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Perioperative Ultrasonography

Ehab Farag, MD, FRCA

Hesham Elsharkawy

David G. Anthony, M.D.

Cleveland Clinic, Cleveland OH

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• Complications during central venous catheterization (CVC)

occur 2% -15% of the time in adults and can be severe1.

• Shummer et al.

– 1794 cases, critical-care physicians

– landmark techniques

– 3.3% complication rate (10 cases pneumothorax/hemothorax

and one stroke leading to death)

1Domino KB, et al. Anesthesiology 2004;100:1411-8.

2Shummer W, et al. Intensive Care Medicine 2004;33:1055-1059.

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• ASA closed claims 13 deaths from CVC insertion.

• Hemothorax from arterial injury & pneumothorax:

major contributors to mortality1.

• 5 million CVCs are performed every year2 even

low incidence (0.5%) of significant complications

would result in 25,000 problems.

1Bowdle TA. ASA Newsletter 2002;66.2Feller-Kopman. Crit Care Med 2005;33:1875-7.

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• The Agency for Healthcare Research and Quality

– US 1 of 11 practices to improve the patient safety and

outcome*.

• 2003, a meta-analysis by Hind, 18 RCTs

– favored US guidance vs landmark techniques

– reduced failure rates

– increased first-attempt success,

– reduced complication rates and faster procedure time

(P<0.0001)

*Rothschild JM. Agency for Healthcare Research and Quality 2001:2245-53.

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Subclavian Vein Approach

• SV offers ideal size for central access.

• Close proximity to the lung, subclavian artery, and

brachial plexus can lead to significant morbidity.

• Other challenges for accessing the SV with US are

deeper location and the presence of the clavicle.

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Femoral Vein Approach

• Baum et al reviewed 100 CT scans

– FV and the femoral artery overlap in the anteroposterior plane

65% of the time1.

• Same finding confirmed in US study in 50 ICU

patients2.

1Baum PA, et al. Radiology 1989;173:775-7.2Hughes P, et al. Anaesthesia 2000;55:1198-202.

TRANSTHORACIC

ECHOCARDIOGRAPHY

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Possibilites with Bedside Ultrasound

• Etiologies of Hemodynamic Decompensation

– Vasodilatory/Distributive Shock

– Cardiogenic Shock

– Heart Failure

– Regional wall motion abnormalities

• Monitor Resuscitation Efforts

Limited TTE Exam Types

• FATE (Focus Assessed Transthoracic Echocardiography),

• FEEL (Focused Echocardiographic Evaluation in Life Support)

• FEER (Focused Echocardiographic Evaluation in Resuscitation Management),

• RUSH (Rapid Ultrasound for Shock and Hypotension),

• CAUSE (Cardiac Arrest Ultrasound Exam)

• BLEEP (Bedside Limited Echocardiography by Emergency Physician)

Our Exam (FATE)

• Three Anatomic windows

• Four “clock positions:” 10:00, 2:00, 3:00 12:00

• Five scanning views

• In the ideal patient!

Proper probe grasp

X

Probe Orientation

Parasternal Long Axis View

• Parasternal Long

Axis

• Left Upper Sternal

Border (3rd-4th

interspace)

– Probe Indicator pointed

towards right shoulder

(10:00)

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Anatomic Correlate

Courtesy of Yale University Echocardiography Atlas

Parasternal Short Axis View

• Parasternal Short Axis

• Left Upper Sternal

Border (3rd-4th

interspace)

– Probe Indicator pointed

towards left shoulder

(2:00)

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Anatomic Correlate

Courtesy of Yale University Echocardiography Atlas

Apical View

• Point of Maximal

Impulse (PMI)

• Anterior Axillary Line

underneath breast

• Probe Orientation: 3:00

(patient’s left flank)

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Anatomic Correlate

Courtesy of Yale University Echocardiography Atlas

Subcostal View

• Probe in subxiphoid region

• Probe orientation: 3:00

• Tilt parallel to back

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Anatomic Correlate

Courtesy of Yale University Echocardiography Atlas

IVC View

• Probe in subxiphoid region

• Obtain the subcostal view,

then rotate the probe

• Probe orientation: 12:00

• Tilt towards the back

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Volume Responsiveness

• Collapsibility Index =

[IVC max (end exhalation) – IVC min (end inhalation)] x 100%

IVC max (end exhalation)

– > 50-75% or exhaled diameter < 1 cm suggestive of hypovolemia

• Distensibility Index =

[IVC max (end exhalation) – IVC min (end inhalation)] x 100%

IVC Mean

– > 12 % variation: volume responsiveness: 93% PPV; 92% NPV

GASTRIC, OPHTHALMIC, AND

PULMONARY ULTRASOUND

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Ultrasound for Gastric Content

Three outcomes should be assessed:

1-Identify if the stomach is empty or full

2-Identify if the contents is fluid or solid

3-Identify the volume of the content

3-Volume of the content (Quantitative)

• Mathematical models predict GV based on antralCSA.

