Abstract
Goal-directed point-of-care ultrasound (POCUS) is real-time, organ-focused ultrasonography performed by the clinician and it is arguably the most important contemporary extension of the physical examination for today’s clinicians. Over the past decade, POCUS has become essential in the early diagnosis and management of a critically ill patient. Goal-directed ultrasound performed by physicians is focused on clinical problems and not limited to a single anatomical area [1]. While the general goals of sonography in the unstable patient are to evaluate cardiac function and assess intravascular volume, in a patient with fever, POCUS can also help to identify the cause of the patient’s clinical condition. In addition, ultrasound guidance is essential in performing bedside procedures. The current chapter uses a case-based approach to illustrate the utility of ultrasound in making a rapid and acceptably accurate diagnosis for a patient with fever and sepsis (Figs. 37.1, 37.2, 37.3, 37.4, 37.5, 37.6, 37.7, 37.8, 37.9, 37.10, 37.11, 37.12, 37.13, 37.14, 37.15, 37.16, 37.17, 37.18, 37.19, and 37.20 and Videos 37.1, 37.2, 37.3, 37.4, 37.5, 37.6, 37.7a, 37.7b, 37.8, 37.9, 37.10, 37.11, 37.12, 37.13, 37.14, 37.15, 37.16, 37.17, 37.18, 37.19, and 37.20). Physicians caring for critical patients should strongly consider integrating focused ultrasound techniques into their routine clinical evaluation. The American College of Chest Physicians (ACCP) and the La Société de Réanimation de Langue Française (SRLF) selected a panel of experts to review the field of critical care ultrasound (CCUS) and to develop a consensus statement on competence in CCUS [3].
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37.1 Electronic Supplementary Material
Normal lung ultrasound findings . Lung ultrasound is easy to perform through several intercostal acoustic windows and can contribute to differential diagnosis in a critically ill patient. A lines are horizontal, regularly spaced hyperechoic lines that are repetition artefacts of the pleural line, and are what is seen in the normal lung. See also Fig. 37.1 (WMV 290 kb)
Lung ultrasound in identifying extravascular lung water . B lines are vertical narrow based hyperechoic lines arising from the pleural line to the edge of the ultrasound screen. These are also known as “comet tail artifacts,” and when several B lines are visible, the term “lung rockets” is used. The number and extent of B lines allow rapid and semi-quantitative estimation of extravascular lung water [2]. Multiple B lines in more than two lung zones suggest diffuse alveolar interstitial syndrome such as pulmonary edema or ARDS. See also Fig. 37.2 (AVI 2837 kb)
Lung ultrasound for detection of pleural effusion . Pleural effusion can be rapidly diagnosed by using bedside lung ultrasound and small effusions can be localized for aspiration. Pleural effusion is best demonstrated in the dependent areas with the probe placed in the intercostal space with the indicator of the probe pointing cranially. The effusion appears as echo free or hypoechoic (i.e., dark) space and is delineated by the chest wall and the diaphragm. The fluid acts as an acoustic window and the underlying lung can also be visualized. In this case compressive atelectasis is seen. In compressive atelectasis, the underlying lung is not consolidated and therefore will change in shape with respiration demonstrating the “jellyfish sign.” See also Fig. 37.3 (WMV 3703 kb)
Lung ultrasound for detection of pleural effusion . Pleural effusion is seen as an anechoic space. The underlying lung appears consolidated with areas of hyperechoic signal corresponding to air in the bronchi—the so-called ultrasound air bronchogram. This patient had pneumonia and sonographic-guided bedside aspiration revealed a simple parapneumonic effusion. See also Fig. 37.4 (AVI 3018 kb)
Lung ultrasound in patients with pneumonia . In patients with pneumonia, bedside ultrasound can demonstrate dense consolidation of the lung tissue characterized as “sonographic hepatization” of the lung. The consolidated lung tissue should be differentiated from the liver or spleen by demarcating the thorax from the abdomen using the diaphragm as the landmark. See also Fig. 37.5 (WMV 3219 kb)
Lung ultrasound for diagnosing loculated pleural effusions . This figure shows a parapneumonic effusion with multiple loculations necessitating a video-assisted thoracoscopic surgery (VATS) procedure. The loculations are easily identified by the multiple fibrin strands in the echo free effusion. See also Fig. 37.6 (AVI 2444 kb)
Venous ultrasound for detection of thrombosis . This video shows left internal jugular vein thrombosis in a young male with pharyngitis and septic emboli to the lungs. The thrombus is identified as the echogenic material within the normally echo-free vessel and confirmed by non-compressibility of the vein. Thrombophlebitis of the jugular vein (Lemierre’s syndrome) most commonly occurs due to the spread of the bacterial throat infection (e.g., Fusobacterium necrophorum) to the carotid sheath vessels and subsequently the bloodstream. See also Fig. Fig. 37.7 (WMV 5192 kb)
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Another view of venous ultrasound for detection of thrombosis. See also Fig. 37.7 (WMV 566 kb)
Bedside ultrasound in a patient with urosepsis . A point-of-care ultrasound was performed in a 70-year-old male who was admitted with urosepsis and gram-negative bacteremia. The figure demonstrates the thickened urinary bladder with a foley catheter in place which prompted a urology evaluation. See also Fig. 37.8 (WMV 3194 kb)
