Accurate evaluation of fluid status in intubated, critically ill patients is crucial for effective patient management. Both hypovolemia and fluid overload can lead to adverse outcomes. Assessing fluid responsiveness—identifying patients who will benefit from volume administration—is essential in these settings. Carotid ultrasound has emerged as a novel, noninvasive method for predicting fluid responsiveness. This systematic review aims to update the literature on carotid ultrasound’s accuracy in predicting fluid responsiveness in mechanically ventilated patients. Carotid ultrasound, also known as carotid duplex ultrasound, is a noninvasive imaging technique used primarily to evaluate the structure and function of the carotid arteries. These arteries, located on either side of the neck, are vital as they supply blood to the brain,neck, and face. Carotid ultrasound combines traditional ultrasound with Doppler ultrasound to visualize the carotid arteries and assess blood flow. In recent years, carotid ultrasound has emerged as a novel tool for assessing fluid responsiveness in critically ill patients. Fluid responsiveness refers to the ability of a patient’s cardiovascular system to respond to fluid administration with a significant increase in stroke volume. This is particularly important in the management of patients in intensive care units (ICUs) or undergoing major surgery. Mechanism Carotid Doppler Peak Velocity (CDPV): Measures the peak velocity of blood flow through the carotid artery. Changes in CDPV can indicate changes in cardiac output and stroke volume in response to fluid administration. Corrected Flow Time (FTc): Assesses the time taken for blood to flow through the carotid artery, corrected for heart rate. FTc can provide insights into the filling status of the heart and fluid responsiveness. META-ANALYSIS OF CURRENT LITERATURE Carotid Ultrasound Parameters and Outcomes Common Parameters: Corrected Flow Time (FTc) Change in Carotid Doppler Peak Velocity (∆CDPV) Change in Carotid Artery Velocity-Time Integral (∆CAVTI) Common Cardiac Output Measures: Transthoracic Echocardiography (TTE) PiCCO […]

A recent meta-analysis underscores the importance of gastric ultrasound in anesthetic practice, particularly for assessing the risk of pulmonary aspiration due to gastric contents. This study aims to establish a reliable upper limit for normal gastric antral area and volume in fasting adults, providing crucial benchmarks for safer anesthesia management. The study analyzed data from 12 primary studies conducted between January 2009 and December 2020, encompassing 1,203 subjects. It determined that the 95th percentile for antral cross-sectional area (CSA) is 9.9 cm², and for gastric volume, it is 2.3 mL/kg. These values provide a critical benchmark for identifying patients at risk of aspiration. Distribution of values of the cross-sectional area measured in the right lateral decubitus position (left) and the gastric volume (right) for all patients. The blue line indicates the median and the red line indicates the 95th percentile value based on the Harrell-Davis method and bootstrap method, respectively. CSA, cross-sectional area. Historically, the threshold for high aspiration risk was set at a gastric volume of 0.8 mL/kg, based on animal studies. However, this meta-analysis reveals that this threshold is overly conservative. The findings suggest that the median gastric volume in fasting adults is approximately 0.6 mL/kg, with the 95th percentile reaching 2.3 mL/kg. The study’s results are significant for clinical practice. They suggest that a gastric antral area of 10 cm² in the right lateral decubitus position can serve as a practical upper limit for fasting patients. Furthermore, the data indicate that an antral grade of 0 or 1 (indicating an empty or nearly empty stomach) correlates with a 98% probability of having a gastric volume below the 95th percentile, thus significantly reducing aspiration risk. This research underscores the utility of gastric ultrasound as a non-invasive tool for evaluating gastric content at the bedside, especially when a patient’s […]

A 52-year-old male patient with a history of chronic shoulder dislocations presented for elective arthroscopic shoulder surgery. Given his past medical history and the expected surgical pain, an interscalene block was planned to provide postoperative analgesia. Given the proximity of the phrenic nerve to the interscalene space, diaphragmatic paralysis is obsolete and a common side-effect associated with this block. To assess the completeness of the diaphragm dysfunction, point-of-care ultrasound (POCUS) was used before the block and repeated postoperatively. The diaphragmatic excursion and thickening were observed through ultrasound imaging to ensure the patient’s safety and comfort, mitigating the risk of respiratory complications. This is an ultrasound image with the transducer in the subcostal area that was used to assess the excursion. Excursions of 0.8 cm were measured during shallow breathing. Transform your practice with the power of POCUS using NYSORA’s POCUS App. Enhance your skills, broaden your diagnostic capabilities, and provide outstanding patient care. Experience the difference today – Download the app HERE.

