Pierre Kory, MPA, MD Medical Director, Trauma and Life Support - PowerPoint PPT Presentation

Pierre Kory, MPA, MD Medical Director, Trauma and Life Support Center Chief, Critical Care Service Associate Professor of Medicine University of Wisconsin School of Medicine and Public Health

GO GOALS ALS  POINT-OF-CARE ULTRASOUND  BRIEF HISTORY – EVOLUTION - DEFINITION  OVERVIEW OF THE 4 DOMAINS CRITICAL CARE ULTRASOUND  CRITICAL CARE ECHO – DIFFERENTIATION OF SHOCK STATES  SEPTIC, HYPOVOLEMIC, CARDIOGENIC, OBSTRUCTIVE - DOES IVC HELP?  CASE BASED OVERVIEW OF SHOCK SYNDROMES  LITERATURE REVIEW SUPPORTING ECHO AS TOOL FOR DIAGNOSIS SHOCK STATES  CARDIAC ARREST STATES – IS TEE THE FUTURE STANDARD OF CARE?  LUNG ULTRASOUND – DIFFERENTIATION OF ACUTE RESPIRATORY FAILURE  ADDRESS WIDESPREAD INACCURACY IN DIAGNOSIS OF ARF  INTRODUCE 5 ULTRASOUND SIGNS AND DEFINED PATTERNS OF ARF  LITERATURE REVIEW OF IMPACT ON ACCURACY  **RESIDENT CASE SESSION – MORE PRACTICE ASSESSING CASES OF SHOCK USING ECHO

HIS HISTOR ORY OF BEDSIDE Y OF BEDSIDE DIA DIAGNOS NOSTIC TECHNOL IC TECHNOLOGY 1808 – Laennec’s stethoscope  1888 - Reflex Hammer  1950 –Korean War – Bedside X-ray  1950’s –Ultrasound - Refrigerator size machines  Research labs only ○ 1960’s-70’s – commercial machines  1980’s – Movable, placed on carts  1990’s- DARPA grant – Backpack Ultrasound!  1990’s – Ultrasonography at the Bedside  Birth of Point-of-Care Ultrasound ○ Machines smaller, powerful, user friendly, ubiquitous ○ Central venous access - further spread of machines ○ 2000’s – Portable machines rival quality of larger  Nelson, Heart , 2013 Noble, NEJM 2011

Hist Histor ory of car y of cardiac output iac output monit monitoring in anesthesia ring in anesthesia Scene from AMC Television Series “The Knick” about a NYC Surgeon in 1905

“Portable” “Portable” X-Ray - 1952 Ultrasound – 2016

THE LA THE LATES TEST AD ADVANCE… “F NCE… “FOREARM” UL OREARM” ULTRASOUND TRASOUND

IMA IMAGING PO ING POWER… IN WER… IN YO YOUR H HANDS  Miraculous Properties  Penetrates through fluid and solid organs  Liver, kidney, heart, spleen ( LUNG)  Obstructed by bone and air **Image taken with lap-top sized machine, 2008,

A “DISR A “DISRUPTIVE” INNO PTIVE” INNOVATION TION “That which transforms a market by introducing simplicity, convenience, accessibility,  and affordability where complication and high cost were the status quo” INITIALLY, Traditional imagers controlled market  expensive, immobile machines, interpreted remotely by experts ○ SUBSEQUENTLY, Technology led to Hand held/Portables – cheap, high quality  images, easy to use, wider spectrum of doctors using the machines ○ devices shown to be of equal efficacy for “decision making” Nelson, Heart , 2013

POINT POINT-OF-CARE UL OF-CARE ULTRASOUND (POCUS) TRASOUND (POCUS) – SOME DEFINITIONS OME DEFINITIONS  “ultrasound exam performed by the care PROVIDER in real time”  Not saved as a still image to be interpreted later by remote specialist  “not a complete study, rather an extension of the clinical examination to rule in or rule out key diagnoses in specific clinical settings”  “geared to addressing highly time-dependent and focused questions and, in general, most focused scans become more obviously positive as the patient becomes increasingly unwell” Grifoni Chest 2013 Atkinson J Emerg Med 2011

Stable vs. Unstable Patients  The benefits of point-of-care ultrasound:  Unstable patients- directs immediate care and potentially saves lives  Stable patients - expedites care, reduces ancillary testing, and educates providers.

Dif Differences betw erences between P een Point-of-Care Ultrasound int-of-Care Ultrasound over T er Traditional Imaging Pract aditional Imaging Practice ce • Avoid Clinical Disassociation of Traditional Interpreters • knowledge of loading conditions, pre-test probability of disease(s) in question • Avoid Time Disassociation of Traditional Interpretation • no delays in performance/interpretation by a remote specialist • avoid lengthy, “comprehensive” exams – focus components to those most relevant • Integrate Exam Findings From Multiple Organ Systems simultaneously - answer broader questions: • Why is this patient in shock? • Why is this patient in respiratory failure? • Why does this patient not have urine output? • Why is the patient’s abdomen distended? • What are causing the bibasilar opacities? 4) Avoid potentially lethal radiation 5) Avoid potentially ”lethal” costs

