Do It With Heart: Pre-Intubation Point-of-Care Echocardiography for Hemodynamic Optimization

Have you ever wondered why that patient coded after endotracheal intubation? As it turns out, it is not uncommon after critically ill patients are intubated. Approximately 60% of critically ill patients require endotracheal intubation and are at high risk for hemodynamic collapse during this procedure. Prior studies suggest that there is up to a 25% risk of hemodynamic instability even in successful critical care unit intubations. Therefore, it is crucial to prevent peri-intubation hemodynamic instability to avoid poor patient outcomes through hemodynamic optimization prior to endotracheal intubation.

Point-of-care ultrasound has evolved as a simple, portable, and noninvasive tool for assessment of hemodynamic status. It can provide invaluable information about diagnoses and direct resuscitation in critically ill patients. This bedside imaging modality can help determine the etiology of shock, guide appropriate interventions prior to patient decompensation, and assess patient response to management changes. It can also assist in the evaluation of intravascular volume status and fluid responsiveness of critically ill patients.

Endotracheal intubation is especially perilous for a patient with right ventricular failure. Performing this procedure in patients with right ventricular failure can result in catastrophic hemodynamic collapse since the right heart is very sensitive to increases in afterload. Right ventricular failure resulting in hemodynamic collapse is an underappreciated complication of patients undergoing intubation and invasive mechanical ventilation.

Echocardiography during the preparation period of intubation allows for direct and noninvasive visualization of the right ventricle at the bedside and can play a major role in the stabilization of critically ill patients. Pre-intubation echocardiography can prevent hemodynamic deterioration by identifying a failing right ventricle, which is extremely sensitive and unable to compensate for any increase in afterload or decrease in preload from endotracheal intubation. Pre-intubation echocardiography can detect signs of a deteriorating right ventricle (pressure and volume overload) such as right ventricle dilation, bowing of the interventricular septum into the left ventricle, decrease in the size of the left ventricular cavity, and decreased left ventricular filling leading to decreased cardiac output (Figures 1–4). If acute right ventricular failure is identified prior to endotracheal intubation, it can help the physician select appropriate management strategies prior to intubation and avoid hemodynamic instability.

 

With pre-intubation detection of right ventricular failure, different strategies can be implemented prior to endotracheal intubation to avoid hemodynamic collapse. Non-invasive positive pressure ventilation can be an alternative in some cases, which has a less pronounced effect on venous return and preload compared to invasive mechanical ventilation. In the setting of pulmonary embolism (or pulmonary arterial hypertension), inhaled nitric oxide can be used to decrease pulmonary artery pressure through pulmonary vascular dilation. Other strategies to avoid worsening right ventricular failure include administration of vasopressors prior to endotracheal intubation and avoiding intravenous fluid boluses.

Pre-intubation echocardiography is a crucial step in the protocol during endotracheal intubation of critically ill patients to prevent poor patient outcomes. It allows clinicians to approach endotracheal intubation-associated hemodynamic instability in a specific, targeted manner. Integration of pre-intubation echocardiography can vastly improve the management and safety of critically ill patients, in hopes of decreasing the risk of poor outcomes.

 

Srikar Adhikari, MD, MS, FAIUM, is a professor in the Department of Emergency Medicine at the University of Arizona Medical Center.

Interested in learning more about POCUS? Check out the following posts from the Scan:

 

CLEAR!

We all have come upon a machine, unplugged, with old gel caked on a probe or worse (see figures 1 and 2 attached), with the images from the patient from the last exam, labeled on the image that was not closed. Now you have to take time before you can even start YOUR ultrasound exam. It is this variation from machine homeostasis, a steady-state of readiness for the next operator, that was the impetus for CLEAR. How can the last operator help the next operator? CLEAR!Figure 1. Curvilinear probe with left over gel

The 20th-century paradigm for ultrasound was a clinician ordered the exam and the patient went to a suite and a sonographer saved images and videos. That sonographer would clean their own machine between patients as there was one machine for the same operator. Their images were read by the imaging specialist and that person relayed back to the clinician the results of the imaging study. These types of ultrasound exams still occur and are billed differently. We call them comprehensive ultrasound exams or referred ultrasound exams.

