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08NTD 2022 - ULTRASOUND imaging in Dengue Fever: In COVID-19 Pandemic

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08NTD 2022 - ULTRASOUND imaging in Dengue Fever: In COVID-19 Pandemic

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This webinar is organized by MyICID and Institute for Clinical Research (ICR), NIH, Ministry of Health in conjunction with Neglected Tropical Disease Day 2022. The purpose of this webinar is to refresh and update our knowledge on Dengue fever, which has been overshadowed by COVID-19 since the beginning of the pandemic.

Presenter: Dr Vijayan P Panirselvam, Advanced Acute Internal Medicine at Hospital Tengku Ampuan Rahimah, Malaysia.
#dengue #WorldNTDDay #BeatNTDs #BestScienceforAll

This webinar is organized by MyICID and Institute for Clinical Research (ICR), NIH, Ministry of Health in conjunction with Neglected Tropical Disease Day 2022. The purpose of this webinar is to refresh and update our knowledge on Dengue fever, which has been overshadowed by COVID-19 since the beginning of the pandemic.

Presenter: Dr Vijayan P Panirselvam, Advanced Acute Internal Medicine at Hospital Tengku Ampuan Rahimah, Malaysia.
#dengue #WorldNTDDay #BeatNTDs #BestScienceforAll

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08NTD 2022 - ULTRASOUND imaging in Dengue Fever: In COVID-19 Pandemic

