Ten good reasons to practice ultrasound in critical care

Abstract

Over the past decade, critical care ultrasound has gained its place in the armamentarium of monitoring tools. A greater understanding of lung, abdominal, and vascular ultrasound plus easier access to portable machines have revolutionised the bedside assessment of our ICU patients. Because ultrasound is not only a diagnostic test, but can also be seen as a component of the physical exam, it has the potential to become the stethoscope of the 21 st century. Critical care ultrasound is a combination of simple protocols, with lung ultrasound being a basic application, allowing assessment of urgent diagnoses in combination with therapeutic decisions. The LUCI (Lung Ultrasound in the Critically Ill) consists of the identification of ten signs: the bat sign (pleural line); lung sliding (seashore sign); the A-lines (horizontal artefact); the quad sign and sinusoid sign indicating pleural effusion; the fractal and tissue-like sign indicating lung consolidation; the B-lines and lung rockets indicating interstitial syndromes; abolished lung sliding with the stratosphere sign suggesting pneumothorax; and the lung point indicating pneumothorax. Two more signs, the lung pulse and the dynamic air bronchogram, are used to distinguish atelectasis from pneumonia. The BLUE protocol (Bedside Lung Ultrasound in Emergency) is a fast protocol (< 3 minutes), also including a vascular (venous) analysis allowing differential diagnosis in patients with acute respiratory failure. With this protocol, it becomes possible to differentiate between pulmonary oedema, pulmonary embolism, pneumonia, chronic obstructive pulmonary disease, asthma, and pneumothorax, each showing specific ultrasound patterns and profiles. The FALLS protocol (Fluid Administration Limited by Lung Sonography) adapts the BLUE protocol to be used in patients with acute circulatory failure. It makes a sequential search for obstructive, cardiogenic, hypovolemic, and distributive shock using simple real-time echocardiography in combination with lung ultrasound, with the appearance of B-lines considered to be the endpoint for fluid therapy. An advantage of lung ultrasound is that the patient is not exposed to radiation, and so the LUCI-FLR project (LUCI favouring limitation of radiation) can be unfolded in trauma patients. Although it has been practiced for 25 years, critical care ultrasound is a relatively young but expanding discipline and can be seen as the stethoscope of the modern intensivist. In this review, the usefulness and advantages of ultrasound in the critical care setting are discussed in ten points. The emphasis is on a holistic approach, with a central role for lung ultrasound.

Executive summary on the use of ultrasound in the critically ill: consensus report from the 3rd Course on Acute Care Ultrasound (CACU)

“…Cardiology and Radiology. Well-rounded training in CCUS is, therefore, likely to require collaboration with these specialties; specific contact persons in these departments provide a valuable source of support when interpreting complex or unusual images [1]. In an ideal world, regular CCUS multidisciplinary meetings discussing cases of interest will enhance the intensivist's ongoing learning and practice.…”

“…Over the past decades, ultrasound (US) has gained its place in the armamentarium of monitoring tools in the intensive care unit (ICU) [1]. A greater understanding of lung, heart, abdominal and vascular US and improved access to portable machines have revolutionised ICU care, with CCUS playing an important role in bedside examination, potentially becoming the stethoscope of the 21 st century [1].…”

“…A greater understanding of lung, heart, abdominal and vascular US and improved access to portable machines have revolutionised ICU care, with CCUS playing an important role in bedside examination, potentially becoming the stethoscope of the 21 st century [1]. Critical care ultrasonography (CCUS) is the combination of general CCUS (lung and pleural, abdominal, vascular) and CC echocardiography, allowing prompt assessment and diagnosis in combination with vascular access and therapeutic intervention [2].…”

Perioperative medicine: why do we care?

“…The role of ultrasound for regional nerve blocks is well known, but heart failure and pneumonia can now be diagnosed efficiently and accurately at the bedside with lung ultrasound. 23 Many of us can relate to the use of echocardiography for timely management of occurrences of perioperative hemodynamic instability. Some examples may well include an unanticipated episode of hypotension during a thoracotomy found to be due to myocardial ischemia and not due to hypovolemia; worsening hemodynamics during a trauma resuscitation found to be due to an undiagnosed hemopneumothorax; an episode of worsening hypotension during a laparotomy found to be due to undiagnosed hypertrophic obstructive cardiomyopathy; or hypotension during a radical prostatectomy after 3 L of crystalloid with minimal blood loss found to be due to hypovolemia.…”

“…Le rôle de l'échographie dans les blocs nerveux régionaux est bien connu, mais une défaillance cardiaque et une pneumonie peuvent maintenant être diagnostiquées efficacement et précisément au chevet du patient grâce à l'échographie pulmonaire. 23 24 Il semble que de nombreux éléments fondateurs de la médecine périopératoire ont maintenant été créés.…”