Cardiac ultrasound in a patient with fever and pulmonary edema . Point-of-care echocardiography shows mobile mitral valve vegetation in a middle-aged male admitted for fever, dyspnea, and pulmonary edema. Severe mitral regurgitation was also seen by color Doppler (not shown). A vegetation is defined as a discrete echodensity with independent mobility typically attached to the valve leaflets. Transthoracic echocardiography has a limited sensitivity for detection of vegetations and should be followed by transesophageal echocardiography in patients with high suspicion for endocarditis. In patients with established endocarditis, transesophageal echocardiogram can delineate the extent of involvement and detect complications (such as valve perforation, abscess formation, etc.). See also Fig. 37.9 (WMV 2320 kb)
Cardiac ultrasound for pericardial effusion . A point-of-care echocardiography shows a pericardial effusion (echo-free space surrounding the heart) with fibrinous debris in a middle age patient with end stage renal disease admitted with fever and chest pain. The patient was diagnosed with uremic pericarditis which resolved with dialysis. See also Fig. 37.10 (WMV 2672 kb)
Cardiac ultrasound in a patient with advanced cancer. A point-of-care ultrasound shows pericardial effusion with debris, pleural thickening, and left-sided pleural effusion in an elderly male with dyspnea. Pericardial effusion is seen in this parasternal long axis view as an echo-free space posterior to the heart but anterior to the descending aorta. Pleural effusion is seen as an echo-free space posterior to the aorta. A mass encroaching onto the left atrium is also seen. This patient was diagnosed with advanced widespread lung cancer. See also Fig. 37.11 (WMV 2826 kb)
Bedside ultrasound for suspected renal disease. Point-of-care sonography of the kidneys shows the hydroureter as hypoechoic (black) fluid-filled area next to the kidneys in this longitudinal image. This image was obtained in a young female with sepsis and flank pain. Subsequent CT scan confirmed an obstructing stone prompting urologic intervention. See also Fig. 37.12 (WMV 7218 kb)
Bedside ultrasound for suspected renal disease. The longitudinal ultrasound of a left kidney shows a large hypoechoic (black) area in the center of the kidney extending into the parenchyma consistent with hydronephrosis . A similar finding was seen on the on the right side in this middle-aged male admitted with septic shock, acute renal failure, and gram-negative bacteremia. Bilateral nephrostomies were required which yielded purulent urine. See also Fig. 37.13 (WMV 5667 kb)
Bedside ultrasound for suspected biliary disease. A point-of-care ultrasound shows a distended gallbladder with a thickened wall (>3 mm) and distal acoustic shadowing which usually represents a stone in the neck of the gallbladder or the cystic duct. This patient was admitted with septic shock and gram-negative bacteremia. The most sensitive ultrasound finding in acute cholecystitis is the presence of cholelithiasis in combination with the sonographic Murphy sign (tenderness in the right hypochondrium) while performing sonography. Both gallbladder wall thickening (>3 mm) and pericholecystic fluid are secondary findings. Other less specific findings include gallbladder distension and sludge. See also Fig. 37.14 (WMV 812 kb)
Bedside ultrasound for suspected biliary disease. A distended gallbladder with extensive sludge is seen on this bedside ultrasound image. A distended common bile duct is also seen. See also Fig. 37.15 (WMV 1027 kb)
Bedside ultrasound for liver disease. A point-of-care ultrasound shows a hypoechoic (black) lesion in the liver surrounded by a hyperechoic rim in a patient admitted with abdominal pain, right upper quadrant tenderness, malaise, and fever. The percutaneous drainage subsequently revealed polymicrobial pyogenic liver abscess. See also Fig. 37.16 (WMV 2412 kb)
Bedside ultrasound for liver disease, showing the air bubbles in the portal circulation. Point-of-care ultrasound examination reveals extensive air (hyperechoic white areas) in the portal venous circulation. This patient was admitted with profuse diarrhea and septic shock. He was subsequently diagnosed with severe Clostridium difficle colitis and pneumatosis intestinalis. See also Fig. 37.17 (WMV 6630 kb)
Abdominal ultrasound in a patient with ascites. Ascitic fluid can be easily seen on bedside ultrasound as echo-free or hypoechoic (black) space in the abdominal cavity. Normal appearing bowel loops are also visualized. Ultrasound allows for safe sampling of the ascitic fluid for both diagnostic and therapeutic purposes. See also Fig. 37.18 (AVI 2837 kb)
Abdominal ultrasound in a patient with ascites. In this image, the ascites are complicated and thick echogenic fibrinous material is seen in the normally echo free ascitic fluid. The debris is seen, appearing as flotsam. See also Fig. 37.20
Video 37.7b
Another view of venous ultrasound for detection of thrombosis. See also Fig. 37.7 (WMV 566 kb)
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Narayanswami, G., Argulian, E., Narula, J. (2018). Evaluation of Fever. In: Nelson, B., Topol, E., Bhagra, A., Mulvagh, S., Narula, J. (eds) Atlas of Handheld Ultrasound. Springer, Cham. https://doi.org/10.1007/978-3-319-73855-0_37
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