CHEST
Postgraduate Education Corner ULTRASOUND CORNER
A Postoperative Patient Decompensates During Transfer From an Outside Hospital Thomas Edrich, MD; Pingping Song, MD; Martin W. Dünser, MD; Bernhard Bacher, MD; and Christian Torgersen, MD
CHEST 2014; 145(5):e14–e16
an outside hospital, a 63-year-old man with severe AtCOPD and a lung mass underwent a left upper
lobectomy complicated by both a persistent air leak requiring chest tube placement and hospital-acquired pneumonia requiring reintubation. A DVT developed in the upper extremity, requiring full anticoagulation treatment. Subsequently, a spontaneous retroperitoneal hemorrhage occurred, as diagnosed by abdominal CT scan, requiring massive transfusion and reversal of heparin with protamine. During resuscitation, the patient developed a distended abdomen (bladder pressure of 23 mm Hg), oliguria, and hypotension requiring norepinephrine. During the transfer by ambulance to our hospital, the norepinephrine requirement escalated to 40 mg/min with continued severe hypotension. Upon arrival, the patient’s skin had mottled, but he had warm extremities and reduced breath sounds over the left chest (but with the chest tube on suction); he was agitated and dyssychronous with mechanical ventilation. The ICU team initiated rapid infusion of crystalloids and ordered emergency-release blood products under the presumption that retroperitoneal hemorrhage had resumed during transport. A chest radiograph (CXR) was ordered, and sedation was increased to reduce dyssychrony. The team then noticed that the chest
tube was not tidaling despite attempts to clear it by stripping. The intensivist immediately performed a goaldirected cardiac and pleural ultrasound. This was later followed by compression ultrasound (CUS) of the leg vasculature. In the cardiac ultrasound, the parasternal and apical views could not be obtained because of lung or air artifacts. However, the subcostal position yielded a long-axis and short-axis view of the heart as well as a view of the inferior vena cava (IVC) as shown in Video 1 (cardiac ultrasound with two-dimensional views obtained only from the subxiphoid position). The short-axis view was obtained by rotating the transducer counterclockwise starting from the subcostal four-chamber view. Video 2 (pleural ultrasound over the left anterior chest) demonstrates a clip of the pleural ultrasound over the left anterior chest. Similar views were obtained from the midaxillary and posterior positions. Video 3 (CUS examination of the proximal leg vessels [left leg only]) shows the CUS of the left leg only. The right leg looked similar. Finally, a focused abdominal ultrasound examination was performed (not shown), which did not reveal any free intraperitoneal fluid. Based on these ultrasound findings and the clinical story, what essential next steps should be initiated soon?
Manuscript received October 25, 2013; revision accepted December 6, 2013. Affiliations: From the Department of Anesthesia, Perioperative and Pain Medicine (Drs Edrich and Song), Brigham and Women’s Hospital, Boston, MA; and the Department of Anesthesiology, Perioperative Medicine and General Intensive Care Medicine (Drs Dünser, Bacher, and Torgersen), Salzburg General Hospital and Paracelsus Private Medical University, Salzburg, Austria. Correspondence to: Thomas Edrich, MD, Department of Anesthesia, Perioperative and Pain Medicine, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02467; e-mail: tedrich@ partners.org © 2014 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.13-2140 e14
Postgraduate Education Corner
Next steps: Focus on treatment of sepsis—the patient displays signs of distributive shock with hyperdynamic left ventricular function and good diastolic filling Discussion The clinical story with a recent severe retroperitoneal hemorrhage led the ICU team to initially suspect a possible rebleed. Thus, they prepared for massive transfusion using emergency-release blood products. However, upon discovery of the dysfunctional chest tube in the physical examination, the possibility of a tension pneumothorax (PTX) had to be considered as well. While awaiting the CXR, pleural ultrasound was deemed to be the most expedient method to investigate this. As seen in Video 2, pleural ultrasound did not reveal a PTX. There was normal lung sliding in the B-mode image indicating that the parietal and visceral pleura were in apposition. Verification using M-mode interrogation of the pleura yielded the characteristic sandy-beach sign. In the video, the large arrow marks the pleura; the small arrows mark motion artifacts superficial to the pleura due to respiratory efforts in this dyssychronous patient. In a meta-analysis of trauma patients, pleural ultrasound had a higher sensitivity than CXR for PTX (86%-98% vs 28%-75%), with similar specificity (97%-100% vs 100%), with the caveat