• (GV (ml)=27.0+14.6×right-lateral CSA (cm2) −1.28×age (yr))

• Predict volume up to 500 ml.• Perlas A, Mitsakakis N, Liu L, et al. Validation of a mathematical model for ultrasound

assessment of gastric volume by gastroscopic examination. Anesth Analg 2013;116:357–63.

Disadvantages:

Not continuous

Cannot quantitate CSF pressure

Operator dependent

Not widely accepted.

Optic nerve sheath is a

continuation of duramater

ICP CSF

pressureONSD

Advantages:

ICP changes transmitted within minutes

Non-invasive

No reported complications

Optic nerve sheath Ultrasonography for

monitoring intra cranial pressure

Scan 1 : longitudinal B- Scan

FDA approved ultrasound probe and machine for ocular ultrasonography

Requirements:

• Mechanical index < 0.23

• Thermal index < 1.0

Scan 2 : transverse B- Scan

Scan 3 : transverse and confirmatory A- Scan

ONSD greater than 5.0 mm reliably predicts an ICP > 20

mm Hg

Sliding Sign

Normal Lung

Absence of lung-sliding

and Comet-tail is 96.5%

specific to pneumothorax.

B-lines’ or ‘comet-tail artifacts’

A-lines

Power slide

“stratosphere sign” or “barcode sign”

Absent lung sliding and Comet-tail

Pneumothorax

Diaphragmatic Motion

Neuromuscular Ultrasound for Evaluation of the Diaphragm, Aarti Sarwal et

al

Intercostal view

Anterior Subcostal View

TechniquePatientswere imaged using a Philips ATL Sono CT 5000using a 2–5M Hz curved linear transducer. Patientswere scanned supine; in the case of ventilated patientsit was necessary to briefly disconnect the ventilatorto assess the patients’ spontaneous respiratory efforts.The patients were asked to breathe comfortably andto sniff when requested. Patients were scanned inter-costally in the anterior axillary line with the probeangled cranially so as to have the diaphragm as closeaspossible to 90 degrees to theprobe. The liver wasusedas a window on the right while the spleen was used onthe left. The M mode line of sight was angled to obtainthe maximal diaphragmatic excursion. I f unilateralparalysis was suspected the normal side was scannedfirst. M mode was performed in conjunction withconventional brightness-mode (B mode) grey-scaleultrasound.

The M mode charts movement against time along theM mode line giving a linear analogue of the motion ofthe object being studied, in this case the diaphragm.Normal inspiratory diaphragmatic movement is caudal,with the corresponding M mode trace being upwards asthe diaphragm moves toward the probe, the expiratorytrace is downwards as the diaphragm moves away fromthe probe (ie cranially). The inspiratory phase ofrespiration is noted by a preceding pause in the tracenot present before the expiratory phase. The phase ofrespiration can also be noted and recorded by thesonographer. A normal sniff is demonstrated as a sharpupstroke on the screen, whereas a paralyzed diaphragmwill either demonstrate absent movement or paradoxical(ie cranial) movement.

For the purposes of our study only the direction ofdiaphragm excursion was noted, we did not takemeasurements of the range of excursion.