POCUS POCUS EVOLUTION TION  1970’s – USA - Ultrasound first used at bedside of trauma patients  1980’s France – Birthplace of Critical Care Ultrasonography ○ ICU Echo in 1980’s, Lung and GCCUS – 1990’s  TEE now performed as a routine assessment of shock patients  1990’s- “FAST” exam coined in Emergency Medicine in U.S ○ Part of EM competency requirements since 1994 ○ Precedent for development of ever expanding POCUS applications ○ POCUS now part of nearly every specialties practice  2000’s - Medical schools now integrating into curriculum ○ Rare for Medicine Residency programs (some recent studies..) ○ Pulmonary/Critical Care Programs – becoming routine

EVOLUTION OF POINT OF CARE ULTRASONOGRAPHY (CCUS) Soni, Arntfield, Kory, POCUS, 2014

GUIDELINES/RECOMMEND GUIDELINES/RECOMMENDATIONS F IONS FOR R USE OF UL USE OF ULTRASOUND TRASOUND  AMA AMA – “ultrasound within scop ultrasound within scope of pr e of pract actice of ( ce of (all) appr ll) appropr opriat ately t ely trained-ph ained-physicians” ysicians”  AHCQR – AHCQR – one of 12 ne of 12 best practices f best practices for patient saf r patient safety ty (CV (CVC access) access)  AC ACGME - - required c component o of t training in in several r ral residency and f sidency and fello llowships wships  PCCM PCCM Residency R sidency Revie view Committ Committee recommends: ee recommends: ○ “ “ training in training in ultraso ultrasound guided CV nd guided CVC and tho C and thoracent acentesis..” sis..” ○ “demonstrat “demonstrate kno knowledge of ult ledge of ultrasound im asound imaging t aging techniq chniques us es used in ed in evaluation aluation of p patients w with p pulmonary d disease o or c critical i illness” AIUM 2004 - “the AIUM 2004 - the concept of an concept of an ‘ultrasound st ‘ultrasound stetho hoscope’ scope’ is rapidly mo is rapidly moving fr ving from the om the  the theore retical t l to reality reality.”  Abraham V raham Verghe rghese se - “great vie great views of hear of heart, adds v adds volume lumes t s to inf info fr from st om stethoscope” ope”  Advocat cates POCUS t POCUS to im impr prove patient int e patient interaction/PHY raction/PHYSICA ICAL EXAM EXAM  20 2017 SUR SURVIVING SEPSIS IVING SEPSIS CAMP CAMPAIGN GUIDEL AIGN GUIDELINES INES:

CCUS Rationale/Evidence…? CCUS Rationale/Evidence…?  Improves safety & Success of venous, pleural, peritoneal, pericardial cannulation and drainages  Uncountable cases of unsuspected life-threatening conditions (AMI, VTE/PE, pleuro-pericardial, valves, aorta, PTX, cardiomyopathy)  Large improvements in accuracy of diagnosis of shock and acute respiratory failure  “suggestion” of improved outcomes  Sequential exams guide resuscitation, titration of inotropes  Under-reported outcomes/benefits, captured in several studies but not as primary outcomes – difficult to design studies on diagnostic tools

UNDER UNDER-RECOGNIZED IMP RECOGNIZED IMPACT CT OF CRITICAL CARE OF CRITICAL CARE UL ULTRASOUND: REDUCTION IN IMA TRASOUND: REDUCTION IN IMAGING TES ING TESTS  Peris A et al, Anaesth Analg , 2010  Introduced LUS to a group of intensivists. Measured CXR and CT scans use 3 months before and after LUS training ○ CT’s: 274 to 135 ( 50% decrease) ○ CXR’s: 803 to 589 (40% decrease) ○ *trend to a lower LOS, lower days on ventilator”  Oks M et al, Chest, 2014  Compared radiology tests between North Shore ICU (no diagnostic U/S) and Long Island Jewish (heavy U/S use) ○ 3.75 CXR/pt vs. 0.82 CXR/pt ( p<.05) ○ . 1 CT/pt vs.04 CT/pt ( p<.05) ○ .17 CT abdo/pt vs. .05 CT Abdo/pt (p<.05)

CRITICAL CARE UL CRITICAL CARE ULTRASONOGRAPHY APPLICA TRASONOGRAPHY APPLICATIONS IONS “WHOLE-BOD HOLE-BODY UL Y ULTRASOUND” TRASOUND”  CARDIAC  Differentiation of Shock States  Assessment of Fluid Responsiveness?  LUNG and PLEURA  Diagnosis of Causes of Acute Respiratory Failure  Characterization/drainage of pleural pathology  ABDOMINAL  Free Fluid, Obstructive Uropathy, Ischemic Colitis  VASCULAR  Catheter Insertion Guidance  Diagnosis of Deep Venous Thrombosis

BASIC CCE – RECOGNIZING SHOCK SYNDROMES

NEJM REVIEW 2012 – CATEGORIZING SHOCK STATES Taken From NEJM Review Paper on Management of Shock, 2012

ASE PRESIDENT EDIT ASE PRESIDENT EDITORIAL ON ORIAL ON POCUS 20 POCUS 2016