that several zones must be scanned to avoid overlooking a localized PTX.1 In the cardiac ultrasound (Video 1), a hyperdynamic left ventricle (LV) with good diastolic filling and a full IVC without respiratory variation was found. This suggested adequate LV and right ventricle (RV) preload, but a low afterload for the LV. These findings were not consistent with hypovolemia due to hemorrhage, but were suggestive of distributive shock. Indeed, in the further course, the patient stabilized after the addition of vasopressin to elevate the systemic vascular resistance and after broadening the antibiotic coverage empirically. A Gram stain of the respiratory secretions demonstrated abundant inflammatory cells and gram-negative rods. Thus, the diagnosis of septic shock due to pneumonia was made. However, the cardiac ultrasound was also notable for marked enlargement of the RV with a dilated IVC. The differential diagnosis includes: • Acute pulmonary hypertension (pHTN) due to tension PTX, high ventilation pressures, or pulmonary embolism (PE) • Chronic pHTN Tension PTX had been excluded using pleural ultrasound (later verified by CXR). Ventilation pressures
journal.publications.chestnet.org
were normal, and there was no significant air trapping after having increased the sedation. Although there were no signs that are highly associated with PE, such as a clot in the RV,2,3 the intensivist did detect a flattening of the interventricular septum during both systole and diastole. pHTN due to thromboemboli could have been responsible for the systolic flattening (pressure overload). The diastolic flattening could have been due to acute volume overload because the patient was being vigorously resuscitated by rapid infusion of fluids during the performance of the ultrasound. Likewise, the distension of the IVC could be attributed to pHTN. In this setting, respiratory variation of the IVC may not be an accurate predictor of fluid responsiveness. Exclusion of a PE with a contrast CT scan was deemed to be an unacceptable risk due to the travel required with this unstable patient and also the risk for further renal injury. In addition, anticoagulation treatment was not considered to be an option in the setting of the recent retroperitoneal hemorrhage. However, the use of an IVC filter was being debated to protect from any possible DVT of the legs. Thus, bedside CUS of the legs was performed to exclude DVT. Video 3 displays the CUS for the left leg showing the common femoral vein above and at the entry of the greater saphenous vein, the superficial femoral vein, and the popliteal vein. The landmark positions of the adjacent and less compressible common femoral artery, the superficial and deep femoral arteries, and the popliteal artery are also shown. Compression completely obliterated the lumen of the veins in each case—no DVT could be demonstrated in either leg. A study by Kory et al4 demonstrated that ICU physicians can be trained to reliably detect DVT in critically ill patients. Although the presence of DVT is a poor proxy for PE,5 the ICU team would have considered inserting an IVC filter at the bedside given the contraindication to full anticoagulation. Finally, the possibility of chronic pHTN was supported by the finding of a thickened RV free wall in the subcostal four-chamber view of Video 1. The diastolic thickness was measured to be over the normal limit of 5 mm (measured to be 8 mm). Subsequent right-sided heart catheterization performed 14 days later demonstrated a pulmonary artery pressure of 67/32 mm Hg. Thus, it is likely that this patient had chronically elevated pulmonary artery pressures and RV hypertrophy with dilation in the setting of severe COPD. In conclusion, focused ultrasound enabled the intensivist to quickly change the presumptive diagnosis from hemorrhagic shock to septic shock. Subsequent sepsis management led to the stabilization of the
CHEST / 145 / 5 / MAY 2014
e15
patient. Transfusion of emergency-release blood products and the attendant risks were, thus, avoided. Reverberations 1. Point-of-care ultrasound should be used by the intensivist to provide immediate guidance for further medical management. 2. Pleural ultrasonography enables sensitive detection of PTX but must be performed over multiple chest regions. Because of its high sensitivity, a negative ultrasound effectively excludes significant PTX. 3. The subcostal window enables both long-axis and short-axis interrogation of the heart and is especially useful in the setting of hyperexpanded lungs that obstruct the parasternal or apical views. Acknowledgments Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information
e16
were met. This work was performed at the Department of Anesthesia, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA. Additional information: To analyze this case with the videos, see the online article.
