Reality and myths

Anaesthesiologist and Ultrasonography

THE ROLE OF AN ANAESTHETIST

Anaesthetists form the largest single hospital medical specialty and their skills are used in all aspects of patient care. Whilst the perioperative anaesthetic care of the surgical patient is the core of specialty work (and this includes all types of surgery from simple body surface surgery in adults to the most complex surgery in patients of all ages, including the premature newborn) many anaesthetists have a much wider scope of practice which may include:

The preoperative preparation of surgical patients The resuscitation and stabilisation of patients in the Emergency Department Pain relief in labour and obstetric anaesthesia Intensive care medicine

Transport of acutely ill and injured patients

Pre-hospital emergency care Pain medicine including: The relief of post-operative pain Acute pain medicine and the management of acute teams Chronic and cancer pain management The provision of sedation and anaesthesia for patients undergoing various procedures outside the operating theatre. Examples of this include different endoscopic procedures, interventional radiology and dental surgery (this list is not exclusive).

Anaesthesia is the largest single hospital specialty but is probably the least well understood. The general public has little idea of the role of anaesthetists, and, sadly, the medical profession as a whole often mirrors this lack of knowledge.

ULTRASOUND

What is ULTRASOUND
The frequency of range of sound above 20kHz is known as ULTRASOUND These waves inaudible to humans, can be transmitted in beams and used to scan the tissues of the body.

History
1500 Leonardo da Vinci 1845 Christian Doppler 1880 Curie Brothers 1900 Langevin 1927 Wood & Loomis 1940 1950 Ludwig, John Wild 1960 Douglas Howry, Hertz & Elder 1970 1990 New Developments 2000 Now and the Future

History of Ultrasound ANAESTHESIA

1978 La Grange P in 1978 described the use of Doppler ultrasound for supraclaviclar brachial plexus

Development of Ultrasound
DMS Acoustics Diagnostic Medical The science of Sonography engineering and the art of generating, An imaging tool that is used to visualise propagating, and the soft tissue receiving sound structure of the body waves
by sending and receiving signals to and fro from the body

Basic Ultrasound Physics

Transducer (AKA: probe)
Piezoelectric crystal
Emit sound after electric charge applied
Sound reflected from patient

Returning echo is converted to electric signal gray scale image on monitor

Echo may be reflected, transmitted or refracted Transmit 1% and receive 99% of the time

Physics
Characterized by sound waves of high frequency.

Higher than the range of Human Hearing

Sound waves are measured in Hertz (Hz) Diagnostic U/ S = 1-20 MHz

Sound waves are produced by a transducer

Instruments
A B C

Monitor and Computer

Converts signal to an image/ archive

Tools for image manipulation

Gain amplification of returning echoes
Overall brightness

Time gain compensation (curve)

Adjust brightness at different depths

Freeze Depth
Zoom in for superficial view Zoom out for wide view Depth limited by frequency

Focal zone
Optimal resolution wherever focal zone is

Image controls

Modes of Display
A mode
Spikes where precise length and depth measurements are needed Ophtho

B mode
Brightness used more often - 2D construction of the image slide

M mode
Moving mode moving 1D image Cardiac mainly

Major Uses of Ultrasound

Obstetrics and Gynecology

Urology
Cardiology To observe structures or functions of the hearth to identify abnormalities. To measure blood flow through the heart and major blood vessels. Lungs filled with air and ribs limits the application.

Modalities
X-ray Measures line integrals of attenuation coefficient Builds images tomographically; i.e. using a set of projections

CT

Nuclear

Radioactive isotope attached to metabolic marker

Strength is functional imaging, as opposed to anatomical

Ultrasound Measures reflectivity in the body

Comparison of modalities
Why do we need multiple modalities? Each modality measures the interaction between energy and biological tissue. - Provides a measurement of physical properties of
tissue. - Tissues similar in two physical properties may differ in a third.
Note: - Each modality must relate the physical property it measures to normal or abnormal tissue function if possible. - However, anatomical information and knowledge of a large patient base may be enough. - i.e. A shadow on lung or chest X-rays is likely not good. Other considerations for multiple modalities include: Cost Safety Portability / Availability

Clinical Applications - Table

Chest
X-Ray/ CT Ultrasound

Abdomen

Head
+ X-ray - is good for bone CT - bleeding, trauma poor

+ widely used needs contrast + CT - excellent + CT - excellent no, except for + heart + extensive use in heart + excellent problems with gas Merge w/ CT

Nuclear

+ PET

MR

+ growing cardiac applications

+ minor role

+ standard

Clinical Applications - Table

Cardiovascular
X-Ray/ CT + X-ray Excellent, with catheter-injected contrast

Skeletal / Muscular
+ strong for skeletal system

Ultrasound

+ real-time + non-invasive + cheap but, poorer images

+ functional information on perfusion

not used + Research in elastography

Nuclear

+ functional - bone marrow

MR

+ getting better High resolution Myocardium viability

+ excellent