultrasound,
and the use for soft tissue applications.
This is actually one of the most common applications
that we use in the pediatric population.
Our objectives for this webinar,
I'll give you a brief overview,
and discuss the applications for soft tissue.
We'll go through case presentations
for each of these applications.
I'll describe the techniques for each of these applications,
and within each application,
the limitations and scanning tips.
So we often have pediatric patients coming in
with cellulitis and abscesses.
It's often difficult to distinguish
whether it's just cellulitis or abscess,
which ultrasound can help us for that.
But also, foreign bodies.
So foreign bodies can be particularly challenging,
and ultrasound can help us determine
whether a foreign body is present.
And if there is, it can actually help us
prior to incision and drainage.
For imaging of soft tissue,
it's preferable to use a linear high frequency transducer.
And this is because the majority of the structures
are very superficial in nature,
especially in pediatric patients.
Now here, you can see a variety of transducers
that are high frequency.
The one in the front is the hockey stick transducer,
and that is actually a higher frequency
which can be utilized,
but generally, all of these can be utilized
for these applications.
Now, it is important in pediatric patients,
and with superficial structures
to adjust the depth accordingly, and to use adjuncts.
Here's an example of depth.
So now, here's a patient with a chin abscess,
and you can see here on top, that here is the abscess,
but we have all of this wasted space.
Now, when you have the structure way up here
and you don't adjust the depth accordingly,
it's very difficult to see the details of that abscess.
Now, when we actually decrease the depth on the right,
now you can see that there's much more detail,
and you can see the extent of that abscess
much better, with again, better detail.
We can use adjuncts,
especially with the superficial structures,
to help the imaging.
Now, if there's a patient
who has either an abscess or a foreign body in the hand,
a water bath is actually quite helpful.
This can be used in the feet as well,
but it's technically quite limited and difficult.
Now, note that you don't actually
have to touch the probe to the patient's hand,
which actually helps with pain control as well,
since you don't have to directly
touch the region of interest.
Alternatives to help you image these superficial structures
are standoff pads.
Now, there are commercially available standoff pads
that you can see here, that are rather costly,
but we can actually make our own very easily
with a saline or tap water-filled glove.
Just make sure that you actually put gel
in-between the probe and the glove,
and then also between the glove and the patient's hand
to improve imaging.
The reason why these adjuncts are important
is that we want to actually
image at the focal point.
So when we increase that depth
between the transducer and the structure of interest,
our structure of interest
will now actually be in the focal zone,
and we'll have better imaging of that structure.
This is what it looks like.
It's important to be familiar
with the structures that you'll see on ultrasound.
Now, it's not as important to tell the difference
between all of the different layers,
but it is important to recognize that this dark, on top,
this is the fluid, this is the in-between the probe
and actually the skin itself.
This hyperechoic line is the epidermis.
We can see hypodermis, and we can see muscle.
And bone will appear hyperechoic
of the anterior cortex and have posterior shadowing.
And this is what it looks like
side by side with a water bath.
And we have a patient's hand here.
Now, you can see, prior to the water bath,
you can barely see this little structure here.
You can kind of see a line.
It's quite difficult to image.
I have put a fair amount of gel
in-between the probe and the skin
in attempts to image this structure appropriately.
However, what we can see here,
is that once we have the hand in the water bath,
here's the water of the water bath,
you can see this foreign body very easily,
and you can see the detail
and the extension into the subcutaneous layer much better.
So you can have a lot better detail
with the use of a water bath and a hand.
So when we're dealing with sterile procedures,
this is the case for any sterile procedures,
it's important to prepare the probe in a sterile fashion.
Now, you also have to remember
that in order to create an image on the screen,
the ultrasound probe needs to have gel on top.
So we can start with our regular gel.
That comes in the bottle that we're all used to.
But then, you actually don't wanna put that
onto a sterile field, because it is not sterile.
You'll have to now cover it with a sterile sheath.
There are commercially available probe covers
that have a kit that have everything you need inside.
It has a cover that goes over the transducer itself,
and extends over the cord, which is ideal.
Therefore, this will not contaminate your sterile field.
It also has rubber bands,
and sterile lubricant to put on top.
Now, if you don't have the luxury
of having these probe covers,
you can actually put the probe inside of a sterile glove,
but be careful, because this area of the probe
is not covered, and that can contaminate your sterile field.
Now, once we've put the sheath on top,
we need another layer of gel,
but we need to use sterile gel.
Now, you can use those sterile lubricant packets.
Those do come within the probe cover kit.
But also, you can use the traditional packets
that we use to perform rectal exams
which we're not doing as many in pediatric patients.
So now onto the actual applications
of soft tissue ultrasound.
This is actually quite common.
We have an 18-month-old female coming in
with what mom reports as a spider bite to her left buttock.
It has become progressively larger, more painful,
and the child now has a fever.
Examination is very difficult,
as it often is with children this age,
but what you can tell is that there's a region
of about four by four centimeters of erythema,
there's some induration, and central papule.
So we can probably tell that there's an abscess
based on that exam.
We're probably pretty suspicious that there's an abscess,
but oftentimes, what happens is we're not sure
if we actually can perform an incision
and drainage at that time,
whether that abscess is ready
to have an incision and drainage.
Now, the most frustrating thing,
and the most resource-costly thing
is to actually perform an incision and drainage
when there is no abscess present.
So particularly in this age group, in an 18-month-old,
you would have to actually have the patient sedated
in order to perform the incision and drainage.
So ultrasound can help us identify
whether an abscess is present.
So we can see here.
We immediately see this structure in the center.
That is anechoic, so that represents some fluid,
but it's actually not as large as we were expecting.
So that is a very small abscess
with some surrounding cellulitis
that actually I would not perform an incision and drainage
at that point.
So cellulitis, we all are very familiar
with diagnosing cellulitis.
It's a clinical diagnosis.
You don't actually need ultrasound to diagnose cellulitis.
But ultrasound is needed when you're not sure
whether there's an abscess present or not.
The technique, we're going to use the linear
high frequency transducer,
as we do with all of these soft tissue applications.
What I usually recommend is
starting at the region that's unaffected of normal skin,
orienting to the normal skin,
and then scanning over the entire affected region.
Then once you've performed this scan,
you're going to rotate your probe 90 degrees,
and scan in the other plane again,
beginning where there's an unaffected region,
scanning over the affected region.
Now, if there's a region in the center
that's a papule, or is particularly indurated,
I tend to focus on that area,
really looking to see if there's an abscess
that's present there.
Now, what we're see on ultrasound, what I can show you,
on this side, with normal skin anatomy,
it's not important, as I mentioned before,
to know the different layers.
It's interesting to see, but it's not important
other than to know that normal skin anatomy
has nice, clean layers.
Now, this is in contrast to cobblestoning,
where you see here, this does not have clean lines,
you have globules, and you have edema
surrounding those globules.
It's referred to as cobblestoning,
which you can see here below, these are cobblestones.
This is pathognomonic for cellulitis.
Now, early on, you may not see
the very apparently cobblestone
that we saw in the last example.
Early on, you can see, this area's just quite hazy,
and you can see stranding, vertical lines.
These are called hypoechoic stranding,
and that is an early sign of cellulitis.
Now, as we progress through cellulitis,
you can see the development of the globules,
or those cobblestones, and surrounding edema.
Now, this anechoic fluid that surrounds the cobblestones
is not an abscess,
and that can commonly be confused for an abscess.
As cellulitis progresses,
you can see there's much more fluid,
and it's much more apparent here.
Now, it's important, especially if we're not sure
whether our findings on ultrasound are normal or abnormal.
It's important to compare to the unaffected side.
So we luckily have two arms, two legs,
we can compare the affected and the unaffected side.
In this example, this is a side-by-side comparison
of a right calf.
This is normal, we can see those nice clean lines,
and this is the left calf that has cellulitis,
you can see the cobblestoning.
There's disruption of that architecture,
and it's also hyperechoic, or bright white,
when compared with the unaffected right side.
Now, this may not happen very often,
but it's important to recognize
that you may have a patient with necrotizing fasciitis.
That is not the typical pattern of cobblestoning,
but what you can see here
are very dirty, scattered shadows,
and that's air within the subcutaneous tissues.
This is obviously a very time-sensitive
and dangerous diagnosis,
but if you see this on ultrasound,
then you need to take action appropriately.
Now, as a I mentioned before,
it's often difficult to distinguish cellulitis from abscess.
Ultrasound can help us with that,
but also, it has treatment implications.
So if we're to perform an incision and drainage,
we can identify surrounding vascular structures,
and neurovascular bundles,
to avoid those for incision and drainage.
The technique, as as I mentioned before,
it's the same for an abscess as it is for cellulitis,
because really, we're looking to see
if there's a presence of abscess.
We're going to start in the area that's unaffected.
We'll scan over the area, spend some time
over that area of greatest fluctuance,
and scan in two planes.
Now, once you find an abscess,
it's important to measure not only the size, but the depth,
if you are to perform the incision and drainage.
And as I mentioned, it's important to identify
surrounding neurovascular structures in order to avoid those
if you are to perform an incision and drainage.
Now, what do abscesses look like on ultrasound?
They can look like a lot of different things.
They're not always anechoic or perfectly dark.
They may be anechoic, they may be hypoechoic,
there may be internal debris,
but because of fluid inside of those abscesses,
there may be posterior acoustic enhancement.
Now, in order to identify abscesses,
especially if they happen to be isoechoic
with the surrounding tissue,
oftentimes, you can use compression
to see if the pus moves, or you can use doppler.
Here, we can see a small abscess, a very tiny abscess,
that if I were to find this,
I probably would not perform an incision and drainage.
All I would do is perhaps warm compresses
and topical antibiotics.
Now, as we progress, we can find larger abscesses.
Here's a situation where you have a quite large abscess.
You may be confused and think initially
this is only the abscess,
but you must look carefully and see the entire region.
This is an example how you can have different echos
within that abscess.
And as you progress to larger abscesses,
you can see here, this is the abscess,
and it's important to measure both the depth and the width.
Here's another example of an extremely large abscess here,
with posterior acoustic enhancement.
And once you find a very large abscess
that you're gonna perform an incision and drainage,
you can further measure the distance
from the skin down to the entrance of the abscess.
You can either measure it this way, or estimate the depth
based on the right side of the ultrasound image.
Here's an example of an extremely large buttock abscess.
As you fan through, you can see anechoic fluid,
but then you can see this isoechoic
and slightly hypoechoic tissue.
This is still part of the abscess,
and you can see loculations inside.
Now, here's an example, one that's actually quite common,
that you have a smaller footprint transducer
that's a linear transducer, and you see this large abscess.
Now, if I were using this transducer,
it would be extremely difficult to measure
and fit it, because you can't fit it all on one screen.
So in this situation,
you would need to change to the lower frequency transducer
in order to get an appropriate measurement.
Of note, this is a pilonidal abscess.
What you can see here,
the depth of the abscess and the width,
it's quite large, almost six centimeters.
Obviously, if I found that on ultrasound,
that I would need to perform an incision and drainage,
or call my surgical colleagues.
Here's another example,
and we have a very small abscess here.
Again, if I found this, this is a very small abscess
that I would not perform an incision and drainage.
If it were uncomfortable,
perhaps I would do a needle drainage,
but that's the most that I would do in this situation.
Here's an abscess.
What you can do, as I mentioned before,
is use a technique called graded compression with a probe.
That's actually performed here.
You can see movement or swirling of the pus.
This is especially helpful
if you have an abscess that's isoechoic
with the surrounding tissue.
Once you see movement,
you're pretty confident that that's an abscess,
and you can refer to that as pustalsis,
or movement of pus within the actual abscess itself.
Here's a case that I had in the emergency department.
This is a 14-year-old girl's sacrum.
She'd actually been in the emergency department
the day before, and the clinician had thought
that there was probably an early abscess present,
but it wasn't ready for incision and drainage quite yet.
The patient returned because she had quite a bit of pain,
and you can see this region here of erythema,
and just a little bit of swelling.
We immediately put the linear transducer on the patient,
and you can see this large area of fluid.
You can see some surrounding cobblestoning,
but this is a very large fluid collection.
Now, it is important to note
that this does look a little bit different
than the patterns that we saw before.
And you can see these dots swirling
within the cavity of the abscess.
This is cystic fluid that represents those dots,
and that's super infected.
So it is pretty typical for a super infected cyst.
Now, once we find an abscess
that needs to have incision and drainage performed,
we can use ultrasound to identify both the ideal location
for performing incision and drainage,
and also identify surrounding neurovascular structures
that we don't actually want to cut into.
Now, generally for abscesses,
we use the technique called ultrasound assistance,
and this is skin-marking
prior to performing incision and drainage.
We don't actually use ultrasound
during the incision and drainage itself.
You can also repeat the ultrasound
following incision and drainage
to make sure that you've actually opened up
and obtained all the pus within the cavity itself.
So here's an example
that one of the fellows presented to me.
This is a patient who had axillary swelling and pain,
and I was a little bit hesitant
to perform incision and drainage.
We did the initial ultrasound here,
and you can see a relatively large abscess.
So we didn't measure it, but you can estimate,
based on the depth on the right side of the screen,
this is at least about one and a half centimeters deep.
So it's actually a quite sizeable abscess.
However, the reason why I was hesitant
to perform an incision and drainage in this region
is that the axillary region
has a lot of neurovascular structures.
And here, you can use color doppler.
You can see the flow
right through the center of that abscess.
If we had actually performed incision and drainage,
that patient would have had significant bleeding
and complications as a result.
So therefore, we actually opted
not to perform an incision and drainage.
We decided to have conservative management
with warm compresses, topical antibiotics.
Because of the surrounding cobblestoning and cellulitis,
we gave her oral clindamycin.
Here's another example of a buttock abscess.
This was a patient that had swelling, tenderness.
We can see the abscess here.
The patient's moving around a fair amount.
And you can see the swirling of the pus
with movement of the probe itself.
This actually was a communication
of the abscess with the rectum,
so there's a fistula, so we needed to call a surgeon.
This was also another example
of an abscess that we would not perform
an incision and drainage based on the ultrasound results.
So I'm obviously a fan of ultrasound,
and point-of-care ultrasound in the emergency department.
But I'm not gonna use ultrasound
when it's not gonna help me clinically.
It's impossible to take the time
if it's not gonna actually impact your patient care.
So if it's pretty obvious on exam
that a patient just has cellulitis,
or conversely, just has an abscess,
I actually don't use ultrasound, it's those ones in-between.
So this is the algorithm that I employ.
If there's a very clear abscess on exam,
I put a needle in it, or I perform incision and drainage.
If there's no abscess, if it's just cellulitis,
then I treat with antibiotics.
And that's pretty easy.
But it's really those ones in the center,
those ones that we're not sure
if there's an abscess present,
or whether it's just cellulitis.
If we performed ultrasound,
and it's positive for an abscess,
then we can therefore go ahead
and perform incision and drainage,
and if it's negative, then we would treat for cellulitis.
So we can also have abscesses in unusual locations.
And now, this is a particularly difficult case that I had.
Two separate cases of swelling in the pinna,
which can be an emergency, as far as the cartilage itself.
If there's an abscess present,
it needs to be promptly drained,
because it can cause a pressure necrosis of the cartilage.
So when, obviously, these cases
always come in the middle of the night,
I needed to call my ear, nose, and throat specialist,
and his first question to me
was whether there was an abscess present.
And clinically, especially the patient on the left here,
it's really difficult to tell
whether there's a fluid collection present,
whether I needed to actually call him in from home
in the middle of the night.
So I performed an ultrasound.
Now, I had previously never done ultrasound of the pinna,
and I didn't know what it was supposed to look like.
So this is the affected side.
Well, we can compare it to the unaffected side.
So you can see here in the unaffected side,
we have hyperechoic cartilage,
you have nice, clean lines around that cartilage,
and when you compare it in the same patient,
here's the cartilage, and you actually have a very thick,
thickened subcutaneous tissue,
and you can see this anechoic fluid collection.
So this was indeed an abscess
that needed to be drained by ENT in the middle of the night.
There are some things that can fool you,
and they're mimickers for an abscess.
The neck is particularly difficult.
This is a patient who had neck swelling.
You can notice here that there's neck swelling
with overlying erythema,
and it's difficult to tell
whether that's an abscess or not.
When we actually perform the ultrasound,
we can see here that this is a lymph node.
In our patient, it's enlarged,
but you can see it's very regular.
There's a central hilum,
there are no anechoic, irregular structures inside,
so this is just an enlarged lymph node.
So that could actually clinically
make you confused for an abscess, but on ultrasound,
it's obviously not something
that we would perform an incision and drainage on.
This one fooled me.
This was a patient with swelling.
And you perform ultrasound, and you can see here,
that looks like cobblestoning.
That looks like here, that that might be an irregular
fluid collection of an abscess.
When you actually,
when I actually performed incision and drainage,
this was not an abscess, but it was a hematoma.
So hematoma can look very similar
to cellulitis and abscess.
So be careful, and use your clinical history
and psychical examination findings
in conjunction with your ultrasound.
This was another child who came in with leg swelling.
You can see here
that there's some abnormalities
of the subcutaneous tissue,
you can see some of that hypoechoic stranding,
and maybe some early cobblestoning.
That last patient was actually a bug bite.
This patient also with leg swelling,
you can see it looks a little bit hazy
in the subcutaneous tissues.
This was actually not cellulitis,
but it was a vaccine reaction.
So you can see reactions,
whether it's an allergic reaction in the prior case,
or swelling after an injection or vaccination.
Those should not be confused with cellulitis.
So the findings of cellulitis are pretty nonspecific.
As I mentioned, a hematoma can look like cellulitis,
bug bites, vaccine reactions.
So really, cellulitis is more of a clinical diagnosis.
And what we're using ultrasound for
is to identify the presence or absence of an abscess.
It's really helpful to use compression.
Look for that pustalsis to see if there's fluid inside.
Look for adjacent structures,
and compare to the unaffected side.
Now, this is actually one of my favorite applications
because I absolutely hate foreign bodies.
I hate hunting for foreign bodies,
and I particularly hate foreign bodies under the nail.
So this was actually a patient
with a suspected foreign body,
and I performed ultrasound to prove to the mother
that there was not a foreign body, and I was wrong.
So (laughing) be careful when you're using ultrasound
to rule things out.
We really wanna rule it in,
and luckily, I actually did rule it in for the patient.
So this particular patient was a 13-year-old male
who fell against a wooden dresser.
He felt that part of the wood
actually went under his nail,
but given the fact that he was a teenager,
he wasn't really sure if the piece of wood
was still under his nail.
But it hurt, and it looked like this.
And so you can see, this line underneath the nail,
and it was hard to tell
whether that was a foreign body or not.
So because it was in the hand,
we put his hand in a water bath,
and you can see here, we can see his nail.
This hyperechoic structure posterior,
this will loop through, is the phalanx,
but if you look just under the nail,
you can see this hyperechoic line
that extends past the eponychium here,
and that is the whole foreign body.
So we removed it, and it was almost two centimeters.
So that was actually a really good example
of using a water bath to identify a foreign body.
Now, foreign bodies can be very easily identified.
The technique is very similar
to what I mentioned before for cellulitis and abscess.
Use a high frequency linear probe.
If there is open skin, as there often is,
be careful, and make sure that you prepare the probe
in a sterile fashion.
Patients will often have a puncture wound,
or an area where they feel
like there's a retained foreign body,
so you really wanna focus your interest there.
Start in the unaffected area.
Scan over the affected area,
really focus on that affected area,
or whether there's a puncture mark.
Then rotate your probe 90 degrees,
and scan over that area of interest in your second plane.
Now, foreign bodies are often very difficult,
because we have relied, historically,
on using plain radiographs to identify foreign bodies.
We all know that the only things
that will show up on radiographs
are glass and metal, and sometimes gravel,
but there are tons of other foreign bodies
like wood, thorns, plastic,
that will never show up on plain radiographs.
In addition, radiographs include,
involve ionizing radiation,
and this is something we obviously wanna decrease
the exposure of ionizing radiation
in our pediatric population.
So ultrasound is great in identifying foreign bodies.
Almost every foreign body is hyperechoic, or bright white.
So whether it's radiopaque, or radiolucent,
they're almost all hyperechoic.
Now, there are certain artifacts
that can help you identify foreign bodies,
what types they are.
Metal will have a ring-down artifact,
and some of the more dense materials
will have posterior shadowing.
In situations of retained foreign bodies,
there can be a hypoechoic halo
surrounding that foreign body itself.
So here's an example of a foreign body.
As we scan through the subcutaneous tissue,
we can see this tiny little dot here.
This shows the importance of scanning
in at least two perpendicular planes.
When you rotate the transducer into the second plane,
you will now see the entire length
of this foreign body here,
with that ring-down artifact.
This is a situation of a needle.
Now, if you had only obtained that first view,
you could easily miss it.
It is important to note
that very small diameter foreign bodies
may be missed by ultrasound.
Here's that hyperechoic foreign body,
with that ring-down artifact, those parallel lines.
And that signifies a metallic object.
Of note, this is actually a needle
that's in the patellar ligament that you can see here.
As I mentioned, there are particular artifacts
that can help you.
The ring-down artifact of metal, you can identify.
Now, sometimes you see the artifact first
before you actually see the foreign body.
Here's an example in the center
of a very small foreign body,
but you can see the posterior shadowing.
You can see posterior shadowing with glass,
and less commonly, plastic and wood.
There are other things like wood
that will have a very dense hyperechoic nature,
but you won't see that ring-down artifact,
or you won't see that dense shadowing.
So again, keep in mind
that almost all foreign bodies are hyperechoic.
Here's an example of a glass foreign body.
You can see this line coming down here,
and perhaps this hyperechoic area.
Very important to obtain two views.
You can see the posterior shadowing deep to that.
Here's an example of a splinter.
On exam, there was barely any splinter that you could see.
Once you put the patient's hand in a water bath,
you can not only see the splinter here,
but the extension deep, of that very large foreign body.
And this foreign body was more than a centimeter
that we retrieved.
Obviously, says it at the top,
and you have the picture here.
This is a very large splinter
that we retrieved from a patient's thigh.
And you probably wouldn't miss this,
but this is often really difficult
to tell where you should perform your incision and drainage.
Now, in the transverse view, as we're scanning through,
you can see the shadow marching up.
These are various cross-sections of the splinter itself.
One other thing that you can do
to help identify a foreign body
is injecting lidocaine surrounding that foreign body.
So if I have a foreign body
that I'm not exactly sure where it is,
I can identify it first on ultrasound,
with ultrasound guidance, inject lidocaine surrounding it.
Anytime there's fluid that you introduce,
it acts as an acoustic window.
So what you can see here is the foreign body,
and then this hypoechoic halo around it.
This appearance is also the same
if it were a retained foreign body.
So in order to remove a foreign body,
oftentimes, the easiest thing to do
is just ultrasound assistance.
So identify the structure on ultrasound, mark the skin,
and remove the foreign body without the use of ultrasound.
Alternatively, especially if you have a foreign body
that's really difficult to remove,
or something round that is moving
as you're trying to remove it,
ultrasound guidance can be helpful.
So you can actually see the foreign body
moving in real time.
One of the tricks that you can do for ultrasound guidance,
particularly if it's a difficult foreign body,
is identify the foreign body on ultrasound,
introduce a needle with ultrasound guidance,
and have the needle extend down to the foreign body,
down to below the foreign body,
keep the needle in place, remove the probe,
and then you can incise down to that needle
that you kept in place,
because your foreign body will be just on top.
Additionally, you can use ultrasound
and look at forceps directly themselves.
So it is important to remember
that ultrasound is quite limited
in detecting small foreign bodies.
It depends on the orientation of the probe
to that foreign body.
Sometimes, especially in the foot,
if the patient steps directly
on a very small diameter, toothpick, let's say,
if you scan in two planes at the bottom of the foot,
you'll only see that very small diameter.
Now, if you do an additional view on the side of the foot,
you can now see the length of that toothpick,
and identify that foreign body.
One thing to note that if you have a patient
with a foreign, a suspected foreign body in their hand,
be very careful, because a lot of the small hand bones
can be mistaken for foreign bodies.
I had mentioned different techniques
for removing foreign bodies.
This is the example of needle localization.
You can see the foreign body here.
We extend the needle down to the foreign body,
we leave that needle in place,
and we can incise down to that foreign body itself.
Here's another example.
This is in real tissue.
We have a foreign body here.
We extend the needle down.
We'll leave that in place,
and we'll incise down to the needle.
We can use forceps.
We can look in real time guidance.
We can see the foreign body here,
and the forceps grabbing.
Now, remember, because this is a metallic object
that not only will you have ring-down artifact
from the metal, but you won't see both sides of the forceps
because they're very dense.
So you will see the anterior portion of the forceps,
and you can see the tip actually grabbing the foreign body.
Here's an example of foreign body, again, in the hand.
Here's that thorn.
This is the example
that you can just see barely any of the thorn here.
When we use the water bath, it extends here.
This is hyperechoic, extending deep.
And this was the foreign body
that was more than a centimeter.
This was an example of a pencil in a foot.
And so, we did use x-ray, you can see it here.
But it's often difficult to identify
exactly where it is based on x-ray.
We can identify that it's there,
but not necessarily where the location is.
So here, we can see the hyperechoic foreign body
with posterior shadowing.
And this is the large pencil tip
that we extracted from the foot.
So I encourage people to practice
identifying foreign bodies.
It's actually quite easy to make phantom models
and practice this technique.
Here, we have a few different types.
We have chickens that we put phantoms,
different materials of wood, metal,
there's a safety pin, and then some plastic.
It is helpful to have a map of what you put in there,
so people can identify.
Polenta is a good alternative, or gelatin Metamucil models.
So here we are,
and we had a few courses with WINFOCUS,
where we had various gelatin and chicken models.
And here are those gelatin models.
It's helpful to practice,
to identify what these abnormal patterns are
on ultrasound before actually scanning on real patients.
So in summary, for the soft tissue applications,
which are extremely helpful in pediatric populations,
we're going to use the high frequency linear transducer.
For cellulitis, we're actually not using ultrasound
to diagnose cellulitis, but we're looking to see
if there's a fluid collection or abscess.
We're also looking for foreign bodies.
All of these techniques,
you wanna make sure that you scan in at least two planes,
look for surrounding neurovascular structures,
and you can really extend these principles
to other applications.
As I showed the example in the neck,
you can identify abscesses in the neck, and other locations
that you may not necessarily be familiar with.
And the other example is the cartilage in the pinna,
that the same principles of an abscess
will extend to those other locations.
As you practice these exams, as you look in phantom models,
as you practice on patients, you'll find that actually,
these are amongst the easiest of ultrasound exams.
They're also the most helpful
in your management of pediatric patients.
Thank you so much for watching this webinar.
If you have any questions or comments,
you can contact me, and my Twitter handle is here.
And also, if you'd like to learn
about other pediatric point-of-care ultrasound topics,
you can refer to the textbook, Pediatric Emergency
and Critical Care Ultrasound.
Thank you very much.

