Bladder_Yale_Final (1)

Transcript

• 00:02In this video tutorial,
• 00:05we will review the necessary
• 00:07steps to obtain accurate
• 00:10bladder volume measurements
• 00:11for patients
• 00:12in the pediatric ED,
• 00:15And we will review some
• 00:16cases where this Pocus application
• 00:19can be used to help
• 00:21streamline your patient care.
• 00:25Indications to perform a diagnostic
• 00:27bladder scan include the following.
• 00:29One,
• 00:31prior to urine catheterization
• 00:33to minimize risk of a
• 00:34dry cath.
• 00:36Two,
• 00:37patients with suspected ovarian torsion
• 00:39before radiology performed ultrasound to
• 00:42deem adequacy of bladder filling.
• 00:45Three,
• 00:47patients with urine retention.
• 00:49Four,
• 00:50patients were reported
• 00:52oliguria or anuria.
• 00:54Five,
• 00:56patients with incomplete bladder emptying.
• 00:59Six,
• 01:01patients who require suprapubic bladder
• 01:03aspiration procedure.
• 01:08Diagnostic bladder scans are to
• 01:10be performed with a low
• 01:12frequency
• 01:13curvilinear transducer.
• 01:18To maximize patient comfort and
• 01:20improve the quality of your
• 01:22study,
• 01:23hold the transducer like a
• 01:24pen.
• 01:25With an incorrect grip, unnecessary
• 01:28pressure is often applied to
• 01:30the patient's skin.
• 01:32With a correct grip, the
• 01:33ulnar side of your hand
• 01:35will be directly touching the
• 01:36patient's body.
• 01:37This will allow you to
• 01:38maneuver the probe as necessary
• 01:41and allow for a more
• 01:42comfortable experience for your patient.
• 01:47Please feel free to wear
• 01:48gloves during your ultrasound scan.
• 01:51Many patients will feel more
• 01:52relaxed, and the routine use
• 01:54of gloves will also decrease
• 01:56the risk of infectious disease
• 01:58transmission.
• 02:01Before we dive into the
• 02:03image acquisition steps for your
• 02:05bladder scan,
• 02:07let's review a couple of
• 02:08important housekeeping items.
• 02:11Firstly, the epic order to
• 02:12choose from the quick list
• 02:13menu is ED diagnostic
• 02:15bladder volume eval.
• 02:17Using this correct order will
• 02:19ensure that your images captured
• 02:21will be transferred to Epic,
• 02:23and a report of your
• 02:24interpretation will be generated.
• 02:26Secondly, it is important to
• 02:28fill out QPath immediately after
• 02:30your bladder scan is completed.
• 02:32An attending signature will be
• 02:34required to push both the
• 02:36images and report over to
• 02:39the medical record.
• 02:43First, you will scan through
• 02:44the bladder in transverse orientation
• 02:46with the indicator towards the
• 02:47patient right. Make sure you're
• 02:49all the way down to
• 02:50the pubic symphysis in order
• 02:52to visualize the bladder,
• 02:54and slowly fan the probe
• 02:56all the way through.
• 02:59Next, you will turn the
• 03:01probe clockwise ninety degrees so
• 03:03that the indicator is pointing
• 03:04towards the patient's
• 03:06head. In this view, you
• 03:07will see the bladder in
• 03:08long axis.
• 03:09Again, you want to slowly
• 03:11fan the probe all the
• 03:12way through and keep an
• 03:13eye out for any abnormal
• 03:15lesions or masses that may
• 03:17be present behind the bladder.
• 03:21In the next step, we
• 03:22will review how to actually
• 03:23obtain your bladder volume measurements.
• 03:26As long as you're using
• 03:27a curvilinear probe utilizing the
• 03:30abdominal or pelvic exam mode,
• 03:32you'll be able to pull
• 03:33up the right calculator.
• 03:35Let's look at the buttons
• 03:37that are
• 03:38squared off in pink boxes.
• 03:40You will once again return
• 03:41to transverse orientation and find
• 03:43the bladder where you see
• 03:45it at its biggest size
• 03:47and hit freeze.
• 03:49Here, you will enter the
• 03:51calque button all the way
• 03:52on the left.
• 03:54This will allow you to
• 03:55enter your first measurement, which
• 03:56will be the height.
• 03:58When you push the measure
• 03:59button, a caliper will appear
• 04:01on your screen monitor.
• 04:03You can use the trackpad
• 04:04to move the caliper from
• 04:06the top of the bladder
• 04:07to the bottom of the
• 04:08bladder.
