So this morning a 65yr old man with shock and respiratory failure was admitted to the ICU, hypotensive on levophed and vasopressin, with a lactate over 10.
So, as usual, my first reflex was to reach for the probe to assess hemodynamics. He had been well resuscitated by a colleague, and the IVC was essentially normal, somewhere around 15 mm and still with some respiratory variation. However, scanning thru the liver, my colleague had noted a large hepatic lesion, which on CT scan (non-infused since patient had acute renal failure) the two radiologists argued whether it was solid, vascular or fluid filled.
Having the advantage of dynamic ultrasound, you can tell that there is some fluid motion within the structure, very suggestive of an abcess, especially in the context of severe septic shock:
So the next step was source control:
Pretty nasty. Pardon my french!
We got over 1.5 L of exceedingly foul pus.
Within a couple of hours the lactate dropped to 3 and the levophed was down by more than half.
I think this case illustrates once again, the power of POCUS in the hands of clinicians. While I am certain that the diagnosis would have been made without POCUS, it probably would have taken additional time as the radiologists themselves were debating its nature, and without POCUS, bedside drainage in the ICU would have been out of the question. That liter might still be in there tonight…
For those interested in how to integrate POCUS in their daily rounds, I think I put together a fair bit of clinical know-how and tips in this little handbook.
Very nice work! Completely agree on the power of bedside diagnostics to expedite clinical decision making and to facilitate clinical care. One question- how do you view the risks of the POCUS care provider in doing U/S guided surgical procedures vs interventional radiologists? Should there be a complication, due you feel that the POCUS provider would be at more risk of criticism by practicing outside their scope vs the trained interventionalist? RG
Excellent question and point of discussion Dr. Ghosh! On a practical level, it probably depends how litigious a society one practices in. South of our border it may be a bit of an issue. From the patient’s standpoint, the sooner the drainage the better, so it’s a pro-con debate between the skills of your POCUS clinician, and the delay to get the patient to someone’s potentially more skilled hands. I don’t think there is anything particularly complex about threading a catheter by seldinger technique into a 10+ cm fluid collection, it’s kinda hard to miss, particularly with direct ultrasound visualization. Certainly, however, this is experience-dependant and the practitioner should feel comfortable with the procedure. Criticism? Certainly. But this often has more to do with territoriality and politics than patient care, in my experience. One easy pathognomonic sign for this type of behavior/attitude is when the critics say it’s fine for the first-line clinician to do the procedure only after-hours. But during regular hours, their skills aren’t “up to par” and should be done by the highest expert…hmmm… 😉
Thanks for reading!
it looks like you went through a lot of liver on the ultrasound to get to the collection, that seems dangerous.
Correct. About 5 cm. Anytime you stick a long needle into a body it is dangerous. I try to chose the shortest route that gives good visibility. Source control in septic shock, however, trumps bleeding risk…
Thanks for reading!