In contrast, a point-of-care ultrasound (POCUS) exam finds the ultrasound equipment more portable and accessible as the price point has lowered. There is usually one machine and multiple operators who use this same machine. In each case that the operator acquires, interprets and uses the information in clinical management at the patient’s bedside without sending them to an imaging suite. The cleanliness of the machine is up to the person who used it last.

Figure 2CLEAR is the acronym and checklist for the components necessary to keep a machine in good working order for patient care. As a provider of emergency medical services and having a strong interest in ultrasound, I have seen the utility of POCUS in the medical setting. It was not called POCUS in the early days, yet machines and operators have been using, and will continue to use, ultrasound for patient care as this movement grows.

CLEAR is about machine homeostasis, ie, getting the ultrasound machine back to a steady-state to be ready for the next patient. The tagline for CLEAR or machine homeostasis is “The last operator is connected to the next operator; YOU may be the next operator.” The message that is intended is leaving the machine in good working order for the next case that needs ultrasound. CLEAR is 5 simple steps to get the machine ready for use and in good working order:

Clean – Clean the machine. In the era of COVID, this might mean twice (in the room, outside the room, and all surfaces)
Locate the machine – Is it in the correct place?
Energize – Is the machine plugged in? Are all the connections tight and working?
Augment supplies – Do you have enough gel, packets, wipes, other supplies?
Remove patient identifiers – Each case should have an accession number and other metadata, which will need to be removed from the machine before the next use. This can usually be accomplished by ending the exam and starting a new exam.

The purpose of CLEAR is to help the operator learn the steps to perform after doing the ultrasound exam.

These can be simplified as:

Clean the machine.
Locate – Put it back to where it is supposed to reside.
Energize – Plug it In!
Augment – Replace supplies, including adding gel for the next person.
Remove – Patient information. End the exam.

The time is not yet here when all patients, or at least all providers, have their own personal ultrasound machine. In the meantime, we share the machine with other doctors and nurses and others. Remember, when sharing ultrasound machines, CLEAR the machine so the next user/operator is ready to go. Our patients will be thankful, as will the next user. You may be the next user! CLEAR the machine.

To read more about CLEAR, check out the article, “CLEAR: A Novel Approach to Ultrasound Equipment Homeostasis,” in the Journal of Ultrasound in Medicine (Prats MINelson BPGold DLBranditz LDBoulger CTBahner DP. J Ultrasound Med. 2019; 38:767–773. doi: 10.1002/jum.14757. Epub 2018 Aug 19).

 

David P. Bahner, MD, FAIUM, FAAEM, FACEP, is Professor and Director of Ultrasound in the Department of Emergency Medicine at The Ohio State University College of Medicine.

Interested in reading more tips for ultrasound use? Check out the following posts on the Scan:

 

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Hey, Ultrasound! What Did I Do Without You?

I trained as a physiatrist, which means a great deal of education on musculoskeletal conditions. Over the course of my residency training, I became more and more comfortable with bony and soft tissue landmarks for examination and targeting various joints, nerves, and tendons for therapeutic injections. As I was supervised by attendings, and carefully followed their instructions, there was no doubt in my mind that the tip of my needle was at the target intended. Why would I doubt a common practice that has been in existence for several decades?Mostoufi

As I started my fellowship in spine/pain/musculoskeletal care, I found the love of my life, the fluoroscope!!  Here, I had access to a tool that made life incredibly easy. I actually could visualize my targeted hip, shoulder, or facet joint, and inject some contrast to identify the needle tip within my target. I could precisely deliver therapeutic medications to a particular nerve root, and even identify vascular uptake and avoid procedural complications.