Brightcove ID

5768895883001

https://youtu.be/1Hy0M-lOGco

Needle Navigation in Ultrasound-Guided Procedures

Read more about Needle Navigation in Ultrasound-Guided Procedures

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Needle Navigation in Ultrasound-Guided Procedures

Publication Date

Thu, 01/10/2019 - 12:00

Media Library Type

Other Videos

Subtitles

- Welcome to our AEN Webinar.
My name is Wolf Armbruster.
- My name is Rudiger Eichholz.
- And I am Thomas Notheisen.
- And our subject today is
- Needle tip control in ultrasound-guided
interventions and procedures, so mainly we're talking about
ultrasound-guided nerve blocks and vascular axis.
- You see three speakers here because we are doing
a lot of ultrasound courses together.
- Why do we recommend to use
ultrasound in invasive procedures?
We all know the cases with landmark vascular axis
with difficult situations where we have
displacement of catheters that's shown here,
or in this photo you see a lot of catheters
and the one in the middle with the red tags
obviously has a little bit of an unusual position
on the lateral side of the clavicle.
If you look at this
on the ***, you will find the ultrasound
guided placements of two catheters; the blue ones,
and the displacement of the red one which was
placed in the subclavian artery in an emergency situation.
So, nobody touts that using ultrasound
reduces complications as such, so we need
to have some ideas how to really
master this method professionally.
What do we need?
We normally talk about three pillars as pre-conditions
for safe and successful ultrasound guided procedures.
The first one is basically probe maneuvers.
We need to know, and to practice, how to handle the probe,
how to get what we want on the ultrasound screen,
so, how to get the target structure.
And the second pillar is sonoanatomy, so we need
to have a deep knowledge of what we are looking at,
and the third thing, and this is going to be the major thing
we are talking about today, this is needle tip control.
To start with, we go over some basic information so that
we know what we are talking about
within the rest of this webinar.
We look at the lateral neck on these two videos here
and the anatomical structures are shown in a
transverse cut which is also known as short axis.
The other term we need is obviously the
longitudinal cut or long axis,
which is shown here on the radial artery on the mid forearm.
In contrast to this, what we call
axis terminology, we talk about planes.
Planes refer to the needle guidance in relation
to the scanning plane and not to anatomy.
The axis terminology refers to anatomy only
and plane terminology refers to how to
guide the needle into the scanning plane.
This shows out-of-plane procedure here, so with only
one little point where the needle cuts the scanning plane
where as here in an in-plane procedure we ideally see
the whole needle in the scanning plane.
What else is important before we start?
We need to know how to orientate the marker
and the probe, so how to put the probe on the patient
to have a good orientation with a needle in the patient
and on the ultrasound screen.
So as a basic rule, we recommend to orientate
the probe marker to our own left eye.
This results in a good orientation so that the
left side on the screen is in fact also the left side
of the probe on the patient.
This is a general rule of course in some procedures
we have exceptions from this.
Okay, so marker to the left eye of the examiner.
Let's look on some ultrasound-guided interventions.
We put the probe on the patient, take a needle, and
puncture the skin, and as it happens to be,
the needle gets behind the scanning plane
and so we create a hematoma.
With our other needle, get a second hematoma,
try again, get a third hematoma.
This is the situation that, to be honest,
happens again and again, so, what was wrong here?
Ultrasound as such, doesn't really improve anything,
so in this case, there was no needle tip control.
Remember, never lose your needle tip.
For this, we need methods how to actually achieve this.
Let's go over some basic probe handling methods.
First of all, in another plane procedure, we recommend
to direct the bevel of the needle towards the probe.
The reason is, once the needle gets into the scanning plane,
the bevel of the needle creates a good reflection
of the sound waves back to the probe,
whereas when you direct the bevel downwards
or if you insert the needle too deeply,
then you will have the same conditions for
the sound reflection, so part of the sound
is being reflected away from the probe
so you won't have a good ultrasound image.
Bevel up is important in ultrasound
out-of-plane procedures.
Let's look at in-plane procedures.
Whenever it is possible we try to have a parallel
needle path in relation to the footprint.
This creates good reflections of
the sound waves back to the probe.
Of course, in this case, the bevel
is directly towards the probe, too.
This is possible, let's say, in distal
sciatic nerve blocks or in temp blocks, too.
But we may have anatomic situations where this is difficult.
The angle of the needle is a littler steeper.
In vascular axis in a subclavian axis,
there's no option to have this parallel needle path
in relation to the footprint, so what would we do?
As a very simple method, we can try to work with our probe.
This is probe handling again, this is the situation.
Most of the sound energy is being reflected
away from the probe, so what we try to do,
whenever it is possible anatomically,
we slightly put emphasis on one corner of the probe
to have a more parallel course of the needle
in relation to the footprint, and hence
we get better sound reflection.
This method is also available as a software solution
of some manufacturers which we see here.
Normally we believe that the sound wave actually travels
in a perpendicular direction from the footprint
into the tissue, but we can actually tell
the piezo crystals to angulate and to send
the sound wave in a specific angle
in relation to the footprint.
This is shown here so you see this line
with the little points and this is actually
the direction of the sound waves
which are directed toward the target structure.
So we have the probe sitting on top of the ultrasound
image here and now the sound travels onto this catheter
and therefore creates excellent sound
reflections back to the probe.
This is shown here in a pleural catheter,
but there is one thing you gotta keep in mind
because beyond this line with the little dots,
the image isn't as good as inside this field.
The reason is that not many piezos
create the beam out image in this area.
Whenever you use this software solution,
you gotta keep in mind not to have your target structure
outside of this field so just don't go here
because the visibility of your needle will be worse
than not having this mode on.
Let's talk about hardware solutions.
Of course we all know echogenic needles
and they have got these little
corner stones inside that create a
better reflection despite very steep angles.
This is what we can see here.
You see a normal needle which actually goes in in a
quite shallow angle and the ultrasound needle is
inserted much steeper and creates a much brighter signal.
On the second image, you see a very steep angle on the
ultrasound needle side and on the
other side you only see a slight shadow,
so there are no reflections of the needle shaft
back to the probe, but because the needle
is perfectly placed in the center of the scanning plane,
it creates a shadow below the needle
so you only have an indirect vision of this needle.
Whenever you have very steep puncture angles
or you work very close to vulnerable structures
like the pleural, you wind up using an echogenic needle.
As an example, we present a vascular axis
of the axillary vein on the subclavian vein.
What you see here is the normal sonar anatomy.
On the medial side, we look at the vein with
the typical double pulsation and and lateral
from this we have the subclavian artery
Again, lateral, we see structures more echogenic structures
which represent the brachial plexus.
On the other side, you see the pleural with some
lung sliding under the plexus structures you see
a little bit of a bone shadow; this is the rib.
We only use this ultrasound image as
a general anatomical orientation so we want
to do the puncture in long axis.
So for this we rotate the probe,
we deliberately place the clavicle on the image
so it's just under the pictogram under the body marker.
Now we've got the subclavian vein in long axis,
and under the vein we've got the first rib,
and then we've got pleurae and the second rib.
As we know that the artery is lateral to the vein,
we just check it to be certain,
to be also safe for the patient.
We check the artery and in best conditions
we also might place the pulsed wave Doppler
inside here and go back to the vein.
We take an ultrasound needle because it's a steep angle
and the direction of the needle is towards the first rib
as an additional safety feature not to cause a pneumothorax.
Here, again, you can see how the
guidewire is placed directly into the vessel.
Some experienced users, they do not use syringes
anymore on the needle, so they pre-position
the guidewire inside the needle and then
place the needle tip inside the vessel under
direct vision and then insert the guidewire directly.
This is quite smart, but only for experienced users.
What else is available on the hardware side?
We have options to have an
in-plane guidance for probes.
There is a little plastic clip which we
connect to the probe, then we have a sterile cover.
On the lateral side of the probe, we've got
this little device that keeps the needle
inside the scanning plane only for in-plane procedures.
This is the result.
It kind of prevents on the one hand the lateral
displacement of the needle in relation to the
scanning plane and also prevents the
rotation error so that the needle is
not in the same direction as the scanning plane.
So we show this device again
on a subclavian vein puncture here.
The needle is inserted, and you see here
that the needle is just slightly too short
so we move the probe away a tiny little bit
until we safely get into the vessel
and here we see the technique how to pre-position
the guidewire and very cautiously
insert it into the vessel.
This is something we would really recommend you to do.
This is a guidewire control.
Because of the material of the guidewire,
we have very good reflections, so it takes only
a few seconds and you are certain where the guidewire is in.
You can do this in short axis as just shown and also
you can rotate the probe and see it in long axis.
Now we've presented some probe handling techniques
on how to improve needle tip control.
We have presented some software solutions,
some hardware solutions, but now
we're coming to the most important thing,
the needle navigation techniques
which you can use in any case,
whether you have any hardware or software assistance or not.
We have divided these method into
those for beginners, so we talk about angle navigation
and a walk-down technique with angle adjustment.
For more advanced users, we talk about
the walk-down technique with probe alignment
and at the end, the smartest and, as we believe,
the safest technique is walk-down technique
with probe alignment and probe rotation,
so let's go over this.
Angle navigation is a rough orientation on how to
navigate the needle in the patient.
Let's go over it in an example.
We place the probe on the patient,
and the probe sits on the patient
in a perpendicular angle on the skin.
We try to find out how deep is our target structure.
We look on the ultrasound image and we see it here.
We aim for the 12 o' clock position
of the target structure and we reach the depth
on the lateral side of the ultrasound image.
We take this depth, which is roughly
one centimeter in this case, and we take
the same distance away from the probe,
so we don't talk about distance from the
plastic cover of the probe, we talk about
the distance where the scanning plane
actually sits on the footprint.
By this, we create a rectangle,
and then we penetrate the skin.
Use 45 degrees, and then you can
puncture your target structure.
However, this method is somewhat unsafe. Why?
Because having all the correct angles is not very easy.
So, using a steeper angle, let's say instead of 45 degrees,
you were using 50 degrees or 60 degrees,
you would actually penetrate the target structure before
you have even seen the needle tip
enter in the scanning plane, so this might be dangerous.
On the other hand, using a 40 or 35 degree angle,
you will reach the scanning plane
before you are in the 12 o' clock position,
so you may get the needle tip behind the scanning plane
and this is not wanted.
This is a method which is suitable for superficial
structures like in vascular axis
where you wanna actually penetrate the
target structure anyway, but we wouldn't
recommend it to use in nerve plots.
So we show you an example.
This is a vascular axis in a
femoral artery on the left side.
So you see in the ultrasound film
that there is some tissue movement in the
12 o' clock position right now and you see the needle tip
being inserted into the artery and then here again
you see the guidewire being inserted
on the spot, so it was pre-positioned.
So we look at it again, and see the motion of the tissue,
you see the needletip and the guidewire.
It's a good method, however, as we said, rather use it
for superficial structures and for vascular axis.
In deep structures, it is quite easy to understand
that the errors of using the wrong angles
actually get greater and greater.
What methods do we have to improve this situation?
Let's have a look on the walk-down technique with angle
adjustment, which was actually published in 2006 already.
In this case, we place the probe on the patient again,
as we always do, and we insert the needle
in a very shallow angle, so on purpose
we want to get into the scanning plane
in a distant to the target structure.
First of all, we want to identify the needle tip.
This is what we see on the ultrasound clip on a IJ axis,
so we see the needle tip in the sternocleidomastoid muscle.
We withdraw the needle and we adjust the angle
to a steeper angle, insert the needle again until we get
the first reflects of the needle tip in the scanning plane.
Have a look here.
The needle tip slowly approaches step wise,
the 12 o' clock position of the target structure.
You might do this again; you might do it
two, three, or four times, whatever is needed,
until you are on the 12 o' clock position
and then you see how the needle tip
sits on top of the vessel with the largest diameter
just under the needle tip, then you can put the needle in.
Here again, there might be some disadvantages because
you've got quite a lot of needle passes.
Especially with patients on the ICU, with a lot of
Aprinol, with coagulation abnormalities, you may not
want to have any needle passes so to improve this
with another technique, whenever anatomically possible,
so we need some anatomical space for the probe
to actually be moved over the patient,
so the angle of needle insertion is basically the same,
aiming on an early identification
of the needle tip very close to the probe.
When the first reflect occurs we stop the needle,
move the probe, forward the needle, stop again,
move the probe, and insert the needle a little more
until we get to the 12 o' clock position.
Then we can puncture the vessel.
This is a step-wise approach where either
the needle moves or the probe.
This is very important information.
Don't move both at the same time.
So, either the needle or the probe.
Let's have a look at this in a different way,
in a nerve block animation.
The needle tip is in the scanning plane
and we stop the needle, we move the probe just slightly,
very tiny little walk-down maneuvers.
We insert the needle again to get another
needle tip reflect on the ultrasound screen.
We do this again and again until we approach the nerve.
Now we look from a different angle
and the scanning plane now.
Tiny, little maneuvers once we get very close
to the target structure and now
we can inject the local anesthetic.
However, shown here we have chosen the 12 o' clock position,
but usually in nerve blocks we don't want
the 12 o' clock position so we wanna have
a tangential needle pass to the nine o' clock
or the three o' clock positions in order to
not accidentally get into the nerve.
But this method is certainly very good
for nerve blocks in general.
Coming to the last procedure, where we think it is the
safest and the best and the one you will have the
most fun with, this is the walk-down technique
with probe alignment and probe rotation
at the very end of this procedure.
The beginning is exactly the same
like in the method shown before,
so we just show the last step here on
how to get to the 12 o' clock position.
Now, you don't keep on going with the
needle and complete the procedure.
First of all, you rotate the probe.
We had a short axis view before and an out-of-plane needle
approach and now we get, through the probe rotation,
an in-plane picture of the needle and a long axis
picture of the anatomical structure.
Then we can insert the needle under full vision.
You see this on the ultrasound image here.
IJ puncture, you also can see that very easily
you get kissing walls and you may have passed
through the posterior wall which you only see
that well in in-plane and long axis procedures.
Again here, you may insert the guidewire either
with pre-positioning or you may,
as most of us have probably used, too,
we may use a syringe and do some aspiration
and then insert the guidewire.
But, why don't you look at the
guidewire while you insert it?
Because we all know the case that for some reason
we get blood out of the vessel,
but then can't insert the guidewire.
With ultrasound you might easily
visualize what the problem is.
Either it is not inside the vessel or it has
actually gone through the posterior wall, or,
third option, something in the vessel
is obstructing the guidewire like thrombosis or something.
Let's have a look at nerve blocks with the same method.
So we show again the last walk-down steps.
In this case to the 12 o' clock position
and then, in a little distance we rotate the probe
so that the last step towards the
vulnerable nerve structure is very well controlled.
What else is an issue?
Look at this.
So especially nerve blocks, we have a situation
that the visibility of nerves varies a lot and
is dependent on the angle of insonation.
So we put the probe on the nerve
and now the reflection is not very good
because it's not the perpendicular angle on the
course of the nerve so we slightly tilt the probe
to get a very good image on the ultrasound screen,
and then, using a short axis and in-plane approach,
it may be an issue that, for some reason it happens, that
the needle is not in the scanning plane, so what do you do?
Do you move the needle or what do you do?
So if you took the probe, you may lose your image.
What you do instead, you do a little parallel sliding
of the probe, keeping the angle so you hopefully get
a good image and a good identification of the needle
for safe approach towards the nerve.
Also, in in-plane procedures, you may have a rotation error
so that the needle path is not perfectly aligned
with the scanning plane and you also of course
have to correct this error by rotation.
Another thing is the inspection of guidewire position,
which we were talking about before already.
This is a method that only takes a few seconds
and gives you a lot more confidence
especially in difficult cases,
in cases on ICU with coagulation abnormalities
in patients where you need to insert large catheters.
As shown here, you see two hyper echogenic dots traveling
through the sternocleidomastoid muscle into the IJ.
Of course you can do this in short axis as shown here
or also in long axis, and then you may proceed
with your dilator and put the catheter in.
We end up having done successful procedures.
We end with the recording here and continue
with the recording with the three of us.
Thank you.
- As a summary of our useful information
about safe needle tip control and
navigation techniques, we created a poster.
The bad news is it's just available in German language.
- But, our textbook is available in English and, of course,
in German, and you can find it on our webpage.
- Coming back to the very beginning of our presentation
where we were talking about the three pillars,
so the preconditions of safe and successful
ultrasound-guided interventions which were
probe maneuvers, sonoanatomy, and needle tip control,
we would like to add two more pillars,
so we have five at the end.
We need sustainable teaching concepts and, at the end,
we need to practice a lot to achieve more.
Thank you for listening.

