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D. Lichtenstein General ultrasound in the critically ill Daniel Lichtenstein General ultrasound in the critically ill Forewords by Michael R. Pinsky and François Jardin With 247 Figures 3 Daniel Lichtenstein, MD Hopital Ambroise Paré Service de Réanimation Médicale avenue Charles de Gaulle 9 92104 Boulogne (Paris-Ouest) France e-mail: dlicht@free.fr Translation from the French language edition: L’échographie générale en réanimation by Daniel Lichtenstein Copyright © 2002 Springer-Verlag France Springer is a part of Springer Science+Business Media All Rights Reserved Library of Congress Controll Number: 2004105722 ISBN 3-540-20822-4 Springer Berlin Heidelberg New York This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provision of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer-Verlag.Violations are liable for prosecution under the German Copyright Law. Springer is a part of Springer Science+Business Media springeronline.com © Springer-Verlag Berlin Heidelberg 2005 Printed in Germany The use of designations, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publisher can not guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. Editor: Dr. Ute Heilmann, Heidelberg, Germany Desk editor: Hiltrud Wilbertz, Heidelberg, Germany Production editor: Andreas Gösling, Heidelberg, Germany Cover-Design: Frido Steinen-Broo, Pau, Spain Typesetting: Fotosatz-Service Köhler GmbH, Würzburg, Germany Printed on acid-free paper 21/3150 ag - 5 4 3 2 1 0 Foreword Diagnostic ultrasonography has come of age in the intensive care setting. It has become increasingly common to have training programs teach residents these techniques as part of their fundamental instruction, to have ultrasound equipment available in the ICU and for it to be used by intensivists as an essential tool in the management of the critically ill patient. Ultrasound machines have many applications. They can be used to diagnosis fluid collections in various bodily cavities (e.g., intra-abdominal abscess, ascites, pleural or pericardial effusions) and guide percutaneous catheter insertion. They can be used to diagnose structural etiologies for cardiovascular and respiratory insufficiency, assess intravascular volume status and define cardiac contraction performance. An example of the wide range of structures that can be examined is included in Table 3.2. In fact, considering the non-invasive nature of this form of investigation and the broad number of conditions and uses that ultrasound enjoys, it is surprising that it has taken so much time for this established technique to be embraced by the critical care community. In this volume, Daniel Lichtenstein has addressed the wide variety of ultrasonic approaches in a rigorous yet easy to read fashion. Ultrasound is a learned technique with numerous specific applications. No volume can be a substitute for hands-on experience and good bedside training. However, as a companion to this training, this book collates in a single volume most of the teaching elements used in ultrasound. The first part of the book addresses in a general fashion the actual technique of acquiring ultrasonographic images of normal biological structures. The second part of this volume focuses on diagnostic aspects of specific organs or bodily compartments. This is the largest section, and nicely separates disease by organ. The section on lung pathology is especially important because it has no counterpart in any other volume on ultrasound. The chapter on cardiac ultrasound is also good but cannot stand alone as the primary information base for echocardiography. However, even though echocardiography is an established sub-specialty of cardiology, this chapter still gives an acceptable overview. The third and final part of the volume addresses the important clinical applications of ultrasound. This part can only describe what the reader must experience first hand, but as a guide, it brings together many important and relevant techniques. In summary, Daniel Lichtenstein has distilled in one volume a unique and complete description of ultrasound in the critically ill. This singular work by one of the leaders in the field should define the standard from which students develop their understanding and abilities in this important and rapidly growing field. Michael R. Pinsky, MD, Dr hc University of Pittsburgh Foreword At the beginning of the 1980s, real-time ultrasound, already widely used by cardiologists, arrived in medical intensive care units. At this time, it provided information on cardiac function, and in this domain the use of this method at the bedside provided noteworthy diagnostic short-cuts. In addition, certain physiopathological questions, which often incited interminable discussion, found immediate answers in this new opportunity to directly examine the cardiac chambers. Contrary to cardiac ultrasound, general ultrasound is not usually part of the working knowledge of intensivists. It is therefore with a certain delay that they realized something obvious: the devices they had acquired to obtain information on the heart were also able to provide much more information in areas that were usually reserved for radiologists. With well-targeted training, the intensivist had a tool that could directly answer the numerous questions raised at the bedside. This book by Daniel Lichtenstein, intensivist and physician-sonographer, perfectly illustrates this progression in the field. The English edition provides a good deal of new information compared to the first French