this is for US learning purpose in critical area (ICU)

1. Basic
Dr Nor Hidayah Zainool Abidin (MBBS, IIUM)
Supervisor:
Dr Fazilawati & Dr Wan Nasharudin
in ICU

2. ECHO - FOCUS
CHEST ultrasound
Abdominal ultrasound-
FAST
Intravascular cannulation

3. FOCUS ECHO
• Hemodynamic monitoring using echo
• For monitoring and therapeutic
• Assess CO, fluid responsiveness, myocardial contractility,
recognize other medical emergency like cardiac tamponade
and acute cor-pulmonale.
• For quick diagnosis and management
• Challenges:
– Mechanical ventilated
– High inotropic support
– Underlying illness that can interfere with ECHO
– Hyperinflated lungs by IPPV, emphysema, surgical incision and
drains, dressings, inadequate exposure and positioning

4. Several factors could alter the CVS
physiology of critically ill patients
•Positive pressure ventilation
•Sedation
•Inotropic agents and CO2 tension

5. Practical use of ECHO is ICU
• To correlates ECHO findings with clinical
examination
– Significant proportion of patients admitted to ICU
with non cardiac illness have underlying cardiac
abnormalities which can be detected by
surveillance ECHO at the time of admission
– Specifics indication
• Evaluation of hypotension or hemodynamic instability,
MI or infarction, respiratory failure and PE.

6. Goal directed therapy
– Detailed cardiac examination including valvular
function, congenital abnormalities intracardiac
shunt and estimation of pulmonary pressure is
best done by certified ECHO MA with
cardiologist consultation.
– Rapid cardiac assessment(RCA), FADE, RACE,
FOCUS, FATE, used bedside  conducted
systematically and must be correlated with
patient clinical status

7. At the end of assessment, must be able to
answer this questions..
What is the left heart function?
What is the right heart function?
Is there any evidence or pericardial
effusion, and tamponade?
What is the volume status?

8. The RUSH exam:
Heart, Inferior vena cava (IVC), Morrison’s/FAST abdominal
views, Aorta, and Pneumothorax (HI-MAP).

9. Basic MODE
• 2D ECHO, M-Mode
• Doppler ECHO
– Supplemented with 2D and M-mode ECHO
– Provide intracardiac hemodynamics – systolic and
diastolic flow, blood velocity and volume, severity of
valvular lesions, location and severity of intracardiac
shunts and assessment of diastolic function
• Views
– Parastrenal long axis
– Parasternal short axis
– Apical view 4 chamber view
– Substernal 4 chamber view

12. Parasternal short axis view

14. Apical view

16. Volume status and preload
responsiveness assessment

17. Theoritical method to measure IVC
2-D image of the IVC
entering the right
atrium
make sure IVC
visualization is not lost
during movements of
respiration
place a M-mode line
through the IVC 1 cm
caudal from its
junction with the
hepatic vein
record the M-mode
through 3 or 4
respiratory cycles.
Freeze the M-mode
image
using calipers,
measure the
maximum and
minimum diameter
from anterior to
posterior wall.

18. IVC diameter
• Low CVP is increasingly is likely as
• IVC diameter (IVCD) < 1 cm
• high CVP increasingly likely as IVCD > 2cm.

19. Simultaneous measurements of the central venous pressure (CVP) and IVC diameter
at the end of expiration in 108 mechanically ventilated patients

20. Physiological respiratory variations in IVC diameter in a healthy volunteer breathing
quietly

21. Respiratory variations in IVC diameter in a patient on controlled ventilation

22. IVC collapsibility index
• Measurement of IVC diameter in different
phases of respiration
• In a spontaneously breathing, cyclic variations
in pleural pressure transmitted to the right
atrium
• produce cyclic variations in VR increased by
inspiration  inspiratory reduction of IVC
diameter.

24. Assessment of volume status
• CI = (Exp Dmax – Insp Dmax)/ Exp Dmax
• 15%
• [(maximumIVCdiameter−minimumIVCdiamete
r)/maximumIVCdiameter]

26. Signs that may suggest the patient
would deteriorate after a fluid bolus
• A dilated LV with impaired contractility
• Dilated right heart chambers with impaired RV
contractility
• Dilated IVC with little or no respiratory
variation
• Paradoxical interventricular septal movement
(septal bounce); A ‘D shaped’ LV
• Interatrial septal deviation to the left

27. Left ventricular function
Overall
size
Wall
thickness
Doppler

regurgitation
Contractility

33. Left heart chambers:
• Is there a small or normal sized LV? Does it
have good contractility? Are there kissing
ventricles?
• Is the wall hypertrophied?
• Is the LA dilated?
• Is there paradoxical interventricular septal
motion (septal bounce)?
Right heart chambers: Is the RV a normal size
with good contractility? Is the RA dilated?
IVC: Is the IVC 2cm or greater? Does it change
with respiratory variation- is it >50%

34. CHEST ULTRASOUND
• Ultrasound wave unable to penetrate aerated
lung tissue.
Historically, this has limited usage for evaluation
of the lung pathology accept pleural effusion.
• However, in the recent years, the recognition
that analysis of ultrasound artefacts arising
from the pleura can provide valuable
information about underlying lung pathology

35. • US wave are able to penetrate non aerated tissues.
• Thus pleural fluid, and non-aerated lungs pathology
(such as consolidation or complete atelectasis) can
be readily visualized.
• Compared with chest radiography and computed
tomography (CT)
– Rapid, portable, real time imaging inexpensive and safe

