CHAPTER 27: ICU Ultrasonography

KEY POINTS

• Ultrasonography has multiple applications in critical care medicine. The development of high-quality portable bedside machines now allows the frontline intensivist to perform the ultrasonographic examination at the bedside of the critically ill patient. The results are applied for diagnostic purposes, to aid in the ongoing management of the patient, and for procedural guidance.

• The frontline intensivist who is in charge of the management of the patient in the intensive care unit (ICU) personally performs and interprets the ultrasound scan at the patient’s bedside. This requires mastery of image acquisition and interpretation as well as the cognitive elements of the field.

• Conceptually, ultrasonography is an extension of the standard physical examination, as it allows the clinician to directly assess the anatomy and function of the body in a manner that complements the traditional bedside physical examination. The examination may be limited or goal-directed in scope and repeated whenever there is a clinical indication. The information derived from the scan is then integrated into the overall management plan.

• Ultrasonographic examination of the heart (goal-directed echocardiography), thorax (lung and pleura), abdomen (limited scope), and venous anatomy (deep vein thrombosis) are key elements of critical care ultrasonography. In addition, ultrasonography has major utility for the guidance of vascular access, thoracentesis, paracentesis, and pericardiocentesis.

INTRODUCTION

Ultrasonography has multiple applications in critical care medicine. The development of high-quality portable bedside machines now allows the frontline intensivist to perform the ultrasonographic examination at the bedside of the critically ill patient. The results are applied for diagnostic purposes, to aid in the ongoing management of the patient, and for procedural guidance. The emphasis is on limited or goal-directed examination, with serial examinations performed as indicated. This chapter will review some important aspects of critical care ultrasonography.

GENERAL PRINCIPLES

The intensivist uses observation, palpation, percussion, and auscultation as key tools in their assessment of the critically ill patient. Conceptually, ultrasonography is an extension of the standard physical examination, as it allows the clinician to directly assess the anatomy and function of the body in a manner that complements the traditional bedside physical examination. In accepting this simple principle, the intensivist uses ultrasonography at point of care whenever it is indicated, just as they would evaluate the patient with standard physical examination methods.

Critical care ultrasonography is performed at the bedside. The frontline intensivist who is in charge of the management of the patient in the intensive care unit (ICU) personally performs and interprets the scan. The results are then promptly integrated into the management plan. This is very different from the standard radiology- or cardiology-guided approach to ultrasonography in the ICU. In this latter circumstance, the intensivist orders the test. Following some period of time, often many hours, the test is performed. Sometime later, a radiologist or cardiologist interprets the scan in a reading room without a clear understanding of ...