Hello everybody! I hope everyone has made it back home safe and sound by this point. I had all of my fingers and toes crossed that all of your journeys went smoothly. I have to admit, it took me quite a while to write this one out. And no it wasn't because of all the notes I typed out. I think I was just stalling to delay posting one of the final blogs. I am sorry my sappy self was selfish and kept these notes hidden from you for so long.....
Anways, here are the notes from the sessions held on Saturday, June 9th:
DEALING WITH ERGONOMIC INJURIES: PHYSICAL AND LEGAL IMPLICATIONS
Causes of MSK problems for Sonographers:
Poor Posture, Improper patient positioning, overuse
of our muscles and joints, repetitive motions, duration of pressure, excessive
force/strain, forceful/awkward movements, and vibrations.
Tips for improving your ergonomics:
Position the keyboard close and directly in front of you, keep
your forearms parallel to the floor at elbow level, keep your wrist in a neutral position
with fingers slightly curved, the monitor should be facing you, you should be no more
than an arm’s length distance between your eyes and the screen, avoid having a death
grip on transducer (I think we all know we do this!), and do not throw cord over neck.
Core concepts:
Keep everything within easy reach, make sure
work is at proper height, reduce excessive forces when possible, maintain good body posture, and
reduce repetition.
“If I knew I was going to live this long, I’d have taken
better care of myself”
Administrators role:
Change the workload distribution, do not
overload the schedule, allow time for breaks between patients, emphasize proper
exercises, have ergonomic specialist visit the department, include ergonomics
in discussion with new employees, and get a massage chair (my personal favorite)
Failure to address ergonomics in the workplace can result in
a $580,000 loss of revenue!!
What should you do if you get injured?
Document and report any persistent pain to your technical
director and your employer, seek competent medical advice, and most importantly if you have no
satisfaction get a second opinion.
If you have received a diagnosis:
Meet with your
supervisor/employer to discuss staffing and workstation solutions to help
correct the problem, work closely with physician to correct issues because many
of these problems are career ending.
CUTTING EDGE TECHNOLOGY: TAKING IT TO THE NEXT LEVEL
How to Measure Aortic Aneurysms
-
Variability in equipment and how sonographer
measures the aneurysm
-
Perpendicular position for accurate measurements
-
Aneurysm size changes between systole and
diastole
o
Nobody knows which diameter is more important
o
Systolic diameter will be largest
o
Just be consistent in which timing the
measurement is taken, especially in patients you are following
-
Can measure inner to inner, outer to outer,
outer to inner, leading edge of adventia to leading edge*
Fusion Imaging
-
Improved accuracy, correlation and visualization
-
New information/training imagers
Volume Imaging: 3D Carotid Reconstruction
-
Manual scan and automated scan types
o
Volume data sets, quantitative linear
-
Automated Scan Benefits for Technologists
o
Shorter exam times, obtain more info, fewer
struggles for that “perfect” image, less potential for MSK injuries
- Automated Scan Benefits for
Physician
o
Acquire more data, data not sampled, new viewing
planes, all the information is there
-
Besides stenosis %, what plaque characteristics
will best predict stroke value
o
Ulceration, internal echogenicity,
o
Stroke rates triples with ulceration
o
Echolucent plaque has 8 times increased risk of
stroke
o
3-D allows description of lesion in quantitative
fashion
Vulnerable Plaque Analysis
-
Classification: Quality, Quantity
-
Ultrasound Elasticity Imaging
o
Determines tissue stiffness
o
Fibrous tissue is twice as stiff as non-fibrous
o
Calcified is 4 times as stiff as fibrous
o
Ratio of strain on atherosclerotic region
compared to adventitia
Angiogenesis Through Stem Cell Therapy for Patients with
Critical Limb Ischemia
-
Patients that would benefit – PAD, Beurger’s
Syndrome
o
PAD: No reconstructive options
§
Failed bypass, endovascular therapies,
complicated by embolisms
o
Beurger’s Disease
-
Adult or stomatic cells (autologous)
o
Bone marrow, blood, blood vessels, heart, fatty
tissue
-
Increase Angiogenesis
o
Capillary growth
o
Mediated by hypoxic environment
-
Increase Arteriogenesis
o
Enlargement of pre-existing vessels
o
Driven by sheer stress
-
Patients who are not standard candidates for revascularizarion:
o
Low abi and tbi, failed medical management, normal arteries above the inguinal ligament, Amputation, DVT, or ongoing infection are
excluded
o Amputation, DVT, or ongoing infection are excluded
-
Process
o
Aspiration of bone marrow stem cells, injected
right into region of ischemia in extremity
INTO THE DEEP: VISCERAL VASCULATURE
Aorta Grafts vs. EVAR
-
Endograft scanning
o
Detect endoleak, max sac diameter, inflow,
outflow, graft flow
o
Find source of endoleak flow
o
Aneurysm sac, graft/limb flow, hemodynamics
o
Need surgical detail of device placement BEFORE
Duplex evaluation
§
Type of device
§
Limb stents
§
Coiling of IMA
§
Hypogastric
§
Iliac bypass
o
Examine entire graft – kinks may occur with
extrinsic compression
§
Graft limb compression – disease on wall between
lumen and graft
o
Complete exclusion of AAA should result in a
decrease in size of AAA before treatment
o
Examine aneurysm sac
§
Document any extra-graft flow
§
Source of flow
o
Endoleaks can be positional!
o
Type 2 is most common
o
Rupture is associated with all types
o
Color in the sac by itself is not diagnostic, you must find the source!
What or Who is TEVAR?