Brightcove ID

5745561443001

https://youtu.be/qfvu9E2iy2k

Lumps and Bumps of the Knee Part 1: Soft Tissue Masses

Read more about Lumps and Bumps of the Knee Part 1: Soft Tissue Masses

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Lumps and Bumps of the Knee Part 1: Soft Tissue Masses

Publication Date

Thu, 01/10/2019 - 12:00

Media Library Type

Other Videos

Subtitles

- Hi, I'm Dr. Scott Weiss.
Today we're gonna talk about
lumps and bumps around the knee.
I'd like to thank Sonosite
for giving me the opportunity to present
some interesting cases to you.
I'm gonna have a focus essentially on Baker's Cysts
because they're so common.
And we're gonna discuss different kinds of cysts
and also different findings you may see within the cyst,
such as septations, loose bodies
and multilobular cysts.
I had a very interesting case of a combination
of a Baker's cyst with a ganglia.
Also I'm gonna discuss a ruptured Baker's cyst
and findings you can see in the gastrocnemius muscle
with a rupture of a Baker's cyst.
So Baker's cysts are very common,
you see them often with osteoarthritis,
you see them with meniscal tears.
Even the pediatric population sometimes has them
even without any trauma.
And very often the pediatric population
they will just go away by themselves,
but it could take up to a year.
In the adult population,
I usually don't interfere
or do anything to a Baker's cyst
if it's not causing any symptoms.
Unfortunately, even if you drain a Baker's cyst,
it very often comes back.
Baker's cysts have been described
as distention of the bursa,
basically between the medial gastrocnemius tendon
and the semimembranosus tendon.
Patients that are over 50 years old,
50% of those patients have
a communication with the knee joint.
When you're diagnosed with Baker's cyst
you wanna be able to see a stalk
that it's basically between the
medial gastrocnemius tendon and the semimembranosus tendon.
Baker's cysts usually are located distal to the joint,
right over the medial gastrocnemius muscle.
If you start noticing a cyst more proximally,
then you start thinking more of a ganglion type of cyst.
If you see a cyst that's underneath the calf musculature
and certainly if it looks irregular,
with different types of echogenicity within it.
Then you actually worry about soft tissue tumor or sarcoma.
And certainly that is something that needs
to be worked up with MRI imaging.
So here is a model of the lower extremity.
We're looking essentially at the femur
all the way down to the ankle.
We can see the posterior aspect of the knee here.
And we rotate anteriorly
and see the articular surfaces.
Most of our focus again is gonna be
the posterior aspect of the leg.
And here you can see the posterior leg
and the posterior aspect of the distal thigh.
You can see the plantaris muslce
and then very long tendon going distally.
Also the popliteus muscle
you can see just below the knee joint.
And here's the deep muscle compartment going
from lateral to medially,
you can appreciate the flexor hallicus
longs muscle,
then the tibialis posterior muscle
and then the flexor digitorum longus muscle.
The plantaris tendon actually is just
superficial to the soleus muscle,
which you do not see here.
Here we are,
we're going to a more involved model
with the muscles of the hamstrings.
You can see the short
and long head of the biceps femoris muscle laterally.
And then medially
you can see the semimembranosus muscle/tendon,
with the semitendinosus muscle/tendon above that.
Baker's cyst you can see
above the medial gastrocnemius muscle.
And within this Baker's cyst
you can see some loose bodies and septi.
Here on the sagittal type of perspective
you see how it just slides superficial to the medial
gastrocnemius muscle,
making it a relatively safe bursa to aspirate.
Here we are, we're kind of looking at it
from below.
And here's our probe.
Now when you do an ultrasound study
of this you wanna make sure you cover
with axial and saggittal views.
When you do sagittal views you wanna
make sure you cover both the medial
and lateral aspect of the bursa,
which you can see the probe moving
on both sides of the bursa here.
And here again is another sagittal view of this bursa.
And again you can appreciate how
there could be septi both distally and proximally.
And loose bodies throughout the Baker's cyst as well.
When you start to aspirate and injection these,
basically you have to probe in a sagital perspective
or a long access to the Baker's cyst.
You can see how you may have to puncture
and go through different septi
in order to drain the entire Bake cyst.
Here's just a close up view of
how the needle may have to penetrate the septi
in order to aspirate the entire cyst.
You'll see in some cases that you may not even have to
go through the septi in order to drain the cyst.
That really depends if the septi is completely
separating the Baker cyst or not.
And here we are going back
as we can appreciate the C shape Baker cyst
with concavity going lateral.
And you wanna make sure that the Baker cyst
is essentially superficial
to the medial gastrocnemius muscle.
If you start seeing a cyst
which is going into the muscle
below the muscle
then you actually start worrying about a neoplasm such
as a sarcoma.
If you see fluid tracking distal
to the Baker cyst,
into the medial gastrocnemius muscle,
then a rupture Baker's cyst is probably your diagnosis.
Baker's cysts are usually caused
by fluid that extravasates from the knee joint
posteriorly through a weakening of the capsule.
Occasionally you could just get local irritation
of the semimembranosus medial gastrocnemius bursa.
But again, often a Baker's cyst is caused by
arthritis or perhaps meniscal pathology
causing fluid which then extravasates posteriorly.
In this case you're gonna see a Baker's cyst
that has a septum in it,
in the distal third of it.
And actually to drain this cyst
we didn't even need to breech that septum,
we just needed to put the needle just proximal to it.
Usually, however, in most cases you need to breech
the septum in order to get different
compartments drained of the Baker's cyst.
This is the case of a 52-year-old female complaining
of five months of pain in her right leg.
Most of the pain seems to be posterior.
MRI and ultrasound did reveal a Baker's cyst
with a septum in it.
She also had a torn posterior horn
medial meniscus/medial meniscal root tear posterior horn.
On physical exam she was tender
in the medial joint line.
Also, again, tenderness in the popliteal fossa.
Here we are starting our diagnostic ultrasound
with comparison view of her normal side on the right side.
We were just going through her medial gastrocnemius muscle
and soleus muscle underneath that.
And here we are in the sagital view
and we can see her Baker's cyst
with a septum in the distal half of the Baker's cyst.
Again, to diagnose a Baker's cyst,
you need to have it basically squeeze
through between the semimembranosus tendon
and the medial gastrocnemius tendon.
Here's a good view of our semimembranosus tendon
attaching on the posterior tibia,
proximal medial aspect.
And there's the MRI as well.
Now we're switching to an axial view
and we get a really nice view of the septum.
It looks like it completely transects
the Baker's cyst in axial view.
Here's some MRIs just to show you again
the anatomy of Baker's cysts
and how we classify them.
Here's a good breakdown of her musculature
in the axial view of her knee.
Here we are just scrolling through
and you can see that Baker's cyst start to form
and you see how it squeezes out
between the semimembranosus tendon
and the medial gastrocnemius tendon.
Here we are just focusing again
on that cyst with those two tendons.
And here's just a scrolling through again
of the axial view to see how that cyst forms.
Here's a sagittal MRI
and just to look at it again,
you can see the medial gastrocnemius tendon
and then as you go more medially
you will see the semimembranosus tendon
start to come into play as well.
And here's our semimembranosus tendon.
We're just scrolling through
to get a better sense of how this cyst forms
between the gastrocnemius muscle/tendon
and semimembranosus muscle/tendon.
(background chatter)
that's me just going in.
Okay, we're starting our procedure.
So in this stage,
in this part of the procedure,
we really just went in the proximal,
or actually the distal part of the cyst.
We didn't go through the septum.
I was anticipating having to breech through
that septum in order to get
to the proximal part of the cyst.
But as you can see,
most of the cyst really was drained
just by putting the needle
just distal to the septum.
So I didn't really need to break through that septum.
So it's my conclusion that this was not
a complete septum or complete division
of the Baker's cyst with that septum.
I'm just gonna inject it with a little bit of cortisone.
Here we are we're just injecting some cortisone.
Sometimes when you break through
plica or septum it could cause more discomfort
for the patient, so if you can avoid it
it's probably easier on the patient.
And again, teaching point is that on this case
we did not have to go through the septum
in order to essentially drain the whole cyst.
And this case is somewhat of an unusually high
location for a Baker's cyst.
Once you get beyond or proximal to the knee joint
you're usually dealing with a ganglion
around the semimembranosus tendon.
But this case I believe is just a Baker cyst
that is a little bit high up.
It had some loose bodies
and we were able to successfully drain it.
A 51-year-old female here for pain in the right knee
for a couple months, no injury.
Pain posteriorly.
She has a nice Baker's cyst.
Here we're starting medially.
I can see a loose body there in the Baker cyst.
Right side of the screen is proximal,
left side is distal.
You can see that Baker's cyst
goes right above the medial gastrocnemius tendon.
Very medially we can see the semimembranosus tendon
coming down and starting on the proximal tibia.
And you could easily mistake
the PCL for the semimembranosus tendon.
You can see that crisscorss pattern
between the semimembranosus tendon
and the medial gastrocnemius tendon.
We're gonna go a little bit lateral
and we can see that cyst just
kind of come into view there.
Again, loose bodies proximal in the cyst
and septation distally.
Now we can see the medial gastrocnemius muscle and tendon
going right underneath the cyst.
I'm gonna take a little axial view.
Right side of the screen is medial,
left side is lateral.
We're starting basically above the cyst,
working our way going down.
And we can see it come,
those loose bodies.
See the communication channel.
You can see right above the medial gastrocnemius muscle.
Starting below now, we're coming up.
Here's a nice view of that channel as it comes up.
Here's that septum coming across.
Sometimes you get a better view of the septum
in a different plane.
Just keep going proximally.
We can see those loose bodies form.
So one thing you don't wanna do,
you can look at this cyst
and you think that little black circle
next to it is part of the cyst,
it's really anisotropy of the semimembranosus tendon.
Here's a really nice view of the septum
going across the cyst.
Here we're gonna start our aspiration.
Here's a nice reverberation artifact of the needle.
And the cyst drained pretty easily.
You can see how the tissue converges around the needle
and ultrasound can help you keep your needle
within the actual cyst,
while that tissue converges around it.
Now I'm just putting cortisone in.
This is a very interesting case
of a very large Baker's cyst
that I drained twice and kept coming back.
This next case is the third such attempt
and also we injected cortisone in the cyst.
The very interesting thing about this case is
that there's actually what I think
is a ganglionic portion of this Baker's cyst proximally.
This cyst has multiple loose bodies
and septum and debris within it.
Unfortunately, even after the third aspiration
and cortisone injection of the cyst
it kept coming back.
And therefore, in order to try to alleviate the symptoms,
I would recommend surgery
even though cysts can frequently come back after surgery.
So this is the actual fluid from
the proximal part of the cyst
and it's very thick.
You see it doesn't really settle.
And it looks like ganglion type fluid.
So I think it was a combination
of a ganglion with a cyst.
So here's a sagittal view of the cyst.
You can see loose bodies distally.
The patient has debris with septations within this cyst.
Unfortunately this was a recurrent cyst
that we tried to aspirate twice prior.
You can see the shadowing effect from the loose body.
And as we go proximally we can see this different lobe,
a little smaller lobe of the cyst proximally.
And this is basically going above the joint line,
making a ganglion more likely.
Here's an axial view,
and again you can see septations within it
and debris.
Just the sheer size of the cyst is quite a large cyst.
And here's the semimembranosus tendon.
Something you don't wanna mistake
for part of the cyst when there's anisotropy involved.
So this is round number three.
He did get a fair amount of relief,
probably mild relief with the last procedure,
and I did shrink the Baker's cyst.
I'm gonna try one more time.
Here's our anticipated path of the drainage.
And injecting maybe with 1.5 cc
of methylprednisolone.
And use the side effect of atrophy
that prednisone can cause in soft tissue,
hopefully to our favor,
'cause there's a lot of synovial debris
and granulation tissue
that I think is part of the problem here.
I'm hoping that the cortisone will help shrink that,
in addition to keep any fluid from coming back.
So here's the beginning of our procedure.
We're going in from a distal to proximal approach.
The needle wasn't big enough
to get to both parts of the cyst.
So here we are, we're draining
essentially just the distal portion of the cyst.
And what we'll see later is the proximal portion
was an entirely different entity essentially.
He has some reverberation artifact
from the needle.
You can see the loose body
with some shadowing underneath it.
This part of the cyst,
as prior aspirations,
was pretty easily aspirated
and a lot of fluid comes out.
That's a 30 cc syringe that I'm holding.
Here's an axial view
and you can see the tip of the needle highlighted.
This gives a good medial, lateral aspect of the cyst
and where you are in that dimension.
Now I'm trying to reach the proximal pole.
I'm trying to reach the proximal pole,
unfortunately I couldn't do it.
There's a little gap here that you can see
between the needle tip
and the ganglionic portion
of the cyst.
So before you start going this proximally,
you're basically right on the popliteal fossa.
You wanna make sure that you can identify
your popliteal vessels.
And here is clearly the popliteal artery.
So we basically just moved our needle proximally
and went to this ganglionic portion.
And out came this thick darker fluid,
certainly more indicative of a ganglion
versus a Baker's cyst.
On our axial view again
you can see our needle tip
and then you can see how close we are
to the popliteal vasculature.
Here we are just injecting with some cortisone.
It is my hope that will keep the cyst from coming back.
Here are the loose bodies in the Baker's cyst,
I can actually feel them now.
Before they were just buried under the fluid,
now I can see my finger kind of rolling
above these hard little pebbles.
I don't think they're going anywhere,
they're just in the soft tissue from the Baker's cyst.
I injected again with a little more than 2 cc
of cortisone, of methylprednisolone.
I'm hoping that that will atrophy
soft granulation type tissue within the cyst,
hopefully keep that inflammation now
from coming back again.
This is the last time we're gonna do it though.
If that doesn't work
then the only thing that's gonna work is surgery.
Here's a case of a ruptured Baker's cyst
and this case is a great example
of how the ultrasound can give you important
information right then and there in the office.
And I was not nearly as worried about a DVT
after doing her ultrasound.
This is a 69-year-old female here
complaining of pain in the right knee/calf
going on for about three weeks.
She had x-rays done in the ER
which didn't show any acute pathology.
However, there was no report of an ultrasound
done in the ER.
Here's a sagittal view of her right knee.
And the popliteal fossa is the most axial view.
And we can see a very sizable Baker's cyst.
Here's an axial comparison view of her
medial gastrocnemius muscle
of her right compared to her left.
And you can see that it's much darker
on the right side
and that's consistent with fluid
extravasation within the muscle.
And that fluid came from a ruptured Baker's cyst.
This basically made the likelihood
of a DVT much less likely for her.
And we treated her in the office
by aspirating the Baker's cyst.
And she did much better afterward.
Here again is our sagittal view.
And we can again see some fluid extravasation
within the medial gastrocnemius muscle.
Here we are, sagittal view of the Baker's cyst.
We're going in with the needle now.
And essentially draining the Baker's cyst.
We basically drained from the distal pole.
And here's a post aspiration MRI
and the Baker's cyst came back,
which unfortunately happens quite often.
But you can see how some of that fluid
basically extravasated distally from the Baker's cyst.
This is a case where ultrasound can really
help you right then and there in the office
to help you differentiate whether this is simply
from a ruptured Baker's cyst versus an actual DVT.
This is the case of a lady that has a ganglion cyst
at the origin of the medial gastrocnemius muscle
and she suffered pain posteriorly.
We were able to drain approximately
30% of her cyst with ultrasound guidance.
And this caused significant relief for her pain.
In this situation you definitely need
some sort of imaging guidance
for your needle because this ganglion cyst
was right next to her popliteal artery
and vein and tibial nerve.
So this is our patient, a 49-year-old female,
about a year and a half of pain
in the posterior aspect of the right knee.
No mechanical complaints.
You can see this pretty complicated
large lobulated ganglion cyst
right at the origin of the medial gastrocnemius muscle.
This is our patient, a 49-year-old female.
She has a multilobulated ganglion cyst
posterolateral of the distal femur,
causing her pain in the back of her knee.
This seems to cause some sort of burning type pain
radiating anteromedially.
It's a pretty sizable cyst.
We're gonna see if we can drain it,
inject it with some cortisone.
Here I am pushing on the outside of her knee,
the lateral part.
We're just gonna try to enter
on the very lateral part of it,
try to avoid going medial to avoid any of the major vessels.
So here we are, we're pushing on the lateral part
of the thigh in prone position.
And that to me was the safest position
to attempt initially.
You really are kind of steering shy
of any popliteal artery
or vein or any large nerves.
So that was the initial approach.
- [Woman] All right, you're gonna feel
some cold spray and a little pinch.
- [Dr. Weiss] So here's our patient lying prone.
Her head is at the right side of the screen,
feet is at the left side of the screen.
And we're using a pretty large gauge needle here.
And you can see the tissue move here
on the right side of the screen.
Since it's so deep it's hard to get
a very clear view of the needle,
but you can certainly make out where it is essentially
based on a jiggle technique
or how the tissue is moving.
And unfortunately our first attempt
we hit a gap, we couldn't reach the cyst
so we had to pull out.
I can try one more time,
I'll try a different approach.
So here we are, we're gonna try
a more posterior approach.
This is a little more dangerous,
as you can see we're closer
to the popliteal artery and vein.
And the tibial nerve.
Here you can see the needle coming in
from the upper right corner of the screen now
rather than versus just the right side of the screen.
And again it's a more oblique type of approach.
But we did get some thick, clear fluid,
confirming that we were in the ganglion.
It's coming, it's just coming slowly.
Here you can see the needle tip
and one of the lobules of the ganglion.
Okay, I'm just gonna get a bigger syringe,
just to get a little more pressure okay?
Here we are, we're changing the ...
I think it was a 10 cc syringe
to a 30 cc, just to get some more negative pressure.
I'm gonna inject a little cortisone around it now, okay?
But that really didn't do much actually.
And here we are,
we're just injecting some cortisone into the cyst.
And you can kind of see it spread throughout the ganglion,
again confirming that we were in it.
And here's that thick, clear gel that we were able to get.
One month right?
Into drainage of a ganglion cyst
in the posterior and distal femur.
And she says her pain is about six out of ten.
Better? 60% better?
Okay, but still occasionally what do you have?
- [Female] Pain just exactly now on the cyst.
(mumbles)
- [Dr. Weiss] Okay.
Overall you're better about 60%?
- [Female] Yeah.
- [Dr. Weiss] Here's our three month followup.
You can see the sagittal view
and you can see the sagittal MRI as well.
And they're pretty similar.
And even though it didn't look like we changed the size much
of the ganglion we certainly helped her symptoms.
And even just draining maybe 20-30% of the fluid
out of the ganglion can help significantly with symptoms,
especially when it's near some vital structures.
Here's the case of a 56-year-old female
complaining of about three months of pain in her left knee.
She had pain with walking.
She had no mechanical compliants.
And ultrasound did reveal a ganglion
just medial to the semimembranosus tendon.
On physical exam, she was tender on the pes bursa region,
also on the medial joint line.
So I think there was some pain referred from this ganglion.
It's important not to diagnose this
as a Baker's cyst as it does not lie
between the medial gastrocnemius tendon
and the semimembranosus tendon.
And you have to have a fairly keen eye
in order to identify this.
A 56-year-old female here for pain in her left knee
for about three months.
No injury.
Mostly on physical exam
she has pain in the pes bursa region.
Also some moderate tenderness in the medial joint line.
She's complaining of pain and stiffness with walking
and bending her knee.
There's no locking.
Just looked at her MRI,
which basically shows arthritis under the knee cap.
She does have what happens to be a ganglion cyst
just medial to the semimembranosus tendon.
So we're gonna go ahead and just look at that.
Are you real tender over here?
- [Female] Yeah.
- [Dr. Weiss] You complain of pian here?
- [Female] Yeah.
- [Dr. Weiss] Or most of your pain seems to be up here?
- [Female] Wow.
- [Dr. Weiss] So this is anterior.
The cyst I believe is right here,
just medial to the semimembranosus tendon.
She's got a nice little crease here,
which probably causes some anisotropy artifact.
I'm gonna try to be a little more generous on my gel.
The semimembranosus muscle on the bottom of the screen.
And here we can appreciate the semimembranosus muscle
transitioning to a fairly thick tendon
right above the medial femoral condyle.
Now I'm just gonna go distal.
Here is that ganglion, I believe.
Here's the ganglion cyst,
somewhat inconspicuous as it kind of
blends in with the surrounding subcutaneous fat.
A little bit tender.
We have a semimembranosus muscle in the right and bottom.
Let's just follow that to it again.
Let's try to keep our probe flush.
And here you can see the medial gastrocnemius muscle.
If you see artifact close by the crease
within the popliteal fossa.
You don't wanna mistake that for a cyst.
Here it is, inserting on the tibia.
The best shot we got so far.
We have medial gastrocnemius muscle.
And the right side of the scan is proximal
and as we go medial you see that semimembranosus tendon.
Here again is that thick semimembranosus tendon
just over the medial femoral condyle.
We'll switch to an axial view.
Here's an axial MRI.
You can appreciate that ganglion
just kind of wrapping around the semimembranosus tendon
and then going medially.
Also you can appreciate that the semimembranosus tendon
is a pretty thick wide tendon,
especially compared to a semitendinosus tendon.
Right side of the screen is medial.
Here we are, we're looking at the semimembranosus tendon,
anisotropy of the tendon as we toggle the probe.
Right here we're right above the joint line.
You see the semimembranosus tendon
and then you see to the left-
- [Male] Press one to connect.
- [Dr. Weiss] You may mistake this
for a cyst the anisotropy.
Go a little bit lateral