There are multiple causes for diaphragm dysfunction, but all regional anesthesia enthusiasts definitely know this one: interscalene block. We are now thrilled to announce the launch of a new course in the Point-of-Care Ultrasound (POCUS) app: Diaphragm Ultrasound. This course is meticulously designed to equip you with the essential skills to assess the diaphragm function at the bedside. Of course, everything is supported by NYSORA’s illustrations. Course Highlights: 30+ Original Illustrations and Animations: Detailed, high-quality visuals that enhance your learning experience. Practical Learning Approach: Follow a stepwise method to diaphragm assessment, from setting up the ultrasound machine to interpreting results, ensuring a hands-on learning experience. Non-invasive Diaphragm Assessment: Learn techniques that can be applied immediately in clinical settings to assess diaphragm function effectively and do not require interventions. This course includes practical skills and provides the necessary background information to understand the full scope of diaphragm functionality and its relevance in clinical practice. Transform your practice with the power of POCUS using NYSORA’s POCUS App. Enhance your skills, broaden your diagnostic capabilities, and provide outstanding patient care. Experience the difference today – Download the app HERE.

A 72-year-old patient was admitted to the Intensive Care Unit (ICU) for monitoring after traumatic brain injury. The patient is fully sedated, ventilated and requires norepinephrine for maintaining adequate cerebral perfusion pressures. He has no severe comorbidities and focused cardiac ultrasound showed normal biventricular function and valves. The patient is rather hypotensive and you are in doubt whether you should administer IV fluids.  Here’s how POCUS can be used to assess the fluid status: Obtain a clear view of the inferior vena cava (IVC) using the IVC view. Use the M-mode 2 cm distal to its junction with the right atrium or 1 cm distal to the hepatic vein. First, assess the diameter of the IVC. The size is between 1.5 and 2.5 cm.  Secondly, assess the minimal diameter and the maximum diameter with M-mode. Calculate the distensibility index: (max. diameter (Dmax) – min. diameter (Dmin))/min. diameter (Dmin) If it is >18%, this patient could benefit from fluid administration. Transform your practice with the power of POCUS using NYSORA’s POCUS App. Enhance your skills, broaden your diagnostic capabilities, and provide outstanding patient care. Experience the difference today – Download the app HERE.

A 58-year-old male patient with acute dyspnea is assessed in the emergency department using the BLUE protocol. The scan reveals no significant lung pathology (A-profile) but prompts the consideration of deep vein thrombosis (DVT). This rapid assessment aids in detecting DVT to prevent potential complications like pulmonary embolism. Here’s how you perform a DVT POCUS scan:  Position the patient supine with the leg in extension and exorotation. Start scanning at the level of the inguinal crease with a linear transducer. For the popliteal position, the leg is flexed to allow scanning of the fossa.  Slowly scan distally and assess compressibility every 1-2 cm.  It is impossible to compress a thrombosed vein.  4. Pay special attention to 5 visualization key points since these are more likely for visualizing clots.  Common femoral vein. Bifurcation of the common femoral vein and the saphenous vein. Bifurcation of the common femoral vein and the lateral perforator vein.  Bifurcation of the superficial femoral vein and the deep femoral vein. Popliteal vein.  5 key scanning points for DVT visualization. CFV, common femoral vein; GSV, great saphenous vein; SFA, superficial femoral artery; DFA, deep femoral artery; SFV, superficial femoral vein; DFV, deep femoral vein; PA, popliteal artery; PV, popliteal vein.  Transform your practice with the power of POCUS using NYSORA’s POCUS App. Enhance your skills, broaden your diagnostic capabilities, and provide outstanding patient care. Experience the difference today – Download the app HERE.