-
Operative
o
Right Fem-Cut down under local anesthetia
o
Four component Medtronic talent stent
o
Build distal to proximal
-
TEVAR has less complications and mortality
compared to open repair
-
Higher stroke rate associated with TEVAR
-
Alters left subclavian and vert blood flow
-
Arch degeneration
-
Vascular Lab
o
Check arch vessels: Subclavian, Celiac Axis
o
Both vessels tolerate coverage well
o
Subclavian – measure brachial pressures, palpate
pulse
o
Celiac – flow or no flow? Physiologic
compression versus occlusion
LUNCH WITH THE EXPERTS
"Carter's Pat-hology" - Vascular Case Studies
I am not going to even try to hide it, I am a sucker for interesting case studies. This presentation had my attention from start to finish. Plus, the speakers had a very natural way of grabbing the audience's attention with humor built in throughout. Or maybe I am favortizing it because I answered the quiz question right and won a certficate for a free online review class....(kidding, of course).
Some of the great cases presented were: Right Kidney Parenchymal Aneurysm, Pop Artery Aneurysm, Pop
Venous Aneurysm looks like a bakers cyst, Renal Artery Aneurysm, Subclavian /
Aorta / SMA / Renal Dissection all in one patient, Pop Pseudoaneurysm, Seroma causing extrinsic
compression on the EIV, Fatty emboli in the LEV after a bone fracture, and thrombosed varicosities in the backside.
I'm sure reading these doesn't compare to being there in person. Being able to see the clips from the scans were great!
There is one thing that was said and I am constantly told in my scan lab. If a patient says, "You ain't looking where it hurts", then once the examine is complete take a look where it hurts! I agree with this one hundred percent. Most of the time it may still end up as nothing diagnostic. But hey it also may end up as one of these great cases one day!
VENOUS SESSION
Venous Hemodynamics
Treatment: What method should we apply? How do we know?
During muscular contraction – systole, during muscle relaxation – diastole
Hemodynamics of drainage, contemplating treatment:
1.
Is the gsv normal?
2.
What if we destroy the gsv?
3.
Will there be frustrated drainage?
4.
Recurrence? Treatment failure?
Iliocaval Management
-
Acute: Pain, hypovolemia, Low-grade fever, limb
swelling, pulmonary embolism
-
Chronic: Asymptomatic, chronic limb swelling
-
Chronic IVC = Abdominal Wall Collateral Veins
-
Etiology: Thombotic complications of IVC
filters, Neoplastic causes with extrinsic compression / intraluminal tumor,
non-neoplastic extrinsic compression, renal vein thrombosis with distal
propagation, Congenital (aplasia, hypoplasia, duplicated IVC), Contributing
factors (Hypercoaguable states, thrombophilia, oral contraceptives,
dehydration, recent surgery)
-
Normally presents as acute on chronic thrombus
-
Appearance: intraluminal thrombus, absence of
detectable flow, extrinsic compression, visualize filter is present
-
Define extent: supra-renal, peri-herpatic, renal
veins patent, continuous or absent flow
-
Initial Treat: Fluid resuscitation, systemic
anticoagulation, elevate limbs
-
Intravascular Treatment: catheter directed
thrombolysis, ultrasound accelerated thrombolysis, suction thrombectomy,
endovascular rheolytic thrombectomy, isolated segmental pharmomechanical
therapy, surgical intervention
Portal Hypertension & TIPS
-
Portal vein diameter varies
o
Increases after eating, deep inspiration, and
val salva
§
Normal under 16mm
o
Decreases in upright position, fasting, and
exercise
§
Normal under 13 mm
-
Portal Hypertension Appearance
o
Size is above normal
o
Loss of respiratory variation
o
Decreased velocity
o
Bidirectional
o
Reversed Flow
o
Hepatic Artery
§
Increased flow
§
Corkscrew appearance
§
May be mistaken for a dilated bile duct
§
Normal waveform, may flatten and lose
pulsatility
-
Early and moderate PHT can not be diagnosed via
ultrasound, only diagnosed in late stages.
-
TIPS – preferred over surgical shunt
o
Avoids anesthesia
o
Contraindictions – inadequate liver reserve,
severe right heart failure
o
Normal Appearance: color should fill lumen, increased flow through
tips and portal vein and hepatic artery, flow over 40 cm/s in pv, over 130 cm/s
in hepatic, high velocity pulsatility flow in TIPS, flow towards TIPS in MPC,
LPV, and RPV
o
Stenosis
§
Occurs at hepatic end
§
Criteria remains controversial
§
Varies location to location
o
US is not an accurate means of assessing the
porto-systemic gradient
o
Try to obtain Doppler during quiet respiration
o
Remember to look for Varices
o
Get baseline examine, observe for changes in the
vessel velocities
Aging Clot: Acute, Chronic, and In-Between
-
Acute: Echolucent, soft and spongy, perhaps
occlusive, free floating partially attached thrombus, vein dilated
-
Chronic: Echogenic, rigid, contract and small,
recanalization with partial lumen restoration, walls thickened and residual
fibrous bands are often seen
-
In Between
o
Identifying recurrence is easier is the
ultrasound is performed after completing the first anticoag therapy, establish
a new baseline for comparison
§
Incomp of a previous normal segment
§
A change in thrombus length more then 9cm
Following the venous session, Patricia Poe gave the closing remarks of the conference. From start to finish it sounds like everything went extremely well for them! A bonus to staying for the end of the venous session was that each attendee was given a chance to win an Apple iPad. Guess who's ticket got drawn!?
Now I will be the first to say, I am the person with the least amount of luck on this planet. I was in complete shock to have my number called! So thank you very much for happening to pull my numbers Patricia! Thanks to the iPad, this blog was created. It is already giving back to the SVU. Now every time I use it I will get to think of the amazing experiences I had at the conference. There was no better way to end the conference.
Until next time,
- Kristen