you see that medial gastrocnemius muscle.
And this is the cyst now
just to the right of the semimembranosus tendon.
See I'm toggling the probe
and it's just coming out of view.
But it doesn't light up like a tendon with anisotropy.
Just going out of view as the probe is just angling away.
Now watch what happens when I go
in the semimembranosus tendon and I toggle it.
Now you can see that tendon.
So when you toggle the probe the semimembranosus tendon
either appears like a black circle or a white circle,
whereas the ganglion will essentially just go out of view.
This is the case of an 11-year-old boy
who presented essentially with a lump behind his knee
for six months prior to seeing me.
There was no injury, there was really no pain in his knee.
Ultrasound did show a Baker's cyst.
We did an MRI 'cause I was concerned
for any kind of intraarticular pathology
and we did actually find a very subtle
osteochondral defect of the
posterior medial femoral condyle.
After about three months of rest
and avoiding any sports,
the Baker's cyst went away.
So here's our 11-year-old boy complaining
of about six months of a lump in the back of his left knee.
And really no symptoms other than just this lump.
Physical exam really didn't show much
other than a large mass in the back of his knee.
Here's our sagittal view
and we can see the Baker's cyst.
We can see the semimembranosus muscle
transitioning into the tendon.
And you can appreciate how thick his hyaline cartilage is
over the medial femoral condyle.
And this is typical in the pediatric population.
You can also see the medial gastrocnemius muscle and tendon
nicely here as well.
Here's an axial view.
Again you can appreciate a Baker's cyst.
It does have a nice thick septum within it as well.
And you can see that stalk of the Baker's cyst
that goes between the medial gastrocnemius tendon
and semimembranosus tendon.
And here's that subtle osteochondral defect
over the posterior medial femoral condyle,
which I believe was the cause for this Baker's cyst.
This next case is of a lady with a ganglion cyst
just posterior to the PCL.
It's important not to mistake this for a Baker's cyst.
It does not lie between the tendons
of the medial gastrocnemius muscle
and the semimembranosus muscle.
On exam, she did have some pain to palpation in this region
and essentially just reassured her it's just a simple cyst.
This is a 49-year-old female,
pain in her left knee for about a year.
She fell directly on it.
She does get some locking and pain with walking.
MRI did show a small tear of the medial meniscus
and a free edge tear of the lateral mensicus.
She has significant diffuse osteoarthritis.
Also a Baker cyst and she does have a ganglion
of the PCL as well.
So here's sagittal view of the back of the knee.
Right side of the screen is proximal,
left side is distal.
Here's our first clip.
We can see a subtle ganglion cyst
just inferior and posterior to the PCL.
Right under the popliteal vasculature.
Put some color on it just to make sure
I'm not mistaking it for a vein or an artery.
Here's that cyst
and you can see that there's no color flow in it.
So that does confirm it's a cyst.
You can see the PCL right underneath it.
We're gonna have to go deep with this ultrasound
so the structures are not entirely clear.
Now this structure does not go between the tendons
of the medial gastrocnemius muscle
and the tendon of the semimembranosus muscle.
So it does not qualify as a Baker's cyst.
Now we're gonna switch to an axial view of it.
The right side of the screen is medial,
left side is lateral.
Okay I'm starting basically just above the joint distally.
Here we are again,
just below the popliteal vasculature
we can see that cyst come into play.
You don't wanna mistake that for a vessel.
Put another color on this again.
Certainly this is important to do.
You wanna make sure it's not a popliteal aneurysm
you're dealing with.
I'm just right in the view of that cyst.
I'd like to thank you for your time
that you spent watching these cases.
I hope that I've demonstrated
that ultrasound can change the way you manage patients.
And hopefully elevate
the standard of care that you give patients.
Again, I appreciate your time and attention,
and I'm looking forward to sharing
some more cases with you in the future.
- [Dan] I want to thank Dr. Scott Weiss again
for a tremendous job.
I'm gonna go ahead and unmute his line.
Dr. Scott Weiss is based in Brooklyn.
It's not mentioned in the video
but he's basically out of Brooklyn and New York.
I believe it's Brooklyn Orthopedics
and Sports Medicine.
Tremendous ultrasound user and advocate,
been using ultrasound now
for I think about seven to eight years.
So tremendous background with musculoskeletal ultrasound.
I'm gonna go ahead and turn the audio over to Dr. Weiss.
Dr. Weiss, are you there?
- [Dr. Weiss] Yeah hey I'm here, Dan,
thanks so much.
- [Dan] Thank you for joining us.
I'll let you go ahead and kind of talk
a little bit about your practice
and how you're using musculoskeletal ultrasound
right now and then we'll get straight to the questions.
- [Dr. Weiss] Okay, well hey, thank you again.
Actually I've been using ultrasound
for about maybe four and a half or five years,
but it really just kind of took over my practice
as you can really just do so much more in the office
with ultrasound as opposed to not having ultrasound.
And particularly with something simple as a Baker's cyst,
which most of the time you think you can just drain
without ultrasound, but sometimes,
and actually more than sometimes
they're quite complicated.
As you saw in the video they can have
various septi, loose bodies and debris.
And with ultrasound you can kind of keep
your needle tip in the black zone,
or in the zone where there's fluid.
And then you can drain hopefully the whole cyst.
Whereas if you didn't have ultrasound
your needle tip may be stuck in some debris or septum
or may not be able to breech a septum
'cause you wouldn't know about it
and you may not completely drain the cyst.
So I'd be happy to answer any questions you may have
and hope everyone got something out of the videos.
- [Dan] Thank you very much.
Yes, Baker's cyst, very common questions that we get.
A lot of people don't like to go near them
and I think your video demonstrations
obviously add a level of comfort
and sureness to ultrasound guided procedures.
So I'm gonna go down the questions.
The first one, they did comment a question about sterility.
In your video you show sterile drape on the transducer,
you show a drape over the patient,
you scrubbed with Betadine,
you've gone the whole nine yards there.
Is that something that you require
on all your ultrasound guided procedures
or is it just because you're dealing with
something that kind of communicates with the joint
and could be tricky?
- [Dr. Weiss] Very good question.
You know when I started off doing injections
I did sterile prep for every one,
my typical viscosupplementation injections,
any kind of injection I use sterile procedure.
This is what I was taught
at some of the courses that I went to.
And as I got more comfortable with ultrasound
I started just using sterile technique for procedures
where I know the needle's gonna be essentially
right under the probe,
where you really can't avoid
proximity or perhaps even touching of the needle and probe.
In those situations I think you really
need to use a sterile technique,
which is a sterile probe cover
or sterile gel,
and obviously prep the area.
And I think it's better to put the sterile drape also,
this way you don't have to worry about
contaminating your probe
outside the region where you're working.
So in Baker's cyst, yeah, I do use a sterile prep
because the needle, again, is right under the probe
and in that case I take that extra precaution.
In my typical suprapatellar injections
I started ...
Actually over the past couple years
I have not used sterile technique
because the probe is essentially
quite distant from the needle
and I'm pretty confident
that there's no contact between the probe and needle.
However, I still cover the probe with a nonsterile prep.
I think you should always
cover the probe with a plastic cover
regardless of what kind of procedure you're doing.
- [Dan] Excellent.
We had another question regarding the needle gauge.
What size needle do you use?
And I think, based on questions
I've heard in the past as well,
this is probably due to the viscosity
of what you're aspirating, is that correct?
- [Dr. Weiss] Definitely that is a big part.
So any kind of ganglion cyst,
there was one Baker cyst that actually had a ganglionic
type of portion to it,
where it was very thick viscous fluid.
In those situations you wanna use
at least an 18-gauge needle.
There have been times where I actually
used a 16.5-gauge needle for, let's say,
hematomas or even ganglions,
which makes it much easier to aspirate.
You're actually causing less pain to the patient,
I believe,
if you use a bigger needle
because you can just drain it much more effectively,
the needle can just stay in for much less time
as opposed to using a smaller needle.
And I think the fact the procedure's quicker
with a bigger needle makes it less painful.
So for Baker's cyst, usually the fluid is pretty thin.
It's typically just like joint fluid in a Baker's cyst.
So the viscosity is really not
much of an issue with the Baker's cyst.
But there are ...
There could be debris in there,
kind of like synovitis within a suprapatellar pouch.
And in those cases it's better to use a bigger needle,
less likely to get clogged.
- [Dan] Okay and we have another one-
yep, go ahead.
Sorry to cut you off.
Go ahead.
- [Dr. Weiss] Just any aspiration
I use at least an 18-gauge needle,
even if there doesn't appear to be much synovitis
or thick fluid just because it makes it,
again, much quicker.
- [Dan] Okay.
Do you follow these up with any kind of injectate?
Do you put any steroids in or do you just aspirate?
- [Dr. Weiss] Usually yeah.
Almost always I inject cortisone in the Baker's cyst
after my aspiration.
And I guess there was
some concern about aspirating Baker's cyst.
I'm usually in no rush to aspirate a Baker's cyst
unless it's really causing discomfort,
'cause they often come back.
And they're usually indicative of arthritis in the knee.
Sometimes a meniscal tear can do it.
And you know if the underlying problem is still there,
very often they do come back.
But in my experience though when people have a lot of pain
and you drain it they do get relief
and it usually lasts for a while.
At least several months
or sometimes it just kind of takes care of the problem.
And when they do come back it may not come back as big.
So I do think it's worthwhile draining the Baker's cyst,
but, again, only in certain situations.
- [Dan] Okay.
Do you aspirate ...
Or do you have to aspirate the front of the knee
any time you're attacking a Baker's cyst?
- [Dr. Weiss] That's an excellent question.
Yes you should check the suprapatellar pouch
to make sure there's no significant
fluid in the suprapatellar pouch.
'Cause then when you drain the cyst
it may just fill up right away.
So you wanna drain both compartments.
Now the question is which order should you do it.
I guess technically it probably makes sense
for us to do the suprapatellar pouch
and then the Baker's cyst.
But either way it sounds like it can fill up,
even if you drain the Baker's cyst first.
I mean if you drain the suprapatellar pouch first,
that fluid from the Baker's cyst,
who knows it may escape into the suprapatellar pouch
and then come back.
So it's a little tricky,
but in my experience I don't think the fluid
moves that quickly from joint to the Baker's cyst.
And I think there is like a ...
There is usually a little breech in the capsule
posteriorly as you get older.
And I don't think it fills up that quickly.
So I think you have time.
If you drain the Baker's cyst
and then later in that same visit
drain the suprapatellar pouch,
that I think is fine as well.
In fact, you can probably inject either or
with cortisone because technically
a fair amount of the time the cortisone
will go right into the Baker cyst from the joint.
I've done that sometimes as well
where I would inject the joint with cortisone
and then not inject the Baker's cyst
because with the thought that it would just
communicate to the Baker's cyst.
- [Dan] Okay. The next one has to do ...
Yep.
The next one has to do with ruptured Baker's cyst,
how can you tell if one is ruptured?
And what do you do after that?
- [Dr. Weiss] Excellent question.
One of the videos showed a ruptured Baker's cyst,
where you'll see some dark fluid type signal
within the medial gastrocnemius muscle.
So that with the right story,
usually I can kind of hang my hat on that.
And I don't have to worry about a blood clot.
But I usually send people out for a followup
ultrasound to rule out DVT anyway
because that is such an easy thing to do
and to diagnose.
And if you miss it,
it could be potentially fatal
as it could travel up to the lung to clot.
But in the office I can pretty much confidently say
you have a ruptured Baker's cyst
and you should get an ultrasound
but I don't feel like they have to go
right to the emergency room to get a stat vascular study.
But again, on ultrasound you'll usually see a Baker's cyst,
but you'll compare the medial gastrocnemius muscle
with the lateral gastrocnemius muscle,
and you'll see how there's just
darker signal fluid within the
medial gastrocnemius muscle
consistent with fluid and a ruptured cyst.
And usually the history is also pretty consistent with that
as they'll have tremendous pain in the calf
and pain to palpation.
Which, again, could be difficult to distinguish from a DVT.
So in that situation ultrasound really can
kind of point you one way or the other,
where it's difficult clinically
and by physical exam
to distinguish DVT versus a ruptured cyst.
- [Dan] Okay have you ever had a Baker's cyst
that could not be aspirated?
- [Dr. Weiss] You mean that I couldn't get fluid out of it,
or that wasn't fluid,
or I mean ...?
- [Dan] Well, they didn't really clarify
so I'm not sure how common that would actually happen
so I'll kind of leave it up to you clinically
to decide whether or not they think
maybe it's too solid
or maybe just too loculated.
I'm not too sure, maybe they'll clarify
and we'll get a part two on that question.
- [Dr. Weiss] Right.
Well one thing you wanna make sure,
sometimes things look like a cyst
and they're solid,
and also on MRI they can appear to be a cyst
and they can be solid as well sometimes.
So location is very important.
If you have a cyst that's deep to the muscle
within the medial gastrocnemius muscle,
you may want to start thinking about a neoplasm
such as a synovial sarcoma,
which you may put a needle in it,
you may get nothing out,
and then that basically tells you it's probably solid,
in which case you gotta work up a possible neoplasm.
That's one situation where you put a needle in
and get nothing out.
I mean sometimes it could be a Baker's cyst
and just a lot of debris
and loose bodies,
and it's just hard to navigate
the needle in clear fluid to aspirate.
So sometimes that can happen as well.
- [Dan] Okay.
The next one is likely from
a more experienced ultrasound user
because of the question nature.
Have you ever mistaken anisotropy for a Baker's cyst?
- [Dr. Weiss] Well that is one of the things
you want to be careful with.
Certainly the semimembranosus tendon,
in axial view,
you can have a fair amount of anisotropy
and it can look just like a Baker's cyst.
And the fact that a Baker's cyst is usually bilobed
or it basically wraps around the medial gastrocnemius
muscle tendon with concavity pointed laterally.
Sometimes you may mistake one of those lobes
for a ...
Sometimes you may mistake the semimembranosus tendon
for one of those lobes of a Baker's cyst.
So certainly you have to be careful with anisotropy,
particularly with the semimembranosus tendon,
because that tendon is pretty wide and big,
so when there is anisotropy of that tendon
it's fairly sizeable and it could look like a cyst.
That's why you really gotta toggle your probe
and make sure you're not mistaking a tendon for a cyst.
- [Dan] Great answer.
As of right now, we are out of questions.
So if anybody has anymore questions to submit
now would be the time.
- [Dr. Weiss] Sure.
I'd be happy to stay on the line.
- [Dan] I was gonna ask, Dr. Weiss,
in your learning curve,
how long would you say it took
for you to become proficient
in distinguishing solid
verus cystic masses on ultrasound
in the case of Baker cyst especially.
What was that learning curve like for you?
- [Dr. Weiss] That's a great question.
And again, one of the things you wanna make sure
you don't mistake a solid mass for a cyst.
So certainly on physical exam
it could be difficult to distinguish the two.
But there are some signs that you wanna
take into account such as the texture,
the hardness of it,
the mobility of it,
which may make you think more towards
a neoplasm versus a cystic structure.
The consistency within the cyst,
if it's very heterogenic,
with a lot of different consistencies,
ranging from hypoechoic to hyperecoic,
that may make you think more in line
with a solid structure as well.
And those are the kinds of things you wanna be careful.
Certainly you put a needle in it that's an easy way to tell
because if you get something back it's obviously not solid.
But you probably wanna kinda have a good idea
before you put a needle in
because if it is a malignancy
it's better not to contaminate it
or kind of breech it with a needle
if it's not necessary.
- [Dan] Excellent answer.
We do have another question.
Okay. All right so
this particular individual missed the answer
on the size of the needle
for aspirating a ganglion versus the cyst.
- [Dr. Weiss] I'm sorry, what question?
What was the question again?
- [Dan] I guess what gauge of needle would you
use to aspirate a ganglion cyst
versus just a cystic structure?
- [Dr. Weiss] I mean a ganglion
usually you can get away with an 18-gauge needle.
That's probably the smallest I would use.
If it's a big ganglion
and it's pretty easy to access,
I would probably use a 16.5-gauge,
believe it or not,
this way it's your best chance of draining it.
Sometimes you could put your needle
right in the middle of a ganglion
and get nothing out because the fluid can be so thick.
So I think it's good to have in your arsenal
also those 16.5-gauge needles
that just make it easier to drain,
particularly with that ganglion
that was at the distal femur,
that was difficult to drain
with an 18-gauge needle I believe I used.
Yeah with our ganglion you wanna use a thicker needle.
Even in the wrist,
where you're not going in very deep,
you need a pretty wide bore needle
to get that fluid out.
- [Dan] Thank you for answering that.
Let's see ...
Still waiting on any more clinical questions there.
We've got a lot of positive comments there.
Let's see ...
We're just gonna scroll through the chat window,
make sure I haven't missed anything.
We'll wait just a few more minutes
for anybody that wants to go ahead
and get another question in.
If not, being end of the day,
we may be also approaching the time
everybody's trying to get offline.
Dr. Weiss, tremendous videos.
The animation was very nice.
Great job on that.
- [Dr. Weiss] Thank you.
- [Dan] I understand that you did that from scratch,
that's your own animation,
that's not a model that you got.
- [Dr. Weiss] Yeah it's fun.
You know anatomy can be complicated
and when you build these models
it really teaches you the anatomy
because you really have to think in 3D
and put things in 3D.
And you realize how complicated the body is.
It's amazing how things
kind of fit right on top of each other
and into each other.
So modeling actually kind of forces you
really to learn the anatomy well.
And that's what ultrasound is really about,
knowing your anatomy
and knowing what's normal,
what's abnormal.
But I can't stress enough to really constantly
review your anatomy.
The better you know your anatomy,
the better you'll be able to figure out
what you're seeing on ultrasound.
- [Dan] We did just get a comment
about the cold spray being used on transducers,
and I wanna comment as somebody that's direct
from the factory here
on the safety of the transducer rubber
with cold spray.
I'm gonna encourage anybody that uses cold spray
around the ultrasound to cover the transducer
to protect it because that cold spray
will degrade rubber and plastic,
and if you use ...
If you commonly used Tegaderms to cover your transducer,
which we don't necessarily recommend,
I know lots of people do it because they're sterile,
but it's not the intended use
of a Tegaderm for a few reasons.
People that use Tegaderms with cold spray,
find that the cold spray melts it to the transducer,
so it will actually bond it to the probe
and things start looking pretty ugly.
If you do not cover your transducer
when using cold spray you will degrade
the rubber surface and it will become brittle.
The climate that we had was from a sonographer of 17 years.
She's now in sports medicine.
They had a transducer get damaged
to the point of being so dangerous
that it could have actually electrocuted a patient.
This was in past years I assume.
Later in the comments it actually says
they saw there in the presentation
that she used the same thing.
They had to pull the transducer from service
do to following safety standards.
Their QC process.
She goes on to say ...
All right, I'm not sure actually if it's a she.
Hold on.
Yes by the name.
It says I just wanna let you know so that the
same thing doesn't happen to any of yours.
I enjoyed the presentation.
This will be great value.
The sonographer of 17 years.
So anybody who has been trying to learn
MSK ultrasound over the years
probably knows that it's usually something
you have to figure out on your own.
There's not a lot of support systems out there
to learn MSK ultrasound 'cause it's still considered so new.
So that's what makes a presentation like this a treat.
To have somebody as experienced as you, Dr. Weiss,
getting on and helping these guys trouble shoot
so they don't have to go through
all the trouble shooting process.
In closing, to that comment,
I noticed with your level of experience
you use a transducer cover
that protects the transducer in many ways in terms of
sterility, the patient,
but also using the cold spray I would
never recommend anybody use that transducer bare naked
with no probe cover while spraying a cold spray.
That will actually degrade the circuits of the transducer.
- [Dr. Weiss] Sure.
Good to know.
Again, I think when I do a diagnostic scan
I don't cover the probe because you're
just doing a diagnostic scan.
I do clean it with peroxide though frequently
and with any procedure,
whether you think the needle's gonna be close
or not close,
I always use a probe cover,
again, just the protect the probe
and the protect the patient
from any possible contamination.
- [Dan] Going along the lines of equipment care,
you said you use various things to clean the skid.
I will also tell everybody
please do not use anything alcohol related to clean
your ultrasound equipment.
That's listed in your manual that came
with the equipment and I believe on our website
there's a list of approved cleaning agents.
And one thing I found commonly
approved across all transducers
was actually hydrogen peroxide,
which is very convenient because it's
about the cheapest thing you can get.
It doesn't necessarily sterilize everything
to the point of some of the other cleaning
chemicals that we just wanna caution
everybody to read your labels,
your list of approved cleaners in your manual.
And also not to use anything that is alcohol based
because that's gonna degrade the rubber surface.
Just to protect your equipment when you use cold spray
with a transducer cover.
And I don't recommend people use Tegaderm with cold spray
because it's gonna melt the Tegaderm
to the plastic housing of the transducer.
We have hit time here.
Dr. Weiss, any closing comments?
- [Dr. Weiss] Yeah sure.
I mean I would just encourage people
not to be afraid to try new things.
I mean, again, most of us probably started
doing these injections blindly,
just using landmarks.
So I would encourage people not to be afraid
to try to do an injection with ultrasound
if they haven't done it before,
or even if they're by themselves in their office.
As long as they know their anatomy well
and they've done it blindly,
no reason to fear
and not to try new things.
It's always good to scan as many people as you can
if you have the time in your schedule to do so,
just to get a sense of what's normal.
This way when you see something that's not normal
you'll be able to pick it up.