It was then and there that I realized that there were substantial shortcomings in what I learned as “landmark-based injections”. I realized that even though I had learned the proper “blind” procedure technique, there was no confirmation that my medication had reached its intended target. More importantly, if my patient did not respond to the procedure, I could not differentiate between a medical condition that was not responsive to the treatment versus shortcomings of un-guided procedures and inadequate delivery of medications to the targeted tissue/joint. For 12 years, I confidently treated thousands of patients by performing spine and musculoskeletal injections using my fluoroscope. I enjoyed using my C-arm, and life was pretty good.

In 2011, while attending a PM&R national conference, I sat through a 15-minute presentation on overdiagnosis of trochanteric bursitis. The speaker eloquently described fluoroscopic-guided bursa injection. This was something that I did on a regular basis as a diagnostic step. He then used ultrasound (US) images to demonstrate a few cases of gluteus medius tendinopathy and also trochanteric bursitis and how US can be superior to X-ray in therapeutic sub-gluteus maximus bursa injection. While sitting and listening, I recognized that it was virtually impossible to press against the lateral trochanter and be accurate about the diagnosis. It is also not possible to use fluoroscopy and be sure that the steroid or regenerative treatments are correctly delivered to sub-gluteus maximus bursa.

Remembering how helpful fluoroscope was to identify particular bony landmarks and assist with the proper treatment of spine and joint disease, here I was discovering a new tool that can enhance diagnostic and therapeutic skills in musculoskeletal care in particular soft tissue disease (nerves, muscles, tendons). This meant a fundamental change in the way I was going to treat patients but also a change in how I train the next generations of Physiatrists, coming through our residency program.

Fig 3aFig 3b

Learning to use the US, and incorporating it into the practice was much harder than I envisioned and also very expensive. At the time, there were limited well-structured educational resources available, and the learning curve was quite steep. As I was learning, I had to beg (or pay) my kids to become my scanning subjects!!

In contrast to a fluoroscope, it is nearly impossible to recognize an abnormal structure on the US unless you are comfortable with the normal anatomy. With a ton of hands-on workshops, mentorship, practice, and with assistance from my new found love of ultrasound machine, and guidelines from the AIUM, ultrasound has become easier and more enjoyable!! The abnormal findings became more clear and treatments more effective. In this process, I found out that patients enjoy looking at the US screen and being explained about finding on a screen full of gray, gray, and grayer lines and curves.

US has transformed how physiatrists practice and teach musculoskeletal medicine. Point-of-care US imaging allows for the residents and fellows to visualize various organs or structures within an organ, recognize healthy and diseased tissue, and diagnose the problem on the spot. This, in turn, will lead to a quick and targeted treatment and satisfied patients.

Examples of musculoskeletal (MSK) conditions that US has proven to be an effective tool to workup or treat includes rotator cuff and biceps tendinopathy, small or large joint injections, upper extremity nerve entrapments, muscle and tendon tears, peripheral nerve lesions, carpal tunnel syndrome (CTS), intersection syndromes, trigger fingers, plantar fasciitis, piriformis and sciatic complaints, treatments of bursitis or tenosynovitis, iliotibial  (IT) band treatment, ischiofemoral impingement, and many diagnoses for which dynamic testing proves to be beneficial.

Fig 6

Despite its cost and extensive training/certification needs, utilization of US in MSK care is predicted to be a standard of care in the next 5–10 years. As more and more practitioners are trained, its use for diagnostic or therapeutic purposes will become the norm.

Fig 7aFig 7b

I still love my fluoroscope and prefer its use in most spine procedures. Adding US has revolutionized my practice and allows me to be a better diagnostician, a better MSK doctor and a better educator for both my patients as well as future providers that come after me. In short, US has been a game-changer.

 

Ali Mostoufi, MD, FAAPMR, FAAPM, is an Assistant Prof. in PM&R at Tufts University, and the president of New England Spine Care Associates (NeSpineCare.com) and Boston Regenerative Medicine (BostonRegen.com).  As a spine and sports medicine practitioner, his clinical practice focuses on Interventional Spine, Diagnostic US, US-based therapeutic interventions and Regenerative Medicine in spine and sports.

Interested in reading more about musculoskeletal ultrasound? Check out the following posts from the Scan:

 

Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community to share your experience.