  1. 1. ULTRASOUND imaging in Dengue Fever : In COVID Pandemic Dr Vijayan Advanced Acute Internal Medicine Hospital Tengku Ampuan Rahimah
  2. 2. Disclaimer • This slide was prepared for the Webinar Series on COVID-19 session on Feb 12th 2022, by Dr Vijayan , Hospital Tengku Ampuan Rahimah , Malaysia. • This is intended to share within healthcare professionals, not for public. • This webinar is organised by Malaysian Society of Infection Control and Infectious Diseases (MyICID) & Institute for Clinical Research, NIH in conjunction of World NTD Day 2022.
  3. 3. The outcome of today’s presentation ❖able to master probe positioning ❖interpreting formed image to guide on clinical assessment and treatment in dengue
  4. 4. Outline of presentation Part 1 : the basic on focus - principal of ultrasound for dengue in covid pandemic Part 2 : detail discussion on ultrasound in dengue , including pitfalls
  5. 5. Part 1 : the basic on focus - principal of ultrasound for dengue in covid pandemic • Ultrasound equipment & cleaning • Diagnostic ultrasound : ➢Echo ➢IVC ➢Lung ➢Abdomen (perinephric) ➢Gall bladder Infection control Probe position, scanning tips, normal images & abnormal images, literature review & pitfalls
  6. 6. Ultrasound equipment • All the parts that does not required , need to be removed • Type of transducer used → S4-1 broadband array for lung/cardiac/abdo scanning • Clean the machine with wipes – wait for 2 mins after cleaning pre-scan, and clean again after using it ( clean the whole machine)
  7. 7. PART 2 ULTRASOUND IN DENGUE INCLUDE : ECHO, IVC, LUNG & ABDOMEN • PROBE POSITION, SCANNING TIPS, NORMAL IMAGES & ABNORMAL IMAGES, LITERATURE REVIEW & PITFALLS
  8. 8. ECHO WINDOW SEVERAL STANDARD POSITION ON THE CHEST WALL WHERE THERE ARE “ECHO WINDOW “ ECHO WINDOW
  9. 9. Placing probe for parasternal view – long axis placing the transducer to the left of the sternum in 3rd or 4th intercostal space with the orientation marker toward patient’s right shoulder or 10 o’ clock
  10. 10. PARASTERNAL VIEW- LONG AXIS
  11. 11. Let’s advance to dengue shock patient ( severely leaking→ hypovolemic) • The lumen of the LV may even be obliterated and the ventricular walls are seen to be “kissing” • Hyperdynamic LV with normal or higher than normal ejection fraction and normal myocardial thickening found Leung JM, Levine EH. Left ventricular end-systolic cavity obliteration as an estimate of intraoperative hypovolemia. Anesthesiology. 1994;81:1102–9. The use of LV end-systolic cavity obliteration is a potentially useful “alarm” suggesting the development of hypovolemic
  12. 12. Parasternal view in dengue shock ( hypovolemia)
  13. 13. Comparison of LV in hypovolemic shock & post fluids resuscitation Pre-resuscitation Post –resuscitation
  14. 14. View appear as ventricles walls are touching each other , but actually slicing the ventricles at the side, not in the middle. Need to push the probe side to side
  15. 15. PARASTERNAL VIEW- LONG AXIS PERICARDIAL EFFUSION
  16. 16. CORRELATION OF INFERIOR VENA CAVA ULTRASOUND IN DENGUE FEVER WE DISCUSS : PROBE POSITION IVC MEASUREMENT AND COLLAPSIBILITY PITFALLS
  17. 17. PROBE POSITION FOR IVC SCAN
  18. 18. Inferior vena cava (behind liver) draining to right atrium liver RA IVC
  19. 19. The biggest challenge would be to differentiate between IVC and descending aorta. The video will show IVC scan , then immediately probe tilt to descending aorta
  20. 20. SEVERAL FEATURES TO DIFFERENTIATE BETWEEN IVC AND DESCENDING AORTA • THE AORTA RELATIVELY TO PATIENTS LEFT AND IVC TO PATIENTS RIGHT • AORTA = CIRCULAR AND IVC = ELLIPTICAL • AORTA = PULSATILE , IVC NOT PULSATILE • AORTA NOT COMPRESSIBLE UNDER GENTLE PRESSURE BUT IVC DOES • AORTA DON’T CHANGE DURING RESPIRATION/ SNIFFING
  21. 21. EXAMPLE OF MEASUREMENT OF IVC IVC – 2.0cm exp – 2.0cm Ins - 1.5cm IVC collapsibility index : 2.0cm – 1.5cm × 100% = 25% (caval index) 2.0cm
  22. 22. Correlation between IVC & CI with CVP Jambeih R, Keddissi JI, Youness HA, IVC measurements in critically ill patients with acute renal failure. Critical care research and practice.2017; https: // doi.org Review Article | SLJR 10 /10.1155 /2017/ 3598392: Article ID 3598392
  23. 23. AS A GUIDE FOR RESUSCITATION Randomized Controlled Trial of Ultrasound-guided Fluid Resuscitation of Sepsis-Induced Hypoperfusion and Septic Shock Khrongwong Musikatavorn, MD*† Poj Plitawanon, MD* Suthaporn Lumlertgul, MD* Khuansiri Narajeenron, MD* Dhanadol Rojanasarntikul, MD* Tanawat Tarapan, MD* Jutamas Saoraya, MD*‡ Western Journal of Emergency Medicine, Volume 22, no. 2: March 2021 ➢ 106 and 105 eligible patients were randomized to the usual-care and UGFM treatment arms, respectively ➢ no significant difference in 30-day mortality between the two groups & no significant difference between the treatment groups in six-hour lactate clearance, SOFA score at 72 hours or the length of hospital stay ➢However, the rate of vasopressor use and the cumulative fluid administration in 24 hours was lower in the UGFM arm
  24. 24. Ultrasound to look for 3rd space fluid loss ❖pleural effusion ❖pericardial effusion ❖intraperitoneal fluid collection ❖gallbladder wall oedema
  25. 25. 12 EXAMINING POINTS The 12-Point exam has been described in helping Italian and Chinese physicians diagnose COVID-19 (Buensenso 2020 and Peng 2020). LUNG SCAN
  26. 26. LUNG SONOANATOMY - NORMAL LUNG PARENCHYMAL • THE BAT SIGN • A LINE
  27. 27. DIFFERENCE BETWEEN A LINE & B LINE – COVID PATIENT
  28. 28. Curtain sign – normal lung finding
  29. 29. LUS in severe dengue with leaking
  30. 30. Severe dengue with 3rd space leaking (pleural effusion)
  31. 31. ABDOMEN SCAN AIM : THIRD SPACE FLUID LOSS & PERINEPHRIC COLLECTION
  32. 32. PERINEPHRIC FLUIDS IN SEVERE DENGUE WITH LEAKING
  33. 33. Gallbladder scan : Gallbladder wall thickening (GBWT) • Gallbladder wall thickening (GBWT) is one manifestation of increased capillary permeability [1] • GBWT above 3mm is significantly associated with more severe cases of dengue, and a thickness greater than 5mm could identify dengue patients with a higher risk of developing hypovolemic shock [2] 1.Simmons CP. Dengue 2.Setiawan MW, Samsi TK, Pool TN, Sugianto D, Wulur H. Gallbladder wall thickening in dengue hemorrhagic fever: an ultrasonographic study. J Clin Ultrasound. 1995;23: 357–362. pmid:7673451
  34. 34. ULTRASOUND OF DENGUE PATIENT, CRITICAL PHASE 26, HCT 48, LACTATE 2.2 4mm IVC – 1.8cm Caval index- 75%
  35. 35. TAKE HOME MESSAGE ❖ need trained personal, as accuracy of finding influenced by training and experience ❖Overall assessment , not dependant at single finding alone ❖Risk of infection control – follow the SOP ALWAYS INTEGRATE ULTRASOUND FINDING WITH THE OVERALL CLINICAL PRESENTATION, PHYSICAL EXAMINATION & LABORATARY TEST
  36. 36. THANK YOU

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