床旁超声在重症医学中的临床应用概况

床旁超声是近年来在重症医学科广泛开展的检查评估手段,随着人们对超声及疾病病理生理状态的深入理解,其在重症医学科中的应用范围正在扩大,相关的操作流程也在逐渐完善,使重症医师对疾病的评估及诊治更加及时、全面。该文就床旁超声在重症医学中的应用进展作一综述,为临床医师提供新思路。     

超声心动图对成人危急重症心血管疾病的应用

目的以危急重症心血管疾病患者为研究对象,分析为患者实施超声心动图检查的价值。方法以93例自2018年3月至2019年4月在我院诊治的危急重症心血管疾病患者作为研究对象,应用GE Vivid I和Philip CX50彩色多普勒超声诊断仪为全部入组病例实施床旁超声心动图检查,对比超声心动图与临床诊断符合率以及超声表现。结果共计检出81例患者,诊断符合率为87.10%,包括主动脉窦瘤破裂1例、风湿性心脏病合并左房血栓2例、肥厚型心肌病3例、心肌炎1例、主动脉瓣狭窄1例、肺栓塞5例、A型主动脉夹层2例、慢性肺源性心脏病4例、心包积液23例、急性心肌梗死合并左心功能不全10例、非急性心肌梗死后左心功能不全22例、急性心肌梗死7例。结论超声心动图在危急重症心血管疾病患者病情检查以及诊断中的应用价值较高。     

肺超声的临床应用进展

超声在肺部的应用远不如在心脏、腹部等领域.近年来经胸壁超声检查肺和胸膜病变的临床应用逐渐增多.由于床旁X线的低敏感性和重症患者搬运到CT室的高风险,且传统的X线和CT不能实时监测疾病的发展和转归,肺超声对危重患者的床旁评估显得特别有价值.床旁肺超声是一个对传统X线和CT检查的很好补充,可以常规应用并减少甚至替代传统放射学检查.     

床旁肺部超声在老年急性呼吸衰竭患者预后评估中的应用

目的探讨床旁肺部超声在老年急性呼吸衰竭患者预后评估中的应用价值。方法采用回顾性分析法,收集2018年1月至2019年1月收治的99例老年急性呼吸衰竭患者临床资料,所有患者给予床旁肺部超声检查,并根据病情给予相应呼吸支持疗法,均随访1年,根据患者预后将其分为存活组(n=76)及死亡组(n=23),仔细阅览患者病历资料,详细记录患者一般情况,对比两组床旁肺部超声检查的疾病相关参数,并分析其对老年急性呼吸衰竭患者预后评估中的应用价值。结果存活组肺超声评分(LUS)低于死亡组,且右侧膈肌位移、左侧膈肌位移、平均膈肌位移均高于对照组,差异均有统计学意义(均P<0.05)。绘制受试者工作特征(ROC)曲线结果显示,LUS评分、右侧膈肌位移、左侧膈肌位移、平均膈肌位移用于预测老年急性呼吸衰竭患者预后的曲线下面积分别为:0.651、0.759、0.765、0.776,其中右侧膈肌位移、左侧膈肌位移、平均膈肌位移的预测价值较好。结论床旁肺部超声在老年急性呼吸衰竭患者预后评估中具有一定价值,可为临床判断患者预后提供重要指导意义。     

床旁多脏器超声在重症患者机械通气脱机风险评估中的临床应用

目的 探讨床旁多脏器超声在重症患者机械通气脱机风险评估中的临床应用价值.方法 选择彩色多普勒超声诊断、床旁超声诊断仪,对患者肺部、膈肌以及心脏实施检查.结果 两组患者在心脏超声检查结果 方面相比较,存在一定差异性(P<0.05).脱机失败与成功患者在肺部超声检查结果 方面互比,脱机成功评分低于脱机失败(P<0.05).脱机失败与成功患者在膈肌厚度方面互比,差异小(P>0.05);患者在膈肌增厚率与膈肌位移相比较,脱机失败的患者低于脱机成功患者(P<0.05).结论 对重症患者实施床旁多脏器超声检查,利于减少机械通气脱机失败率,保证临床治疗效果,符合临床需求.     

