Bedside contrast-enhanced sonography of critically ill patients

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report

Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging, are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report

Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.

Intravenous administration of ultrasound contrast to critically ill pediatric patients

BACKGROUND

The off-label use of contrast-enhanced ultrasound has been increasingly used for pediatric patients.

OBJECTIVE

The purpose of this retrospective study is to report any observed clinical changes associated with the intravenous (IV) administration of ultrasound contrast to critically ill neonates, infants, children, and adolescents.

MATERIALS AND METHODS

All critically ill patients who had 1 or more contrast-enhanced ultrasound scans while being closely monitored in the neonatal, pediatric, or pediatric cardiac intensive care units were identified. Subjective and objective data concerning cardiopulmonary, neurological, and hemodynamic monitoring were extracted from the patient's electronic medical records. Vital signs and laboratory values before, during, and after administration of ultrasound contrast were obtained. Statistical analyses were performed using JMP Pro, version 15. Results were accepted as statistically significant for P-value<0.05.

RESULTS

Forty-seven contrast-enhanced ultrasound scans were performed on 38 critically ill patients, 2 days to 17 years old, 19 of which were female (50%), and 19 had history of prematurity (50%). At the time of the contrast-enhanced ultrasound scans, 15 patients had cardiac shunts or a patent ductus arteriosus, 25 had respiratory failure requiring invasive mechanical oxygenation and ventilation, 19 were hemodynamically unstable requiring continual vasoactive infusions, and 8 were receiving inhaled nitric oxide. In all cases, no significant respiratory, neurologic, cardiac, perfusion, or vital sign changes associated with IV ultrasound contrast were identified.

CONCLUSION

This study did not retrospectively identify any adverse clinical effects associated with the IV administration of ultrasound contrast to critically ill neonates, infants, children, and adolescents.

Contrast-Enhanced Ultrasound (CEUS) in Non-Traumatic Abdominal Emergencies

Conventional ultrasound imaging (US) is the first-line investigation in acute non-traumatic abdominal emergencies, but sometimes it needs further examinations, such as computed tomography (CT), to reach a certain diagnosis. Contrast-enhanced ultrasound (CEUS), through injection of contrast medium, may provide the radiologist with additional information that could not be investigated with baseline US. It could help reach a diagnosis and rapidly determine the proper therapy in an emergency setting. The purpose of this review is to explain and illustrate the various possibilities and limitations of CEUS in acute non-traumatic abdominal diseases, in particular acute inflammation, parenchymal infarcts, and hemorrhages.

Contrast-enhanced ultrasonography to evaluate risk factors for short-term and long-term outcomes after liver transplantation: A pilot prospective study

PURPOSE

To evaluate whether Doppler ultrasonography (DUS) and contrast-enhanced ultrasonography (CEUS) can identify liver donation after brain death (DBD) and cardiac death (DCD) with the risk of developing short-term primary graft dysfunction (PGD) or arterial and biliary complications within 1 year.

MATERIALS AND METHODS

Consecutive DBD and DCD donors who underwent DUS/CEUS examinations before surgical procurement from February 2016 to June 2018 at our institution were included. The US and CEUS images of each donor liver were analysed, and the parameters were recorded.

RESULTS

The mean time for US examination was 32 min (range, 20-59 min), and all donors tolerated the examination well. In terms of short-term outcomes, among the 52 eligible donor livers, 20 (38.5 %) of their recipients developed PGD. The multivariable analysis showed that decreased enhancement of donor livers on CEUS (OR = 15.976, 95 % CI: 1.652-154.628, P = 0.017) and high recipient model for end-stage liver disease (MELD) scores (OR = 1.050, 95 % CI: 1.004-1.099, P = 0.034) before liver transplantation (LT) were independent factors of PGD. In contrast, for long-term complications, among the 48 eligible donor livers, 16 (33.3 %) developed arterial or biliary complications within 1 year. The multivariable analysis did not show any independent factors of arterial or biliary complications within 1 year.

CONCLUSIONS

A decrease in enhancement on CEUS is an independent risk factor for poor short-term outcomes of LT. CEUS may be promising for predicting post-LT outcomes of critically ill donors effectively and safely by evaluating the haemodynamic changes in DBD and DCD donor livers.

Assessment of extravasation on ruptured uterine artery pseudoaneurysm using contrast-enhanced ultrasonography during uterine balloon tamponade

Objective

Contrast-enhanced ultrasonography (CEU) has been used in critical trauma situations to visualize extravasation; however, its use is limited in the field of obstetrics. Cases of ruptured uterine artery pseudoaneurysm (UAP) were analyzed to clarify the efficacy to CEU during uterine balloon tamponade.

Methods

Cases of ruptured UAP diagnosed at a teaching university hospital from January 2015 to December 2017 were retrospectively analyzed. UAP was diagnosed using color Doppler ultrasonography. Extravasation was identified using computed tomography and double checked using CEU with an intravenously administered contrast agent (Sonazoid; Daiichi Sankyo Company, Ltd., Tokyo, Japan) and an ultrasound instrument (HI VISION Preirus; Hitachi Aloka Medical, Ltd., Tokyo, Japan). A balloon was then inserted into the uterine cavity and inflated at the point of bleeding until extravasation ceased.

