A surgeon and colleague of mine who had run into some roadblocks with interventional radiology on a particular week (renovations to the interventional room) asked me to help him out with an acute cholecystitis whom he wanted to optimize first and later operate semi-electively (elderly, some acute renal failure with the acute cholecystitis) and needed a drainage procedure.
In this case, the gall bladder was quite superficial and was easily punctured. Note the confirmation of wire position in the gall bladder lumen at about 4:00 min, which is an important step to ensure proper position prior to dilation and pigtail insertion. Also note the final confirmation of position by aspiration of pus. She ended up draining about 250cc of purulent and foul-smelling material.
This video illustrates the procedure and shows how feasible and relatively easily this can be done. Such an approach can be immensely useful in situations where a surgeon or an operating room are not available, if the anatomy allows. In this case the patient improved rapidly and was operated successfully in the following weeks.
The technique of ultrasound spotted or guided pigtail catheter insertion is remarkably simple and safe in experienced hands, saving significant time and patient transport risks (especially ICU patients). It is a seldinger technique which should be familiar to any acute care physician used to inserting central lines. In my opinion this should be part of the armamentarium of any acute care doc.
Belle journée aujourd’hui à a deuxième collaboration éducative entre l’ASMIQ (Association des Spécialistes en Médecine Interne du Quebec) et le CCUS, lorsque une trentaine d’internistes ont approfondi leur habiletés échographiques.
Tel que promis, et dans l’esprit de #FOAMed, voici les présentations et videos:
Dr. Ian Ajmo nous fait une revue de l’évaluation de la volémie, en particulier l’échographie de la veine cave inférieure (VCI):
Here is a one of the “classic” and physiologically important echocardiographic signs:
What do you see in this parasternal short axis view, and what are the physiological implications?
Scroll below for the answer!
This is the “D” sign, aptly named for the D-shape taken by the LV (normally circular) when RV overload occurs and there is paradoxical septal motion and flattening, as early diastolic RV pressure exceeds early diastolic LV pressure. This is NOT a good thing and points to a very strained hemodynamic pattern.
Note the RV is huge in this cut, bigger than the LV (remember that in all views, the RV should be about 60% of the LV size – this is simply due to the semi-lunar shape the RV takes as it “wraps” around the LV – they both have the same stroke volume). Also note the small posterior pericardial effusion.
So what is the diagnosis here? Well there isn’t enough information to say with just this image. This happens to be a case of worsening ARDS, but all you can tell is that there is acute right ventricular failure due to pressure overload, so that the diagnosis includes (a) PE, (b) acute pulmonary hypertension due to some kind of pulmonary disease – ARDS, pneumonia, etc… Obviously, in the absence of significant parenchymal abnormalities on CXR or B lines/effusions/consolidations on lung ultrasound, PE should be strongly considered.
Here is an excellent review on RV dysfunction and focused bedside ultrasound assessment:
The 7th edition of our symposium was awesome! We had over 130 participants from all over Canada, the USA, and even had a few europeans hop the puddle and come share in the learning and practice! All in all, two great days.
Thanks to the entire faculty, including #FOAMites Haney – @criticalcarenow, Mike – @bedsidesono, Vicki – @nobleultrasound, Taylor – @canibagthat, Jean Francois and Maxime – @EGLS_JFandMax who really made sure each participant had a great learning experience.
In the spirit of #FOAMed, we’ll be putting up ALL the lectures on the website in the next few weeks (www.ccusinstitute.org), and eventually a system for CME might be put in place. So make sure to bookmark or come back visit, as there were some really great lectures. Select workshops will also be uploaded.