Transcript Role of radiology in critical care of mothers and infants

ROLE OF RADIOLOGY IN
CRITICAL CARE OF MOTHERS
AND NEONATES
MNCH SYMPOSIUM
KNH/UON
7TH FEBRUARY 2014
DR. P. OTHIENO
CONSULTANT RADIOLOGIST
KNH
OBJECTIVES
 Overview of the role of radiological imaging in critical care of:
i) expectant mothers for:
- Maternal causes
- Foetal causes
ii) Infants - newborns
 Related issues
NEED FOR MEDICAL IMAGING
Radiological imaging is used to:
• Confirm or exclude presence of disease
• Determine type of disease
• Determine extent of disease
• Determine progress of disease
• Assess presence of complications arising from the disease process
Complements clinical and lab data
IMAGING OF THE CRITICALLY ILL
For optimal patient outcome, key issues are speed and
accuracy of radiodiagnosis. These depend on:
• Facilities/equipment available
• Their location
• Skills, experience
• Protocol
RADIATION PROTECTION OF PATIENTS (RPOP – IAEA)
• Pregnant women and children classified under “special groups” by
IAEA
• The exam must be justified, (Consider risk vs. benefit) and the
procedure optimized to answer the clinical question
• Reduce exposure to radiation
• Applies in usage of ionizing radiation – radiography, CT (MRI)
• Protection of growing foetus, gonads
References:
•
INTERNATIONAL COMMISSION ON RADIOLOGICAL PROTECTION, 1990 Recommendations of the ICRP, Publication 60, Pergamon Press, Oxford (1991).
•
INTERNATIONAL COMISSION ON RADIOLOGICAL PROTECTION, Pregnancy and Medical Radiation, Annals of the ICRP, Publication 84, Pergamon Press, Oxford
(2000)
CONSIDERATIONS IN MATERNAL IMAGING
• Radiation protection of patient (mother) & foetus must be
observed
• The foetus and young infant are at greatest risk for radiationinduced disease
• Ionising radiation – radiography, CT, fluoroscopy, interventional
procedures
• MRI procedures limited
• Restrict use of contrast media
MATERNAL CONDITIONS
• APH
• PPH
• PIH
• Thrombembolism (cerebrovascular or pulmonary)
• Amniotic fluid embolism
IMAGING MODALITY
MATERNAL CONDITION
IMAGING FINDINGS
PORTABLE
RADIOGRAPHY
PULMONARY
CARDIOVASCULAR
TRAUMA
Line placement
Lung infections
CCF
Pneumothorax, hemothorax, lung contusion
US
APH
PPH
Placental abruption, praevia
Retained placenta/POCs
DVT
Pelvic infection/abscess
Pleural, pericardial effusion
Tapping, draining of fluid collections
Line placement
Obstructive uropathy
CT
PULMONARY EMBOLISM
CTPE emboli in pulmonary arterial vessels
PIH
Cerebral oedema, hemorrhage
FOETAL US – FOETAL WELL-BEING
Ultrasonography is safe, non-invasive
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•
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Foetal cardiac activity
BPP score
Resistive indices – UmbilicaI artery, middle cerebral artery
Gestational age, and weight
CONSIDERATIONS IN NEONATAL IMAGING
• Chest radiography is the most frequently done examination & the
most difficult to interpret
• Radiation dose reduction
• Temperature control to prevent hypothermia
• Sedation and monitoring
• Immobilize patient with devices
• Digital radiography reduces exposure errors
• Limit use of contrast media - nephrotoxicity
IMAGING MODALITY NEONATAL CONDITION
IMAGING FINDINGS
PORTABLE
RADIOGRAPHY
- CHEST
RESPIRATORY DISTRESS
PULMONARY
CARDIOVASCULAR
(CONGENITAL)
CARDIAC ANOMALIES, SHUNTS, INFECTIONS,
DIAPHRAGMATIC HERNIA, TTN, HMD, MAS,
- ABDOMEN
NECROTISING
ENTEROCOLITIS
PNEUMATOSIS COLI
