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Postgraduate Education Corner: Ultrasound Corner |

A Woman in Her 60s With Septic Shock, Abdominal Pain, and a Positive UrinalysisWoman With Septic Shock, Pain, Positive Urinalysis FREE TO VIEW

Yonatan Y. Greenstein, MD; Seth J. Koenig, MD, FCCP
Author and Funding Information

From the Division of Pulmonary, Critical Care, and Sleep Medicine, Hofstra North Shore – Long Island Jewish Health System, New Hyde Park, NY

Correspondence to: Yonatan Y. Greenstein, MD, Hofstra North Shore – Long Island Jewish Health System, Division of Pulmonary, Critical Care, & Sleep Medicine, 410 Lakeville Rd, Ste 107, New Hyde Park, NY 11040; e-mail: lungdoc@yonatangreenstein.com


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(3):e7-e9. doi:10.1378/chest.13-2455
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Published online

A woman in her 60s, with a past medical history of hypertension, presented to the ED complaining of a 1-day history of fevers, chills, nausea, vomiting, and abdominal pain. She was unable to further characterize the pain; however, she did deny the presence of diarrhea and dysuria.

In the ED, the patient was febrile to 39.2°C (102.6°F), tachycardic to 110 beats/min, hypotensive to BP of 80s/50s mm Hg, with mild tachypnea and normal oxygenation on room air. She was given multiple boluses of normal saline in the ED. Laboratory data were notable for a WBC count of 34,000/μL; serum creatinine level, 2.25 mg/dL; venous lactate level, 5.9 mmol/L; and a grossly positive urinalysis. A norepinephrine drip was started, blood and urine cultures were obtained, and the patient was given broad-spectrum antibiotics. Upon arrival in the medical ICU, a focused, goal-directed ultrasound study was performed to further evaluate her shock state and to guide management (Videos 1-7, Video Set 1).

Video 1 - 7

Focused, goal-directed ultrasound study

Based upon the patient’s history and clinical examination thus far, what would be the next logical step in management of this patient?
Next steps: Urgent source control with a percutaneous nephrostomy tube

Discussion Video

Next step is urgent source control with a percutaneous nephrostomy tube

A published study has demonstrated that focused, whole-body ultrasonography allows the intensivist to quickly identify the cause of undifferentiated shock and help guide its management.1 This patient presented with fever, leukopenia, acute kidney injury, positive urinalysis, and shock physiology. A focused, whole-body ultrasound approach was used. The Discussion Video contains labeled versions of Videos 1-7 with an explanation of each video’s interpretation.

Discussion Video 1

Focused whole body ultrasound study

Ultrasonography was initially used to characterize this patient’s shock state and guide resuscitation. Video 1, representative of all lung fields, demonstrates an A-line pattern of aeration with normal lung sliding. The A-line pattern was not surprising, as this patient presented with a normal pulmonary examination and no evidence of heart failure. It is, however, reassuring that after a fluid challenge, she had no evidence of pulmonary edema. This would be demonstrated by a B-line pattern on lung ultrasound.2 The presence of lung sliding throughout her lung fields ruled out a pneumothorax with 100% negative predictive value.3-5

Goal-directed echocardiography was performed to identify the etiology of shock and further guide resuscitation. Video 2 is a view of the parasternal long axis of the heart. Cardiac contractility was normal without obvious valvular abnormalities. No pericardial effusion was present. Video 3 is the parasternal short-axis view of the heart. While it is a suboptimal view, due to translational motion from respiratory effort, this view is useful as it does not demonstrate end-systolic effacement of the left ventricle or a pericardial effusion, and it shows normal motion of the interventricular septum, suggesting no marked volume and/or pressure overload of the right ventricle. An apical four-chamber view of the heart was not attainable, however. Video 4 shows this patient’s subcostal window. Left ventricle function was normal, and no pericardial effusion was seen. Normal right-ventricle size and function made the diagnosis of obstructive shock unlikely.

Inferior vena cava (IVC) size and respiratory variation may predict fluid responsiveness in a patient with shock. Using the IVC size and respiratory variation to assess fluid responsiveness in passively breathing patients who were mechanically ventilated is well established.6-8 This is not the case for patients with spontaneous breathing; however, experts generally agree that if the IVC diameter is < 1 cm, there is a high likelihood of fluid responsiveness, and if the diameter is > 2.5 cm, there is a low probability of fluid responsiveness.9,10 Video 5 is a still M-mode image through the IVC. The maximum diameter of the patient’s IVC was 2.29 cm, and although not calculated on the screen, one can appreciate minimal respiratory variation in the diameter of the IVC. With these data in mind, vasopressor support was continued along with judicial use of crystalloids for BP support.