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My Sonography Experience With COVID-19

It is been almost 5 weeks since I got infected with SARS-CoV-2 (also known as COVID-19), my life-changing experience.1

The day all started, during my night shift, I started with low-grade fever, chills, and myalgia; I did not doubt for a second that I had to have the test for SARS-CoV-2. That same day, most of my mild COVID-19 patients had these same cold-like symptoms, but some of them did not have a known epidemiological contact. Without time to have any other tests done, laboratory or X-ray, I self-quarantined at home waiting for the result. And finally, it came in the midst of the night; I received the “positive”.

In the morning, as more symptoms started to appear, headache, diarrhea, anosmia, ageusia and dry cough, it was a relief to have my hand-held ultrasound device at home. With the rush, I even left my oximeter, which measures heart rate and blood oxygen levels, in my hospital locker.

There is now growing evidence regarding the imaging findings of COVID-19, but at that time, the only studies were performed via CT scan and X-ray. With my ultrasound probe, I scanned following 8 zones (2 anterior, 2 lateral of both hemithorax) plus posterior lobes. I felt relieved (didn’t last long) to see there was a normal A-line pattern. More relief came when at some point I had a dull but constant right lower abdominal pain with normal appendix and no hydronephrosis on ultrasound.

 

What impresses most about this disease is its dynamic pattern, with sudden changes during the evolution. As my symptoms waxed and waned, so did my lung ultrasound, probably in a different manner than I would have expected. As the disease progressed, I saw all the possible lung findings, from the initial posterobasal scattered B-lines, to small pleural effusions, irregular pleural line, coalescent B-lines, and finally subpleural consolidations, especially in posterior and lateral areas. My personal impression was that I wasn’t feeling worse when I had more B-lines, but when the subpleural consolidations started to appear and spread. Each time I had new subpleural consolidations, there was a worsening in my symptoms coming: more myasthenia, cough, and diarrhea. After the second week, the subpleural consolidations were replaced by coalescent and scattered B-lines. Following that, the irregular pleural line persisted longer.

March 22 still

 

Surprisingly, during the third week, things started to worsen again, and on ultrasound there was a big consolidation appearing in one lobe, that was my sign for a therapy shift towards antibiotics.

My personal feeling is that consolidations are more reliable than just the number of B-lines, and correlated better with my symptoms. Actually, after 3 weeks from the symptom onset, after recovering and testing negative for SARS-CoV-2, I still had several areas with scattered and coalescent B-lines, as well as thickening of the pleural line. We have to be more flexible and take into account other parameters (i.e. oximetry), rather than rely solely on the number of affected areas on ultrasound, to compose the clinical picture, and influence the management.

As I remarked before, what impresses me most about this disease is the ultrasound dynamism. After having recovered, I still had new areas of thickening of pleural line that appeared in the back (asymptomatic) for the following week (4th), and almost 5 weeks after, I still had one plaque. And after 5 weeks, I am still surprised to have unnoticed findings, such as an asymptomatic pericardial effusion.

As a firm sonobeliever, I found it extremely useful to monitor my disease for sonographic progression and or resolution, and quickly detect complications. After this experience and having returned to work, I would have no excuse to irradiate my patients before scanning them, in the same way I went through.

Definitely, this experience was the best lesson I could have before returning to the trenches.

 

Yale Tung Chen, MD, PhD, is an associate professor at Universidad Alfonso X El Sabio, in Madrid, Spain. He was diagnosed with COVID-19 and shared his symptoms and ultrasound images each day on Twitter @yaletung. Follow his thread at #mycoviddiary.

Interested in reading about topics that could be of interest during the COVID-19 pandemic? Check out the following posts from the Scan:

Thank you

Thank you. 

Thank you to all of the medical professionals who are working tirelessly to care for the massive influx in patients resulting from the COVID-19 pandemic. Thank you for risking your own health to care for others. Thank you for taking the time away from your families. 

Thank you to the many medical professionals who have answered calls to action. 

Thank you to all of the truckers and production and store workers who are ensuring that everyone can still get the supplies and services they need.

