Focused Real-Time Ultrasonography for Nephrologists.

Matthew J Kaptein,Elaine M Kaptein

doi:10.1155/2017/3756857

Abstract

We propose that renal consults are enhanced by incorporating a nephrology-focused ultrasound protocol including ultrasound evaluation of cardiac contractility, the presence or absence of pericardial effusion, inferior vena cava size and collapsibility to guide volume management, bladder volume to assess for obstruction or retention, and kidney size and structure to potentially gauge chronicity of renal disease or identify other structural abnormalities. The benefits of immediate and ongoing assessment of cardiac function and intravascular volume status (prerenal), possible urinary obstruction or retention (postrenal), and potential etiologies of acute kidney injury or chronic kidney disease far outweigh the limitations of bedside ultrasonography performed by nephrologists. The alternative is reliance on formal ultrasonography, which creates a disconnect between those who order, perform, and interpret studies, creates delays between when clinical questions are asked and answered, and may increase expense. Ultrasound-enhanced physical examination provides immediate information about our patients, which frequently alters our assessments and management plans.

Highlights

Real-time ultrasonography has become an invaluable extension of the physical examination
inferior vena cava (IVC) collapsibility performs comparably to other “dynamic” predictors of volume responsiveness such as pulse pressure variation (PPV) and stroke volume variation (SVV) when assessed by an increase in cardiac index of at least 10% in ventilated patients (Table 4)
We propose that bedside ultrasound evaluation of bladder volume be part of the physical exam in all hospitalized patients with acute kidney injury (AKI), chronic kidney disease (CKD), end-stage renal disease (ESRD), or urinary tract infection, and in those who are at risk for urinary retention/obstruction due to urethral stricture, prostatic hypertrophy, neurogenic/atonic bladder, or uterine prolapse

Summary

Background

Real-time ultrasonography has become an invaluable extension of the physical examination. The RUSH (Rapid Ultrasound in SHock) and FAST (Focused Assessment with Sonography for Trauma) protocols are routinely used for the immediate assessment and management of unstable patients [1,2,3]. The RUSH exam focuses on the heart to assess for contractility, pericardial effusion, or tamponade, and the inferior vena cava (IVC) maximum diameter and collapsibility to estimate intravascular volume and to guide volume management [4]. Ultrasound findings influenced management [4, 6,7,8] and were useful in guiding volume administration or restriction and pressor therapy, which resulted in improved 28-day patient survival, a reduction in stage 3 acute kidney injury, and more days alive and free of renal support [9]. We have developed our approach by incorporating previously described point-of-care ultrasound evaluations and personal experience

Limited Cardiac and Inferior Vena Cava Ultrasound

Urinary Bladder Ultrasound

Limited Renal Ultrasound

Findings

Summary