Results

Three patients exhibited ruptured UAP during the study period. Bleeding points were successfully identified using CEU in all cases, and hemostasis was achieved using uterine balloon tamponade. Obliteration of UAP was confirmed using magnetic resonance imaging, and no patients developed recurrent UAP or any complications.

Conclusion

CEU can be used at the bedside to promptly diagnose ruptured UAP. Moreover, it precisely facilitates balloon compression at the point of bleeding.

Contrast-enhanced ultrasonography of post-interventional hematoma: the bleeding mushroom is growing inside

Catheter ablation is an effective treatment in patients with symptomatic atrial fibrillation. Complications are infrequent and usually resolve with minimal or no intervention, but active bleeding due to arterial injury during the vascular access can sometimes represent a life-threatening complication. Contrast-enhanced computed tomography is the standard technique to detect active bleeding, but it may not be immediately available. We report a case of iatrogenic hemorrhage after catheter ablation, in which contrast-enhanced ultrasonography played a decisive role in the recognition of active arterial bleeding due to injury to the right common femoral artery.

Emergency and critical care applications for contrast-enhanced ultrasound

INTRODUCTION

Contrast-enhanced ultrasound (CEUS) using intravascular microbubbles has potential to revolutionize point-of-care ultrasonography by expanding the use of ultrasonography into clinical scenarios previously reserved for computed tomography (CT), magnetic resonance imaging, or angiography.

METHODS

We performed a literature search and report clinical experience to provide an introduction to CEUS and describe its current applications for point-of-care indications.

RESULTS

The uses of CEUS include several applications highly relevant for emergency medicine, such as solid-organ injuries, actively bleeding hematomas, or abdominal aortic aneurysms. Compared with CT as the preeminent advanced imaging modality in the emergency department, CEUS is low cost, radiation sparing, repeatable, and readily available. It does not require sedation, preprocedural laboratory assessment, or transportation to the radiology suite.

CONCLUSIONS

CEUS is a promising imaging technique for point-of-care applications in pediatric and adult patients and can be applied for patients with allergy to CT contrast medium or with impaired renal function. More high-quality CEUS research focusing on accuracy, patient safety, health care costs, and throughput times is needed to validate its use in emergency and critical care settings.

Cardiothoracic MRI in the ICU: A 10-Year Experience

RATIONALE AND OBJECTIVE

The objective of this study was to identify the feasibility and pitfalls of cardiothoracic magnetic resonance imaging (MRI) in intensive care unit (ICU) patients.

MATERIALS AND METHODS

This retrospective study identified adult ICU patients scheduled for cardiothoracic MRIs during a 10-year study period. ICU patients scheduled for brain MRIs served as a comparison group. A chart review was performed to identify factors impacting a patient's ability to undergo an MRI. Differences between completed and canceled examinations for both cardiothoracic and brain MRIs were evaluated. For the cardiothoracic group, clinical indications and the diagnostic value of the study performed were also identified.

RESULTS

A total of 143 cardiothoracic MRIs and 1011 brain MRIs were requested. Cardiothoracic MRI patients were less frequently completed (52% vs 62%), more frequently men (64% vs 43%), younger (55 vs 63 years), less likely mechanically ventilated (8% vs 29%), more likely to require intravenous contrast (83% vs 23%), and had longer examination times compared to brain MRI patients (64 vs 21 minutes). Successful completion of cardiothoracic MRI was associated with lower serum creatinine, higher glomerular filtration rate, and the absence of mechanical ventilation; significant differences were not seen with regard to gender and use of vasoactive agents. Cardiothoracic MRI results were diagnostic in 69% of examinations, most frequently when performed for myocardial disease (84%) and aortic disease (33%), and less frequently for viability (33%).

CONCLUSIONS

In an ICU population, successful completion of cardiothoracic MRI is challenging but feasible in patients with intact renal function and the absence of mechanical ventilation. Examinations were most frequently diagnostic for myocardial and aortic disease indications.

Emergency radiology

US has a relevant role in the initial assessment of non-traumatic emergencies of the abdomen, sometimes being conclusive and some other times for selecting the patients for further imaging with CT. Injection of a contrast medium may give to the radiologist additional information to that obtained at baseline US and Doppler examination, since real-time, contrast-enhanced US (CEUS) may allow observing findings in the abdomen not recognizable at baseline US or even at color Doppler imaging. Extravascular use of microbubbles may also be useful in clinical practice to rapidly solve a number of unclear aspects. CEUS has a number of distinct advantages in acute patients, including its quickness, low invasiveness, and its possible bedside use. The information based on contrast enhancement is useful for initial diagnosis, therapeutic decision making, and follow-up of the critically ill patients. The purpose of this review is to illustrate the possibilities and limitations of abdominal CEUS in the acute setting, with special emphasis on the detection and characterization of acute inflammatory processes, infarcts, and hemorrhages.