Thank you to everyone who is remaining safe at home, despite going stir-crazy. 

Thank you to all of the parents who suddenly had to become home-school teachers. 

Thank you to everyone who has transitioned to working from home each day.

Coronavirus

Interested in reading about topics that could be of interest during the COVID-19 pandemic? Check out the following posts from the Scan:

 

Cynthia Owens is the Content Specialist at the American Institute of Ultrasound in Medicine (AIUM).

The Personal Touch: The importance of human interactions in ultrasound

As I write this, the novel coronavirus COVID-19 is spreading across the globe, inciting fear and anxiety. Aside from frequent hand-washing and other routine precautions, many leaders, officials, and bloggers are advocating for limiting person-to-person contact. This has resulted in cancelation of many professional society meetings, sporting events, and social gatherings, and has stimulated new conversations regarding working from home and virtual meetings. Although these suggestions have many clear benefits (such as the decreased burden of commuting; limiting the spread of infection), there are additional reports describing the impact loss of face-to-face interactions may have on job satisfaction, workflow efficiency, and quality.Fetzer-David-14-2

The current practice of medicine, more than ever, relies on a team approach. No one individual has the time, knowledge, or experience to tackle all aspects of an individual’s care. No one is an island. Unlike many television shows that highlight a single physician performing everything from brain surgery to infectious disease testing, the reality is that we each rely on countless other members of the healthcare team. That practice of medical imaging, ultrasound, in particular, is no different. Whether we work in a radiology, cardiology or vascular, or obstetrical/gynecology practice, the team, and more importantly the relationship between team members, is paramount to an effective and impactful practice.

As a radiologist in a busy academic center, I rely on and value my personal relationship with my team of 50+ sonographers. These relationships have been facilitated by day-to-day, face-to-face interactions, allowing me to get to know the person behind the ultrasound images. These interactions foster an environment of trust. For my most experienced sonographers, my implicit trust ultimately leads to fast, efficient and precise exam interpretations, while for sonographers I rarely work with, my index of suspicion regarding a finding is naturally heightened, impacting my confidence in my diagnosis and thus affecting my interpretation, and ultimately how my report drives patient care.

The trust goes both ways: a strong relationship also fosters honest communication whereby sonographers can come to me with questions or concerns regarding exam appropriateness, adjustments to imaging protocols, and the relevance of a specific imaging finding. The direct interaction provides an opportunity for sonographers, new and experienced, to be provided immediate direct feedback regarding their study—they can learn from me, and often I from them, making us all that much better at the end of the workday.

In addition to trust, open communication allows for users of ultrasound to take advantage of one of the key differentiating features of ultrasound compared to other modalities: the dynamic, real-time nature of image acquisition. Protocol variations can be discussed on-the-fly. Preliminary findings can be shared with the interpreter, and additional images can be obtained immediately, without having to rely on call-backs, inaccurate reports, and reliance of follow up imaging (often by other modalities). This ultimately enhances patient care and decreases healthcare costs. In our practice, we have the ability to add contrast-enhanced ultrasound for an incidental finding, allowing us to make definitive diagnoses immediately, without having to recommend a CT or MRI—this would not be possible if it were not for a personalized checkout process.

We continue to hear about changes in ultrasound workflow across the country: sonographers and physicians, small groups and large, academic and private practices have all considered or have already implemented changes that minimize the communication between sonographer and study interpreter. This places more responsibility on the sonographer to function independently, and minimizes or even eliminates the opportunities for quality control and education. Sonographer notes and worksheets, and electronic QA systems, are poor substitutes for the often more nuanced human interaction. In my experience, these personal encounters enhance job satisfaction, and the lack of it risks stagnating learning and personal drive. There have been many sonographers that have left local practices to join our medical center specifically to take advantage of the sonographer-radiologist interaction we continue to nurture.

