Sound Decisions.

A case study exploring the use of the Butterfly iQ+ in nursing care.
A Case Study by
Original Research by
Harriet Howgill RN
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and
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“Hand-held ultrasound impacts decisions I make regarding secondary care admission and patient discharge orders.“

Introduction

Time pressure is a widely recognized and encountered phenomenon among nurses worldwide. Tools that support quick, accessible fact-finding at the bedside are one possible mechanism to better support nurses by providing relevant information at speed to support clinical decision-making. More information can help narrow differential diagnoses, can expedite patient triage, and may ultimately help avoid circumstances in which nurses are challenged to provide quality care in a time-intensive under-resourced environment. 

Case History  

A middle-aged male with metastatic cancer presented to the Acute Medical Unit (AMU). He had recently developed spinal cord compression that palliative therapy failed to improve.  Blood work demonstrated severe acute renal impairment.

The patient had a long-term urinary catheter in-situ and no recent history of urine output. A bladder scan was performed immediately. With the Butterfly iQ+, I was able to perform an investigation to confirm my clinical suspicion of obstructive renal failure from a blocked catheter right away.

His bladder was scanned using the Auto Bladder Calculation feature of the Butterfly iQ+. His bladder was identified as a round anechoic area, was positioned centrally within the window, and the volume was auto-calculated.

The ultrasound revealed a distended bladder, with a volume of 422mls (Figs 1. and 2.) with echogenic mobile debris.

This directly and quickly informed my decision to flush the patient’s catheter. Subsequent aspiration removed a large quantity of blood-stained debris from the bladder, which allowed straw-coloured urine to flow freely. 400+ mls was drained.

Imaging Exam

Left: Cine acquisition of bladder volume. Right: 3D render of distended bladder.

What Does This Teach Us?

With handheld ultrasound, instead of sending the patient for departmental imaging to establish the diagnosis, I was able to detect urinary retention due to a blocked catheter immediately at the patient’s bedside. This straightforward bedside intervention allowed the patient to avoid transport to the Radiology Department,  accelerated treatment based on an informed result and subsequently to be be discharged more quickly.

Image 1. Normal Side. Pediatric Lung setting, demonstrates clear pleural line with sliding and z lines (aka comet tails). No indication of B lines; normal appearing lung

Image 2. Abnormal side. Additional air bronchograms further identifying the consolidated lung region. With respiration consolidated lung is partially obscured by B lines. Consolidated lung with dynamic air bronchograms

Image 3. Abnormal Side. On left of image: few B lines indicating presence of fluid in lung, irregularly appearing pleural line with sub pleural consolidation (~ 2 cm in depth). Consolidated lung area looks like liver hence the term, lung hepatization. Echogenic dots are air bronchograms; these collections move with respiration therefore they are called dynamic air bronchograms. (Note: dynamic air bronchograms = pneumonia; static air bronchogram - no movement with respiration = atelectasis)

Harriet Howgill RN

Trainee ANP in Acute Medicine, currently seconded to Critical Care Outreach Service. Special interests in resuscitation, vessel health and POCUS.