36. Aims
To understand the basic principles and practical
application of transthoracic ultrasound
To be familiar with the sonographic appearance
of the normal thorax
To identify basic thoracic pathology

37. Equipment
• Phased array, low freq (3-5MHz) evaluation of
pulmonary edema and pleural effusion
• Microconvex 5-8MHz – better artefact
visualization than lower frequency transducers,
but depth of penetration may be insufficient for
large patient
• High frequency linear array transducer (6-
13MHz) allow detailed pleural line analysis, and is
optimal for pneumothorax detextion but has
limited applicability

38. • Anterior zone -
extrapleural air
(pneumothotax)
• Posterior/ Lateral –
consolidation,
Effusion
• All zones –
interstitial or
alveolar fluid a.k.a
extracappilaties
lung water
Examination technique

39. A lines
The horizontal bright
(hyperechoic) pleural line (P)
and A line (A) flanked on each
side by dark rib shadows
The pleural line is the reference line for artefact
analysis and lung sliding analysis.
A-line artefacts
these are bright horizontal repetitions of the
pleural line due to reverberation artefacts, and
are a normal finding

40. B artifacts
• previously known as comet-tail artefacts
or ultrasound lung comets
• Discrete vertical bright lines originating at
the pleural line and fanning out to the
bottom of the screen without fading
• Arise from reverberation artefacts
generated at the interface of fluid-filled or
fibrosed interlobular septa abutting the
visceral pleura
• The presence of multiple B lines, termed ‘B
pattern’, erases the A-line artefact.

41. • With greater loss
of aeration the B
lines become
more closely
spaced, or
confluent (white-
out)
B lines are equivalent to Kerley B lines seen on the chest radiograph although they may be
present before radiographic changes are visible. Isolated B lines or short, ill-defined vertical
artefacts are of uncertain significance

42. What is B lines?
• Hyperechoic
• Starts at pleura
• Moves with respiration
• Extend off the screen
• Erases A-lines

43. Lung sliding analysis
• With tidal inflation of the normal lung, the
visceral pleura slides against the parietal
pleura.
• On ultrasound this is seen as movement
below the pleural line.
• The movement is best appreciated using M-
mode imaging, which shows an image
reminiscent of the seashore

44. Lung sliding (sea shore sign)
• The smooth
horizontal lines
above the pleural line
(P)
• The ‘sandy’
appearance below
the pleural line
artefact from visceral pleural
sliding with tidal ventilation
extrapleural tissues static over time

45. Pneumothorax
Absent lung
sliding
demonstrated
with a 1–5 MHz
phased array
transducer in M-
mode.
Note the smooth horizontal lines
above and below the bright
(hyperechoic) pleural line (P).

46. Specific pathologies
• US is also sensitive to the changes in severity
of disease and can thus be used to monitor
disease progression and make timely clinical
decision.
• Normal lung has A lines and lung sliding.
• About a quarter of population has one or two
B lines in the lung bases but other artifact
should be absent.

47. Pleural effusion
• US enable to detect small pleural effusion
(<50ml) not visible on chest radiograph
• Provide nature of effusion  septated pleural
collection are better characterized with US than
CT scan.
• Identification of diaphragm on scanning over the
lower lateral chest
• Diaphragm appear as smooth bright hyperechoic
overlying the abdominal content (liver as spleen)
• Pleural fluid manifest as hyperechoic
(homogenous dark)

48. Liver (L), diaphragm (D), pleural effusion and collapsed/consolidated lung (C)
demonstrated with a 1–5 MHz phased array transducer aligned with the
longitudinal axis of the patient in the basal right mid-axillary line.

49. Pleural fluid quantification
• In supine mechanically ventilated patient 
Posterior pleural fluid separation >5cm
strongly predict drainage > 500ml
• In semirecumbant mechanically ventilated
patient the maximum pleural separation (in
mm) multiplied by 20 give estimation of
drainage volume
• However precise volume measurement is
rarely necessary for clinical decision making.

50. Complex septate effusion (viewed with low-frequency ultrasonography) with multiple
septa (S) and loculations (L).

51. Thoracocentesis
• US guided thoracocentesis decrease
complications and improves fluid collection
rates
• Allow identification of the optimal site for
drainage, measurement of depth of the pleural
space.
• Potential hazard such as diphragm and pleural
adherences can be avoided

52. Alveolar consolidation
Dark (hypoechoic) diagonal region representing the oblique fissure,
and the bright (hyperechoic) punctiform air bronchograms.

53. The lung pulse sign consists of vibrations in the M-mode trace (below the pleural line) due
to transmitted cardiac pulsation
Complete lobar collapse

54. ABDOMINAL ULTRASOUND

55. Right upper quadrant FAST scan
- free intraperitoneal fluid in the hepatorenal
recess (Morison’s pouch).

56. INTRAVASCULAR CANNULATION
transverse (short axis) plane
The vein has an oval contour without external compression

57. Appears slit-like when light external compression is
applied

58. Acquisition of ultrasound proficiency is best achieved
with a combination of
1. Theoretical learning (basic physics of ultrasound,
relevant anatomy, image interpretation),
2. Direct supervision of image acquisition
3. Practice
Conclusion
Image
interpretation
Image integration
into care path
Image
acquization
Bedside US has 3 distict
skill requirement:

59. References
• Oh’s Intensive care Manual
• Hemodynamic monitoring Using ECHO in the
critically ill patients by Wan Nasrudin WI, MSA
Year book 2013/2014
• http://www.criticalecho.com/content/tutorial-
4-volume-status-and-preload-responsiveness-
assessment