If its there, scan it! The consensus#FOAMed #FOAMcc #FOAMus #POCUS

 

This is the ‘bread and butter’ approach for us for many things on ITU and it is clear we are amongst the many both advocating its usage. To blow the grandiosity horn, we are becoming experts as well!

This article (part 1 of 2) discusses the consensus opinion on many of the areas we choose to scan on the unit, from vessels to gallbladders! See here. I have broken it down into the key recommendations…

Non-cardiac Thoracic Imaging

Suitability of ultrasound to establish the diagnosis and assist in drainage:

Pleural Effusion

  • We recommend that ultrasound should be used to complement physical examination and conventional chest radiography to diagnose and localize a pleural effusion. Grade 1A.
  • We recommend 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.
  • We have no recommendation regarding the preference to use of either static or dynamic technique to do so.

Diagnosis of Pneumothorax

  • We recommend 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

  • We suggest that a systematic approach incorporating bedside ultrasound may be a primary diagnostic modality for the ICU patient with respiratory failure. Grade 2B.

 

Abdominal Imaging

Ascites (Nontrauma Setting)

Suitability of ultrasound to establish the diagnosis to assist in drainage:

  • We recommend 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

  • We suggest 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

  • We suggest 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

  • We suggest 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

  • We have no recommendations regarding this issue due to the paucity of data.

Vascular Imaging

Deep Venous Thrombosis (DVT)

Complete versus focused examination extremities: of the lower

  • We recommend 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 con- trast venography). Grade 1B.

Accuracy of focused DVT screening by critical care providers

  • We recommend that intensivists can reliably perform a focused screening examination by ultrasound to diag- nose lower extremity proximal DVT. Grade 1B.

Imaging to Assist Intravascular Catheter Insertion

General consideration

  • We recommend 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)

  • We recommend that in most patients, the use of real- time 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, we recommend that the short-axis view be used during insertion to improve success rate. Grade 1B.

One- versus two-person ultrasound-guided vascular cannulation

  • We recommend that one (rather than two) person technique is sufficient for ultrasound-guided vascular cannulation. Grade 1C.

The use of Doppler

  • We suggest 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

  • We have 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

  • We suggest that a detailed postcannulation 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

  • We recommend that dynamic ultrasound-guided IJ venous cannulation should be used (instead of land- mark technique) to improve success rate, shorten procedure time and reduce the risk of procedure-related complications in adult patients. Grade 1A.

Subclavian/axillary location

  • We suggest 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

  • We recommend 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 bene t is mostly realized by novice operators in adult patients. Grade 1A.

Other locations

  • We suggest that the use of ultrasound dynamic guidance (instead of the landmark technique) may improve the success rate and diminish complications during periph- eral venous (adults and children) and arterial cannulation (adults). Grade 2B for venous and 2B for arterial catheterization.

 

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