• 04:09You can then repeat these
• 04:10steps
• 04:11still in transverse orientation
• 04:13to obtain a width measurement,
• 04:15and you can now save
• 04:17a still image of your
• 04:18transverse measurements by hitting the
• 04:20acquire button.
• 04:22To obtain your bladder length
• 04:24measurement, you'll have to unfreeze
• 04:25the screen by hitting the
• 04:27two d mode button that
• 04:28is an orange color above
• 04:30the track pad. You will
• 04:31once again hit the calque
• 04:33button, and the machine will
• 04:35remember your prior two measurements
• 04:36and allow you to
• 04:38now obtain a
• 04:40third measurement.
• 04:42Place the caliper on the
• 04:44trigone area of the bladder
• 04:47and obtain the longest distance
• 04:50seen
• 04:51towards the bottom part of
• 04:52the bladder.
• 04:54Once you obtain this final
• 04:56measurement,
• 04:57the ultrasound machine will automatically
• 04:59generate the bladder volume using
• 05:02a predesignated
• 05:04formula
• 05:05that has been programmed into
• 05:06the system.
• 05:09Your final step will be
• 05:10to interpret your, point of
• 05:12care ultrasound findings related to
• 05:13the bladder.
• 05:14Depending on why you're doing
• 05:15the study in the first
• 05:16place, you will make an
• 05:17assessment whether there is sufficient
• 05:19or insufficient amount of urine
• 05:21for a catheterization
• 05:22procedure and likewise sufficient or
• 05:24insufficient amount of urine for
• 05:26radiology performed ultrasound to assess
• 05:28for ovarian ovarian pathology.
• 05:30And you will also be
• 05:31asked to provide a general
• 05:32assessment of the amount of
• 05:33urine in the bladder, which
• 05:34you will correlate clinically
• 05:36and apply those volume measurements
• 05:38to expected bladder capacity and
• 05:40established norms for post void
• 05:42residuals.
• 05:45The good news is that
• 05:46you will not be expected
• 05:48to memorize anything.
• 05:49All of the necessary formulas
• 05:51that you may need will
• 05:52be embedded into the Q
• 05:54Path worksheet
• 05:56created for bladder volume
• 05:58evaluations in our ED.
• 06:00This will help you with
• 06:01your interpretations as you fill
• 06:03out the
• 06:04worksheet findings in real time.
• 06:09So let's look at some
• 06:10practice cases.
• 06:16Case one.
• 06:17A two year old girl
• 06:18with Lennox Gastaut seizure disorder,
• 06:21g tube dependence, neurogenic bladder,
• 06:23and global developmental delay
• 06:25presents with unexplained tachycardia and
• 06:27increase in seizure frequency.
• 06:30As part of her workup,
• 06:31urine testing is ordered.
• 06:33Mom opts to do a
• 06:35urine catheterization herself as she's
• 06:37routinely does this at home,
• 06:39but she was unsuccessful and
• 06:40reports was unable to obtain
• 06:42any urine.
• 06:44She is very concerned that
• 06:45her daughter is dehydrated,
• 06:47and the nursing staff does
• 06:48not feel comfortable performing a
• 06:50repeat catheterization
• 06:52at this time.
• 06:55You first record the bladder
• 06:57in transverse orientation,
• 06:58and although it appears less
• 07:00round than you usually expect,
• 07:01there seems to be a
• 07:02fair amount of urine present.
• 07:05You then rotate the probe
• 07:07ninety degrees
• 07:08and
• 07:09assess the bladder in a
• 07:10longitudinal
• 07:11orientation
• 07:12where once again the bladder
• 07:14is seem to be filled
• 07:15with plenty of urine.
• 07:19You go back to transfer
• 07:21orientation and freeze the screen.
• 07:23Obtain a height measurement from
• 07:25top to bottom.
• 07:27Obtain a width measurement from
• 07:29left to right.
• 07:31Save that image.
• 07:32You then get the length
• 07:34of the bladder in longitudinal
• 07:37orientation,
• 07:38placing the calipers across the
• 07:40longest possible distance.
• 07:43The ultrasound machine automatically calculates
• 07:46the volume
• 07:47estimate of eighty two cc's.
• 07:53You review these findings with
• 07:55mom and the nursing staff
• 07:57and feel that a
• 07:59repeat attempt at urine catheterization
• 08:02would be
• 08:03reasonable to perform.
• 08:07Repeat catheterization
• 08:09is successful and ultimately diagnostic
• 08:11for a urinary tract infection
• 08:13with, greater than one hundred
• 08:15thousand
• 08:16colony forming units of enterococcus.
• 08:18A renal ultrasound performed by
• 08:20diagnostic radiology revealed debris within
• 08:23the right ureter, which was
• 08:24causing obstruction,
• 08:26and hydrouretoronephrosis,
• 08:29which was managed by the
• 08:31inpatient
• 08:32urology
• 08:34service.