Multiple studies have shown that nonradiologist physicians can be trained to perform and interpret renal ultrasonography, with excellent sensitivity and specificity.11-13 Ultrasonography of the patient’s kidneys was performed in a search for a cause of her septic shock. Video 6 is a longitudinal view of the patient’s left kidney, which appeared relatively normal. The characteristic bean shape was surrounded by an echogenic capsule. The renal sinus appeared hyperechoic compared with the surrounding parenchyma. The renal calyces and pyramids, although present, were difficult to distinguish. There was no evidence of nephrolithiasis, pyelonephritis, or hydronephrosis. Video 7 shows the patient’s right kidney, which had abnormalities consistent with hydronephrosis. The renal pelvis and calyces were markedly dilated, and the normally hyperechoic renal sinus was replaced by an anechoic fluid. No obstructing stone was visualized on this ultrasound study.

It is important to evaluate the bladder for distension in any patient with hydronephrosis to rule out urinary outlet obstruction. This patient’s bladder was not distended. The intensivist performing renal ultrasound must be able to differentiate hydronephrosis from renal cysts. Renal cysts are, typically, very well circumscribed, spherical, and demonstrate an anechoic lumen. The patient presented in this case had a single renal cyst near the superior pole of the right kidney.

CT images of the abdomen and pelvis were notable for an obstructing, right-sided ureteral stone. In consultation with urology, the patient was taken emergently to the interventional radiology suite, and a right-sided percutaneous nephrostomy tube was placed. The patient was discharged home 7 days later.

  • 1. A focused, whole-body approach to ultrasonography provides valuable information to the intensivist managing a patient in septic shock.

  • 2. Any patient presenting with septic shock and signs or symptoms suggestive of a renal or urinary source should have hydronephrosis excluded. Identification of hydronephrosis has dramatic implications for patient management and can be easily learned and performed by an intensivist ultrasonographer.

  • 3. Renal cysts, which are relatively common, may be mistaken for hydronephrosis, especially when they encroach upon the renal pelvis.

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 were met.

Additional information: To analyze this case with the videos, see the online article.

Volpicelli G, Lamorte A, Tullio M, et al. Point-of-care multiorgan ultrasonography for the evaluation of undifferentiated hypotension in the emergency department. Intensive Care Med. 2013;39(7):1290-1298. [CrossRef] [PubMed]
 
Lichtenstein D, Mézière G, Biderman P, Gepner A, Barré O. The comet-tail artifact. An ultrasound sign of alveolar-interstitial syndrome. Am J Respir Crit Care Med. 1997;156(5):1640-1646. [CrossRef] [PubMed]
 
Lichtenstein DA, Menu Y. A bedside ultrasound sign ruling out pneumothorax in the critically ill: lung sliding. Chest. 1995;108(5):1345-1348. [CrossRef] [PubMed]
 
Rowan KR, Kirkpatrick AW, Liu D, Forkheim KE, Mayo JR, Nicolaou S. Traumatic pneumothorax detection with thoracic US: correlation with chest radiography and CT—initial experience. Radiology. 2002;225(1):210-214. [CrossRef] [PubMed]
 
Sartori S, Tombesi P, Trevisani L, Nielsen I, Tassinari D, Abbasciano V. Accuracy of transthoracic sonography in detection of pneumothorax after sonographically guided lung biopsy: prospective comparison with chest radiography. AJR Am J Roentgenol. 2007;188(1):37-41. [CrossRef] [PubMed]
 
Barbier C, Loubières Y, Schmit C, et al. Respiratory changes in inferior vena cava diameter are helpful in predicting fluid responsiveness in ventilated septic patients. Intensive Care Med. 2004;30(9):1740-1746. [PubMed]
 
Feissel M, Michard F, Faller JP, Teboul JL. The respiratory variation in inferior vena cava diameter as a guide to fluid therapy. Intensive Care Med. 2004;30(9):1834-1837. [CrossRef] [PubMed]
 
Moretti R, Pizzi B. Inferior vena cava distensibility as a predictor of fluid responsiveness in patients with subarachnoid hemorrhage. Neurocrit Care. 2010;13(1):3-9. [CrossRef] [PubMed]
 
Brennan JM, Blair JE, Goonewardena S, et al. Reappraisal of the use of inferior vena cava for estimating right atrial pressure. J Am Soc Echocardiogr. 2007;20(7):857-861. [CrossRef] [PubMed]
 