Brightcove ID

5768898572001

https://www.youtube.com/watch?v=qGzDm3dSR7g&f

Dialysis Vascular Access Flow Volume

Read more about Dialysis Vascular Access Flow Volume

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Dialysis Vascular Access Flow Volume

Publication Date

Thu, 01/10/2019 - 12:00

Media Library Type

Other Videos

Subtitles

- Hi, my name's Diane Dutoya.
I'm a clinical nurse consultant for dialysis
and vascular access.
I've been using ultrasound in the renal setting
for about 13 years now.
I'm going to be talking to you today
about using ultrasound measurement
of blood flow volume in dialysis
arteriovenous fistulas and grafts.
The objectives today: we'll describe blood flow
volume monitoring and the benefits;
the ultrasound anatomy of arteriovenous fistulas
and arteriovenous grafts.
We'll discuss ultrasound volume flow monitoring.
We'll look at the equipment and software used.
We'll look at understanding Color and Pulse Wave Doppler.
We'll look at performing the actual volume flow calculation.
We'll look at some results and some
clinical pearls from my experience.
So, blood flow monitoring in arteriovenous fistulas
and arteriovenous grafts the volume flow,
or what we call it in dialysis, the access flow,
is the amount of blood flowing through
an arteriovenous fistula or arteriovenous graft
in milliliters per minute or mLs per minute.
We need a volume flow higher than the dialysis
pump speed to prevent recirculation of blood.
So, for example, if the volume flow
of an arteriovenous fistula was 300 mLs per minute,
but we wanted to set the pump at 350 mLs per minute,
we wouldn't be providing enough blood for the pump
to function, or we would be causing recirculation.
So, we do need to have a volume flow that would
support the amount of blood that we need
to put through the dialysis machine.
And this is demonstrated in our video here.
Blood flow monitoring benefits.
We can do a single measurement of a blood flow volume.
This is in isolation; it gives us a little bit
of an idea, at least, of what the fistula or graft
is running at; however, we also like to look
at the trend because a downward trend
in the volume flow can indicate an issue
such as a significant stenosis in the fistula or graft.
It promotes early detection and preemptive intervention
of significant stenosis to minimize
under dialysis and AV fistula thrombosis.
So we use it in the unit that I've worked in regularly.
We do volume flow or access flow measurements
sometimes monthly, sometimes twice monthly
and sometimes in the home population,
only every three months.
It really does depend on the fistula,
but regular volume flow monitoring,
in my experience, really helps us
detect issues and intervene early.
Blood flow monitoring, there's a few guidelines
out there that support us doing
regular blood flow monitoring.
The National Kidney Foundation or the KDOQI Guidelines
say that surveillance in fistula, the preferred
method is direct flow measurements.
They don't say specifically how we do those flow
measurements, but they just recommend that we
do direct flow measurements to perform surveillance.
The Kidney Health Australian caring guidelines,
we call them, they talk about vascular access
surveillance and they recommend that regular
access flow screening increases the detection
of AV fistula stenosis compared to clinical
examination/low arterial pressure
or recirculation measurements alone.
The regular access flow screening with preemptive
repair, and they talk about either angioplasty
or surgery, reduces arteriovenous fistula thrombosis
and may prolong arteriovenous fistula survival.
And the European Best Practice Guidelines
under their guideline of surveillance of vascular access.
Objective monitoring of access function should be
performed at a regular base by measuring access flow,
and again, volume flow access lower or interchangeable.
So, we'll look at the blood flow through
an arteriovenous fistula or arteriovenous graft.
There are obviously different types
of fistulas and grafts out there.
We'll talk about those, give you some examples.
But when we look at the blood flow
in the arteries and veins in our body,
we know that the pump, the heart, creates
the pressure wave that will push the blood
down the arteries and it travels from an area
of low resistance at the heart to high resistance
as we get towards the periphery and so that creates
the blood flow down the arteries and then the veins
return the blood to the heart.
Prior to making a fistula, the blood flow
in the arm arteries, as I said before,
travels from an area of low resistance
to an area of high resistance.
So, the heart has a big open area.
It's a low resistance and then as it pushes
the blood towards the smaller and smaller capillaries,
they create more resistance, and so the blood flow
from the heart to the hand will travel
in a pulse wave and it isn't particularly
hard flow when we compare it to once
an arteriovenous fistula is created.
You're looking more in the low hundreds or even below
a hundred mLs per minute in an adult arm.
So the types of anastomosis that we see
to create an AV fistula would be
an end to side anastomosis where the vein
is taken and cut and the end of the vein
is then joined into a hole on the artery.
So this is end to side, the other part of the vein
is just tied off and it's not necessary.
So, that's end to side.
So you can see here that the blood would travel
down the artery and then be allowed to pass
now back up to the heart via the vein.
A side to side anastomosis means
that the vein isn't tied off at the distal end.
It's kept open and so the side of the artery
is joined to the side of the vein
via small holes made by the surgeons.
And the blood can flow from the artery and can
travel back up the arm or down towards the hand.
It can travel in both directions.
So that's a side to side.
In Australia, we don't see those very often.
And it really depends on the surgeon choice.
The only issue with that is that it does
allow blood to then travel to the hand
and can cause venous hypertension.
To create an arteriovenous fistula
the surgeon makes an incision at the point
where he wants to join the artery and the vein.
He then clamps the artery and the vein,
and then he creates a very small incision in the artery.
He ties off the distal end of the vein,
and cuts it and then takes that end and joins it
onto the surgical hole that was created.
The vein and artery are sown together.
The clamps are released and then they monitor
the flow and make sure there's no leaks,
and then they suture up the skin.
So, monitoring the blood flow through
an arteriovenous fistula, you see
that the blood can travel down
the artery towards the anastomosis.
You can see this on the video here.
Blood will travel down the artery,
either from the brachial artery,
if there's an anastomosis at the brachial artery,
it'll then travel through the anastomosis.
If there's the anastomosis down at the radial artery,
it will travel down; a small portion will be
continued to the hand some times.
Some times not much goes back to the hand.
And then where the anastomosis is, blood is now able
to travel back up the vein, and back towards the heart.
Once we've done that creation and we allow
the blood to go through that anastomosis
and back up to the heart, what we've done is we've
created a low pressure system now which allows
more blood because of the drop in resistance.
More blood will now start to flow down the artery
but also back up the vein and towards the heart.
So, we'll start to see the artery dilate and the vein
dilate and the flow of blood increase dramatically,
sometimes over a thousand mLs a minute.
It really depends on how big the anastomosis is,
how good the arteries are, and how good
the veins are, and so when we check the flow
of blood through a fistula, what we're doing
is checking if there's an issue
with either the pump, the heart,
the arteries or the outflow veins.
So volume flow measurement doesn't
particularly identify where the issue is,
but it does tell us if there's an issue.
Once we've anastomosed, if we have a good pump,
the heart, a good artery, and a good draining vein,
we see that the flow increases
dramatically in that circuit, and this we can
check by checking the volume flow,
and the volume flow measurement will
give us a baseline, the first one that we do.
And we would hope that that would be
in the range of, in my units we prefer
greater than 400 mLs a minute, some units
prefer greater than 600 mLs a minute.
It really depends, and then following doing
the baseline measurement, we would like
to see that that measurement continues to increase
as it matures and it doesn't start to drop off.
If it starts to become less volume flow, we start
to look at causes for why the flow has dropped down.
So, if we look at this, the inflow and the outflow.
When we talk about inflow and outflow
with an AV fistula or an AV graft,
we usually refer to the inflow as the arterial inflow.
So, whichever is the feeding artery,
and then also just running into the anastomosis
is the area that we would refer to all
of that as inflow and then outflow we refer
to the vein all the way to the heart.
So, all of that is outflow vein.
So when we talk about an inflow problem
or an outflow problem, that's sort of
the areas that we're talking about.
So, on this diagram, you can see that the inflow
artery is a brachial artery that's feeding
through the anastomosis, and again, we would
continue to call that inflow in dialysis,
and then the vein that we would be
puncturing for needling and all the way
up to the heart would be the outflow.
So, inflow, outflow.
We're just gonna look a little bit
at the actual flow through the vessels.
So, the blood flow through the fistula
or any vessel in our body has a pulsatile flow,
but the pulse varies depending on the resistance
in the vessels and the pulse wave created
by the heart beating and how it dissipates
throughout the body, but it also is
affected by any kind of resistance.
So, if we look at anastomosis on an AV fistula,
that creates some resistance and turbulent flow
as the blood flows around, and then a nice straight segment
vein, like here, or an artery, we tend to see
more laminar flow where the blood cells tend
to run in a nice laminar line and you'll get
a little bit of turbulence along the edges,
particularly if the flow is very fast,
but you tend to see that the flow is
fairly laminar and there's not a lot of swirling
because the blood cells or the blood's not
hitting resistance and swirling around.
So this is sort of an image of what I would
call laminar flow or fairly straight line flow.
Whereas you can see in this vessel that it's
another example of what we would call non-laminar
flow or restricted flow where it's traveling
through some resistant areas or some narrowing.
When blood is running through a tube
and then there's some narrowings in it,
that can either be from plaque,
or what we call neointimal hyperplasia,
which causes a lot of the vein stenoses.
Once that narrowing gets to less than 50%,
you start to see some changes in the flow,
the volume flow of the blood because it causes
some resistance that slows down the flow in the blood.
So, you can see here that this vessel
has some narrowings in it, and that flow
then not only becomes slowed down,
it becomes a bit more turbulent
as it hits all of those areas of narrowing.
So, that's not as laminar.
So, as blood flows through a narrowing,
the blood flow needs to increase in speed.
So sometimes you'll see an ultrasound,
a formal ultrasound that'll talk about
the velocities and sometimes in dialysis
we get a bit confused because we think
that the velocities in centimeters per second
relates to the volume flow, but they're
completely different measurements.
So, the volume flow is the actual volume
of blood traveling through a vessel in mLs per minute.
So, for example, 400 mLs per minute is
traveling or 500, 600; whereas the velocity
is how fast the blood is actually traveling
in centimeters per second, and so if you look
at this vessel here, you can see that
the lumen narrows and the blood then is
running through this vessel and it won't change.
400 mLs is running in; 400 mLs has to run out,
otherwise the vessel would dilate and explode.
So, the volume flow will remain unchanged,
however, how fast the blood has to run
to get that volume of blood through changes.
So, for example, in the wider area,
400 mLs a minute can run slower,
but in a narrowed area, to get 400 mLs a minute
through a narrowing, it has to run faster.
So, that's where we see an increase
in the velocity where it speeds up
in order for that amount of blood
to fit through the narrowed area.
So, that's the difference between velocities
and volume flow.
So, that though allows us to then measure
a volume flow of any kind of fluid traveling
through a container or a pipe or a tube
or a vessel or a blood vessel.
If we work out the velocity and the diameter
in that area that where we measured the velocity,
we can do a calculation to say what volume
of fluid, and in this case blood
is traveling through the tube.
So a narrowing is, like I said, it increases
the blood flow but what we mean is the blood,
speed of the blood flow.
So the volume flow through the changing diameters.
So the volume of blood flowing through a vessel
remains the same throughout the human system
unless there's a significant obstruction or heart issues.
So, if I have 600 mLs a minute running
through a fistula vein, so the outflow vein,
it would have to remain at 600 mLs
a minute for the entire outflow vein.
It can't be 600 mLs in one section
and 300 mLs a minute in another section
because then you would get congestion
and dilation and that thing would
rupture in no time, so whatever flows in,
the same volume will be flowing out.
However, the way it travels to have that volume
flowing in and out will change.
So the speed that it travels through
narrower or wider areas will change.
And this will give you an idea here.
So, if we look at this 600 mLs of fluid
traveling through this fairly straight
piece of vessel, we'll say this is the artery,
then the artery stays at 6 mLs, so the 600 mLs
of fluid will stay the same velocity
because it doesn't need to speed up
or slow down because it's the same diameter.
So, it can fit through just as easily,
but the wider it goes all the way to 12 mL
in diameter, the 600 mLs a minute
would have to travel a lot slower
because you'll get a lot more blood through.
We look at the changing diameters here
and the blood traveling through in this video
you can see that as the blood goes
into the widest sections it can travel slower
to get, for example, this say this was running
at 600 mLs a minute, the 600 mLs a minute
traveling through this section is a lot slower
than the 600 mLs to get through the narrowed sections.
So that you can see there, so it does need
to speed up; so that means that the velocities
through the narrowings increase, and when we
measure the velocities, we need to be
really cautious that we measure the diameter
that relates to the velocity measurement.
So if I do a velocity measurement,
for example, here, but measure the diameter
here, my calculation's gonna be completely wrong.
So, I must do my velocity measurement
exactly in the same area that I've done
my diameter measurement.
So that's a really important thing
to do when you're doing your volume flow measurements.
Volume flow measurement utilizing ultrasound.
We know that there are a few different ways
to do volume flow measurements.
In dialysis in most units we're familiar
with a couple of them, dilutional measurements
where we'll either use an ultrasound and saline
as our dilutant or we'll use warm dialysate
as our dilutant to measure the volume flow,
but we can only do that on dialysis.
So, another way that we can do it is
to measure utilizing ultrasound.
So, as I've talked about before,
the volume of blood flowing through a vascular system
can be estimated by measure the velocity
in centimeters per second and the diameter
where that velocity was measured.
So, as I said before, it needs to be very carefully measured
and so this is a little tip to make sure
that when you're doing ultrasound volume
flow measurements, that you're doing
them as accurately as possible.
So, software's being developed to perform the volume flow
calculations for us, and what we do is we need
to provide a diameter and a velocity.
An ultrasound that allows us to measure velocity
and has the software package in there to allow
us to calculate the volume flow will
allow us to do volume flow measurements.
So we measure the velocity.
We provide the diameter in the area where we did
that velocity measurement, and then we ask
the machine to calculate by hitting calculate.
So, there's a few benefits of using
ultrasound for blood flow monitoring.
It can be measured at any time
unlike other methods that can only be performed on dialysis.
So, if I've got someone who's turned up for dialysis
and I'm a bit concerned about their fistula
and I'm not sure whether I should actually start
the dialysis, whether there's any value, I don't
want to put two needles in and then start dialysis.
So I can capture a volume flow measurement
before I even start.
It also allows us to monitor pre-dialysis patients
who've had an arteriovenous fistula or graph created.
Before they start dialysis we can then start
monitoring the volume flow, get a baseline,
but also continue to monitor it if they don't start.
It allows the measurement of the volume flow
in specific vessels.
One of the problems that I have
with the dilutional method is that I have
a lot of vessels where we are cannulating
into two different sections, so, I'm not
cannulating their forearm and use my venous
outflow needle in the upper arm and there's
a basilic outflow in the middle of that.
So, it doesn't give me an accurate volume flow
measurement, and those people, I either have
to try to put two needles in the one vessel
to do the measurement on the day
or if someone who's not aware that there's
a collateral in between goes and does
the measurement that looks all of the sudden
like the volume flow's changed dramatically.
So, if I have two branches and I'm trying
to get the surgeon to tie one off, I can
measure both branches and let them know
which one has the higher volume flow and which is
the one which may be the best one to tie off.
It only takes a few minutes to perform
the measurement, so it's quick and easy.
Once you've had a lot of practice,
it's quite straightforward.
I can also do the measurement in the brachial artery
while they're on dialysis without slowing down
the patients getting on dialysis.
It does require training to ensure
the accuracy of the measurement.
So we'll talk about some real things
that we can look at that will improve
your measurements, will insure
they're as accurate as possible.
So, that's some of the things we'll discuss further on.
And they're less accurate if they're measured
in an area of high velocity or turbulent flow.
So, it is a measurement, so we do need
to be cautious that we get the best measurement
that we can get when we make our calculations.
So, the equipment that we would need
to be able to do volume flow measurements
with ultrasounds are an ultrasound system with a transducer.
It would also need software included in it to allow it do
Color, Pulse Wave Doppler and volume flow calculations.
So, those sometimes you need to request to be added on.
They aren't always included in the bundle
that you buy, but I usually just make sure
that when I look at the bundles
and look at it that I compare and find
the system that I want that has all of those
things included, or ask for them as add-ons
and get the quote for all of them.
So, blood flow sampling through an arteriovenous fistula.
The inflow, we have the pulsatile arterial flow.
It does change a little bit from an artery
once we do anastomose it to the outflow vein.
The resistance drops a little bit,
so you'll see that the arterial pulse wave
in an artery attached to an AV fistula is slightly different
to your artery without a fistula attached to it.
The anastomosis area, it has arterial flow,
but it can be very turbulent.
So, it's very hard to get a good velocity
measurement in there because the blood is
running all over the place and spinning around.
And then in the outflow, it's a little bit
pulsatile but it doesn't have your real peaked
pulse wave, it's more of a monophase,
just a phasic sort of flow, and that peters off
and becomes just a really dampened phasic flow
as it gets closer and closer to the heart.
So, if we look at this, this is
a pulsatile arterial blood flow here.
And that's measured in the area just prior
to the inflow and you can see that you've
got your nice peaked pulse waves there,
and that's a nice capture of a pulse flow there.
And then this is in the anastomotic area
and this is actually not particularly bad
for an anastomotic area.
You can see this is obviously a little bit
away from the curve here.
It's in a straighter line away from the curve.
If you tend to capture the curve, you'll see
that it's very hard to get rid of the artifact.
It's very turbulent in that area
and it's not a great place to be doing
measurements because they won't be particularly accurate.
And then the phasic venous outflow,
and you can see, like I said, here that's
really just slow waves in the outflow section.
It's not particularly pulsatile,
which is what we want of a fistula.
We don't want it to be pulsatile because that'll
be telling us there's something going on,
and this again is not too bad an area
to be doing a measurement because you can
see that the vessel has quite nice laminar flow.
The walls are particularly irregular,
but in a lot of our fistulas we know,
particularly the native fistulas,
but also grafts that have been
cannulated heavily, there are areas
in that outflow vein or outflow graft segment
that have very irregular walls.
And so, you can imagine it would be
very hard to get a good accurate measurement.
So, Doppler.
Doppler software can measure the velocity
of blood flow much like a policeman with a radar gun.
It measures the flow coming towards
or away from the transducer face,
but it cannot measure blood flow at a perpendicular angle.
So, you can see here, the images, you can see
as the blood travels towards the probe it's able
to capture, as it travels away from the probe,
it'll capture, but if it's straight up
and down, it's not able to measure it.
So, we always need to have a little tilt
on our probe when we're measuring.
Blood flow going towards the transducer
face is assigned a positive number.
You can see that here, there it's 18.
And the blood flow going away from the transducer
is given a negative number, so a negative 18.
And you can really just tilt your probe
slightly so that you can have it angling
towards or away from the probe.
It's displayed on a Color Doppler map
or a spectra waveform graph using the Pulse Wave Doppler.
So you can see here your pulsed wave
which is a nice pulse wave there.
And again, once you start to do the measurements,
you'll know that you're getting a really good reading
when you have this really nicely defined pulse wave.
So, if we look at this sample of Doppler measurement,
the blood flow towards the transducer,
the arterial flow, you can see that I have
the transducer tilted here and any blood
traveling towards the transducer would be
displayed as red and that would give us
an image that would look red and then the
venous flow is traveling away from the transducer
and so it's assigned a blue color, or a negative number.
So that's one way.
You can see in this second example
the probe is now tilted in the opposite direction
and you can see there that the arterial blood
would be flowing away from the transducer
and the venous blood would be flowing
towards the transducer, so, in this scenario,
the arterial blood would be assigned
a blue color and a negative number,
and the venous would be assigned a red or a positive.
So, really, it just depends on your decision
of which way you want to tilt your probe,
or which way the colors would show.
You can also invert it so that if you prefer
to always have your arterial as red and your venous
as blue and you've got it tilted the wrong way,
you can invert it so that it reflects that.
Then when you do it perpendicular,
with the transducer perpendicular, the system
can't tell what is to away because you're pointing
completely at 90 degrees so you can imagine
there that it can't tell what's traveling to,
or away, so it's not able to assign it a color or anything.
So, it'll display no color on the spectral waveform.
So you need an angle.
When you're doing your measurements,
we're used to, in dialysis, tending to just use
B mode, so we're not that familiar and we tend
to forget that we do actually need to tilt
our probe so that we can then work out
which is towards and which is away,
and also then be able to do a flow measurement
because it needs to be able to measure the velocity.
So you can see here that the probe on the arm,
it's pressing down a little bit and you would
need to do what we call heel to toe
which would be to push one side, and you can
see the video here, one side tilted
so that that means that blood would need
to be flowing towards or away from it.
Always angle with the vessel and angle the color box.
It's important to remember that if we're doing
this, if we don't have a lot of gel, we tend
to be pushing down on the skin and that's
not such an issue with an artery which doesn't
tend to compress easily, but with our fistula veins
which are soft and low pressure, we can
actually compress the vessel and change the flow dynamic.
So, it's really important that we have a lot
of gel so that we're able to create
that tilt without pushing down
on the vessel and compressing the vessel.
So, Color Doppler.
The velocity is actually displayed
in a color map in centimeters per second.
And this is adjustable.
So, the venous or low flow states,
and the arterial high flow states,
so aliasing occurs if flow is faster
than the set scale, so we need to adjust our scale.
So if the flow is really fast,
we need to adjust up to capture that.
So you can see here.
There's aliasing.
So the scale's been set too low for the true velocity flow.
What it's doing, and you can see the flow here
is seven centimeters per second, or negative seven
centimeters per second, and you can see
there's a lot of aliasing here.
So we need to be adjusting this so that it's
higher, maybe 18 or higher, we just keep adjusting
until we get a nice laminar flow and we don't
have all that yellows, and whites and blues.
We want to get just the all blue or all red.
Sometimes the turbulence and the velocity
is just too high and we struggle,
but usually we need to adjust it
so that we really get that correct.
So, aliasing is often seen in turbulent flow
or when your scale is set too low.
So, when you put it on, just set your scale,
adjust it to ensure that you get it to the best you can.
Velocity may also be displayed and measured
using Pulse Wave Doppler shown on the Spectral Waveform.
So it's measured in centimeters per second,
and aliasing may also occur if the scale is set too low.
So, again here, you can see that over on the side here
it's got the scale of velocity in centimeters per second.
And again, if this is adjusted too low,
you'll find you'll get aliasing.
So you need to set it so that you get
the whole, sort of, waveform in the screen,
So you may need to dial it up or down
so you can adjust that.
So, I've talked a little bit about ultrasound
volume flow measurements and the importance
of accurate measurement.
When it is a user-dependent method if we are
measuring our diameters incorrectly or we're
measuring into areas with a lot of turbulence
and aliasing, we may not be getting the better
measurements that we can get.
So, there's some tips that I've got.
Number one is avoid turbulent areas
like the anastomosis or anywhere with irregular walls
or an irregular diameter vein.
You can imagine, for example here, if I was
to try and do a velocity measurement here
and then do the diameter and I was
just a millimeter left or right
of where I did the velocity measurement,
the turbulent flow would mean that my measurements
could be slightly out, and we know that if we
measure the walls incorrectly, we may end up
with an incorrect volume flow measurement.
It's harder to get an accurate diameter measurement
if we're choosing these irregular walled areas,
so particularly where we're cannulating,
or in the anastomosis area where it's curved,
we may not measure directly the diameter that we should be.
So this will increase risk of operator-dependent variability
in those areas.
So we really need to be looking at areas
that have a nice straight wall.
So, turbulent flow may also cause the velocity
measurement to be less accurate.
So again, if the blood is traveling
along the vessel (murmurs), if it's traveling
along and then it starts to roll around
in these sort of wider walled areas,
it's not going to be as accurate
as if it's traveling in a straight line
towards and away from the probe.
So, it's important that we try to pick
areas where there's less turbulent flow
and make sure that we're really getting
the best velocity measurements.
Then also, a soft, aneurysmal vein,
it's easier to accidentally compress it
during the measurements, so your big dilated veins,
just a little bit of pressure from your probe,
or trying to do your heel/toe, that tilt will
change the diameter and change the way
that the blood's flowing through that vessel
and then may mess with our measurements.
Inflow measurements are more accurate
than outflow measurements.
So, I recommend using the inflow arteries,
particularly the big brachial artery
to do your volume flow measurements
because you've got a nice laminar flow.
The walls are fairly regular and it's a lot
easier to do an accurate measurement into those areas.
The only thing is, obviously, the amount
of blood running down a brachial artery
is slightly different to the amount
that's running in the fistula, but when we're
talking about doing trends of volume flow
measurements where we're looking at a trend
which may be, for example it was a thousand
mLs a minute, five months ago and then it
was 800 mLs a minute, then it was 600 mLs
a minute, we know something's going on.
So, we're not looking at trends.
It's not particularly an issue because whatever's
running down the brachial artery,
those sorts of flows, if it slows down,
it's because the fistula's slowing down.
It's not because the feet or the hand is slowing down.
So, performing the measurement, that's really
important with any ultrasound that we follow
the same principles of ergonomics, that we make
sure we set the environment up really well.
Make sure that the arm or the leg
that we're planning to scan is
in our line of sight of the ultrasound.
We're not having to try and turn around
to look at the ultrasound, that we line it all up.
And also, seat yourself and have yourself
at the right height so that you
don't cause any strain to yourself.
Scan the arm, the artery and the vein.
If it's a fistula or a graph, you start
and you scan a lot, and then try and pick the best area.
So, preferably the larger, noncalcified artery
like the brachial artery is better
than using a radial artery.
If you've got a radial-cephalic fistula
but the radial artery is quite small
and calcified and has turbulent flow,
again, it's really difficult to get
an accurate diameter and an accurate velocity there.
So, sometimes it's better to scan
and have a good look and pick your best,
and the best might be the brachial artery.
And what I do then is I just document
that that's where I've done the measurement,
so when I continue to do more measurements
to get a trend, I go back to the same place.
Use a light touch; remember not to compress
the vein or it will distort the measurements.
Use lots of gel to allow you to angle
the probe in the gel without compressing
the low pressure veins, and you can
see that example of that here.
So, performing the measurement.
Choose the area with laminar flow,
and you can see here the example.
Preferably we like it to be all red,
or all blue, whichever way you're around,
whichever way you've got it, and not like this.
If I was doing a measurement in here
or if I saw a volume flow measurement
and this is what it looked like, I would
be a bit suspicious that it was accurate.
So, measure the volume flow in the artery,
or any laminar segment of the graft,
or the fistula, the vein segment.
It's good to do both if you're doing a baseline,
and if you have two big branches, it's good
to measure both branches if you can,
but if it's not possible to get a segment
of outflow vein that's really suitable,
I just avoid doing it altogether,
and just do the brachial artery.
But it really is dependent.
But then make sure that you know
where you did the measurements.
Don't just put inflow or outflow.
I would put brachial artery, two centimeters
above elbow crease, or outflow vein,
mid-forearm, things like that so that we knew
that we were measuring in similar areas.
And just a tip, the flow in the brachial artery
will not be less than the flow in the outflow vein.
So, if you measured a brachial cephalic fistula
and you measured the outflow cephalic vein volume flow,
and it was 1000 mLs a minute and then you measured
the brachial artery and it was 500 mLs a minute,
we know that that's not possible because the flow
to the fistula has to have come from the brachial artery.
So, the brachial artery can't be running
at 500 mLs a minute and then have the fistula
running at a thousand because all the fistula
flow has to come from the artery.
So, that's a good way to test.
So sometimes doing the inflow and outflow is good.
I do see formal ultrasounds sometimes
where they note that the inflow is 500 mLs
a minute and the outflow is 1000 mLs a minute
and I know then to go and look at their actual images
because I know that the measurements weren't correct
because the inflow brachial artery can't
be 500 and the outflow be a thousand.
It's just not possible.
And I usually what I find then is
that they've measured the outflow
just at the anastomosis, in a very turbulent area.
So, for actually performing the volume flow measurement.
So this is a video here of performing the measurement.
So, performing the volume flow measurement.
This is just a video of actually performing the measurement.
So you capture the image.
I'm not going to talk about the steps
to do the volume flow measurements in this video
because different ultrasounds are different.
So I just recommend that you look at your manual,
or you speak to the rep if you've not done,
and then, or speak to a sonographer who'd be happy
to train you how to do the measurement.
But basically you would just need to use
the ultrasound to measure the diameter,
capture the velocity and then calculate
the volume flow measurement.
It's really important.
I prefer to do my measurement of my blood vessel
in B mode without the color because sometimes
the aliasing in the color could make it hard
to get the true diameter of the vessel.
So, I think it's really important, if possible,
to do your diameter measurement in B mode
without color superimposed because that
can make it a little bit tricky.
So then once you've got the volume flow
measurements, you can document the results.
I create a spreadsheet, just in Excel.
Again, it's probably a good idea
to document the date, at least the date,
what the measurement was and where that measurement
in the inflow or outflow vein was
performed so that people can relate it
because I think, particularly if you're
doing an outflow vein that we know
is only one lumen of two lumens.
So in the median cubital you're measuring
the basilic outflow limb, rather than the cephalic limb.
So, it's important to document where you are
measuring them or if you're just doing
the brachial artery, then it's good for the next person
measuring to make sure that they do the same.
A single volume flow measurement has
a lot less value than a trend.
If I have a one-off measurement and it's 600 mLs
a minute, if it was always 600 mLs a minute,
I wouldn't at all be concerned, but if it was
2000 mLs a minute six months ago, and all of the sudden
it was 600, that's much more concerning.
So it's really important to do these measurements
regularly, so routine surveillance, part
of your surveillance is to do them routinely.
It will not only help you intervene appropriately,
it will also stop you from intervening
inappropriately, because if you are
constantly measuring and it's always 600,
you'll less likely want to go ahead and do
something because it's actually been stable.
So set up a protocol for ongoing monitoring
of volume flow to help identify
the volume flow that is trending down.
So you can see these two examples here
that, like I said here, was 1600 mLs a minute
but it was trending down and so then when it got
to 450 mLs a minute, we did a formal ultrasound,
found a stenosis and did an angioplasty.
Whereas you can see that this fistula,
from the day it was made, was 450, 500 mLs
a minute and there was no intervention needed.
Just some clinical pearls.
This first one would be, plan your measurement sites.
I really look at each individual arteriovenous fistula
and graft, look at whether it's a radial cephalic fistula
or if it's a brachiocephalic fistula.
Scan the entire inflow artery and outflow vein
or veins and pick the best sites for measurement.
Look at it, if it's a brachiocephalic
or a radial cephalic fistula.
And then also look at the documentation
and see if there's been volume flow measurements
with ultrasound before, where were they doing those
and see whether it's important to stay in the same site.
So, maybe it's not possible anymore
because the outflow vein has been over cannulated
and is now quite dilated and unusual.
So avoid turbulent areas.
So particularly the anastomosis in that area there.
It's very turbulent, or any stenotic areas,
or where it bifurcates or big aneurysmal areas
and things like that; avoid anywhere where
the vein walls are very jagged or changed dramatically.
Again, it's very hard to get an absolute diameter
where you did the velocity measurement when you do that.
Don't compress the low pressure veins.
Again, if you compress your vein slightly,
it's no longer a circle and then your diameter
measurement is going to be incorrect.
So, it's really important that you use
a lot of gel and when you do your heel to toe
to get the flow to and from the probe,
you're tilting it in the gel, not pressing
on the skin and compressing the vein,
and causing a variation in the velocity or the flow.
The flow in from the artery will not be less
than the flow in the outflow vein.
So, that's important.
If you're doing a radial artery inflow,
then the flow in the fistula can sometimes
be slightly more because there can be blood
coming from the ulnar artery and through the palmar arch
and back up through the fistula and that's why,
if possible, I try to stick to the brachial artery
if I'm trying to look at comparison,
because I know that everything that goes down
the brachial artery is going to feed the fistula
in some way or another and if my outflow measurement
is more than my inflow measurement,
I know I'm not getting it right.
While learning the skill, compare your measurement
with other volume flow measurements,
such as dilutional methods, if you've
got those available to you in your unit.
I used to use the ultrasound dilution method
and then compare it my ultrasound volume
flow measurements to just, sort of as a double check
to make sure that I was doing them correctly,
and I found that they were very, very similar.
I didn't find much variation once I got
my technique down pat.
Just be mindful that sometimes we have been
doing the dilutional measurements and there's
been a branch in-between, so our dilutional measurements
were actually not correct.
So be really mindful of the anatomy
of the fistula that you're doing.
So, if you're doing an ultrasound measurement
of the area where you're cannulating and it comes
up at 600 mLs a minute and then you do
a dilutional one and it's always over a thousand,
have a look, there probably is a collateral
or a branch between and so your dilutional one's
actually been incorrect all along.
So, that's really important to know your anatomy.
So, that's all the clinical pearls.
The best thing is to get the ultrasounds and practice.
I like to measure my pre-dialysis patients,
use the brachial artery and get my technique
down pat with the brachial artery 'cause it's
a nice vessel to measure because it's got
nice laminar wall, sorry, laminar flow
and the walls are nice and straight.
And then with the new fistulas they do
still have nice straight walls
and laminar, but they can be soft.
So you do need to be mindful.
But it's good to practice on them, doing your heel
to toe using lots of gel and not distorting
the vein when you're doing your measurements.
And then when the people are on dialysis,
so that you're not interfering with their dialysis
time, I put them on dialysis with their needles
in and then, if it's possible, I do ultrasound
measurements of their brachial arteries
so that I can still get in and do that
even though the needles are in.
They're not in the way and I can do
the brachial artery measurements
without making them wait to start on dialysis.
So, practice, practice, compare it with other
methods and speak to other nurses who've
maybe used it before or go and visit
your sonographers and your ultrasound department,
and see if they would be prepared to sit
with you to do some practice with them.
Thank you for your time.