edition (1992). The author’s experience has in fact been enriched by daily work at the bedside of patients hospitalized in Ambroise-Paré Hospital’s ICU. Among these new contributions, let us cite in particular lung ultrasound, a discipline that Daniel Lichtenstein has thoroughly described. In addition, a large number of current technical procedures are simplified using ultrasound guidance. In Daniel Lichtenstein’s hands, the ultrasound device has become an indispensable tool in the practice of intensive care and emergency medicine. Prof. François Jardin, PU-PH Preface An English translation of L’Echographie Générale en Réanimation was necessary, after two French versions in 1992 and 2002. Ultrasound has, it is true, gained a more important place in emergency and intensive care medicine. Technological evolution alone does not explain this popularity. Technology develops extremely quickly, but we have always suggested – and continue to do so – that before rushing to the most modern ultrasound units, we should already make optimal use of so-called obsolete devices. Since at least 1978, the quality of the images was sufficient to make life-saving diagnoses. One interesting outcome of technological progress is increasing miniaturization, which makes ultrasound easier to exploit in unusual places such as the ambulance or airplane. Whom is this Book Intended for? This book has a twofold purpose. Its first aim is to describe the fullest exploitation possible of general ultrasound in the ICU. It is also intended to help popularize a method that remains obscure to those who have never used it. All participants in emergency medical care are therefore concerned. Junior radiologists called to the ICU or the emergency room to examine a critically ill patient may feel disconcerted, at the beginning, by this type of patient not usually seen in routine practice. In a single volume they will find all and only the information necessary on this very particular patient. The experienced radiologist controls ultrasound. However, our observations have highlighted applications that we did not find in the daily practice of our colleagues, nor in the ultrasound textbooks. The critically ill patient, often on mechanical ventilation, has extremely complex characteristics, resulting in a specific combination of ultrasound signs, and specific interventional procedures following a specific logic, not the logic surrounding the ambulatory patient, a familiar task for the radiologist. Finally, theoretical potentials of ultrasound that have not yet been validated are presented in this book, opening the door to continued research. We ask the experienced reader to be indulgent with the simplifications made in the initial chapters. On the other hand, intensivists, emergency physicians, and those requesting ultrasound examination wish to penetrate the heretofore impenetrable domain of ultrasound. With ultrasound they will discover wide-ranging possibilities. Furthermore, we must note that ultrasound is increasingly becoming irreplaceable given the desire of intensivists to acquire at least minimal skill aimed at the best possible management of difficult situations, at any time, day or night. We hope that these pages will provide an informative resource while keeping intensivists informed of the pitfalls resulting from suboptimal use of this tool. This book should in no case be considered as a »pilot’s license« but only a didactic aid providing easier access to full use of ultrasound. VIII Preface The Images This edition, derived from the first French edition, has collected figures taken with an ADR-4000 (a device that has been available since 1978), in its time facilitating salutary management of countless critical situations, and a Hitachi EUB405 Sumi (1992). The ADR-4000 and its mechanical sector 3.0-MHz probe, has given images of a lesser quality than more modern devices. We preferred to keep characteristic figures and did not replace these, since a clinically contributive image is definitely better, in the emergency, than the sophisticated image dear to the imaging specialist. The Hitachi 405 with its electronic 5-MHz probe provides latest-generation resolution. All figures in this book have been taken (with a few exceptions indicated) with these devices. Ultrasound unites elements that cannot be dissociated: the operator, the patient, the machine. The operator’s experience is essential. The echogenicity of the patient is also crucial. The quality of the machine comes far behind these two points. The most costly and modern ultrasound device cannot go through bones or airy structures, dressings, nor transform a poorly echoic patient into an echoic one. These are the true limitations of ultrasound. An ultrasound device from the end of the 1970s can save lives. In the figures, letters are used logically. The letter A indicates any artery, B the urinary bladder, C the colon, D the duodenum, E the stomach, F any fat areas, G the gallbladder, H the heart, I the small intestine, K the kidney, L the liver but also sometimes the lung, M any pathological mass, O the esophagus (œsophage in French), P the pancreas, R the rachis, S the spleen, T the trachea, U the uterus, V any vein, and X various organs. The letters RA, RV, PA, LA, LV designate the cardiac chambers (respectively, right auricle, right ventricle, pulmonary artery, left auricle and left ventricle). These terms are recalled in the figure legends. In order not to alter the information, the arrows are located at a slight distance (1 or 2 mm) from the indicated target. One