An unusual echo finding.

Abstract

The focused intensive care echo (FICE) is a relatively new accreditation available to those wanting to train in echocardiography in the intensive care setting. It has been developed by the Intensive Care Society in conjunction with the British Society of Echocardiography. As more clinicians who are not specialist practitioners in echocardiography learn this skill, there will be an increasing likelihood of an unexpected finding that the operator will not be able to explain. This makes the ability to record, keep and then have the images reviewed by an expert an absolutely essential attribute to any imaging equipment. Our recent experience in managing a patient highlights this issue. The patient presented with septic shock to a district general hospital. Investigations identified the source of the sepsis to be two large liver abscesses. The patient was transferred to our intensive care unit (ICU) as our hospital is a regional hepato-biliary centre, and an ultrasound-guided drain was subsequently inserted. Despite the apparent abscess drainage, the patient remained in septic shock. A FICE was performed to ascertain whether any intervention could be employed to improve the patient’s haemodynamics. The results were unremarkable until the sub-costal window was obtained (Figure 1). This showed spherical echo-free regions that in this patient’s context represented persisting liver abscesses. The following day a second ultrasound-guided percutaneous drain was placed in the second abscess after which there was a gradual improvement in the patient’s condition; the patient was discharged from the ICU after a 15-day admission. FICE is a valuable tool in the investigation of a critically ill patient’s haemodynamic status. As an increasing number of intensivists acquire this skill the likelihood of an incidental finding like the one we have described will increase. Such findings have previously been described using trans-oesophageal echocardiography, including a liver lesion, a liver laceration and a retroperitoneal haematoma. In our patient’s case the cause of the incidental finding was known; however, this may not always be the case. During the FICE accreditation process all scans are reviewed. Post accreditation this is not the case. It will be essential that if a practitioner discovers either something they cannot explain or feel is important to confirm its nature there is a way for the images to be stored and then reviewed by an expert. It would also seem prudent to have a pre-arranged method of getting images reviewed before the need to achieve this under a time constraint.