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208 PART 2: General Management of the Patient

dynamic changes (gut movement, diaphragmatic movement, shape critically ill, it allows the intensivist to rapidly assess the patient with
change with force application to the abdominal wall). Initially, asci- hemodynamic and respiratory failure. The combination of focused
44
tes collects in the hepato/renal space and in the pelvic area, so the cardiac and thoracic ultrasonography supplemented with vascular
examination focuses at these points. Larger amounts accumulate diagnostic and limited abdominal ultrasonography gives the frontline
in the lateral abdominal area and around both the spleen and liver. intensivist a powerful tool for diagnosis and management in the ICU.
Identification of ascites may lead to paracentesis. The principles The use of ultrasonography represents the adoption of a well-validated
of thoracentesis apply as well to paracentesis. The best site, angle, imaging modality in a new clinical arena. It is very likely that critical care
and depth and of needle penetration is determined with ultraso- ultrasonography will become a routine part of critical care medicine in
nography, followed by site preparation and device insertion at the coming years, as intensivists incorporate it into their practice as a logical
indicated site and at the angle defined by the transducer. There extension of the physical examination.
should be no change in patient position between the scan and the
needle insertion.
2. Assessment of renal failure: Obstructive uropathy is an unusual
but remedial cause of renal failure in the ICU. Renal ultrasonogra- KEY REFERENCES
phy gives information regarding the etiology of renal failure, even
as it is used to rule out obstruction. The examination is easy to • Barbier C, Loubières Y, Schmit C, et al. Respiratory changes
perform. Both kidneys are imaged in longitudinal axis. Obstructive in inferior vena cava diameter are helpful in predicting fluid
uropathy causes dilation of the pelvocalceal area with hypoechoic responsiveness in ventilated septic patients. Intensive Care Med.
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obstruction or a blocked urinary bladder catheter. Small kidneys • Cholley B. International expert statement on training standards for
with hypertonic cortex suggest chronic renal failure. critical care ultrasonography. Expert Round Table on Ultrasound
3. Examination for abdominal aortic aneurysm: An abdominal in ICU. Intensive Care Med. 2011;37:1077-1083.
aortic aneurysm is readily identified using a left paramedian sagit- • Doerschug KC, Schmidt GA. Intensive care ultrasound: III. Lung
tal scanning plane in transverse and longitudinal axis between the and pleural ultrasound for the intensivist. Ann Am Thorac Soc.
umbilicus and the xiphoid process. The skill may be used when 2013;10:708-712.
indicated for rapid bedside assessment of hemodynamic failure. • Fragou M, Gravvanis A, Dimitriou V, et al. Real-time ultrasound-
Barriers to Implementation of Critical Care Ultrasonography: Ultrasono guided subclavian vein cannulation versus the landmark method
graphy is a well-established imaging modality and is fully validated in critical care patients: a prospective randomized study. Crit Care
by the radiology and cardiology specialties. The critical care commu- Med. 2011;39:1607-1612.
nity has chosen to adopt this well-established modality to the special • Kory PD, Pellecchia CM, Shiloh AL, Mayo PH, DiBello C, Koenig
demands of the ICU. Issues related to cross specialty competition S. Accuracy of ultrasonography performed by critical care physi-
and economic control have blocked the rapid dissemination of ultra- cians for the diagnosis of DVT. Chest. 2011;139:538-542.
sonography to frontline intensivists. This conflict will diminish as • Labovitz AJ, Noble VE, Bierig M, et al. Focused cardiac ultrasound
ultrasonography becomes a routine part of critical care function, and in the emergent setting: a consensus statement of the American
when nonintensivists come to understand that deployment of ultra- Society of Echocardiography and American College of Emergency
sonography in the ICU will not threaten their traditional domination Physicians. J Am Soc Echocardiogr. 2010;23:1225-1230.
of the field.
The majority of frontline intensivists in the United States do not yet • Lichtenstein D, Mezière G, Seitz J. The dynamic air bronchogram.
have training in critical care ultrasonography. This constitutes a barrier A lung ultrasound sign of alveolar consolidation ruling out atelec-
to implementation. The National Societies that represent the interests tasis. Chest. 2009;135:1421-1425.
of intensivists have taken effective steps in developing training options • Lichtenstein DA, Mezière GA, Lagoueyte JF, et al. A-lines and
for attending level intensivists. These popular training programs are B-lines: lung ultrasound as a bedside tool for predicting pul-
designed for the bedside clinician as well as the clinical faculty who monary artery occlusion pressure in the critically ill. Chest.
are responsible for training a new generation pulmonary/critical care 2009;136:1014-1020.
fellows. As of July 1, 2012, certain aspects of critical care ultrasonogra- • Mayo PH, Beaulieu Y, Doelken P, et al. American College of
phy have become a mandatory component of fellowship training, and it Chest Physicians/La Société de Réanimation de Langue Française
is likely that others will follow shortly. In this way, within a few years, Statement on Competence in Critical Care Ultrasonography.
graduating fellows will be competent and ultrasonography will become Chest. 2009;135:1050-1060.
a routine part of critical care practice. The field of critical care ultraso- • Schmidt GA, Koenig S, Mayo PH. Shock: ultrasound to guide
nography is developing along similar lines in countries in Europe and diagnosis and therapy. Chest. 2012;142:1042-1048.
the Asia-Pacific area.
Critical care ultrasonography requires a paradigm shift in imaging • Vezzani A, Brusasco C, Palermo S, Launo C, Mergoni M, Corradi
strategy. Intensivists have previously been passive participants in the F. Ultrasound localization of central vein catheter and detection of
imaging process. They ordered the test, but someone else performed postprocedural pneumothorax: an alternative to chest radiogra-
and interpreted it. The shift occurs when intensivists understand that phy. Crit Care Med. 2010;38:533-538.
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themselves. The result is immediate and synergistic with the clinician’s raphy: validation of a curriculum dedicated to noncardiologist
comprehensive understanding of the entire case. residents. Crit Care Med. 2011;39:636-642.

CONCLUSION
Ultrasonography is a useful imaging modality in the ICU. When REFERENCES
used for procedural guidance, it improves the safety and efficiency of
ICU-related procedures. When used for the bedside evaluation of the Complete references available online at www.mhprofessional.com/hall

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