References 1. Wilkerson RG, Stone MB. Sensitivity of bedside ultrasound and supine anteroposterior chest radiographs for the identification of pneumothorax after blunt trauma. Acad Emerg Med. 2010;17(1):11-17. 2. Casazza F, Bongarzoni A, Centonze F, Morpurgo M. Prevalence and prognostic significance of right-sided cardiac mobile thrombi in acute massive pulmonary embolism. Am J Cardiol. 1997;79(10):1433-1435. 3. Torbicki A, Galié N, Covezzoli A, Rossi E, De Rosa M, Goldhaber SZ; ICOPER Study Group. Right heart thrombi in pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry. J Am Coll Cardiol. 2003;41(12):2245-2251. 4. Kory PD, Pellecchia CM, Shiloh AL, Mayo PH, DiBello C, Koenig S. Accuracy of ultrasonography performed by critical care physicians for the diagnosis of DVT. Chest. 2011;139(3): 538-542. 5. Parvizi J, Jacovides CL, Bican O, et al. Is deep vein thrombosis a good proxy for pulmonary embolus? J Arthroplasty. 2010; 25(suppl 6):138-144.
Postgraduate Education Corner
Postgraduate Education Corner ULTRASOUND CORNER
A Postoperative Patient Decompensates During Transfer From an Outside Hospital Thomas Edrich, MD; Pingping Song, MD; Martin W. Dünser, MD; Bernhard Bacher, MD; and Christian Torgersen, MD
CHEST 2014; 145(5):e14–e16
an outside hospital, a 63-year-old man with severe AtCOPD and a lung mass underwent a left upper
lobectomy complicated by both a persistent air leak requiring chest tube placement and hospital-acquired pneumonia requiring reintubation. A DVT developed in the upper extremity, requiring full anticoagulation treatment. Subsequently, a spontaneous retroperitoneal hemorrhage occurred, as diagnosed by abdominal CT scan, requiring massive transfusion and reversal of heparin with protamine. During resuscitation, the patient developed a distended abdomen (bladder pressure of 23 mm Hg), oliguria, and hypotension requiring norepinephrine. During the transfer by ambulance to our hospital, the norepinephrine requirement escalated to 40 mg/min with continued severe hypotension. Upon arrival, the patient’s skin had mottled, but he had warm extremities and reduced breath sounds over the left chest (but with the chest tube on suction); he was agitated and dyssychronous with mechanical ventilation. The ICU team initiated rapid infusion of crystalloids and ordered emergency-release blood products under the presumption that retroperitoneal hemorrhage had resumed during transport. A chest radiograph (CXR) was ordered, and sedation was increased to reduce dyssychrony. The team then noticed that the chest
tube was not tidaling despite attempts to clear it by stripping. The intensivist immediately performed a goaldirected cardiac and pleural ultrasound. This was later followed by compression ultrasound (CUS) of the leg vasculature. In the cardiac ultrasound, the parasternal and apical views could not be obtained because of lung or air artifacts. However, the subcostal position yielded a long-axis and short-axis view of the heart as well as a view of the inferior vena cava (IVC) as shown in Video 1 (cardiac ultrasound with two-dimensional views obtained only from the subxiphoid position). The short-axis view was obtained by rotating the transducer counterclockwise starting from the subcostal four-chamber view. Video 2 (pleural ultrasound over the left anterior chest) demonstrates a clip of the pleural ultrasound over the left anterior chest. Similar views were obtained from the midaxillary and posterior positions. Video 3 (CUS examination of the proximal leg vessels [left leg only]) shows the CUS of the left leg only. The right leg looked similar. Finally, a focused abdominal ultrasound examination was performed (not shown), which did not reveal any free intraperitoneal fluid. Based on these ultrasound findings and the clinical story, what essential next steps should be initiated soon?