Brightcove ID

5768898572001

https://youtu.be/USO2G0uilhI

Alternatives for Opioids for Pain Management in the Emergency Department

Read more about Alternatives for Opioids for Pain Management in the Emergency Department

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Alternatives for Opioids for Pain Management in the Emergency Department

Publication Date

Thu, 01/10/2019 - 12:00

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Other Videos

Subtitles

- Hello everyone, thank you for joining us for this webinar.
My name is Alexis LaPietra and today we are going
to be talking about alternatives to opioids
for pain management in the emergency department.
So a few numbers to start off with,
1.9 million is the number of Americans
that are currently abusing or misusing opioids,
75% is the percentage of heroin abusers in treatment
that state they started using heroin after becoming addicted
to prescription opiates.
This is a stark change from what we saw 30 or 40 years ago
where 95% of heroin abusers in treatment
stated they started using heroin
when they started using heroin.
So we see now a shift from heroin users
starting their opiate addiction with heroin
but now opiate addiction starts with prescription opiates,
and unfortunately later transitions to heroin abuse.
51 is the number of Americans that die every day
from an opioid overdose which is about 18,893 Americans
every year that die.
This is rapidly becoming the number one
preventable cause of death nationally, opiate overdose.
This also affects extremes of age when I think about seniors
and pediatric patients.
So when we often think of opiate abuse
we are not thinking of geriatric patients.
However, we see that there are
2.8 million geriatric patients
that are abusing or misusing
opiates every year.
This is multifactorial.
But part of it is geriatric patients
listen to their physicians,
and when they hear the physician say,
take this medication every four or six hours,
they often don't hear the p.r.n., or as needed,
for pain part.
So they continue to judiciously take their medication
every four to six hours and when they get to the bottom
of the 15, 20, or 30 tablets,
this population is unfortunately addicted
to that medication physiologically.
Also we look at pediatric patients.
And this population, we don't typically see practitioners
prescribing opiates to pediatrics.
What we see are that the young adults see
these pill bottles in mom, dad, grandma,
grandpa's medicine cabinet,
and they have a peaked interest
and they recreationally use these medications.
So we have about 467,000 adolescents
that are currently non-medical users
and also 168,000 that are addicted.
So this goes just beyond prescribing,
this also goes to thinking about
how many tabs you're prescribing because
there is an excess of this medication in the community
and that can lead to unnecessary use and abuse.
So this epidemic is multifactorial.
But as we saw more and more opiate addiction
we looked and saw, wow, there was
more and more opiate prescribing.
So we all know the story that in the early 90s
there was a push for better pain management
and documenting pain scores more judiciously.
And there were no more tools in practitioner's toolboxes
and I think that it was well-intentioned prescribing
of opiates that got us here,
but the more opiates that we are prescribing
the more addiction that we see.
So in the emergency department,
when we see patients and we see patients with acute pain,
our number one goal is to get them feeling better.
Again, as mentioned earlier,
when we think about what we have
to help patients feel better,
I think practitioners feel that they
only have a few things in their toolbox.
They have Tylenol, they have anti-inflammatories,
and if neither one of those work then they have opiates.
And often opiates are treated as a first line medication.
But what we found was with liberal opiate prescribing
over the past two decades that
has led to significant addiction.
So although opiates are important,
and we have to utilize opiates when necessary
for certain kinds of pain,
this reflexive prescribing of opiate
has unfortunately led to a terrible opiate crisis
and significant addiction.
Therefore, looking now at more pain management research
and seeing what medications are out there,
researchers and practitioners have discovered
there are a multitude of alternatives
for specific conditions that are as effective,
if not more effective, than opiates.
So let's try and decrease opiate use;
therefore, stopping some of this addiction,
and we're going to do that by using more alternatives.
At St. Joseph's Regional Medical Center
in Patterson, New Jersey, we developed a program
called ALTO, or Alternatives to Opioids.
And this was a program that was developed, again,
based on the opiate crisis
and the belief that there were definitely medications
and modalities that we could use in lieu of opiates,
not because we didn't want to give opiates
but we wanted to do better.
We wanted to elevate pain management,
successfully treat patients,
but we also wanted to reevaluate
the need for first line opiate prescribing.
The five conditions that have great evidence
that alternatives are as effective or more effective
than opiates are renal colic, musculoskeletal pain,
lumbar radiculopathy, migraine headache,
and extremity fracture/dislocation.
And because you are watching an ultrasound-focused podcast,
what we're going to talk about is ultrasound-guided
regional anesthesia.
This is a fantastic modality for the management
of extremity fracture dislocation pain.
So why is this good?
Why do we wanna learn about this?
Well, it is first of all targeted, focused pain relief.
When we administer opiates systemically
the side effect is the brain gets foggy
and well, they forget about their pain.
But with ultrasound-guided regional anesthesia
you can put local anesthetic exactly where the pain
is coming from and completely stop that pain.
There is no amount of opiate that's going to safely
completely resolve fracture or dislocation pain.
So this is a major plus
for ultrasound-guided regional anesthesia.
It is also long acting.
When we think about opiates, morphine,
one of the longer acting intravenous opiates,
we're not getting all that many hours of analgesia.
But when we administer certain long-acting local anesthetics
we can have up to 12 or 24 hours of relief.
And if a catheter is placed at that site
we can have days of relief.
So this is long-acting, complete pain relief.
Additionally when patients are potentially unstable,
their vitals signs aren't looking great,
we may not want to give them large amounts of opiates.
But we can perform a nerve block.
There is no vital sign changes
that we see with the nerve blocks.
And lastly, it's a hands-on procedure,
there's instant gratification, and it is billable
when you perform it.
So it's a win-win situation.
In addition to the Sonosite ultrasound machine
that you'll need at bedside to complete
ultrasound-guided regional anesthesia,
there are a few other things that you will need.
First of all is patient consent.
The only contraindications to doing this procedure
are patient refusal or allergy to local anesthetic,
and lastly cellulitis overlying that needle site.
So once you have patient consent,
you've talked to your team about the appropriateness
of a block you wanna go ahead and put the patient
on the cardiac monitor,
wanna be measuring the blood pressure,
heart rate, pulse oximetry.
You want to have an, excuse me, an intravenous line
to administer any potential medications that you may need.
You also want some ChloraPrep or sterile cleansing solution
so that your site stays sterile and nice and clean.
In addition, you need sterile gloves
to perform this procedure.
You also want a needle.
So there are special needles that you can use
for ultrasound-guided regional anesthesia,
which have some echogenic notches in them.
They have extension tubing as well.
If you don't have anything fancy like that
you can reach for a spinal needle,
as long as you have a needle that is long enough.
You want about a two to four inch needle,
21 to 25 gauge to perform this procedure.
You wanna visualize your needle at all times.
You also need your local anesthetic.
So ropivacaine or bupivacaine
are two long-acting local anesthetics of choice,
and depending on the type of block you're doing
you'll need about 15 to 30 milliliters.
You want to also have a sterile probe cover
on your linear transducer so that when you're
doing your scanning you have the probe sterilely covered.
So let's talk about when we're gonna use this.
So this patient right here is a 92-year-old female
who tripped over her slippers and fell to the ground.
The family heard the fall,
brought her into the emergency department.
Based on your physical exam,
there's an externally rotated shortened leg,
she has significant pain in the hip.
You're very suspicious that she has a hip fracture.
But you need to get your x-ray.
You wanna get her moving so you put that line in
and think let's just do some morphine to start.
So she gets four milligrams of morphine.
Goes off to x-ray, she comes back.
That was about 15 or 20 minutes and she is crying.
She says she has no pain relief at all.
So she's about 60 kilograms.
We look a her vital signs, she's certainly not somnolent,
so you give her another four milligrams of morphine.
You get your x-ray back, you think woops,
there we go, she has a hip fracture.
You're gonna talk to the PMD, talk to orthopedics.
20 minutes go by, you get back in the room.
She's still in significant pain,
crying, pleading with you to give her something.
You check the line, you flush the line, the line is good.
You decide to give her another four milligrams of morphine.
So at this point you think, my gosh,
I'm giving this elderly woman 12 milligrams of morphine,
but again, our goal is to get people feeling better.
Now the patient has a bed.
The nurse is calling to give report.
You go in to talk to the family and the patient
and everybody's in distress.
The patient feels horrible.
She has had 12 milligrams of morphine.
Her pain is intolerable and not controlled.
Now you're gonna wheel her upstairs,
transfer her to a stretcher,
and you've really gotten nowhere with her pain management.
So what can we do?
What we can do is a femoral nerve block
or a fascia iliaca compartment block.
The indications for femoral nerve block
are hip fracture and femur fracture.
This is a fantastic modality
because it gets patients complete pain relief
with prolonged pain relief that help with transferring,
with bedpan use, with x-ray,
and with any kind of movement in the bed.
Femoral nerve block contraindications, again,
which I discussed earlier
include allergy to local anesthetic,
patient refusal, and cellulitis over the site.
The lower extremity will be paralyzed
after your femoral nerve block,
but these patients are not ambulatory.
So there is really no contraindications
in terms of mobility because they're not walking.
So geriatric hip fracture.
Why is it so important to control geriatric pain?
I would say practitioners are more worried
about oversedating or the side effects
of prescribing too many opiates in this population,
but we really, as practitioners,
have to also think about oligoanalgesia
or undertreatment of pain.
When we look at geriatric patients
who are cognitively intact, inpatient,
for treatment of their hip fracture,
patients who receive less than 10 milligrams
of intravenous morphine per day tend
to have a nine times higher rate of delirium
than cognitively intact patients
who receive more than 10 milligrams of morphine.
What that means is when we're undertreating
this terrible severe pain it's actually leading
to significantly more delirium.
So when we think, again, of the treatment of hip fracture,
yes, we wanna balance out analgesic needs
and side effects of opiates,
but also we wanna provide adequate pain relief
to this population.
Another study showed that patients of all the modalities
or medications that could be made available,
patients benefited most or had
most successful pain management
with ultrasound-guided regional anesthesia.
So systemic opiates, immobilization,
neurostimulation, multimodal analgesia,
all of these options, none of them were as successful
as doing a nerve block at bedside
and completely blocking that pain.
Yes, they may still need some opiates for breakthrough,
but it will be significantly less,
and the appropriate management of geriatric pain
is so important to prevent delirium.
So let's talk a little bit about
how you do this nerve block.
So this is a wonderful block to start off with
if you're new to ultrasound-guided regional anesthesia,
because there's not many contraindications,
there's not many side effects,
and it's pretty easy to find.
When you're using the ultrasound probe
you want to sit it right within the inguinal crease
between the anterior superior iliac spine
and the pubic tubercle.
In this crease, when you place the ultrasound probe down,
you should easily visualize a pulsating femoral artery,
and that is your landmark to have success with this block.
When we see our ultrasound screen,
you will see the femoral artery pulsating,
the femoral vein medial to it.
So now we know we're in the right spot.
Some little tricks to make sure
that you are where you need to be,
when starting off in the inguinal crease,
you can track a little bit towards the feet,
a little bit caudad, and you'll start
to see the femoral artery split.
That is too low, too inferior, you need to back up
and see the femoral artery as one vessel,
and again, pulsating femoral artery.
And then you'll see the collapsible vein,
when you apply pressure,
a collapsible femoral vein medial to that.
So once you have your femoral artery,
you've seen that it's split distally,
you come back up.
Then you want to look lateral.
And what you should see there is a nice femoral nerve,
a wedge shaped, somewhat honeycomb appearing
with some echoes bouncing around.
You'll see that is your femoral nerve.
And that is your target.
Holding your probe in an in-plane,
or preparing for an in-plane position,
you will take your needle,
pop through the top layers of the skin,
inject a little bit of local anesthetic
to form a wheal.
And then you want to advance your needle slowly,
visualizing the needle tip at all times.
In the in-plane technique you will
see the full length of the needle,
so as to be sure you are not puncturing
or damaging any surrounding tissue.
When you do that you will be aiming for the nerve laterally,
you are avoiding the artery which is next,
and then the vein that is completely medial to that.
Your needle should be aiming for the corner pocket
or just below that femoral nerve
with a goal of infiltrating 15 to 30 milliliters
of local anesthetic into that area above the fascia.
When you do that you will see black and echoic
local anesthetic distributing below that nerve,
typically lifting that nerve up off
of the underlying structures below.
And the local anesthetic will therefore bathe that nerve
and you should be able to have a really nice block.
Local anesthetic of choice is dependent on the patient
and how long you want duration of analgesia.
But typically for hip fractures,
because these patients are operative
are certainly not getting up and walking home anytime soon,
a long duration of analgesia is desired,
therefore you'd want to reach for ropivacaine
or a bupivacaine.
Both have about the same duration of action,
about 12 to 24 hours.
But bupivacaine tends to be a little bit more cardiotoxic.
So practitioners often reach for ropivacaine 0.5%.
When we are also thinking about short-acting analgesia
where we only want one to two hours of analgesia on board
you can use lidocaine.
Very important math to do before your nerve block
is to calculate the toxic level of local anesthetic
to make sure you are well below the toxic level.
When we're using lidocaine
five milligrams per kilogram is the cutoff,
when using bupivacaine or ropivacaine
you do not want to go above
three milligrams per kilogram of local anesthetic.
And we typically do not use epinephrine with our injections,
so you're going to be without epi.
So complications, dreaded complications
are compartment syndrome
and local anesthetic systemic toxicity.
So any block that you perform you do run the risk
of local anesthetic systemic toxicity
because you are using a local anesthetic.
But compartment syndrome is specific,
typically for lower extremities,
typically more for distal lower extremities
like tibia fractures.
But when you're dealing with the hip fracture
you still, of course,
always want to worry about compartment syndrome,
especially in the leg.
The literature on compartment syndrome is pretty clear
that despite use of regional anesthesia for pain management,
compartment syndrome still presents
with a severe acute change in the character of pain
and is typically not missed
despite regional anesthesia being performed.
So in one study that was evaluating
compartment syndrome detection with regional anesthesia,
they found that 98% of patients exhibited the classic signs
of, again, an acute change in the character of pain,
intensity of the pain,
despite having a nerve block on board.
And there's a lot of military literature
about compartment syndrome and regional anesthesia.
And again, they all favor the use of regional anesthesia
for the management of extremity pain.
The most important thing when evaluating
for compartment syndrome is being sure to have routine,
diligent neurovascular exams performed.
Regardless of whether or not there
is a nerve block on board,
anybody with a fracture needs
to have diligent neurovascular testing.
And this holds true whenever regional anesthesia is employed
because you want to really make sure you are checking
and evaluating for all
of the neurovascular components necessary.
Local anesthetic systemic toxicity, again,
is an entity that any patient is at risk for
anytime you're administering local anesthetic.
Local anesthetic systemic toxicity depends on a few things.
It depends on the volume of local anesthetic administered.
Depends on the concentration and as well as the location.
Some locations throughout the body,
especially the neck area, have more vascularity
and maybe at risk for increased
rapid uptake of local anesthetic.
So these are things to be considered,
and again, calculating your maximum dose
of local anesthetic prior to administration
is very important.
LAST has a spectrum of presentations.
It can present in a mild form,
which you'll have some ringing in the ears,
you might have a little bit of paresthesia,
little bit of headache, or sometimes visual disturbances.
And in the most severe form you could potentially have
cardiopulmonary arrest or cardiovascular collapse.
So this is partly why we place patients on a cardiac monitor
and have intravenous access available.
If patients have any sign of severe LAST
you want to administer antidote immediately.
So what is the treatment?
If it is in the mild-to-moderate neurologic presentation.
Again, you may see some ringing of the ears,
stroke-like symptoms, or seizure.
For the seizure component of it,
benzodiazepines are indicated just
as if you would give for any other seizure.
However, when we are losing airway
or we are having issues with cardiovascular compromise
we want to remember our ABCs and of course ACLS.
If the patient is significantly decompensating
and goes into a VFib,
this is a very high mortality situation,
you need to be aggressive and you may even want to consider
cardiopulmonary bypass at this point.
If the patient does go into cardiovascular collapse,
hypotension, VFib,
or you're noticing that we're getting a thready pulse,
and the patient is going downhill.
You need to administer intra-lipids immediately.
Intra-lipids are not for when the patient is getting CPR.
Intra-lipids are to prevent CPR
because once the patient does decompensate completely
the mortality is very high.
So any suspicion that we're going
in the wrong direction cardiovascularly
after local anesthetic administration
intra-lipids are indicated.
They should always be within reach,
whether it's in your Pyxis Department
or in your ultrasound-guided regional anesthesia carts
and they need to make sure, you need to make sure
that you check their availability
and also check the expiration date
prior to every block you perform.
The dosing is one milliliter per kilogram
of a 20% lipid emulsion.
You wanna give that in bolus form every five minutes.
And the max dose of intra-lipids
will be three milliliters per kilogram.
You can also use an infusion after that
of a .25 milliliter per kilogram
per minute 20% lipid infusion.
So you want a bolus immediately every give minutes,
titrate to stability.
But once you get to three millimeters per kilogram
if you're still okay you wanna start them on an infusion.
So, in summary, when we think about geriatric hip fracture
we wanna think what can we give that is quick and effective?
What do we want to do to treat the pain
but not flood geriatric patients with opiates,
not oversedate, not lead to poor outcomes,
but really, truly treat their pain.
What do we want to think about in terms of delirium?
We want to remember that yes, opiates can contribute
to delirium but in fact undertreatment of pain can as well.
And we want to try to give
good care to our senior population.
All of these are reasons to entertain
ultrasound-guided regional anesthesia
for your hip fracture patients.
Again, you want to place that probe in the inguinal crease,
see the pulsating femoral artery, and go lateral to that.
It is a relatively easy superficial block.
Calculate your local anesthetic,
make sure the patient is on a monitor,
and watch as you see immediate relief
of that severe terrible hip pain,
and you'll probably get yourself a hug afterwards.
So thank you so much, I appreciate all of your time
and the opportunity to speak to you about this.
And hopefully we'll get to talk more.
Thanks.