• 08:35So as it turns out,
• 08:36it does not take much
• 08:38urine at all to predict
• 08:40a successful catheterization
• 08:42in patients under two years
• 08:43of age.
• 08:45Without focus to visualize bladder
• 08:47contents,
• 08:48the rate of successful urine
• 08:50catheterization
• 08:51in this age group was
• 08:52published to be seventy two
• 08:54percent during the observational phase
• 08:56of a study published by
• 08:57Chen et al. In two
• 08:59thousand and five. However, when
• 09:01the investigators applied POCUS to
• 09:03determine whether there was at
• 09:05least two cc's of urine
• 09:07present in the bladder, the
• 09:08rate of successful
• 09:10catheterization
• 09:11when done by nursing staff
• 09:13was reported to be as
• 09:14high as ninety six percent.
• 09:17Case two highlights
• 09:19the point of care ultrasound
• 09:21role in ovarian torsion to
• 09:23expedite confirmatory
• 09:25testing.
• 09:26Here we have an eighteen
• 09:27year old female who presents
• 09:29with sudden onset of intense
• 09:31right lower quadrant pain and
• 09:33nausea.
• 09:34She reports no fever or
• 09:35hematuria,
• 09:37denies the possibility of pregnancy,
• 09:39and has never had a
• 09:40pelvic exam.
• 09:42For you, she is very
• 09:43tearful and uncomfortable and is
• 09:45tender to touch to the
• 09:46right lower quadrant area.
• 09:48You need to prioritize getting
• 09:49a urine sample with a
• 09:51transabdominal
• 09:52ultrasound
• 09:53to assess for ovarian torsion.
• 09:55You record her bladder in
• 09:57transverse orientation
• 09:58and note a nicely fluid
• 10:00filled structure with posterior acoustic
• 10:03enhancement.
• 10:05Upon interrogation and longitudinal access,
• 10:08you again see a nicely
• 10:09filled bladder with a normal
• 10:11appearing uterus
• 10:13behind it.
• 10:16You obtain your measurements in
• 10:18transverse.
• 10:19The bladder height is about
• 10:20seven point three centimeters.
• 10:22The bladder width is about
• 10:24nine point seven centimeters.
• 10:26And in longitudinal,
• 10:27your bladder length is about
• 10:29eight point five centimeters,
• 10:31which gives you a total
• 10:32bladder volume of about three
• 10:34hundred and fourteen cc's.
• 10:37This is incredibly useful information
• 10:39as you would expect bladder
• 10:40capacity in an adult to
• 10:42be about five hundred cc's.
• 10:46You determined she should be
• 10:47ready for radiology ultrasound
• 10:49without delay,
• 10:51but you also have a
• 10:52bonus finding on your bedside
• 10:54scan. When you gently angle
• 10:56her probe towards her right
• 10:58side
• 10:59using her bladder as an
• 11:01acoustic window, you actually can
• 11:03see her ovary on the
• 11:04right. It appears morphologically
• 11:06normal in its size, shape,
• 11:09and appearance of small follicular
• 11:11structures within. These findings make
• 11:13it incredibly unlikely that your
• 11:15patient has acute right sided
• 11:17ovarian torsion.
• 11:21On the flip side, you
• 11:22may have come across a
• 11:23case where something just doesn't
• 11:25look quite right deep in
• 11:27the pelvis.
• 11:28In this patient who who
• 11:30there were also some concerns
• 11:31for ovarian torsion,
• 11:33you can see a large
• 11:34ovoid lesion with some follicular
• 11:37architecture,
• 11:38which is present behind the
• 11:40uterus and pushing up on
• 11:41the uterine fundus.
• 11:43The bladder here is decompressed,
• 11:45but even though diagnostics for
• 11:47ovarian torsion by ultrasound are
• 11:48best left for our radiology
• 11:51experts
• 11:52to confirm,
• 11:53any abnormal screening findings such
• 11:56as this one should heighten
• 11:58the level of urgency
• 12:00and should also help expedite
• 12:02the time it takes to
• 12:03get your patient to her
• 12:05definitive
• 12:05imaging study.
• 12:07Now back to the case
• 12:08of the patient with acute
• 12:09right lower quadrant pain,
• 12:11your pocus helped determine the
• 12:13suitability
• 12:14of getting her over to
• 12:15radiology
• 12:16to have their formal diagnostic
• 12:18testing done. At radiology, a
• 12:20normal right sided ovary was
• 12:22again visualized.
• 12:24However, she had findings compatible
• 12:26with acute appendicitis.