Manuscript received October 25, 2013; revision accepted December 6, 2013. Affiliations: From the Department of Anesthesia, Perioperative and Pain Medicine (Drs Edrich and Song), Brigham and Women’s Hospital, Boston, MA; and the Department of Anesthesiology, Perioperative Medicine and General Intensive Care Medicine (Drs Dünser, Bacher, and Torgersen), Salzburg General Hospital and Paracelsus Private Medical University, Salzburg, Austria. Correspondence to: Thomas Edrich, MD, Department of Anesthesia, Perioperative and Pain Medicine, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02467; e-mail: tedrich@ partners.org © 2014 American College of Chest Physicians. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details. DOI: 10.1378/chest.13-2140 e14
Postgraduate Education Corner
Next steps: Focus on treatment of sepsis—the patient displays signs of distributive shock with hyperdynamic left ventricular function and good diastolic filling Discussion The clinical story with a recent severe retroperitoneal hemorrhage led the ICU team to initially suspect a possible rebleed. Thus, they prepared for massive transfusion using emergency-release blood products. However, upon discovery of the dysfunctional chest tube in the physical examination, the possibility of a tension pneumothorax (PTX) had to be considered as well. While awaiting the CXR, pleural ultrasound was deemed to be the most expedient method to investigate this. As seen in Video 2, pleural ultrasound did not reveal a PTX. There was normal lung sliding in the B-mode image indicating that the parietal and visceral pleura were in apposition. Verification using M-mode interrogation of the pleura yielded the characteristic sandy-beach sign. In the video, the large arrow marks the pleura; the small arrows mark motion artifacts superficial to the pleura due to respiratory efforts in this dyssychronous patient. In a meta-analysis of trauma patients, pleural ultrasound had a higher sensitivity than CXR for PTX (86%-98% vs 28%-75%), with similar specificity (97%-100% vs 100%), with the caveat that several zones must be scanned to avoid overlooking a localized PTX.1 In the cardiac ultrasound (Video 1), a hyperdynamic left ventricle (LV) with good diastolic filling and a full IVC without respiratory variation was found. This suggested adequate LV and right ventricle (RV) preload, but a low afterload for the LV. These findings were not consistent with hypovolemia due to hemorrhage, but were suggestive of distributive shock. Indeed, in the further course, the patient stabilized after the addition of vasopressin to elevate the systemic vascular resistance and after broadening the antibiotic coverage empirically. A Gram stain of the respiratory secretions demonstrated abundant inflammatory cells and gram-negative rods. Thus, the diagnosis of septic shock due to pneumonia was made. However, the cardiac ultrasound was also notable for marked enlargement of the RV with a dilated IVC. The differential diagnosis includes: • Acute pulmonary hypertension (pHTN) due to tension PTX, high ventilation pressures, or pulmonary embolism (PE) • Chronic pHTN Tension PTX had been excluded using pleural ultrasound (later verified by CXR). Ventilation pressures
journal.publications.chestnet.org
were normal, and there was no significant air trapping after having increased the sedation. Although there were no signs that are highly associated with PE, such as a clot in the RV,2,3 the intensivist did detect a flattening of the interventricular septum during both systole and diastole. pHTN due to thromboemboli could have been responsible for the systolic flattening (pressure overload). The diastolic flattening could have been due to acute volume overload because the patient was being vigorously resuscitated by rapid infusion of fluids during the performance of the ultrasound. Likewise, the distension of the IVC could be attributed to pHTN. In this setting, respiratory variation of the IVC may not be an accurate predictor