ULTRASOUND IN ICU

Dr S Manimala Rao.
Director Critical Care & Aneathesiology
YASHODA HOSPITALS
Hyderabad A.P

Dr. Mrinal Madireddi

Jr. Consultant
Dept of Anaesthesiology & Critical Care
Yashoda Hospitals . Hyderabad. A.P.

The Anaesthesiologist used to rely on their educated hands for managing

patients for controlled ventilation in the 60’s. The mechanical ventilation replaced
the educated hand. There was no looking back from then onwards.
Anaesthesiologist have become pioneers in ventilatory management not only in
OR but extending it to post surgical units and at a later date to all critical care
units.
In the last decade or two the anaesthesiologist have perfected techniques
like regional blocks, transesophageal ECHO with help of ultrasound and made
ultrasound as their technological arm. This in turn led to be referred as point of
care of ultra sound.
Transesophageal ECHO was introduced in the 80’s by cardiologists to
visualise cardiac structures not seen by transthoracic ECHO. However the
cardiac anaesthesiologist recognised its usefulness and readily focussed to learn
and use it in the intraoperative cardiac surgery and became experts in the
same.They now run courses for echocardiography work shops and are not
depending on the cardiology collegues for interpretation(1)
More recently the critical care anaesthesiologist have focussed on rapidly
interpreting the transthoracic ECHO for evaluating the cardiac function namely
the global and regional wall abnormalities , differientiating non cardiogenic
pulmonay edema, diagnosing pulmonary embolism as well as cardiac
tamponade (2) They have also realised the importance of fluid management by
balancing fluid rescucitation and avoiding fluid overload in very sick patient with
or without shock. Whether to give fluid or not is always a clinical dillemma. There
is no fool proof methodology. The IVC ultrasounds has come very handy in
critical care unit to achieve fluid management goals non invasively. This has
become the point of care in this aspect of clinical problems which are fairly
common in ICU (3)
USG guided vascular acess was first described in the 1970’s and has
evolved to become a highly recommended method of patient safety. It has
become a common place to use it routinely for central vascular access. It is also
used for difficult peripheral vein and arterial line. It has now become common to
train anaesthesiology resident for placing the lines with aid of ultrasound.(4) The
anaesthesiologist also developed the art of giving regional nerve block with
ultrasound guide and it has become a routine

anesthetic technique.(5) ultrasound is also being used to assess the difficult

airway. It has aslso been used successfully in the studies to see whether ET tube
is in trachea or esophagus. This methodology can be a useful adjunct in
management however it may not replace ETCO2 monitoring. Sonography is an
effective technique in confirming intubation in 3sec. (6)

Ultrasound has been used to detect the gastric content and volume. It is
important to know how much is the content, so that care is taken to prevent
regurgitation.and aspiration. The anaesthesiologists monitor cerebral blood flow
by transcranialdoppler and also use it to monitor blood flow in trendelenburg
posiotion in laparascopy and anterior interbody spinal fusion (7)
Now that anesthesiologist and intensivist have become adept in using
ultrasound in their daily practice, and further extending it to lung imaging. The
lung ultrasound is used to diagnose pneumothorax; ARDS, interstitial lung
disease, pleural effusion, so on and so forth.Anaesthesiologist have used
ultrasound to detect pneumothorax in anesthetised patient. This major
catasthrophic event is diagnosed rapidly and the life threatenig problem is treated
urgently. (8) Traditionally chest X-ray is the main investigation to diagnose
pneumothorax, however it time consuming. The lung sliding in combination with
B lines, lung point and lung pulse is useful in diagnopsis of pneumothorax by
USG. A simple algorithym will help to diagnose or exclude pneumothorax at
bedside with help of ultrasound therefore it has become good point of care
testing at bedside.(9) Having the knowledge and expertise any anaesthesiologist/
intensivist can interpret effectiviely and efficiently without consulting any other
specialist in emergency. The apprehension faced by them is the worry regarding
the misinterpretation of the images. This can be overcome with proper training,
short term courses, certification, attending WINFOCUS workshops and hands on
experience. We as specialists who provide high quality of care to our
patients.One cannot lag berhind due to want of training.The future is to develop
skills to diagnose and manage our patients needs by ultrasound in the
perioperative period as well as in in critical care units(10)