Results

The results are summarized in Table 1.Normal examination (Figures1 and 2): Threepatients

scanned demonstrated normal diaphragmatic move-

Table 1 Summary of details and findings on all subjects

Subject SexAge

( years) Reason for suspicion Chest X-ray findings Findings with M mode US

1 M 26 C6 fracture tetraplegia High L hemi-diaphragm onCXR

L diaphragmatic paralysis

2 M 61 Dyspnoea when swimming orstanding in deep water

High R diaphragm on CXR R diaphragmatic paralysis

3 M 16 C5 incomplete tetraplegia No CXR abnormalities No abnormality seen4 M 31 C4 incomplete tetraplegia No CXR abnormalities No abnormality seen5 F 23 Disseminated

encephalomyelitisNo CXR abnormalities R diaphragmatic paralysis

6 M 51 M ixed connective tissuedisease, loss of lung volume,paradoxical respiratorymovements

Both diaphragms raised onCXR

Normal diaphragmaticmovement bilaterally

7 M 29 Attempted suicide by hanging,incomplete C3 tetraplegia

Raised R hemi-diaphragm onCXR

R diaphragmatic palsy

8 M 18 Complete C2 tetraplegia,pushbike accident

No CXR abnormalities(ventilated)

L diaphragmatic palsy. Secondscan done due to increasingtime off ventilator noimprovement

9 M 28 Complete C2 tetraplegia,ventilator dependant

No CXR abnormalities(ventilated)

Bilateral palsy withparadoxical movement

10 M 17 M ulti trauma, R brachialplexus injury

Raised R diaphragm on CXR R diaphragmatic palsy withparadoxical movement

Figure 1 M mode ultrasound trace of normal diaphragmmovement. Normal trace of diaphragmatic movement. Ininspiration, movement is caudal, with the corresponding Mmode trace being upwards as the diaphragm moves toward theprobe. In expiration, the M mode trace is downwards as thediaphragm moves away from the probe

Diaphragmatic paralysis

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Spinal Cord

ment. The M mode trace demonstrated caudal move-ment of the diaphragm bilateral ly (towards the topof the screen) and a sharp upstroke on the sniff test.

Diaphragmatic paralysis (Figures 3 and 4): Sixpatients were found to have evidence of a unilateraldiaphragmatic paralysis. This wasowing to high cervicalspine injury (n¼3), brachial plexus injury (n¼1)disseminated encephalomyelitis (n¼1) and idiopathic(n¼1). Four of these patients were noted to have araised hemi-diaphragm on CXR. Of the two who didnot have a raised hemi-diaphragm on CXR, one waspermanently ventilated.

M mode tracing of movement on the normal sidedemonstrated caudal movement with inspiration anda sharp upstroke on the sniff test. The M mode trace

of theparalyzed sideshowed no activecaudal movementof the diaphragm with inspiration and paradoxicalmovement (ie cranial movement on inspiration) parti-cularly with the sniff test. No measurements ofdiaphragmatic excursion were taken.

One patient had evidence of bilateral diaphragmaticparalysis. This patient’s M mode trace showed para-doxical movement bilateral ly with inspiratory effort.His chest X-ray did not show raised diaphragms, thoughit should be noted that he was permanently ventilated.

The sensitivity of Chest X-ray was 66.6% forunilateral paralysis and 57% for paralysis in general.

Discussion

The diaphragm is the principal muscle of respiration.In concert with the other accessory muscles of respira-tion it enlarges the chest cavity on inspiration, allowingthe lung to passively inflate owing to the negativeintra-thoracic pressure. When the diaphragm relaxes,the intrathoracic pressure rises, and air is forced outof the chest. I f one or both of the hemi-diaphragmsis paralyzed, the negative pressure created at inspirationby the other muscles of respiration causes the dia-phragm to passively move cranially, as opposed to itsnormal active caudal movement. M ethods of evaluationof the suspected paralyzed diaphragm focus on eitherobserving the direction of movement or measuring thepressure in the chest.

Fluoroscopy has traditionally been the modality ofchoice for imaging of the suspected paralyzed dia-phragm (the default gold standard). Houston et al,5

however, noted a number of limitations to this modality;it requires patient cooperation and the ability of thepatient to maintain themselves upright, involvesa significant radiation dose and is a subjective method,with results difficult to reproduce. Some of thetechniques that a patient uses to compensate for

Figure 2 M mode ultrasound trace of normal diaphragmmovement. In a normal diaphragm a sharp upstroke isdemonstrated when the patient sniffs

Figure 3 M mode ultrasound trace of paralyzed diaphragm.A paralysed diaphragm demonstrates absent movement withrespiration

Figure 4 M mode ultrasound trace of paralyzed diaphragm.In a paralysed diaphragm, there is paradoxical (ie cranial) orabsent movement when the patient sniffs

Diaphragmatic paralysis

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Spinal Cord

Subxiphoid view

Posterior subcostal view