胸部超声在呼吸系统疾病中的应用进展

正随着超声技术的进步,重症监护病房(intensive care unit, ICU)医生已经可以使用床旁即时超声扫查胸部(包括肺和胸腔),其简单、快速、重复和无创等优点,可以避免转运危重患者行计算机断层扫描(computed tomography, CT)的风险和辐射暴露,减少胸部X线和CT使用次数。为进一步增强ICU医生鉴别与动态评估呼吸系统疾病的能力,本文将胸部超声在危重患者中的应用进行综述。1.超声评估气胸,更多用于排除诊断     

急诊床旁超声的临床应用

急诊床旁超声检查是急诊医学的关键医疗技术之一,该检查与执业超声医师实施的超声检查不尽相同,急诊床旁超声主要是针对临床急症,包括严重创伤、严重血流动力学不稳定、紧急超声引导等重点部位扫查,以便及时评估急危重症患者的病情并做出快速诊疗,可极大提高急诊救治效率.该技术在急诊中的应用日益广泛,文章将对它的历史发展、应用范围以及...     

床旁超声在高龄危重患者血液净化穿刺置管的应用观察

目的探讨床旁超声在高龄危重患者血液净化置管中的应用价值。方法观察1例高龄感染性休克、多器官功能障碍综合征(MODS)患者应用床旁超声指导血液净化置管的情况,分析超声在介导穿刺及并发症监测中的作用。结果超声引导直视(ultrasound-guided)深静脉置管建立通路,与快速超声筛查(quick-look ultrasound)标志定位相比,具有快速、安全、成功率高等优势;此外,床旁超声可迅速判断导管位置及发现动静脉瘘等穿刺相关并发症。结论高龄危重病患者放置血管导管,应该倡导置管前快速超声筛查,最好在超声直视下操作。     

肺部超声在重症患者胸部评估与护理中的应用

目的探讨重症加强护理病房(ICU)护士应用超声对重症肺炎患者进行胸部评估的可行性及价值。方法对ICU护士进行超声技术系统培训,对重症肺炎患者进行床旁胸部超声检查,对患者肺部情况进行评估,比较护士培训前后专业理论知识与超声声像辨识能力,同时比较与专业的超声医生对重症肺炎患者胸部评估的差异。结果 ICU护士培训后胸部超声知识掌握度明显高于培训前,差异有统计学意义(P0.05),培训后ICU护士对胸部超声知识和病理征象检出情况,与专业超声医生比较差异无统计学意义(P0.05)。结论胸部超声对于重症患者护理有显著的临床价值,经过培训的ICU护士可以较为准确地应用超声进行胸部评估。     

超声定位联合渐进式注水法在老年重症患者鼻肠管置管中的应用

目的探讨超声定位联合渐进式注水法在老年重症患者鼻肠管置管中的应用价值。 方法选择2018年1至10月在浙江医院重症医学科行经鼻肠管肠内营养支持的老年重症患者52例为研究对象。置管过程中使用床旁超声联合渐进式注水法引导鼻肠管置入,并在不同解剖位置定位鼻肠管头端。以腹部X线检查确认鼻肠管头端位于幽门后作为成功置管的标准。计算置管成功率,超声定位法的敏感度、特异度、阳性预测值、阴性预测值及准确性。 结果52例老年重症患者中48例（92.3%）置管成功,其中46例（88.5%）一次性置管成功,平均置管时间为（21.0±4.7）min;4例（7.7%）置管失败,经腹部X线确认均为胃内打折。48例置管成功患者中有46例使用超声定位成功,2例幽门后未探及鼻肠管声影。超声定位法的敏感度、特异度、阳性预测值、阴性预测值和准确性分别为95.8%、100.0%、100.0%、67.0%、96.2%。 结论超声定位联合渐进式注水法能快速、准确、安全地引导老年重症患者鼻肠管置入,具有较好的临床应用价值。     

改良床旁肺部超声评估方案对重症患者肺实变和肺不张的诊断价值

  目的 探讨改良床旁肺部超声评估方案（BLUE方案）对重症患者肺实变和肺不张的诊断价值。方法 选呼吸衰竭需机械通气超过48 h的患者,同时行床旁胸部X线、CT检查及BLUE方案、改良BLUE方案检查患者肺实变、肺不张情况,并与床旁胸部X线和CT对比,同时比较改良BLUE方案与BLUE方案评价肺实变与肺不张的差异。结果 最终78例患者纳入本研究。胸部CT发现70例（89.74%）患者存在不同程度的肺实变、肺不张。床旁胸部X线诊断肺实变、肺不张的敏感性为31.29%,特异性为75.00%,诊断准确率为38.46%。改良BLUE方案发现68例患者存在肺实变、肺不张,诊断肺实变、肺不张的敏感性为95.71%,特异性为87.50%,诊断准确率为94.87%,与胸部CT比差异无统计学意义（P>0.05）。BLUE方案发现48例患者存在肺实变、肺不张,诊断敏感性为65.71%,特异性为75.00%,诊断准确率为66.67%。BLUE方案未发现的肺实变、肺不张,胸部CT证实肺实变、肺不张部位主要位于双肺下叶后基底段。结论 重症机械通气患者肺实变、肺不张发生率高,改良BLUE方案可以发现绝大部分肺实变、肺不张,具有较高的敏感性、特异性及诊断准确率,由于其具有即时、床旁、无创、可重复的优越性,将成为床旁评价重症患者肺实变、肺不张的首选的、重要的安全检查手段。     

