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Tele-Ultrasound to Guide Management of a Patient with Circulatory Shock

Inferior vena cava respirophasic diameter variations between expiration (1:1.6 cm) and inspiration (2:1.2 cm). The top 2-dimensional image shows the correct ultrasound plane approximately 2 cm distal to the inferior cavo-atrial junction for M-mode measurements shown below.

Inferior vena cava respirophasic diameter variations between expiration (1:1.6 cm) and inspiration (2:1.2 cm). The top 2-dimensional image shows the correct ultrasound plane approximately 2 cm distal to the inferior cavo-atrial junction for M-mode measurements shown below.

A 65-year-old man with a medical history of chronic obstructive pulmonary disease and ethanol abuse presented to the emergency department with tachypnea, tachycardia, and an altered mental status. He was hypotensive at 90/60 mm Hg. Examination of the patient showed confusion and decreased left-sided breath sounds. The serum laboratory values were significant for a urea nitrogen level of 77 mg/dL and creatinine level of 6.49 mg/dL. A chest roentgenogram revealed hyperinflated lungs and a large left-sided infiltrate. The patient was treated with antibiotics and 2500 mL of crystalloid fluid, and admitted to the intensive care unit (ICU). Within 1 hour of arrival to the ICU, an arterial blood gas revealed a serum pH of 7.15, and the patient required intubation. Twenty minutes later, the patient became hypotensive and was placed on a norepinephrine infusion. The patient remained hypotensive even though norepinephrine doses were escalated. The pressing clinical question at this point was whether further volume resuscitation would be beneficial or not. The covering postgraduate medical trainee decided to involve the institution’s tele-ICU program covered by a trained intensivist attending. The trainee had some former basic training in echocardiography but had not performed any in 2 years. The joint decision was made to use immediate tele-ICU–supervised bedside cardiac and inferior vena cava ultrasound to guide shock state management. The trainee was reminded and gently directed by the tele-ICU intensivist on the basic maneuvers through which to obtain parasternal long, 4-chamber, and inferior vena cava windows. The patient remained paralyzed from the intubation, and for the ultrasound examination portion, tidal volumes were increased to 9 mL/kg ideal body weight. The ultrasound examination did not show a pericardial effusion. Biventricular function was hyperdynamic. Inferior vena cava respirophasic variation was noted to be >20% (Figure). Given these findings, the cause of shock was thought to be a combination of distributive and hypovolemic shock. The patient was given a rapid infusion of 2000 mL normal saline solution. The patient’s blood pressure increased over the next 30 minutes, and the norepinephrine infusion was stopped.

Bedside ultrasound has become an essential tool for the management of critically ill patients, serving as both a real-time noninvasive diagnostic tool and a procedural augmentation tool. To use it to its full potential, medical trainees require attending supervision to ensure consistent and accurate image acquisition and interpretation.1Recent data have shown that tele-intensivists can instruct trainees to acquire high-quality ultrasound images2 and that the transmitted image quality can be sufficient for meaningful remote image interpretations.3

Our case report illustrates that tele-intensivists can extend the utility of ultrasound by supervising and guiding providers with or without only partial training in ultrasound and by extending direct trainee ultrasound supervision to time periods when no direct bedside attending supervision is available and when treatment decisions otherwise would have been made without supervision and feedback on image acquisition and interpretation. The tele-ICU interface between ultrasound supervisor and bedside ultrasound trainee has the distinct advantage of providing direct audiovisual communication in real time to optimize image acquisition and interpretation, thereby providing standardization of ultrasound supervision independent of the time of day or night. On the system level, this provides a more standardized and supervised foundation on which to base ultrasound-guided management decisions that can significantly affect patient outcomes. On a provider level, it ensures that medical trainees and physician extenders can feel more confident in their technical image acquisition and image interpretation skills.

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-Christian Becker, MD, PhD, Mario Fusaro, MD, Dhruv Patel, MD, Isaac Shalom, MD, William H. Frishman, MD, Corey Scurlock, MD, MBA

This article originally appeared in the May 2017 issue of The American Journal of Medicine.

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