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Ultrasound in critically ill patients: Society of Critical Care Medicine Guidelines

Ultrasound in critically ill patients: Society of Critical Care Medicine Guidelines

With the supreme importance of prompt diagnostics in critical care patients, evidence-based guidelines for the use of bedside ultrasound by intensivists and specialists in the ICU and equivalent care sites for diagnostic and therapeutic purposes for organs of the chest, abdomen, pelvis, neck, and extremities are mandated.

In November 2015, Society of Critical Care Medicine came out with Guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients-part I: general ultrasonography.

Following are the major recommendations of the guidelines

Noncardiac Thoracic Imaging

Pleural Effusion

Suitability of Ultrasound to Establish the Diagnosis and Assist in Drainage

  • The Panel recommends that ultrasound should be used to complement physical examination and conventional chest radiography to diagnose and localize a pleural effusion. Grade 1A.
  • The Panel recommends that ultrasound guidance should be used to assist in drainage (including needle guidance), particularly of small or loculated effusions compared with landmark technique. Grade 1B.
  • The Panel has no recommendation regarding the preference for use of either static or dynamic technique to do so.

Diagnosis of Pneumothorax

The Panel recommends that ultrasound should be used to complement or replace conventional chest radiography to diagnose a pneumothorax, depending on the clinical setting and need for rapid results. Grade 1A.

Diagnosis of Interstitial and Parenchymal Lung Pathology

The Panel suggests that a systematic approach incorporating bedside ultrasound may be a primary diagnostic modality for the intensive care unit (ICU) patient with respiratory failure. Grade 2B.

Abdominal Imaging

Ascites (Nontrauma Setting)

Suitability of Ultrasound to Establish the Diagnosis to Assist in Drainage

The Panel recommends that ultrasound guidance (instead of the landmark technique), whether real-time or preprocedure, should be used to determine the optimal location for performance of paracentesis. Grade 1B.

Acalculous Cholecystitis

Suitability of Ultrasound to Establish the Diagnosis

The Panel suggests that bedside ultrasonography may be used to provide additional valuable information to the clinical presentation to establish the diagnosis of acalculous cholecystitis. Grade 2C.

Ability of the Intensivist to Use Ultrasound to Establish the Diagnosis Accurately

The Panel suggests that intensivists/critical care providers should not personally perform ultrasound primarily for the diagnosis of acute cholecystitis. Grade 2B.

Mechanical Causes of Anuria/Oliguria

Suitability of Ultrasound to Establish the Diagnosis Thereof

The Panel suggests that ultrasonography may be used to exclude mechanical causes of acute renal failure in the ICU. Grade 2C.

Ability of the Critical Care Provider to Use Ultrasound to Establish the Diagnosis Accurately

The Panel has no recommendations regarding this issue due to the paucity of data.

Vascular Imaging

Deep Venous Thrombosis (DVT)

Complete versus Focused Examination of the Lower Extremities

The Panel recommends that a focused ultrasound technique using gray scale imaging to evaluate vein compression at the common femoral and popliteal veins should be used to diagnose most proximal DVTs (compared with contrast venography). Grade 1B.

Accuracy of Focused DVT Screening by Critical Care Providers

The Panel recommends that intensivists can reliably perform a focused screening examination by ultrasound to diagnose lower extremity proximal DVT. Grade 1B.

Imaging to Assist Intravascular Catheter Insertion

General Consideration

The Panel recommends that ultrasound guidance of vessel cannulation (compared with landmark technique) should be used to improve the success rate, shorten procedure time and reduce the risk of procedure-related complications such as pneumothorax. Grade 1B.

Components of the Examination

Static versus Dynamic (Preprocedure vs Real-time)

The Panel recommends that in most patients, the use of realtime ultrasound is preferred over static, preprocedure marking. Grade 1B.

Long Versus Short Axis

Although there are benefits to visualizing the vasculature in both short- and long-axis images by ultrasound, the Panel recommends that the short-axis view be used during insertion to improve success rate. Grade 1B.

One Versus Two-person Ultrasound-guided Vascular Cannulation

The Panel recommends that one (rather than two) person technique is sufficient for ultrasound guided vascular cannulation. Grade 1C.

The Use of Doppler

The Panel suggests that conventional B-mode imaging to assist in vessel cannulation should be used compared with using audible Doppler only with no imaging. Grade 2B.

The Use of Needle Guides

The Panel has no recommendation regarding routine use of a device placed on the ultrasound transducer to guide needle placement. This should be left to provider discretion.

Completion Examination

The Panel suggests that a detailed post cannulation ultrasound examination may be used (instead of conventional chest radiography) to confirm catheter location and exclude a pneumothorax in adult patients. Grade 2B.

Internal Jugular Location

The Panel recommends that dynamic ultrasound-guided internal jugular (IJ) venous cannulation should be used (instead of landmark technique) to improve success rate, shorten procedure time and reduce the risk of procedure-related complications in adult patients. Grade 1A.

Subclavian/Axillary Location

The Panel suggests that ultrasound dynamic guidance is of limited value for most operators to guide subclavian vein catheterization in adult patients (and that landmark technique is used instead). Grade 2C.

Femoral Location

The Panel recommends that ultrasound dynamic guidance (instead of the landmark technique) should be used to improve the success rate and reduce complications for femoral venous cannulation although this benefit is mostly realized by novice operators in adult patients. Grade 1A.

Other Locations

The Panel suggests that the use of ultrasound dynamic guidance (instead of the landmark technique) may improve the success rate and diminish complications during peripheral venous (adults and children) and arterial cannulation (adults). Grade 2B for venous and 2B for arterial catheterization.

You can read the full guidelines by clicking on the following link: –

Frankel HL, Kirkpatrick AW, Elbarbary M, Blaivas M, Desai H, Evans D, Summerfield DT, Slonim A, Breitkreutz R, Price S, Marik PE, Talmor D, Levitov A. Guidelines for the appropriate use of bedside general and cardiac ultrasonography in the evaluation of critically ill patients-part I: general ultrasonography. Crit Care Med. 2015 Nov;43(11):2479-502. [106 references] PubMed External Web Site Policy

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