A 68-year-old woman presented at the emergency department with acute respiratory failure and fever. Lung ultrasound showed a B-profile in all four BLUE points, suggesting pulmonary edema. This prompted us to do a cardiac ultrasound.  Consecutively, a focused cardiac ultrasound was performed. The parasternal long-axis view showed a lesion suggestive of endocarditis which was then confirmed by an official cardiologist ultrasound.  Endocarditis is a serious medical condition that affects the inner lining of the heart and the valves. The causal pathogen may be bacterial but occasionally fungal or viral. Endocarditis is often diagnosed by the formation of vegetations on the heart valves or other endocardial surfaces. These vegetations can interfere with the normal function of the heart, leading to complications such as severe regurgitation, cardiac failure, stroke, or systemic infections if bacteria from the heart enter the bloodstream. Endocarditis requires prompt diagnosis and treatment with antibiotics or, in severe cases, surgery to repair or replace damaged valves. Point-of-care ultrasound (POCUS) is a valuable tool in assessing endocarditis, offering real-time imaging capabilities that aid in detecting vegetations, abscesses, and valvular abnormalities.  When evaluating endocarditis through ultrasound, distinctive pathology characteristics to observe include: Mobile lesion Hyperechoic density Endocarditis is often accompanied by regurgitation Parasternal long-axis view revealing endocarditis. LV, left ventricle; AV, aortic valve; LA, left atrium; MV, mitral valve.  Transform your practice with the power of POCUS using NYSORA’s POCUS App. Enhance your skills, broaden your diagnostic capabilities, and provide outstanding patient care. Experience the difference today – Download the app HERE.

Subclavian vein cannulation is an essential medical procedure used to access central veins for various clinical purposes. The incorporation of point-of-care ultrasound (POCUS) has significantly enhanced the precision and safety of this technique. POCUS allows healthcare providers to visualize and navigate the subclavian vein with accuracy, reducing complications and improving the overall success of the procedure. When it comes to subclavian vein cannulation, these expert tips can make a significant difference: Always identify the vein, artery, pleura and ribs before starting the procedure.  Subclavian vein cannulation carries the least risk for catheter-related infections, while femoral vein cannulation has a higher risk. In cases involving small or flat veins in intubated patients, techniques like the Valsalva maneuver or positive end-expiratory pressure (PEEP) can enhance vein distention, simplifying the cannulation procedure. Always augment your ultrasound-guided subclavian vein cannulation with a lung ultrasound together with a quick cardiac ultrasound to check for the rapid atrial swirl sign (RASS). This will allow you to rule out pneumothorax and confirm the position of the catheter insertion. Transform your practice with the power of POCUS using NYSORA’s POCUS App. Enhance your skills, broaden your diagnostic capabilities, and provide outstanding patient care. Experience the difference today – Download the app HERE.

In our last post we taught you how to identify fluid content inside the stomach. Fluid content however may be the result of endo- or exogenous factors.  Let’s quickly recap our case from the last post:  A 40-year-old man with a wrist fracture presented after having a drink 3 hours prior to his admission. You performed a gastric ultrasound since you are dealing with emergency surgery and you visualized fluid content: Ultrasound and Reverse Ultrasound Anatomy of a stomach with fluid content Endoluminal gastric content can be caused by numerous factors such as delayed gastric emptying by stress or opioids, non compliance, gastric secretions, etc.  The following tutorial will teach you how to differentiate a low from a high risk stomach. For fluid content, the cross-sectional area (CSA) of the antrum should be measured in the lateral decubitus position to assess the risk of aspiration. This is done by tracing the outer layer of the antrum or the serosa. Cross-sectional area of the antrum. By using the CSA and the age of the patient, the volume can be estimated using this formula: Gastric volume = 27.0 + (14.6) x (CSA of antrum in right lateral decubitus position) – 1.28 x age If the fluid content is >1.5 mL/kg, the stomach is considered full and thus high risk. Fluid content <1.5 mL/kg is compatible with a fasting state and thus low risk. Transform your practice with the power of POCUS using NYSORA’s POCUS App. Enhance your skills, broaden your diagnostic capabilities, and provide outstanding patient care. Experience the difference today – Download the app HERE.