Some elements driving these transformations are difficult to change: growing numbers of patients; increasing reliance on medical imaging; medical group consolidation; etc. Many changes to sonographer workflow have been fueled by a focus on efficiency (decreasing scan time, improving modality turn-around times, etc.). Unfortunately, these changes have been made with little regard to how limiting team member communication impacts examination quality, job satisfaction, and patient outcomes; for those of you in a position to address workflow changes, consider these factors. For sonographers yearning for this relationship, do not be afraid to reach out to your colleagues and supervising physicians—ask questions, be curious, and engage with them. Nearly everyone appreciates a human interaction, and even the toughest personality can be cracked with a smile and some persistence. In the end, it is the human interactions and the open and honest communication that not only make us better healthcare providers but happier and healthier human beings.

 

David Fetzer, MD, is an assistant professor in the Abdominal Imaging Division, as well as is the Medical Director of Ultrasound in the Department of Radiology at the UT Southwestern Medical Center.

 

Interested in reading more about communication? Check out the following posts from the Scan:

The Excitement of New Ultrasound Technologies and Their Effects on Imaging-Guided Interventions

Recent advancements in ultrasound technologies have generated excitement in the field of ultrasound-guided intervention. For me, an interventional radiologist, these developments create new potential to perform needed procedures and a complementary approach to addressing our patients’ complex medical conditions. Further, benefits from these technologies include enabling us to achieve better patient outcomes, improve patient satisfaction, gain operational efficiencies, and improve stake holder’s satisfaction.azar_nami

The new technologies to which I’m referring are ultrasound contrast and ultrasound fusion. Ultrasound fusion is an element of artificial intelligence that combines the anatomic details of cross-sectional imaging like CT scan, PET scan, and MRI with the power of real-time ultrasound and is gaining more acceptance and popularity in medicine. Similar to a car’s GPS, ultrasound fusion helps a user find something. The powerful tool enables the operator to find lesions, which normally are difficult or even impossible to find on standard ultrasound. Needle navigation in the form of virtual tracking is a bonus that identifies needle location even when it is obscured by air or bone. It’s also a great teaching tool for inexperienced physicians who are interested in interventional radiology.

Ultrasound contrast is also emerging as a powerful tool in the field of interventional radiology. It enables the operator to better visualize a lesion and characterize the lesion and surrounding tissue. Now, we also can perform an ultrasound contrast sinogram to assess any cavity or catheter location, which opens new horizons in the field of ultrasound intervention, mainly in pediatric intervention.

An additional benefit for ultrasound contrast that it can be given without worrying about renal injury. This is very valuable when it comes to avoiding the toxic effect of iodinated contrast, especially in renal transplant intervention. Also, its very sensitivity to assess bleeding when compared with that of Doppler ultrasound. This technology allows us to discharge our patients home earlier after procedures when the contrast study is negative.

This is a very exciting time in the field of interventional radiology (IR). So many procedures that we could not perform using real-time ultrasound in the past now can be safely done with only ultrasound. Our patients appreciate how convenient it is. The procedures are done quickly, without the need to move the patient from their bed onto a stiff CT scan table. The lack of ionizing radiation in IR is also an attractive concept to the patient (mainly pediatric and/or pregnant), the clinician, and our IR staff.

Our institution is very supportive of utilizing advanced ultrasound technologies, as ultrasound allows us to gain operational efficiencies and is a more cost-effective alternative to CT-guided procedures. Operational efficiencies are gained by doing interventional cases portably with ultrasound, thus allowing the interventional CT suite to be utilized for diagnostic exams, which bring additional revenue to the institution. The ordering clinicians are also cognizant of radiation dose reduction, so providing an alternative to CT-guided procedures appeals to them.

Even though the implementation of contrast-enhanced ultrasound and fusion has been slower in the United States when compared with our colleagues abroad, it has brought a lot of excitement to my colleagues and me in interventional radiology. Like any new technology, the more we use, the more we appreciate its value. I predict they will become the new norm in daily practice. These advancements will continue to evolve and be an essential part of medicine.

 

Interested in reading more about contrast ultrasound? Check out the following posts from the Scan:

 

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Nami Azar, MD, MBA, is an Associate Professor of Radiology in the Department of Radiology at University Hospitals of Cleveland Medical Center in Ohio.