1/ Thought of doing a quick #tweetorial on image acquisition for #POCUS friends starting to do #VExUS
It's kind of "how I do it" guide and not necessarily optimized for research.
1st: Look at the IVC in both long and short axes
If big, do further scans 👇 #MedEd#FOAMed
2/ Lateral approach works best to obtain a straight segment of the portal vein (straight = best Doppler shift) and a nice hepatic vein too.
Place transducer approximately in the anterior axillary line pointing towards sternal notch. Then fan antero-posteriorly. #POCUS#VExUS
3/ Forgot what is fanning?
Its also called tilting or some people say, "look" in a particular direction from the same spot. #POCUS
4/ When you fan anteriorly, you'll see portal vein and hepatic vein comes into view on posterior fanning. With minor adjustments and a little rotation, both veins can be seen in the same view. #POCUS
5/ Normal hepatic vein tracing - can appreciate both S and D waves below the baseline👇 @kosmosplatform
6/ These waveforms will be blunted if you ask the patient to hold their breath at end-inspiration 👇
Either do it at end-expiration or during quiet respiration 'when possible'. I know #POCUS is often done in suboptimal conditions & sick patients who cannot follow instructions.
8/ Now lets move on to another window, that is subxiphoid.
In this window, stay slightly towards the right (towards liver); otherwise, bowel gas impedes the views. Remember the abdominal B-lines? #POCUS
9/ In the transverse view, probe orientation marker is to the right (abdomen preset) or to the left (cardiac preset).
If you fan the probe superiorly, hepatic veins-IVC junction comes into view; You'll see portal vein on fanning inferiorly. #POCUS#VExUS
11/ Now long axis view from the subxiphoid window.
If you 'look' to the midline, you'll see aorta. From there, if you fan to the right (towards liver), IVC comes into view and fanning further right will reveal portal vein. #POCUS#VExUS
12/ Labeled image for better clarity 👇
Though I generally prefer lateral over midline scan, in some patients (obese but lax abdomen; elderly) have great subxiphoid windows.
As mentioned before, hepatic veins often give disturbed flow due to small tributaries here.
13/ Same window, showing hepatic vein. In oblique views, you can also see portal vein. #POCUS
15/ Last component is renal; obviously most of you know how to find kidneys.
Just sweep slightly posterior from the lateral portal vein window, 'look' posteriorly with the probe marker aiming towards posterior axillary line.
16/ As discussed before, use Power Doppler to identify the interlobar vessels when the color pick up is not good.
Here is a normal renal parenchymal tracing (artery on top, vein at the bottom) #POCUS#VExUS
17/ Hope its helpful. Not as sophisticated as @Wilkinsonjonny 's graphics but a quick curbside teaching 🙃 #POCUS#VExUS
18/ How can #VExUS#POCUS thread be complete without the flashcard...🤭
Here it is 👇
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#Nephrology#POCUS case of the day:
What do you think is this anechoic structure adjacent to liver?
See thread 👇 for the answer and more images. #MedEd#IMPOCUS
Let's start with a poll before seeing other images: ☝️? #POCUS
The answer is right renal cyst. Note how the kidney appears with fanning the probe. #POCUS
Is rest of the kidney normal? doesn't appear to be...🤔
Looks D-only but could this be S-wave? (or a delayed D? Pt has Afib and predisposed to having smaller S but wondering if there is some S-D fusion here)
Renal #POCUS in a #dialysis patient: Looks fine at first glance (thin parenchyma as expected) but fanning anteriorly reveals a large cyst, which would have been missed otherwise. Labeled images and notes in thread 👇 #Nephrology#MedEd#IMPOCUS
Labeled first image #POCUS
Note: peri-renal fat (usually prominent in ESRD patients) can be confused with free fluid.
Labeled second image #POCUS (obtained with phased array probe)
Note: EKG is not needed 😀
#Nephrology consult for worsening creatinine in the context of diuresis in a patient with #heartfailure
Documented weight 3 kg ⬇️ than the previous day. No accurate urine output. Pt feels OK (has some unrelated issue).
Question: over diuresis? #POCUS#MedEd#VExUS see thread 👇
So, there is decreased LV systolic function and obviously diastolic dysfunction. Bi atrial enlargement. No significant pericardial effusion (there was trace on PLAX).
Next step in the hemodynamic circuit #POCUS assessment?
btw repeat weight was similar.
Next: IVC #POCUS assessment to assess right atrial pressure.
Here it is 👇
Big and plethoric (take it as 15 mmHg in a spontaneously breathing person - we get RVSP of ~41 mmHg based on the above tricuspid gradient)
Stimulated by the enthusiasm of #MedEd student and #nephrology fellow, did a small experiment to see how well #POCUS -determined blood flow in the continuous renal replacement therapy (CRRT) circuit correlates with the actual no. 1/ First, got a color #Doppler img. of the tube 👇
2/ How do you calculate flow? It is the same principle that we use to determine flow rate in an arteriovenous fistula 👇 #POCUS
3/ 2nd step: measured the diameter of the tube (double-lined structure) - 0.42 cm