Sonography has evolved to become one of the most versatile modalities for
diagnosing and guiding treatment of critically ill patients. It consists of both
cardiac (Echocardiography) and non-cardiac (lung, abdominal and vascular)
ultrasound.
It can be used for the following in the ICU:
Hemodynamics
Non-invasive assessment of cardiac output
Assessing myocardial contractility and regional wall motion abnormalities
Volume status assessment
Predicting volume responsiveness
Diagnosing diastolic ventricular dysfunction and estimating filling pressures non-
invasively
Assessing right heart function and diagnosing acute cor pulmonale in ARDS and
pulmonary embolism
Detecting pericardial effusion and tamponade
Pulmonary
Detecting pleural effusion
Rapid diagnosis of pneumothorax
Differentiating consolidation, alveolar-interstitial syndrome, pulmonary embolism
and pneumothorax.
Vascular
Diagnosing deep venous thrombosis
Abdomen
Detecting ascites and collections
Diagnosing urinary bladder distension and hydronephrosis
Studying renal arterial resistivity indices as an indicator of renal blood flow
Resuscitation
Differentiating fine ventricular fibrillation from true asytole
Diagnosing potentially reversible causes of PEA or asystole such as pericardial
tamponade, myocardial infarction, severe hypovolemia, pulmonary embolism or
tension pneumothorax - the Focussed Echocardiographic Evaluation in
Resuscitation (FEER)
Asessing for cardiac standstill to help with prognostication during resuscitation
Other diagnostic uses
Detect fluid in pericardial, perisplenic, perihepatic aand pelvic areas in trauma -
the Focussed Assessment with Sonography for Trauma (FAST)
Detecting raised ICP using optic nerve sheath diameter
Diagnosing sinusitis in intubated patients
Therapeutic
Guided arterial and central vascular access
For guided thoracocentesis and abdominal paracentesis
Pericardiocentesis
Bedside Percutaneous nephrostomy
Guided drainage of collections
The ability to assess myocardial function and cardiac output non-invasively is
immensely useful in the management of the complicated or mixed shock states.
This along with the ability to assess volume status has made it an essential
hemodynamic monitoring tool in the ICU.
While echocardiography and sonology may be thought to be the forte of
cardiologists and radiologists, it is crucial to recognise that critical care sonology
has a different focus and uses different techniques to look at different aspects
from traditional cardiology echocardiography. It complements rather than
replaces traditional sonology.
This modality is likely to be particularly useful in resource challenged countries as
it is non-invasive, economical, repeatable and can be performed at the bedside.

The use of ultrasound has expanded enormously over the last two decades in
critical care research and practice. Despite the fact that the method has several
inherent limitations and is largely operator dependent, it enables clinicians for
rapid, by-the-bed, and relatively inexpensive diagnostic evaluation of unstable
patients. Point-of-care ultrasound applications such as lung ultrasound are
gradually replacing traditional imaging modalities (i.e., chest X-rays), while the
use of ultrasound for procedure guidance has been shown to reduce
complications and thus to increase patients’ safety [11–12].

Current trends promote the optimization of two-dimensional ultrasound imaging

by applying various technologies. Advances in ultrasound software can reduce
artifacts and “noise” such as speckle arising from coherent wave interference or
clutter arising from beamforming artifacts, reverberations, and other acoustic
phenomena, while infusion of contrast agents during imaging facilitates
interpretation of various pathologies [13, 14]. In that sense, the application of
echogenic material could optimize procedural ultrasound applications. This may
be of importance as ultrasound scanning is oftentimes performed under
suboptimal conditions in the ICU, while the presence of mechanical ventilation,
air and/or edema, may affect the clarity of images [15].
Inferior vena cava analysis and transaortic Doppler signal changes with the
respiratory cycle in mechanically ventilated patients are good predictors of fluid
responsiveness.

The diagnostic role of lung ultrasound is well established in the ICU. Lung
ultrasound showed high sensitivity and specificity values (ranging from over 80%
for the lower lung fields up to over 90% for the upper lung fields) and
considerable consistency in the diagnosis and localization of alveolar-interstitial
syndrome. As the method grows and technology advances, lung ultrasound may
represent an alternative to computed tomography in the monitoring of pulmonary
disorders, although further studies are clearly required to validate this notion.

Surely, applying point-of-care ultrasound in the ICU requires formal training.

Critical care fellowships offered by European and US residency programs are
currently taking on the burden of such responsibility [16]. Notably, several US-
based institutions are integrating ultrasound teaching programs in medical
schools’ curricula as this would aid all graduates to obtain basic ultrasound skills
[17,18]. Such skills should not be used as a replacement to standard physical
examination and/or to clinical judgment, but as an adjunctive tool that could
facilitate patients’ diagnosis and treatment. Changing practices by implementing
ultrasound technology in the ICU is a cost-efficient and robust strategy which
signals an era of pure “visual” medicine

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