More Point Before closing this preface, we must note that the present book reflects an experience born of the synthesis of two disciplines that are sometimes distant in their philosophy but inseparable in the daily routine of a hospital: intensive care medicine and imaging. This may explain positions that run against the current of academic teachings: the situation of ultrasound with respect to techniques using ionizing radiations, the importance of maneuverable – but not too small – equipment, the indication of certain interventional procedures, the existence of lung ultrasound signs, etc. We ask readers to be tolerant, since they may feel a discrepancy with what they have been taught. For instance, applications are described for which radiological signs already exist. Why then complicate things? Let us take the example of pneumothorax. This disorder can,it is true,sometimes be diagnosed with the clinical examination alone, or by radiography alone.Consequently,if considered separately,the ultrasound sign of lung sliding alone may seem anecdotal. Yet if lung sliding is associated with other interdependent signs, progressively building a whole, this whole will take on increasing importance in patient management. Before reaching this stage, an observer of good faith but not fully informed may find certain processes difficult. In addition, and without evoking overwhelming advantages such as immediate bedside diagnosis at the lowest cost, one issue should be highlighted. The side Preface IX effects of ionizing radiations are beginning to be better known. Very irradiating techniques such as computerized tomography are very recent (less than 30 years), and the biological and mutagenic effects can just now be understood. It is with a view to a possible future policy of irradiation control that we have desired to make the first move in this direction. Some may judge our position excessive, others will consider it as one of the answers to the principle of precaution. Finally, this edition is intended to be imperfect and incomplete. The aim of any research is not to provide the absolute and final answer to a question, but rather to try to push back what we could call a twilight zone, in order to decrease the rate of errors.We impatiently await any idea or correction or improvement from those who have made the effort to open this book. These ideas will be welcome and taken into account for the next edition. Daniel Lichtenstein, MD Acknowledgements This book would not have been written without the help of many participants. Nathalie inspired the idea of the first French version. Jean-François Lagoueyte opened the doors to medicine, Bruno Verdière and Gil Roudy held the doors open to the concerns of intensive care. Without them, nothing would have begun. François Jardin, Yves Menu and Jean-Jacques Rouby were the first to support our project, at a time when this approach to critically ill patients was considered marginal. Let them be warmly thanked. A circle of faithful colleagues from the first hours of this enterprise took part in most of our studies and have used ultrasound for direct management of their patients. Nathalie Lascols, President of the Cercle des Echographistes d’Urgence et de Réanimation Francophones (ceurf.net), has provided invaluable work. Gilbert Mezière played a first-line role and only his modesty kept his name from the list of authors. Agnès Gepner, Olivier Axler, Philippe Biderman, Christian Mirolo and many others also privileged us with the opportunity to merge scientific work and friendship. Special thanks are due to Alain Koiran. Others have taken part in or encouraged this project in one way or another, and we would like to thank them: Eve Adeline, Dan Benhamou, Jean Bernard, Parmod Bithal, Gérard Bleichner, Michel Bléry, A. Jay Block, Slah Bouchoucha, Nathalie Boulet, Jean-Marie Bourgeois, Michel Boynard, Uta Braun, François Brivet, Laurent Brochard, Jean Carlet, Pierre Carli, Paul L. Cooperberg, Pierre Coriat, JeanPaul Courret, Fabrice Czarnecki, Jean-Claude Deslandes, Jean-François Dhainaut, Gilles D’Honneur, Quy Do Dang, Eryk Eisenberg, Konrad J. Falke, François Fraisse, Gérard Friedlander, Guy Frija, Saoul Gayol, Jean-Pierre Goarin, Ivan Goldstein, Patrick Goldstein, Jacques Grellet, Philippe Grenier, Charles Haas, Pierre Haehnel, Laurent Holzapfel, Pierre Kalfon, Roger Kalmanowicz, Renaud Krylatov, Pascal Lacombe, Alan R. Leff, Jean-Jacques Lehot, François Lemaire, Philippe Loirat, William Löwenstein, Isabelle Mabile, Christine Margulis, David Marrache, David Marsh, Jean Marty, Eric Maury, Charles Mayaud, Paul H. Mayo, Henri Mazzola, Georges Mion, Montasser Mouelhi, Linda Northrup, S.A. Pandalai, Paolo Pelosi, Dominique Périès, Jean-Daniel Picard, Michael R. Pinsky, Gabriel Richet, Peter Rinck, Rudolf Ritz, Joëlle Robinet, James A. Russell, Stephen A. Sahn, Cathy Sebat (and the entire team of New Caledonia hospitals), Stanley S. Siegelman, Nicolas Simon, Mohammad Siyam, Michel Slama, Marc Tenoudji-Cohen, Stéphanie van Duin, Philippe Vignon, Jean-Pierre Vilaverde, Jean-Louis Vincent and Francis S.Weill.We again thank the paramedical team of the Hospital Ambroise-Paré who have surrounded this project with affection, and extend our especially warm thanks to the night team. Finally, we are honored to offer this translated version to Jeannette and Harry, who would not have believed it could be accomplished, and to David and Sidney, who have valiantly lived through the many hours devoted to this exciting but exacting project. Jean-Jacques, this book is finally dedicated to you.