FREE INTRAPERITONEAL AIR
AIR IN HEPATIC PORTAL SYSTEM
INTESTINAL OBSTRUCTION
US
JAUNDICE
BILIARY ATRESIA
CHEST
SUPERFICIAL LESIONS, PLEURAL EFFUSIONS
MEDIASTINUM, DIAPHRAGM
CRANIAL INFECTIONS
CRANIAL TRAUMA
MENINGITIS, CEREBRAL ABSCESSES
INTRACRANIAL HEMORRHAGE
VACUUM EXTRACTION – CEPHALHEMATOMA
IMAGING
MODALITY
US
NEONATAL CONDITION
IMAGING FINDINGS
NECK MASSES CAUSING
AIRWAY
OBSTRUCTION
CYSTIC HYGROMA,
THYROGLOSSAL DUCT CYST
CT
NECK MASSES CAUSING
AIRWAY
OBSTRUCTION
PULMONARY EMBOLISM
CYSTIC, SOLID, VASCULAR,
CALCIFIED, CHOANAL ATRESIA
TRACHEOESOPHAGEAL
FISTULA
DEMONSTRATION OF FISTULA
NUCLEAR
MEDICINE
FLUOROSCOPY
PULMONARY EMBOLISM
CHALLENGES THAT GAVE RISE TO THE EMERGENCE OF
POINT-OF-CARE ULTRASOUND
• Radiologists too few to fulfil the demand for imaging services
• Mushrooming of ultrasonography practice by questionably
qualified/trained personnel
• US is Used by many, understood by few
• Lack of appropriate training, standards, documentation,
legislation, regulation
POINT-OF-CARE IMAGING – ULTRASOUND
What is point-of-care US?
Point-of-care ultrasound refers to the use of portable
ultrasonography at a patient’s bedside for diagnostic and
therapeutic purposes because of the critical nature of the
patient’s condition.
• http://www.diagnosticimaging.com/articles/radiologists-develop-point-care-ultrasoundtraining#sthash.Q0YhfcH0.dpuf
POINT-OF-CARE IMAGING
• Refers to radiological imaging performed at the patient’s bedside
• Critically ill patients cannot be moved easily to radiology
department
• Exams performed at patient’s bedside using portable equipment
• Results are obtained readily and easy to interpret
• Currently at KNH portable radiography, US at labour ward
POCUS – IT’S ROLE AND CHARACTERISTICS
• It is practised by non radiologists/sonographers
• Answers a yes or no question - Exam is focused and goal-directed
• Exam is for a well-defined purpose linked to improving patient
outcomes
• Exam findings are easily recognizable
• The exam is easily learned
• Exam is quickly performed
CHALLENGES AT KNH
ROOT CAUSE
PROBLEM
PEOPLE
Staff shortage
Inadequately skilled
Apathy in attending CPD, research
Multidisciplinary approach not much observed
Poor work ethic – lateness, documentation, training
Equipment unavailability
Equipment working condition
Lack of funds
Lack of computerised medical records
Prior exams not available for comparison
Poor documentation
No protocol in place
Procurement procedures
ENVIRONMENT
PROCESSES &
PROCEDURES
POLICIES
WAY FORWARD
• Analysis of root causes and obstacles giving rise to the
current situation needs to be undertaken and appropriate
interventions made where possible
• Multidisciplinary approach in active patient management protocol development, clinicoradiological/pathological case
discussions etc.
• Need for US education which is credible, of high quality
• Need for US practitioners to refresh, upgrade skills
• POCUS training at KNH for labour ward staff
• Procurement of equipment and training, PACS
CONCLUSION
• If the examination involves ionizing radiation (especially for expectant
mothers) then the risk vs benefit must be considered and the
examination justified
• Practice radiation safety at all times
• Point-of-care imaging will assist in answering urgent clinical questions
• A multidisciplinary approach to managing critical ill mothers and
neonates is required to optimise the clinical outcome
Thank
you!