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Webinar Point-of-Care Ultrasound and the Hospitalist - Does it Matter

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Webinar Point-of-Care Ultrasound and the Hospitalist - Does it Matter

Publication Date

Thu, 01/03/2019 - 12:00

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- [Instructor] Alright thanks for joining us.
Let me give you a little bit of background about myself.
I am a Hospitalist in my clinical time,
and practice at Abbott Northwestern Hospital
in Minneapolis, Minnesota.
It's about a 650 bed quaternary care center.
A teaching hospital with a
internal medicine residency here.
My ultrasound background started kinda 2004,
2005 when we had a small little
machine that I started rounding with,
and experimenting with.
And then in 2006 I started
the internal medicine bedside procedure team,
which is a team that does about 500 procedures a year,
and is a completely ultrasound based team
training team with internal medicine
residents and run by Hospitalists.
About a year later started the
Clinical Simulation Center here,
which is a simulation center that's
ultrasound real and involves procedural simulation,
as well as ACLS resuscitation simulation,
team-based training with ultrasound involved.
And then the ultrasound curriculum really
formalized here in 2011 with the IMBUS program,
which is the Internal Medicine Bedside UltraSound program
within the residency program here that has
trained 70 or 75 physicians since 2011,
and ED docs and ICU docs, and internal medicine residents,
and Nurse Practitioners, and family practice docs
so a wide range of people we've trained since 2011
in that program.
So that's the background on me.
The goal of this talk is to take this image
where ultrasound has been a huge part
of emergency medicine now,
and has become standard of care in that area
as a huge part of critical care,
intensive care medicine.
A huge part of anesthesia,
and a big part of rheumatology,
and physical medicine, and lots, and lots of other areas.
Different specialties as well as
sub-specialties amongst internal medicine.
So the goal of this talk is to really hone on
why this is an important piece,
and why it has a huge value for
internal medicine physicians, and especially Hospitalists.
And that value has lots, and lots of different areas
that it covers, if nothing else, because medical students
and residents are being trained in point of care ultrasound,
and as Hospitalists and attendants,
and people who are working with these new graduates as
your partners if nothing else to be aware,
and to know of what the new modalities are.
Because those around you, and those who you are training
are becoming trained in it.
But also has huge impacts on patient care,
patient safety, physician satisfaction,
patient satisfaction, efficiency of care, cost reduction,
radiation based imaging reduction potential
so all of those areas.
I'm gonna try to demonstrate for you really what's the
high yield areas of point of
care ultrasound for the Hospitalists.
Lemme take one little starting point here
just to kinda get everyone on the same page
from various backgrounds,
and experiences with ultrasound here.
And let's lay out the picture of what
Hospitalist point of care ultrasound is.
It is you at the bedside as a Hospitalist
who knows a lot about the patient in front of you.
You know about their past medical history.
You know about what their labs have come back as.
You know about what their heart sounded like
when you listened with your stethoscope.
You know about what medications they're on,
what interventions they've had this morning.
So you know a whole lot of information
about your patient which is really, really key
to point of care ultrasound,
and one of the big differences
that helps this be different from formal ultrasound.
So, in that situation, you ask a focused question,
and you're gonna use the ultrasound to
try to answer that focused question.
First of all you have to technically obtain an image
so there is a technical skill that goes along with this.
And then there's enough experience
that you know whether or not that image
is adequate to answer the question that you're asking,
or whether it's an inadequate image.
If the image is adequate you interpret it,
in real time, at the bedside there.
And the key, and one of the most important pieces about
point of care, competency, is that you are able then
to take that piece of information,
and integrate it with the rest of the clinical picture.
It is one more piece of information
to go along with the labs,
to go along with the physical exam
to go along with the history,
to go along with all of those pieces.
So integrating in the point of care ultrasound
interpretation is really, really important.
The key is that you're doing it in real time though.
It's not separated in time and space
from the time you're asking the question.
It is done in real time,
and you're able to get an answer in real time.
What that allows you to do then is to say,
"My differential when I started this
"and when I asked a question was this.
"However what I just found on ultrasound
"changes my differential so let me
"ask a different question here,
"and let me get a different image.".
Maybe I go from the heart down to
the right upper quadrant now
based on what I saw.
Something you can't do with the echo tech
at bedside doing a formal echo,
or with the ultrasound tech at the bedside
you can't ask them to.
Alright let's change this.
Let's go to a different ultrasound here.
Finally you put together your differential,
and you treat, or you intervene.
You give fluids for that hypotensive patient
with the flat inferior vena cava.
And then because this is with you,
and because you are the one performing,
interpreting, and integrating you can come back,
and check again in an hour
after you give a fluid bolus to see what's happened to
that patient, and that'll develop some b-lines.
Or are they still hyperdynamic,
and have a flat IVC?
So this is a tool that isn't a one time come and go.
It is with you, and allows you to come back,
and check, and adjust.
So that sounds very much like
your physical exam as an internist.
Sort of our bread and butter here the physical exam.
And it looks very much like our physical exam as well
from a zoomed out view here.
Point of care ultrasound in the middle
is a tool that is with you
from asking the question
you're gonna answer it
with what tests you acquire the images yourself,
you interpret 'em, and you act on 'em,
and that is very much like our physical exam.
What it's different from is referral ultrasound,
and both of these modalities are key,
and essential to taking high quality care
of patients in a hospital setting.
However they differ from each other,
and they both have different roles.
The key difference in this diagram
that's pointed out nicely by Dr.Sonia Lucas,
is that referral ultrasound starts with the person at the
bedside who knows the patient who asks the question,
and decides alright which imaging test am I going to
select to try to answer my question?
The person who comes to the bedside to
obtain the images is not the person who knows the patient.
It is an ultrasound tech, or an echo tech,
who gathers images, and puts together a
package deciding which images
to send to either the radiologist,
or the cardiologist who then is
going to interpret the image.
And then that person who kind of knows the patient,
probably a little bit of history,
but not nearly the depth you do,
or maybe doesn't know the patient at all,
is gonna interpret the images
that the person who obtained them gave to them,
and put together an interpretation,
and send it back to you.
So separated in space and time
from when you asked the question originally,
and you are going to take that interpretation,
and act on it.
So lemme give you a couple little case examples here.
They are meant to just demonstrate the difference
between the continuity that exists here,
and the fragmentation that exists here.
They both have benefits.
You've got experts at each level here,
but the fragmentation sometimes gets in the way
of what we're trying to accomplish,
so I'll show you two quick little cases here.
The first one is a 32 year old lady
who had a gallbladder taken out about six days ago.
She had her gallbladder taken out
because of pretty classic right upper quadrant pain
for her gallbladder, and the pathology on the
gallbladder showed a edematous gallbladder with
no stones in it, and she's six days postop,
and has increasing shortness of breath,
and the shortness of breath was there
a little bit before surgery.
She hadn't been eating much at all before surgery,
and hasn't been eating much since,
and the shortness of breath is increasing.
On exam she's in sinus tach, going 120.
A little bit more hypotensive
than she had been pre-operatively.
Sats were fine and, on exam,
her lungs were decreased, especially on the right,
and heart sounds were distant.
Couldn't see her jugular venous pressure.
She was bigger lady.
And had a little bit of edema,
both lower extremities up to about the mid shin.
Her belly was unremarkable.
Here's her EKG which is sinus tach at first glance there.
A little bit of low voltage maybe,
and we'll go onto the next slide,
and we'll come back to this.
So put a probe on her chest,
and here's what you see in this 32 year old
who's post-op day 6 from a lab collie.
She has a significant, large,
Pericardial circumferential effusion here in the
parasternal long axis with a
hyperdynamic underfilled left ventricle,
and with a collapsing right ventricular outflow tract in
the long axis during diastole.
Here she is in the short axis, she's got a swimming heart,
with that same hyperdynamic left ventricle,
and her right ventricle is nicely collapsed here,
as you can see.
It looks like little monkeys jumping on top of
that right ventricle.
So this is tamponade, and in retrospect,
the other piece on her EKG that you see in the
background here, is that she's got alternans,
as we move through her EKG there.
As well as the lo voltage,
that was a little more apparent, initially.
So she had a pulsus of 30, and had a pericardiocentesis with
800 of bloody fluid removed.
Everything from a workup standpoint was
negative on that fluid.
So the internist goes back a little bit,
just out of curiosity, and looks at the surgeon's HNP,
where she has some hypertension,
she's tachycardic at that time, preoperatively.
And not much else on the exam there.
She was mildly tender up in right upper quadrant.
She then had a formal right upper quadrant ultrasound done,
preoperatively after the surgeon saw her,
and preop formal, right upper quadrant,
done in radiology showed a thickened gallbladder wall,
a little bit of pericholecystic fluid,
no Murphy's sign.
She had a normal bile duct,
and she had a small right pleural effusion.
The comment about the inferior vena cava is
that it was patent.
So look at the images from the formal radiology study.
Not from the bedside, point of care exam,
but from the formal radiology study.
And certainly, the gallbladder wall is edematous and
there's a tiny bit of pericholecystic fluid.
But look at this as an internists,
not as the radiologist who is asked to
evaluate the gallbladder for cholecystitis.
And in this image you see an inferior vena cava,
that the formal radiology report comment says patent,
which it truly is.
But the piece that pick up on here,
in this inferior vena cava is that this is
a three centimeter inferior vena cava,
in a relatively small statured lady, somewhat obese,
but a small statured lady.
So a three centimeter IVC with dilated hepatic veins,
and a right pleural effusion on this formal ultrasound.
So the combination of those things, I am 99% sure,
with her sinus tack and her shortness of breath before
getting her gallbladder out, that she had early tamponade,
early elevated pressures on the
right side causing gallbladder edema that
led to her getting her gallbladder out.
And what could be different here?
It looks like cholecystitis,
she's got right upper quadrant pain,
and she's got an edematous wall.
If you go down this route over here,
and the person who knows the patient orders the test,
the person who interprets it interprets it
as edematous gallbladder wall.
And the person who acts on it takes out the gallbladder.
I don't know that it's different,
if you went back and played this back.
But it's surely just a different thought process of
the internists that the bedside, looking at this patient,
knowing that she's got shortness of breath and
a pleural effusion and then has this huge IVC,
maybe the path is a little bit different.
Let me give you one more case, that demonstrates kind of the
same thing, and strangely uses the gallbladder again.
So this is a 47 year old who had Rheumatic Heart Disease,
and has severe mitral and tricuspid rgurgitation,
as well as pulmonary hypertension.
She had been having right upper quadrant pain for
several months and this had increased over the
past few days.
She had been seen as an out-patient,
and the plan was to take out her gallbladder,
if they could optimizse her cardiovascular status.
Because she was having on-going pain and
her formal ultrasounds as an out-patient had
stones in the gallbladder.
So the plan was to take out her gallbladder.
But she came in because the pain had
increased significantly in the past couple days.
When she came in she was volume overloaded,
her bedside ultrasound shows a big, dilated IVC,
which wasn't surprising, dilated hepatics.
She had bilateral interstitial patterns in her lungs,
consistent with pulmonary edema.
Had pleural effusions, and had edema up in mid legs.
So the plan when she came in was to diurese her,
and then get a formal right upper
quadrant ultrasound in the morning.
In the morning, she diuresed really well.
She peed quite a bit, her shortness of breath got better,
and her pain in the right upper quadrant got better as well.
The point of care ultrasound at the bedside,
the IVC had gotten smaller, and now had some collapse to it.
Her interstitial edema on the lung ultrasound had improved,
and all of that correlated with her net loss of
about 1.2 kilos overnight, and her negative fluid output.
Her blood pressure that morning, though,
was a little bit low, and they were worried about
sepsis from cholangitis.
So they held her diuretics and they gave IV fluids.
Before that happened,
she had her formal right upper quadrant ultrasound,
when she was feeling good,
from a shortness of breath standpoint.
And her gallbladder right upper quadrant pain was minimal.
And here's the formal right upper quadrant ultrasound.
She has a normal gallbladder wall,
this is measured at two millimeters,
and has some small stones in the gallbladder,
but an unimpressive gallbladder.
So with the IV fluids overnight and
holding her diuretics the next day,
she was actually more short of breath and on more oxygen.
And at the same time,
her right upper quadrant pain was back and worse.
So at the bedside, with the point of care ultrasound,
she had an increased inferior vena cava again,
with more dilation of her hepatics,
and no collapse on her IVC, and she now had
florid bilateral interstitial syndrome,
consistent with worsening pulmonary edema.
Remember the gallbladder from several hours before on
the formal ultrasound.
And then here's what her point of
care ultrasound looks like right now,
when she's got right upper quadrant pain,
and when she is short of breath.
Her gallbladder wall here is clearly thickened,
and she had scattered stones in here.
But a mark at the different gallbladder wall,
compared to several hours before,
on the formal right upper quadrant ultrasound.
This was measured at seven or eight millimeters,
compared to the two millimeters measured
several hours before.
So quite a discrepancy between the point of
care ultrasound right now when she was
having right upper quadrant pain,
and the formal ultrasound several hours prior,
when she was having minimal right upper quadrant pain.
So at that point we gave the patient the probe,
and we said, "Put this probe right where it hurts most.".
Everyone knows about a Murphy's sign,
people know about a sonographic Murphy's sign as well.
And this is a patient-driven sonographic Murphy sign,
so give them the probe and have them put it where it hurts.
And if this is what it looks like on the screen when
the patient says, "Right here", and you are right over the
gallbladder, that is a pretty darn good Murphy's sign.
And all of us take Murphy's sign plus stones with
a pretty darn strong positive predictive value,
with respect to cholecystitis.
So what was going on here?
We wondered if the images from the
formal right upper quadrant ultrasound the day before
were on the wrong patient or if something happened.
So the discussion with radiology and the plan was
to repeat a formal ultrasound.
But it was gonna take about three or four hours to
get hat done, and we knew she needed to be diuresed.
So we diuresed her, and she eventually got
the formal right upper quadrant ultrasound repeated that
afternoon, where she did have less than it was in the
morning, but still edematous thickened gallbladder wall.
So she underwent mitral vio ventricle bicuspid valve
replacement four weeks later,
and she never had a cholecystectomy,
she has had no further right upper quadrant pain for
over two years now.
So almost for sure, her right upper quadrant pain and
edema was transient, correlated just with
her right sided pressures, secondary to volume overload,
as well as her valvular and pulmonary hypertension.
And once that was taken care of,
her right upper quadrant pain went away.
This demonstrates, I think, a couple different pieces.
One of which is separation and time,
between you at the bedside with a patient who's got pain,
and when a formal ultrasound sometimes can get completed,
especially interpreted, and back to you to act on.
And additionally, the separation in the person who
is interpreting this image of
a swollen gallbladder wall with stones,
and staying consistent with cholecystitis,
separated from the person who is going to act on it.
There on, in some cases, hopefully in this case,
that demonstrate just the benefit of having the
continuity form start to finish within the hands of
the person taking care of the patients.
Alright, let's look into a couple pieces about
physical exam now, which looks just like point of
care ultrasound, sometimes, from a continuity standpoint,
and is our bread and butter as internists.
And let's take an evidence based look with
a few tables here from Steven McGee in his book.
The first one is something we do all the time,
and it is whether or not someone has ascites.
And our classic physical exam here with likelihood ratios of
varying degrees, both positive and negative,
for the ways we can test for the presence or
lack of ascites.
Fluid wave, shifting dullness, et cetera.
This is an example of ascites, 100% yes.
And exactly how much is present here with
the ultrasound on exam.
This is a nice cirrhotic little shrunken liver,
with the black ascites around it.
Down here is more subtle ascites,
that clinically is important,
but not detectable with traditional physical exam.
And here you see some small bowel with peristalsis in it.
So if I really wanna know whether or
not someone has ascites, this is the way I look,
rather than with shifting dullness anymore.
Same thing with pleural effusions, elevated diaphragms,
and hospitalized patients postoperatively,
all of these pieces that make our traditional exam a
little bit tougher for being accurate in whether or
not there is effusion, and how much there is.
Going one step beyond,
here is a nice free flowing pleural effusion above
the diaphragm, with a lower lobe that is
atelectatic from the compression of the fluid around it.
In contrast, a physical exam that looks very similar to
this physical exam, but a fluid here that
looks quite different.
So this fluid, from here to here to here,
above the diaphragm, outside of this atelectatic lung tip,
is densely loculated with all sorts of fiber stranding.
And this patient who we thought was
a transudative heart failure effusion,
this turned out to be empyema.
And just seeing that difference on ultrasound makes you
more likely to put a needle in that, diagnostically,
than you might have if you thought this was
just a transudative heart failure effusion.
And then finally, let's just take liver and spleen size.
First spleno and hepatomegaly,
and we've got pretty good exam tests here,
from a traditional exam standpoint,
when they're positive, for calling something big or small.
However, the sensitivity for
picking up splenomegaly hepatomegaly, lacks.
And here we've got a nice, normal sized spleen,
for example, up here, with the ipsilateral left kidney,
and a nice, significantly enlarged spleen down here that
looks like a football, extending way beyond the
inferior pole of the left kidney.
And if I really care whether or not someone has
a large spleen, especially if they're a bigger patient,
the ultrasound probe is where I go to be
confident in that exam.
So lots and lots of different points of physical exam for
internists, that we can do better with ultrasound.
This is the IMBUS curriculum, which has tons and
tons of pices to it, all of which we think plays a
role in the internist and Hospitalist physical exam.
But we don't have time for all that today,
so I'm gonna show you the stuff we do
within our ultrasound program here.
Really comes down to three big areas.
Lots and lots of different pieces, but if you were gonna
take the three big hitters,
you would take pulmonary ultrasound,
cardiac and fluid responsiveness,
and then some abdominal ultrasound.
So that's what I'm gonna try to highlight for you here,
is a few high yield areas,
a point of care ultrasound for the Hospitalist.
Let's take a very typical presentation that
we see as Hospitalists all the time.
A 66 year old guy who's got a past history of heart failure.
Now he's got shortness of breath and edema.
He was found to have UTI, and probably pneumonia,
as well as his CHF being exacerbated.
So they're diuresing him and having him on
antibiotics for a couple days.
And their assessment is that he's still hypervolemic,
he's got pitting edema, peripherally,
and he's diuresed about three liters with the Lasix so far.
But getting more tachycardic,
and blood pressure's still fine.
So they decide to give a chest x-ray to
further assess his fluid balance before
they diurese him further, because the clinical picture
doesn't quite fit with what they think,
he's still quite volume overloaded.
His hypertension gets worse, and his tachycardia worsens,
and they're worried he's got a possible PE.
So they transfer him.
When he arrive here, up in the upper green box here,
you've got a normal inferior vena cava,
and a nice, normal respiratory collapse, normal size.
His inferior vena cava, when he arrives,
is nonexistent, it is this tiny little slit that
opens every once in a while, just during expiration.
And here it is over on the right side in short axis.
You can see this little eyeball winking at you every once in
a while here, and that is the inferior vena cava.
So a virtually nonexistent IVC, consistent with an
extremely low, single digit central venous pressure.
Here's a nice, normal parasternal long axis,
with normal squeeze.
And here is his left ventricle,
in the parasternal long axis.
Note he's tachycardic,
and his fractional shortening is increased here.
So he has a hyperdynamic tachycardic left ventricle in
the setting of a single digit CDP,
based on his very flat inferior vena cava.
So he is intravascularly not volume up.
So how do assess that?
We use neck veins when they're visible.
They're great and they're helpful and
they're a classic physical exam finding.
They're not always visible based on patient body habitus,
and somewhat tough to interpret.
It takes a while to become an expert at
neck vein identification.
So inferior vena cava acts as a surrogate for
the same thing that neck veins tell us about,
the right atrial pressure, or the central venous pressure.
Here is a example of a correlate to a very flat neck vein.
The CVP, like we just saw in the single digits,
whereas here, this is consistent with
elevated beck veins with a distended inferior vena cava and
minimal collapse here with respiration.
Central venous pressure tells us something about
right sided filling, about volume status,
but is separated from what we really care about
on the left side of the heart.
And central venous pressure or inferior vena cava doesn't
do a whole lot for telling us about
what we really care about in the end, which is,
is this person who's hypertensive going to
respond to a fluid challenge or a fluid bolus?
So we can get one step closer to that question with
ultrasound, and the way we do this is with
a few cardiac measurements, and a patient who's sitting up,
we're gonna measure the LV outflow tract
diameter right here, which is 2.2 centimeters.
And then we're going to put a doppler gate in
the LV outflow tract.
So here's the left atrium, left ventricle, aortic valve,
and LV outflow.
You can do that either in the apical three chamber or
in the apical five chamber, as is shown down here.
And with doppler we're gonna measure their BTI,
which is gonna give us a stroke volume,
combined with the heart rate,
is gonna give us a cardiac output.
So, we can either give that person a fluid bolus,
or we can lay them down, raise their legs,
and as we raise their legs, that fluid that's sitting in
their legs, a couple hundred CCs
gets mobilized to the central circulation,
and acts as a small fluid bolus.
Then we repeat the ultrasound, everything stays the same,
with the exception of heart rate and VTI, or stroke volume.
And we see what does the stroke volume or
cardiac output do with that little fluid bolus?
In tis example here, there is a significant improvement in
cardiac output with the leg raise.
This is equally accomplished by giving the person 250 CCs of
fluid and seeing if there's an improvement in this.
So this is getting one step closer to that question.
We ask all the time,
"Should I give this guy some fluid, yes or no?".
An equally important question for Hospitalists is,
you've got a patient with heart failure,
who you are diuresing, and you want to take off just enough,
but not so much that you bump their kidneys and
you bump their creatinine and
you worsen their renal function.
We do this not infrequently, and what it results in is
usually, no longterm harm, but if someone's ready to go,
from a heart failure standpoint, they've been diuresed,
they're not short of breath anymore,
but they're bumped today, and we're gonna
keep them one extra day, add one more day to their length of
stay just to make sure that
their kidneys turn around and come back down.
So here's a good example of one that is in play.
You've got a 76 year old guy with heart failure,
with preserved EF, he's got a big left atrium,
he's got a thick wall,
tiny little pericardial effusion here.
And he's got elevated right sided pressures with
a big, distended IVC,
and he's got bilateral interstitial syndromes, diffusely,
which is consistent with pulmonary edema.
His weight's up, and his creatinine is
a little bit above his baseline, which is not normal.
You can diurese this guy and follow neck veins or CVP,
or inferior vena cava.
And you do that this way.
As he diureses, the IVC becomes smaller and
more collapsible until it is consistent with a very low CVP.
And if this guy doesn't have pulmonary hypertension,
doesn't have tricuspid rigor, et cetera, et cetera,
the right sided pressures can be helpful in following what
his left sided filling pressures are.
However, most of these patients have
some other abnormality that makes the
CVP not a great surrogate for what
their left sided filling pressures are.
So we need to go a step further,
and let's go a little bit closer to the left side of the
heart, and let's combine one ultrasound with
the inferior vena cava.
This guy starts up here in the upper left hand corner in
this example, and he has florid pulmonary edema,
diffused b-lines everywhere you look,
he's on BiPAP, and his Sats are low in the ICU.
As you diurese him, his inferior vena cava stays big and
dilated, his pulmonary picture improves slightly,
his b-lines are decreasing in number.
The more and more you diurese, the better he feels,
