Apologies for a long hiatus. Thought I’d share a case from last night. A 54 year old man had been admitted with e.coli sepsis complicated by portal vein thrombosis and multiple hepatic lesions a few weeks ago. A follow up scan by the hospitalist showed the following:
Yup, nasty. So our ICU Outreach service was called (we do all manners of procedures on the wards/er) and it happened to be me.
So 10pm I make my way with all the necessary gear (not much you can’t get done with ultrasound and caffeine!):
Here is the clip:
So this is a synthesis of several US loops. The first ones simply show the lesion, which under US is clearly fluid – movement well seen with respiration/pulsation. Next you see the associated ascites and a quick peek at a subxiphoid view of the heart.
You then see the procedure itself, with a needle insertion (purposely jerky for visualization’s sake), and, following a 3 way stopcock connection, gradual drainage of the abcess.
I chose to hand-drain it in this case to avoid possible blockage of the tube if simply left, since it was a small 8.5 french pigtail catheter (better for comfort). You can see that the access cavity was essentially obliterated. 400 ml or so drained:
So technically this was very simple, however the one important teaching point is to pick an inferio-lateral approach, as an easier but more treacherous one – simple lateral – might result in going thru the pleural space because of the lateral costodiaphragmatic recess which extends quite inferiorly. So when picking the entry point, it is important to make sure it is below the diaphragmatic insertion. Otherwise the potential to seed the pleural space with abcess content is there. This would be sub-optimal.
The advantage of bedside ultrasound? Quick and easy drainage during the weekend when interventional radiology isn’t readily available.