Preparation of the patient
From Echocardiography in ICU
The echocardiographic examination is an important step in the management of the patients, you will need to get the best images possible. All these elements are important to optimize:
The best images are obtained when the patient is lying on his left side, with the left arm widely abducted. Critically ill patients are most of the time difficult to move. You can start scanning without moving the patient, but if you don't get acceptable images, you will need to move him/her:
- You can place a pillow under the patient's right side and bend the patient's knees, with the ankles directed toward the right side. This will help to shift the body weight to the left and bring the heart closer to the chest wall. It will help to avoid the interfacts created by lung interposition.
- A very easy and effective way to improve your images and find an echographic window is to abduct the patient's left arm. This will widen the intercostal space and allow you to find an echographic window between the ribs.
It will be easier to focus on the echo if the room is quiet, and as dark as possible for a better visualization of the images on the screen. You should close the door or the curtains to ensure the patient's privacy.
-Scanning hand: at the beginning of your training, it will be important to decide with which hand you will want to scan. The easiest would be to use your dominant hand and always scan in the same position, with the same hand. You will develop and improve your scanning skills, and understand how the little movements of your wrist or hand will modify the image.
-Holding the probe: for parasternal and apical views, you can hold the probe between your thumb and your 2nd and 3rd fingers. You should rest your wrist on the patient's chest, this will allow you to put less pressure on the probe and will help you to steady your position without sliding. For the subcostal view, you will need to put some vertical pressure on the probe. You can hold the probe with your palm, and direct it with your second finger.
-Position of the machine: it is important to find a good spot at the bedside. Ideally, the machine will be in front of you, you will scan with one hand and be facing the screen. If it is not possible, you can place the machine at the opposite side of the bed, this will allow you a good position. If you place the machine behind you or on your side, you will have to turn your back and will get tired very fast. Some echocardiography devices are so small you can put them on the patient's bed, others have some adjustable screen.
-Gel: very important! The gel will improve the contact, i.e. transmission of ultrasounds, between the probe and the patient's skin. Put as much as needed but don't forget to wipe it before you leave the patient, it is very uncomfortable to have something wet and sticky on your skin or sheets.