Schmidt GA, Koenig S, Mayo PH. Shock: ultrasound to guide diagnosis and therapy. Chest. 2012;142(4):1042-1048. [CrossRef] [PubMed]
 
Torres-Macho J, Antón-Santos JM, García-Gutierrez I, et al; Working Group of Clinical Ultrasound, Spanish Society of Internal Medicine. Initial accuracy of bedside ultrasound performed by emergency physicians for multiple indications after a short training period. Am J Emerg Med. 2012;30(9):1943-1949. [CrossRef] [PubMed]
 
Mandavia DP, Aragona J, Chan L, Chan D, Henderson SO. Ultrasound training for emergency physicians—a prospective study. Acad Emerg Med. 2000;7(9):1008-1014. [CrossRef] [PubMed]
 
Gaspari RJ, Horst K. Emergency ultrasound and urinalysis in the evaluation of flank pain. Acad Emerg Med. 2005;12(12):1180-1184. [CrossRef] [PubMed]
 

Figures

Tables

Video 1 - 7

Focused, goal-directed ultrasound study

Discussion Video

Next step is urgent source control with a percutaneous nephrostomy tube

Discussion Video 1

Focused whole body ultrasound study

References

Volpicelli G, Lamorte A, Tullio M, et al. Point-of-care multiorgan ultrasonography for the evaluation of undifferentiated hypotension in the emergency department. Intensive Care Med. 2013;39(7):1290-1298. [CrossRef] [PubMed]
 
Lichtenstein D, Mézière G, Biderman P, Gepner A, Barré O. The comet-tail artifact. An ultrasound sign of alveolar-interstitial syndrome. Am J Respir Crit Care Med. 1997;156(5):1640-1646. [CrossRef] [PubMed]
 
Lichtenstein DA, Menu Y. A bedside ultrasound sign ruling out pneumothorax in the critically ill: lung sliding. Chest. 1995;108(5):1345-1348. [CrossRef] [PubMed]
 
Rowan KR, Kirkpatrick AW, Liu D, Forkheim KE, Mayo JR, Nicolaou S. Traumatic pneumothorax detection with thoracic US: correlation with chest radiography and CT—initial experience. Radiology. 2002;225(1):210-214. [CrossRef] [PubMed]
 
Sartori S, Tombesi P, Trevisani L, Nielsen I, Tassinari D, Abbasciano V. Accuracy of transthoracic sonography in detection of pneumothorax after sonographically guided lung biopsy: prospective comparison with chest radiography. AJR Am J Roentgenol. 2007;188(1):37-41. [CrossRef] [PubMed]
 
Barbier C, Loubières Y, Schmit C, et al. Respiratory changes in inferior vena cava diameter are helpful in predicting fluid responsiveness in ventilated septic patients. Intensive Care Med. 2004;30(9):1740-1746. [PubMed]
 
Feissel M, Michard F, Faller JP, Teboul JL. The respiratory variation in inferior vena cava diameter as a guide to fluid therapy. Intensive Care Med. 2004;30(9):1834-1837. [CrossRef] [PubMed]
 
Moretti R, Pizzi B. Inferior vena cava distensibility as a predictor of fluid responsiveness in patients with subarachnoid hemorrhage. Neurocrit Care. 2010;13(1):3-9. [CrossRef] [PubMed]
 
Brennan JM, Blair JE, Goonewardena S, et al. Reappraisal of the use of inferior vena cava for estimating right atrial pressure. J Am Soc Echocardiogr. 2007;20(7):857-861. [CrossRef] [PubMed]
 
Schmidt GA, Koenig S, Mayo PH. Shock: ultrasound to guide diagnosis and therapy. Chest. 2012;142(4):1042-1048. [CrossRef] [PubMed]
 
Torres-Macho J, Antón-Santos JM, García-Gutierrez I, et al; Working Group of Clinical Ultrasound, Spanish Society of Internal Medicine. Initial accuracy of bedside ultrasound performed by emergency physicians for multiple indications after a short training period. Am J Emerg Med. 2012;30(9):1943-1949. [CrossRef] [PubMed]
 
Mandavia DP, Aragona J, Chan L, Chan D, Henderson SO. Ultrasound training for emergency physicians—a prospective study. Acad Emerg Med. 2000;7(9):1008-1014. [CrossRef] [PubMed]
 
Gaspari RJ, Horst K. Emergency ultrasound and urinalysis in the evaluation of flank pain. Acad Emerg Med. 2005;12(12):1180-1184. [CrossRef] [PubMed]
 
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