the less oxygen he needs,
the less prominent the b-lines are,
the more scattered they are, the less diffuse they are.
And you continue diuresing, and there are fewer and
fewer b-lines, and now you have a nicely collapsing IVC and
the patient is feeling pretty darn good.
And here the patient feels good, you've got
a couple b-lines left, which are gonna be present in the
absence of shortness of breath and hypoxia.
The b-lines are so sensitive here,
but they are present on the ultrasound long before
hypoxia and clinical shortness of breath are present.
And this is probably a good spot to stop.
He has no symptoms anymore, his b-lines are resolving,
his right sided pressures look good.
And if you go one more step here to the
completely flat inferior vena cava,
and his creatinine bumps, maybe you've gone a
little bit too far.
And your lungs are pristine here,
there is not a single B line left.
So using lung combined with IVC,
is getting one step closer to, what are the
left sided pressures, the wedge pressure,
the left atrial pressure doing?
But let's go advance one more time here,
and go all the way to the left side with
the surrogate marker.
And we're gonna do this with doppler,
and the first piece we're gonna do is mitral inflow.
So the doppler gate here, right at the tip of the
mitral leaflets, looking at mitral inflow,
coming towards the probe.
And this is the E phase, and the A phase of
diastolic filling through the mitral valve.
This is the E and the A wave,
and we can measure what's the E velocity right here,
then we're gonna put the gate on tissue right here,
at the medial mitral valve, right on the septum.
And we're gonna ask the machine to tell us how well that
heart is relaxing there.
And we are gonna get movement away from the
probes allotted on the bottom of the line here,
in the same E and A phase of diastole.
And this is the septal E prime,
or the tissue doppler E phase.
If we take the blue star, so the mitral inflow E,
and we divide it by the tissue doppler E prime,
we get a number that is related to left atrial pressure.
And this is a non-invasive assessment of left sided or
wedge pressure that we can follow in patients.
So taking us from IVC to lungs plus IVC,
all the way to a left atrial pressure assessment,
and a combination of those things can
help us manage diureses in our heart failure patients so
that we don't bump every one of them's creatinine and
keep them for an extra day in the hospital,
we find tune things a little better.
We get very used to treating heart failure,
and then every once and a while we get surprised and
have an additional tool to help avoid those
surprises is helpful.
That's what this demonstrates.
So a 38 year old guy who's short of breath,
and comes in hypertensive with a headache.
Everything looks like heart failure.
He's got crackles bilaterally, he's hypoxic,
he's got a systolic ejection murmur.
And the chest x-ray is consistent with heart failure.
He has a big heart.
So he gets diuresed, and he gets IV ace-inhibitor.
He pees a ton and his pressure drops a ton.
He passes out and diureses is stopped,
and he's gonna get admitted to the intensive care unit,
because of his hypotension.
And Hospitalist puts a probe on his chest,
and this is what his heart looks like.
So he has a hyperdynamic kissing left ventricle,
so function is great from a squeeze standpoint.
He's got thick walls,
and if you look very closely,
right here in the LV outflow tract, in systole,
systole, systole, systole, systole.
You see a little white dot populating the
LV outflow tract in systole.
And this is the anterior mitral leaflet,
so this is systolic anterior movement of the mitral leaflet.
And this patient has
hypertrophic obstructive cardiomyopathy, ....
And the further you diurese this patient,
the smaller his LV chamber gets, the more he obstructs,
and you can kill these patients by over-diuresing them.
He needs some volume and his heart to
be slowed down here a little bit.
So heart failure, super common, COPD, equally as common,
for us as Hospitalists.
And the combination of those two is always a part of
our daily lives.
Sorting the two out, is this patient short of breath today?
He comes in with a little cough, a little bit of edema,
feeling a little more short of breath.
Is is because of his heart failure,
some diastolic disfunction and an EF in the 40s?
Or is it because of his COPD?
And teasing that out can be really difficult.
Labs don't give us a ton of information all the time,
they can kind of leave us in the gray land of
a pretty big differential diagnosis in these patients.
And the way we treat this typically is
we give them antibiotics for their pneumonia,
we rule out Pneumo and PE, we treat their COPD with
some steroids and some NEBs,
and then we treat the possibility of some heart failure or
that interstitial markings on the
chest x-ray with diuretics.
And they usually get better,
because we've treated everything.
But once again, we can do this a
little more elegantly with ultrasound.
So let's take a look at this guy in this example.
He has a terrible ejection fraction,
a severely reduced LV systolic function,
he's got a big left atrium.
He has an inferior vena cava consistent with
elevated right sided pressures,
along with small bilateral pleural effusions,
and then his right upper, left upper, left lower,
and right lower lung fields all have b-lines.
So a diffuse interstitial bilateral pattern with
elevated pressures, pleural effusions,
and a heart that looks like systolic heart failure.
And this is heart failure, and needs diuretics.
Alright, let's take him on a different day,
where he's got the same heart,
but today he's got a flat inferior vena cava,
because he's been sick for about a week.
He has normal lungs in his left upper, left lower,
and right upper fields.
But in his right lower lobe, he's got consolidation with
a small pleural effusion,
and he's got dynamic air bronchograms.
Here's a closer view of his dynamic air bronchograms in
a consolidated lower lobe.
And he has a low bar pneumonia today.
He is volume depleted, intravascularly,
with the flat inferior vena cava.
And diureses in this guy today in only gonna harm him.
And this guy needs antibiotics and
maybe some COPD medications if he's exacerbated.
But clearly does not need diuretics,
because he does not have pulmonary edema.
And one more day, kind of a more
typical IVC for someone with COPD,
and some elevated right sided pressures, maybe.
He's got the same, normal, terrible heart,
but he has clean lungs everywhere you look.
And there's no way to be short of breath from
pulmonary edema without b-lines on your lung ultrasound.
Lung ultrasound is so sensitive for interstitial processes,
when they abut the pleura,
like pulmonary edema does typically.
This rules out that this guy is clinically short of
breath from pulmonary edema today,
and this is just his COPD.
Despite the couple crackles,
despite indeterminate chest x-ray, despite the
BMP that's in the middle ground,
this guy is not short of breath from pulmonary edema.
So we get very used to seeing CHF and COPD and
kind of have a reflex of treating it.
This is an example where a tool with
a little better diagnostic ability sometimes is helpful,
when we get into those routines as Hospitalists.
A 62 year old guy who says, "My COPD is going crazy because
"I ran out of meds.
"Treat me for my COPD exacerbation.".
You get a peak at his heart and his left ventricle.
This is kind of an off axis apical four chamber,
two chamber view.
Here's his left ventricle, which is hyperdynamic.
His left atrium is very large and
something doesn't look right with his mitral valve.
So you put color flow on it and he's got
wide open mitral regurge, so severe MR.
And you get another view of his mitral valve,
and without any color on it, you know this mitral valve is
not normal, these leaflets do not coapt,
and he's got a flail mitral leaflet here.
Zoom in on it and there you can see it even nicer.
They just criss-cross here and they don't coapt well.
So what sounds like COPD from a patient standpoint,
you should be able to hear this murmur.
But we get very into the routine of treating things that
are common to us, and this can help us avoid that
pit fall sometimes.
Let's take a little different view now,
move out of the heart and the lungs,
and let's go to the belly, the other high yield area,
and take acute renal failure that comes in the
middle of the night, and we admit it as Hospitalists.
New renal failure and the differential there,
as everyone is well familiar with,
is pre-renal, post-renal, and intrinsic renal.
And this guy's got a reason, possibly, for all of these.
And our typical approach to these people is
let's assess them for pre-renal, give them some fluids.
Let's make sure that this 70 year old guy doesn't have
a big prostate with post-obstructive or
with post-renal failure, and put a Foley in him and
get a formal kidney ultrasound in the
morning to reload hydro.
And then if neither of those fix things,
we can go down the intrinsic renal route.
So we put a lot of Foley's into
people with acute renal failure.
This Foley that goes into this bladder here doesn't
do a lot of benefit.
This is an empty bladder, and this is how a bladder should
look after it has a Foley in it.
But we try to avoid putting Foley's into this bladder,
because it's not helping anything in the
acute renal failure patient.
It's just an unnecessary Foley, potentially.
This is the Foley that's in place in a
distended bladder with probably a liter or
so of fluid in it.
And this Foley is not draining, because of the
hyperechoic clot that is in this bladder here.
So this is a Foley that's in place.
We can use the ultrasound for Foley troubleshooting,
and to avoid some Foleys that we don't need.
So let's take that differential and use ultrasound to
do this a little more elegantly.
Let's look at the inferior vena cava,
and the person who comes in with acute kidney injury.
This guy's got a flat, dehydrated looking IVC,
and has a nice, normal looking kidney here.
So this is pre-renal to start with at least.
Let's look at the middle picture here.
So we've got a big, distended bladder,
over a liter of fluid in this bladder.
And you look at the kidneys,
and he's got these little black fingers starting to
project out of the center of the kidney, and this is hydro.
It's present on both sides.
So he's got a big bladder with bilateral hydro.
And this guy in this example has a big prostate as well.
This is the patient that needs a Foley put in.
Finally, this guy on the right here,
you look at the bladder, the bladder is not distended.
And you look at his inferior vena cava,
goes along with a nice, normal central venous pressure.
So probably not super dry.
And you look at his kidneys and he's got
normal looking kidneys.
And this is the tougher, intrinsic renal.
But this guy doesn't need the empiric Foley because
he doesn't have a bunch of urine in his bladder.
And that helps stratify which one of these three arms are
you in, very quickly in the middle of the night.
So those are some big hitters for us as Hospitalists.
Heart, lungs, some of the belly stuff,
kidneys and bladder.
And the other big area for us as
Hospitalists I procedural guidance.
So we're gonna jump a little bit and talk a little bit about
what has become really best practice,
as a very evidence based area of point of care ultrasound.
It is easily learned by people who have
done central lines or thoras for 20 years without it,
as well as new residents in training.
And we're not gonna go way into the literature on this,
it's extremely evidence based.
We're gonna talk about a few nuances about
procedural guidance for Hospitalists.
We do about 500 procedures a year on the procedure team,
and a pretty nice mix here of what Hospitalists do in
their clinical practice.
The key here is that if you look at everything we do
on the procedure team, procedure wise,
this is the total volume of procedures.
And the vast majority of these we do with ultrasound.
If you look at what we do not do with ultrasound,
this is what's left.
We do over half of our lines with ultrasound,
we do some very difficult third or fourth tri art lines.
We don't do any paras without ultrasound.
We don't do any central lines, except for the rare,
occasional resuscitation coding line.
We don't need them for skin biopsies,
we need them for almost half of our LPs.
And we do a lot of LPs on the obese, vented patient in
the Intensive Care Unit that can't move to
interventional radiology for floral.
We use it on a lot of joints.
Anytime we're gonna poke an abcess or
what we think is an abcess and drain it, we use ultrasound.
So we use ultrasound for the
vast majority of our procedures.
Central lines have become standard of care with ultrasound,
and we use it, and here's a little additional piece we do
in the patient who's unstable.
We'll look at their ipsilateral chest for
lung sliding before we put a central line in,
which is shown up at the top here, number one.
Some nice lung sliding, which rules out pneumothorax on that
side, and tells us that the lung is sliding as well.
We put the needle in with ultrasound guidance,
watch it into the vessel, and then through that,
we thread the wire, and we confirm that the
wire is heading caudad within the IJ.
The next step is we get a subside point view after the
catheter is in place, or an apical view.
And right here, around this blue,
is where the SVC enters the right atrium.
This patient has a pace maker wire going from
his right atrium into his right ventricle here,
which is that hyperechoic line.
But if you watch right here, we take a saline flush and
we flush it through the distal port on the central line.
And you'll see a little stream on bubbles come right out of
here right now, and then pass into the RV.
We don't see the tip of the central line here,
so this central line is very close to the RA,
but not in the RA, and it's in the SVC.
And we use this line immediately at the bedside in
someone, if we need to start pressers without waiting for
a chest x-ray.
Finally, we write our notes and we clean up and
we come back after and we look at the same side of the
chest anteriorly, to make sure that
there's no pneumothorax present.
And that's how we expedite using that central line,
and do a better job of ruling out pneumothorax than
a portable chest x-ray in the
semi-upright ICU patient on the vent.
Thoras, we use all the time.
We have a similar approach to
making sure there's no pneumothorax prior to.
With lung sliding, we use ultrasound to
guide our exact enter space, entry point.
There's a nice ateletatic lung tip again with
a free flowing pleural effusion, no loculations here to
change what we're gonna do.
We drain, and then after, we look again.
Here is a zoomed in view of abdominal and lung.
This is a nice curtain sign with
a completely dry pleural space here,
and a re=expanded lower lobe after the thoracentesis.
Over here, we have a different picture.
We've got some pleura fluid left.
This guy had a bunch of pressure and coughing towards the
end of the procedure.
And the reason probably is that his lower lobe here
didn't expand after the fluid drainage,
and he's gonna reaccumulate that pleural effusion unless the
mucus plug that is in that lower love is removed.
And then finally, we come back and we make sure there is
no new pneumothorax present after the procedure as well.
So we do ultrasound in a lot of procedural settings to
speed up or replace the portable chest x-ray.
And the portable chest x-ray gets some use still,
but is decreasing in its value.
It's great for big questions,
but here in this heart failure looking,
some pleural effusion, some interstitial,
maybe atelectasis sort of read,
this could be a lot of things.
And we use ultrasound not only for
procedural replacement of portable chest x-rays,
but also to help differentiate what is this?
Is it a big pleural effusion with some atelectasis?
Is it a consolidated pneumonia with
dynamic air bronchograms?
As you see here.
Here is another dynamic air bronchogram consolidation,
with a small pleural effusion.
Or is it a completely atelectatic lower lobe with
a smallish effusion?
And this is a picture of a mucus plug here.
So all four of those are very different clinical scenarios
with portable chest x-rays that can look very similar.
The chest x-ray itself also has some benefit when
we add ultrasound to it.
Here is a pleural effusion that's being treated as
a heart failure pleural effusion based on the
chest x-ray and trying to diurese.
When we put the ultrasound probe on it,
there is clearly more here than just
a transudative heart failure effusion.
We have tumor all over the diaphragm and over the lung here.
So this is not just heart failure.
So it helps our chest x-rays.
Does it go beyond what a CT can tell us?
And the answer is yes, sometimes.
This is a guy with heart failure,
who has a chest x-ray that has a
left pleural effusion on it.
And as an out-patient,
he tries to get diuresed significantly.
It doesn't get much better, so they get a CT scan as an
out-patient to make sure he doesn't have a PE.
And he has this persistent atelectasis with
pleural effusion.
He comes in because he got diuresed too far,
and his left pleural effusion actually got
bigger since the out-patient chest x-ray.
And he's hypotensive and his kidneys are dry.
So we come to tap them,
and here's what his ultrasound looks like.
Here's the diaphragm, the hypoechoic pleural effusion that
has several fiber strands and appears some loculations.
Here's the base of the lung, the lung stops right here,
and this is a tumor sitting on top of the diaphragm.
He goes on to get biopsied,
and this is a synovial sarcoma in this guy's pleural space.
And even in retrospect back on the CT,
really hard to tease out that there's anything other than
atelectasis present there.
So ultrasound benefits for sure with the
portable chest x-ray gives us more information,
and sometimes even helps us with the CT scan.
Sometimes we are without CT scans and without x-rays and
the stakes are very high in those times.
And ultrasound has a huge value here.
So this is a guy in the middle of the night,
2:15 in the morning, in a quaternary car center ICU,
who goes into a PEA Arrest on the vent.
The HNTs are really not in play here.
In hospital PEA Arrest, this is hypovolemic shock,
maybe hemorrhagic, maybe not.
This is I need a needle,
this is I need a needle somewhere else and some volume.
This is I need some lytics, or this is cardiogenic shock and
pump failure, and send me to your cath lab or
put me on ECMO.
But it's one of these five areas most of the time,
in house for the PEA Arrest.
Very rarely is it a still heart in all five of these areas.
We have an intervention that we can potentially fix if
we identify it quick enough.
So ultrasound sits right next to our code carts on
every floor of the hospital.
And ultrasound for sure for the PEA Arrest is involved in
almost all of our codes.
How do we do it?
So you gotta be able to get a window,
get a subside ... window or an apical window,
either between or during compressions,
to try to help sort out which of these five is it.
And here's how you do it,
in about a minute and a half, usually.
Give yourself about 20 seconds, 15, 20 seconds,
and if you see sliding bilaterally,
as in the green image up top here,
not pneumothorax, as is demonstrated down here.
You have ruled out number one in your differential of
five things here, in about 20 seconds.
He does not need empiric chest tubes.
Next take a picture of the heart,
whether it's apical or the subside void or
the parasternal, or whatever it is,
get an image of the heart.
Here's a parasternal long axis example,
and this is when our patient had a big,
distended right ventricle.
The septum has shifted over into the
underfilled left ventricle.
It's not a nice, normal looking heart like this.
It is not tamponade, and it is not sever cardiogenic shock.
So you have ruled out tamponade, you have
ruled out cardiogenic shock,
and you are left with a couple things left on your list.
So you go to the inferior vena cava,
and he does not have a totally flat, hard to find,
it takes you five minutes to get there, inferior vena cava.
So this is probably not hypovolemic shock.
He doesn't have a normal IVC, this guy's got,
again in the green window, a big,
distended IVC with no collapse.
So you go to his groin, here is his right femoral vein on
the top, that collapses when you push on it.
And then his left femoral vein,
even when the artery compresses here with
compression, does not collapse.
So he has a big thrombus here in his left femoral vein with
a big RV, elevated pressures.
And this guy gets Lidex pushed at 2:15 in the morning.
He has five minutes of CPR with a
mechanical compression device,
and he leaves the hospital with no neurologic deficit.
That's how your PEA differential in house gets done in
about a minute or a minute and a half,
and how you choose an intervention that is
really tough to choose empirically.
So of all things, this I think is going to
become standard of care.
That's just the right way to take care of
these really sick patients in house,
and they don't have the PEA Arrest.
The same thing applies to the
really hypotensive shocky patients we see all the time.
And when you've got sinus tach, PEA Arrest,
or narrow and fast PEA Arrest,
this is where ultrasound just has to be
involved in these patients.
Because it is very quick to give you which of
these five things are in play and which are not.
As Hospitalists, we are at the center of
some of medicine's most complex hunts.
Out ability to take optimal care of our patients in
the hospital is directly related to our diagnostic ability,
which is very tightly tied to the
tools we've got to go searching.
MRI scans, CT scans, x-rays, traditional physical exam,
formal ultrasound, are all crucial to optimal care.
I hope that you realized during this talk that
the addition of point of care ultrasound in
the hands of the Hospitalist at the bedside taking care of
the patient in real time, is truly additive to all of
those other tools we've got.
In addition, it allows us to integrate findings in
real time at the bedside, take one piece of data and
add it to everything else we know about a patient.
And those two things together is really what
our diagnostic ability is about.
But if our diagnostic ability was all we were as
internal medicine physicians, we would be missing something.
A huge part of who we are and what we do is about
the relationship that we have with our patients.
And the occasional argument against point of
care ultrasound in the hands of Hospitalists or
internal medicine physicians, based on the idea that
replacing the stethoscope or the laying on of hands with
a piece of technology is going to hurt that part of
internal medicine, the patient relationship,
just does not hold water.
The first time or the 600th time your at the bedside with
a patient and you have an ultrasound there and
you are demonstrating to that patient what
is going on with them on the screen,
you're explaining to this patient heart failure while
you're showing him his left ventricle,
explaining why he can't get up the stairs to
sleep on the second floor,
or why he needs to take his Lasix.
If anything, the relationship is improved here,
because the patient understands his disease far better,
because you have spent time at the bedside with the patient.
And patient understanding of disease and satisfaction is
something we care a ton about,
something we get rated on,
but we also just care about as internists.
And HCAP scores and how well do you understand your disease,
how well did people explain things to you?
This tool at the bedside nothing but helps all of
those aspects of what we are as internists.
I will close with one slide here just about
what next steps you can take.
And this is a huge talk by itself,
but let me give you a few pointers about what the
first steps might be, as a Hospitalists who's trying to
start doing point of care ultrasound.
And the key is finding others around you,
whether it's in your hospital, or if there are none in
your hospital, in the community around you.
There are people, and that number is growing exponentially.
A good starting spot is procedural guidance.
It's very evidence based,
it is clearly a patient safety benefit.
There are cost savings to procedures at the bedside,
and with ultrasound involved in the right hands,
there is no safety difference.
So this is a great spot to start if you're looking for
a niche to get a machine and to get it introduced.
Education beyond that and even within that.
There are tons and tons of conferences.
The ACP, the American College of Physicians,
Society of Hospitalist Medicine,
both have courses at the national conference this year.
ACP has the two day pre-course,
American College of Emergency Physicians,
the Society of Critical Care Medicine,
the World Congress on Ultrasound and Medical Education,
these are all great national forums for education.
There is a ton of online education as well.
One of the best podcasts out there is the
Ultrasound podcast, at ultrasoundpodcast.com,
does a great job of covering all sorts of topics.
Sonositeinstitute.com has great resources as well.
Videos and three dimensional and lots of
different pieces for online learning.
Doctor Chris Fox at the University of California Irvine,
has a huge curriculum on iTunes University that's free.
And then there are many eBooks of
which the ultrasoundpodcast.com has two of
the best free eBooks available there.
And then engage in some collaboration,
whether that's at national conferences,
like the Society of Ultrasound and Medical Education,
or the American Institute of Ultrasound and Medicine,
those conferences are great spots to collaborate and
research across institutions,
but also within your institution with
cardiology and radiology, really is a huge piece to
moving this forward and breaking down the
political pieces that can exist when trying to
start point of care ultrasound as a Hospitalist.
Hopefully that talk's helpful,
and hopefully it gives you a little bit of
excitement around point of care ultrasound for
the Hospitalist, but also demonstrates really the
imperative need for it if we want to take the
most efficient and best care of our patients going forward.
Thanks very much.

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Sonosite Synchronicity Introduction

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- [Narrator] A better way to report
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The number one cause of physician burnout is paperwork,
but with Sonosite Synchronicity Workflow Manager,
everything you need is just a click away.
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Sonosite Synchronicity software helps you
minimize billing errors and enforce
compliance for better financial returns.
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Interface all point-of-care ultrasound
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so you can generate reports faster than ever.
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Streamline credentialing by automating reports
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Less screen time, more patient time.
Sonosite Synchronicity Workflow Manager.
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- [Narrator] Sonosite's history of reliability
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We revitalize pre-owned machines
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This rigorous 10-point inspection ensures the reliability
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It starts with a device history analysis,
including not only the records associated
with the original manufacturing,
but also any customer-reported service events.
From there, we run a comprehensive suite of tests,
updating software with the latest patches and upgrades.
Wherever necessary, components are swapped out
for the most up-to-date hardware.
Appropriate safety checks are performed
to ensure system specifications are met.
And finally, a certified sonographer
ensures the precision and reliability
of every ultrasound machine.
A comprehensive 12-month warranty
backs up the entire process,
so you can focus on improving patient outcomes.
Sonosite pre-owned ultrasound devices.
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