Emergency surgery presents a unique challenge as patients may not be fasted. Assessing gastric content, whether full or empty, becomes pivotal, influencing anesthesia choices and perioperative strategy to mitigate aspiration risks during intubation.  By employing ultrasound to assess gastric content, medical professionals can swiftly and confidently make decisions regarding anesthesia and airway management. This non-invasive technique allows for the visualization of gastric contents, helping differentiate between clear, empty stomachs and those with residual contents. Imagine the following case: A 40-year-old patient broke his wrist after falling from the stairs. 3 hours before the accident, he had a couple of glasses at an after-work celebration. Your surgeon is eager to operate on him. What’s your strategy? In these cases, gastric ultrasound can be of immense value. Imagine you use your POCUS knowledge and scan the stomach. You see the following ultrasound image: Ultrasound and Reverse Ultrasound Anatomy of a stomach with fluid content. Here, the stomach is filled with hypoechogenic intraluminal content. Fluid in the stomach leads to distinctive visual indicators. This includes a noticeable rounding and distension of the antrum, along with thinning of the stomach walls. When assessed sonographically, a clear distinction can be made between two types of fluids: clear fluids and non-clear fluids (such as suspensions or milk).  Clear fluids are anechoic.  Non-clear fluids appear hyperechoic. However, it is important to understand that the stomach itself also produces fluid. Gastric ultrasound can help to differentiate between endo- and exogenous fluid content. In our next post, we will teach you how much fluid is considered too much. Stay tuned. Clinical decision pathway for anesthesia in emergency surgery based on gastric ultrasound. Transform your practice with the power of POCUS using NYSORA’s POCUS App. Enhance your skills, broaden your diagnostic capabilities, and provide outstanding patient care. Experience the difference […]

Paracentesis, a procedure to puncture and access free intraperitoneal fluid or ascites, is used for both diagnostic and therapeutic purposes. Causes of ascites include liver disease, heart disease, malignancy, kidney disease, chronic inflammation, or hypoalbuminemia. Ultrasound guidance is crucial in this procedure for site determination and needle guidance, reducing risks like vessel or bowel injury. Here are some key tips for a successful ultrasound-guided paracentesis: Use a curvilinear transducer to detect free fluid presence and a linear transducer for the ultrasound-guided puncture. This method minimizes bleeding risks at the insertion site, puncture site infections, and abdominal wall hematomas. It’s essential to identify and avoid puncturing dilated veins (caput Medusa) in ascites patients. Locate and steer clear of the inferior epigastric artery, typically 5-6 cm lateral from the midline, using color Doppler. Avoid needle insertion through the suprapubic area due to the vicinity of the urinary bladder. Remember that visceral structures like bowels move autonomously and tend to float due to their air content. Monitor these floating structures closely during needle insertion to reduce bowel puncture risks and needle contamination. Transform your practice with the power of POCUS using NYSORA’s POCUS App. Enhance your skills, broaden your diagnostic capabilities, and provide outstanding patient care. Experience the difference today – Download the app HERE.

We are thrilled to announce the launch of a brand new course in the ‘Vascular’ category in NYSORA’s POCUS app: Abdominal Aortic Aneurysm (AAA). This comprehensive course is designed for healthcare professionals who wish to expand their expertise in ultrasonography for assessing AAAs. What you’ll learn: Sonoanatomy of the abdominal aorta: Discover the detailed anatomy of the abdominal aorta through high-quality ultrasound images and illustrations. Scanning technique: Learn how to properly scan the abdominal aorta to look for signs of AAA. Identification and assessment of AAA: Gain crucial skills in recognizing and evaluating AAAs, enhancing your diagnostic abilities. Correlate ultrasound findings with interventions: Enhance your decision-making with practical tips and clear algorithms. Transform your practice with the power of POCUS using NYSORA’s POCUS App. Enhance your skills, broaden your diagnostic capabilities, and provide outstanding patient care. Experience the difference today – Download the app HERE.