• 12:28Luckily, you had already made
• 12:29the right call to obtain
• 12:31lab intravenous access, made her
• 12:33NPO, and started a normal
• 12:36saline bolus.
• 12:39Case three is a post
• 12:41void residual bladder volume measurement.
• 12:44In this case, a ten
• 12:45year old circumcised male presents
• 12:47with mild idiopathic swelling to
• 12:49his penis
• 12:50and had an otherwise normal
• 12:51genitourinary
• 12:52exam.
• 12:54On review of symptoms, he
• 12:55says that he wakes up
• 12:56to go to the bathroom
• 12:57several times at night. And
• 12:59for over a year, the
• 13:00teachers had reported that he
• 13:01goes to the bathroom several
• 13:03times a day while he's
• 13:04at school.
• 13:06Your plan is to do
• 13:06a dose of Benadryl for
• 13:08the,
• 13:08mild swelling and obtain a
• 13:10urinalysis to screen for potential
• 13:12causes of these symptoms.
• 13:14However, he is only able
• 13:15to void a small amount
• 13:16with great difficulty.
• 13:22You record his bladder in
• 13:24transverse orientation and slowly fan
• 13:26all the way through.
• 13:33You then record his bladder
• 13:34in longitudinal orientation.
• 13:38When you obtain your measurements,
• 13:39his bladder volume is three
• 13:42hundred and twenty three cc's
• 13:43calculated,
• 13:45which is an abnormal
• 13:47residual, which signifies
• 13:49incomplete
• 13:50bladder emptying.
• 13:54Based on your POCUS results,
• 13:55you have the patient go
• 13:57to radiology to have a
• 13:58renal ultrasound done where hydronephrosis
• 14:01is not found, but incomplete
• 14:03bladder emptying again is confirmed.
• 14:05Your urinalysis did not show
• 14:07any signs of glucosuria
• 14:09or signs of infection.
• 14:11Putting everything together, you recommend
• 14:12a trial of MiraLAX
• 14:14with an outpatient
• 14:15referral to urology should symptoms
• 14:17persist.
• 14:18You also review the potential
• 14:20for urine retention
• 14:22secondary to antihistamine medications like
• 14:24Benadryl.
• 14:27A potential pitfall when scanning
• 14:29for the bladder is that
• 14:30your probe is actually not
• 14:32low enough.
• 14:33Note the split screens of
• 14:34the same patient during a
• 14:35scan done around the same
• 14:37time.
• 14:38On the top row, the
• 14:39curvilinear probe is placed in
• 14:41the suprapubic
• 14:42area with the probe slightly
• 14:44angled towards the umbilicus.
• 14:46This results in only bowel
• 14:48to be present and seen
• 14:49on the monitor.
• 14:51On the second row of
• 14:52images, the curvilinear probe has
• 14:54been placed over the pubic
• 14:55symphysis and slightly angled in
• 14:58a called out direction.
• 15:00At this point, the bladder
• 15:01can be seen to come
• 15:02into view on the screen.
• 15:06The other important pitfall to
• 15:08be aware of is that
• 15:09large cystic structures in the
• 15:11pelvis may mimic the appearance
• 15:13of a bladder.
• 15:14I would pay particular careful
• 15:16attention in patients who present
• 15:19with urine retention as a
• 15:20chief complaint. Here we see
• 15:21a ten year old girl
• 15:22who complained of nuance and
• 15:24constipation
• 15:25and a sensation of incomplete
• 15:27bladder emptying. Ultrasound images by
• 15:29point of care and radiology
• 15:31thought the cystic structure being
• 15:33measured was her bladder.
• 15:35However, her bladder was completely
• 15:37decompressed and empty during the
• 15:39time of the ultrasound scans.
• 15:41What was thought to have
• 15:42been a ureterocele
• 15:44was actually part of a
• 15:46mature cystic teratoma,
• 15:48which was diagnosed by pelvic
• 15:50MRI.
• 15:51At the time of the
• 15:52MRI study, the bladder could
• 15:54be
• 15:55better visualized,
• 15:56and the mass effect causing
• 15:58bladder compression
• 15:59was more clearly seen.
• 16:04In summary, we have reviewed
• 16:06some cases where focus
• 16:08was used as a tool
• 16:09to expedite patient care and
• 16:11help to guide procedures.
• 16:13BladderScan by Pocus for the
• 16:15assessment and interpretation of volume
• 16:17measurements is an important skill
• 16:19for PEM physicians to learn.
• 16:22As always with Pocus, if
• 16:23you see something unexpected
• 16:25that doesn't fall into the
• 16:26typical pattern recognition appearance,
• 16:29please do not hesitate to
• 16:31ask for help.