of fluid responsiveness. Exclusion of a PE with a contrast CT scan was deemed to be an unacceptable risk due to the travel required with this unstable patient and also the risk for further renal injury. In addition, anticoagulation treatment was not considered to be an option in the setting of the recent retroperitoneal hemorrhage. However, the use of an IVC filter was being debated to protect from any possible DVT of the legs. Thus, bedside CUS of the legs was performed to exclude DVT. Video 3 displays the CUS for the left leg showing the common femoral vein above and at the entry of the greater saphenous vein, the superficial femoral vein, and the popliteal vein. The landmark positions of the adjacent and less compressible common femoral artery, the superficial and deep femoral arteries, and the popliteal artery are also shown. Compression completely obliterated the lumen of the veins in each case—no DVT could be demonstrated in either leg. A study by Kory et al4 demonstrated that ICU physicians can be trained to reliably detect DVT in critically ill patients. Although the presence of DVT is a poor proxy for PE,5 the ICU team would have considered inserting an IVC filter at the bedside given the contraindication to full anticoagulation. Finally, the possibility of chronic pHTN was supported by the finding of a thickened RV free wall in the subcostal four-chamber view of Video 1. The diastolic thickness was measured to be over the normal limit of 5 mm (measured to be 8 mm). Subsequent right-sided heart catheterization performed 14 days later demonstrated a pulmonary artery pressure of 67/32 mm Hg. Thus, it is likely that this patient had chronically elevated pulmonary artery pressures and RV hypertrophy with dilation in the setting of severe COPD. In conclusion, focused ultrasound enabled the intensivist to quickly change the presumptive diagnosis from hemorrhagic shock to septic shock. Subsequent sepsis management led to the stabilization of the
CHEST / 145 / 5 / MAY 2014
e15
patient. Transfusion of emergency-release blood products and the attendant risks were, thus, avoided. Reverberations 1. Point-of-care ultrasound should be used by the intensivist to provide immediate guidance for further medical management. 2. Pleural ultrasonography enables sensitive detection of PTX but must be performed over multiple chest regions. Because of its high sensitivity, a negative ultrasound effectively excludes significant PTX. 3. The subcostal window enables both long-axis and short-axis interrogation of the heart and is especially useful in the setting of hyperexpanded lungs that obstruct the parasternal or apical views. Acknowledgments Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article. Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information
e16
were met. This work was performed at the Department of Anesthesia, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, MA. Additional information: To analyze this case with the videos, see the online article.
References 1. Wilkerson RG, Stone MB. Sensitivity of bedside ultrasound and supine anteroposterior chest radiographs for the identification of pneumothorax after blunt trauma. Acad Emerg Med. 2010;17(1):11-17. 2. Casazza F, Bongarzoni A, Centonze F, Morpurgo M. Prevalence and prognostic significance of right-sided cardiac mobile thrombi in acute massive pulmonary embolism. Am J Cardiol. 1997;79(10):1433-1435. 3. Torbicki A, Galié N, Covezzoli A, Rossi E, De Rosa M, Goldhaber SZ; ICOPER Study Group. Right heart thrombi in pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry. J Am Coll Cardiol. 2003;41(12):2245-2251. 4. Kory PD, Pellecchia CM, Shiloh AL, Mayo PH, DiBello C, Koenig S. Accuracy of ultrasonography performed by critical care physicians for the diagnosis of DVT. Chest. 2011;139(3): 538-542. 5. Parvizi J, Jacovides CL, Bican O, et al. Is deep vein thrombosis a good proxy for pulmonary embolus? J Arthroplasty. 2010; 25(suppl 6):138-144.
Postgraduate Education Corner