Bedside ultrasonography in the ICU: part 2

This is the second of a two-part review on the application of bedside ultrasonography in the ICU. In this part, the following procedures will be covered: (1) echocardiography and cardiovascular diagnostics (second part); (2) the use of bedside ultrasound to facilitate central-line placement and to aid in the care of patients with pleural effusions and intra-abdominal fluid collections; (3) the role of hand-carried ultrasound in the ICU; and (4) the performance of bedside ultrasound by the intensivist. The safety and utility of bedside ultrasonography performed by adequately trained intensivists has now been well demonstrated. This technology, as a powerful adjunct to the physical examination, will become an indispensable tool in the management of critically ill patients.     

Utility of hand-carried ultrasound for consultative cardiology

Although the stethoscope has been an important part of the bedside cardiac diagnostic examination for generations of physicians, this clinical tool has been relatively unchanged in over 150 years. Echocardiography is established as an essential diagnostic imaging method for patients with known or suspected cardiovascular diseases. However, routine echocardiography systems are large and heavy, and although they are portable, they remain inconvenient for bedside patient rounds. Technologic advances have resulted in miniaturization of electronic components and small, lightweight ultrasound systems have been recently introduced. These hand-carried units offer clinically acceptable two-dimensional image quality for rapid "quick-look" bedside diagnostics, in particular focusing on global and regional left ventricular function and presence or absence of pericardial effusion. This article proposes a general approach to the rapid hand-carried ultrasound cardiac exam as an extension of the physical examination. It details case examples and reviews the initial clinical experience of hand-carried ultrasound on cardiac consultation rounds. Hand-carried ultrasound has promise to have an immediate impact on bedside patient management though expediting and facilitating the delivery of medical care.     

床边超声心动图检查在首诊心血管急危重症中的应用价值

目的:探讨床边超声心动图检查在首次诊断心血管急危重症疾病中的应用价值及操作体会。方法:回顾性分析我院2010-01-2010-12期间行急诊床边超声心动图检查共271例患者的资料。结果:床边超声心动图检查的阳性率为44.3%,其中有节段性室壁运动异常的急性冠状动脉综合征94例(包括室壁瘤破裂1例),瓣膜性疾病6例,心包积液5例,主动脉夹层3例,感染性心内膜炎赘生物2例,先天性心脏病3例,心房占位性病变4例,其他3例。因床边超声心动图检查首次确诊疾病,修正临床治疗,甚至挽救患者生命的有20例。结论:对症状不典型、初诊为急性冠状动脉综合征的主动脉夹层,及时进行床边超声心动图检查可起到鉴别诊断、改变治疗方案的作用;对表现为胸闷或气促的心包大量积液患者可明确诊断,指导心包穿刺引流;对高度怀疑的急性肺栓塞,床边超声心动图检查可现场动态观察临床抢救是否有效。     

Technology insight: hand-carried ultrasound cardiac assessment--evolution, not revolution

Hand-carried ultrasound devices can enhance the art of bedside physical examination by increasing diagnostic accuracy, detecting disease at an earlier stage, and improving triage and referral of patients. Although limitations of device cost and portability can be overcome with technologic advances, the shortage of standardized imaging and training opportunities now needs to be addressed to move the technique forward. Cardiologists are the best-qualified subspecialists to design and teach a simplified training program for bedside use of hand-carried ultrasound devices to assess the cardiovascular system.     

Clinical application of temporary pacemaker insertion guided by bedside ultrasound in elder and critical patients

Background Ultrasound-guided temporary pacemaker implantation has been proven safe and efficient. However, few studies have focused on elder and critical patients. Methods Twelve elder and critical patients underwent temporary cardiac pacing through the jugular vein or subclavian vein, with bedside ultrasound images to assist the placement of electrode within the right ventricle. Results Ultrasound-guided temporary cardiac pacemaker insertion was successful in all of the 12 patients. Electrodes were sent into the right ventricle correctly with the help of ultrasound imaging. In all cases, temporary pacemaker functioned well without procedure-related complications. Conclusion Temporary cardiac pacing guided by ultrasound is safe and effective in elder and critical patients, which is worth of promoting, especially in intensive care unit.     

