hepatic abcess drainage

October 28, 2016

Bedside Ultrasound Case: Control the source. #POCUS #FOAMed, #FOAMcc, #FOAMus

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.

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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.

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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.

 

Cheers!

 

Philippe

August 24, 2015

Bedside Ultrasound-Assisted Procedure: Hepatic abcess drainage. #FOAMed, #FOAMcc

Hi,

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!):

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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.

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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:

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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.

cheers!

Philippe