Hand carried echocardiography in the critical care setting

Miniaturized echocardiography units known as hand carried ultrasound (HCU) now exist with features similar to those used for standard echocardiography. The small size and low cost of these units may lead to increased availability of echocardiography to be performed by all physicians taking care of critically ill patients. Use of HCU by critical care physicians may allow for improved bedside diagnosis with improved accuracy over physical examination. Studies comparing HCU with standard echocardiography in the critical care setting have reported that HCU is limited by decreased image quality and that it may miss important diagnoses even when used by experienced sonographers and echocardiographers. Despite its limitations, however, HCU can often answer important clinical questions in the critically ill. This review explores the current literature on the use of HCU in the critical care setting, discusses the limitations of HCU, and examines the costs of implementing this new technology.     

Handcarried Echocardiography to Assess Hemodynamics in Acute Decompensated Heart Failure

Heart failure is a major source of cardiovascular morbidity, including acute decompensations requiring hospitalization. Because most therapeutic interventions in acute heart failure target optimization of cardiac output and volume status, accurate assessment of these parameters at the point of care is critical to guide management. However, physician bedside assessments of left ventricular (LV) function and volume status have limited accuracy. Traditional echocardiographic platforms, while useful for assessing ventricular and valvular function and volume status, have limitations for bedside use or frequent serial evaluation. Handcarried cardiac ultrasound devices, with their substantially lower costs, portability, and ease of use, circumvent many of the limitations of traditional echocardiographic platforms. The diagnostic capabilities of handcarried devices provide the opportunity for ultrasound assessment of LV function and serial bedside evaluation of volume status in patients with acutely decompensated heart failure.     

Usefulness of ultrasound lung comets as a nonradiologic sign of extravascular lung water

The "comet-tail" is an ultrasound sign detectable with ultrasound chest instruments; this sign consists of multiple comet-tails fanning out from the lung surface. They originate from water-thickened interlobular septa and would be ideal for nonradiologic bedside assessment of extravascular lung water. To assess the feasibility and value of ultrasonic comet signs, we studied 121 consecutive hospitalized patients (43 women and 78 men; aged 67 +/- 12 years) admitted to our combined cardiology-pneumology department (including cardiac intensive care unit); the study was conducted with commercially available echocardiographic systems including a portable unit. Transducer frequencies (range 2.5 to 3.5 MHz) were used. In each patient, the right and left chest was scanned by examining predefined locations in multiple intercostal spaces. Examiners blinded to clinical diagnoses noted the presence and numbers of lung comets at each examining site. A patient lung comet score was obtained by summing the number of comets in each of the scanning spaces. Within a few minutes, patients underwent chest x-ray, with specific assessment of extravascular lung water score by 2 pneumologist-radiologists blinded to clinical and echo findings. The chest ultrasound scan was obtained in all patients (feasibility 100%). The imaging time per examination was always <3 minutes. There was a linear correlation between echocardiographic comet score and radiologic lung water score (r = 0.78, p <0.01). Intrapatient variations (n = 15) showed an even stronger correlation between changes in echocardiographic lung comet and radiologic lung water scores (r = 0.89; p <0.01). In 121 consecutive hospitalized patients, we found a linear correlation between echocardiographic comet scores and radiologic extravascular lung water scores. Thus, the comet-tail is a simple, non-time-consuming, and reasonably accurate chest ultrasound sign of extravascular lung water that can be obtained at bedside (also with portable echocardiographic equipment) and is not restricted by cardiac acoustic window limitations.     

床旁介入超声在老年危重患者中的初步应用

目的探讨床旁介入超声在老年危重患者诊疗中的安全性及疗效。方法入选2013年1月至2015年8月福建省立医院内科病区的危重症老年患者85例。使用便携式超声仪,对所有患者行床边超声引导下穿刺活检术或置管引流术。结果行穿刺活检术者共15例:13例诊断明确;2例无法获取明确病理诊断。行置管引流术者共70例,其中23例各类非感染性积液引流通畅,相应症状消失;47例各类感染性积液患者在置管引流术后第2天的体温、心率、白细胞数以及积液深度均得到明显改善(P0.05),病情好转。行置管引流术者中2例胸穿置管并发中等量出血。结论床旁介入超声在老年危重患者诊疗中安全、便捷,具有较好的应用价值。