Contrast Case - V3

Patient Explanation

Your doctor has ordered an ultrasound with contrast of your liver today.

That means that we are going to be taking some pictures of your liver and then giving you an injection that has tiny microspheres of air that will circulate through your bloodstream and give us better pictures.

It's gonna look at the blood flow in your liver.

You will not feel flushed, you will not feel warm, and you don't have any special precautions when you're done.

Do you understand that? Yeah. Okay.

Starting the Procedure

Alright, let's get started. I'm gonna have you lie back on your back please.

Liver Scanning and Evaluation

So we are scanning the liver and evaluating the liver tissue.

We normally do a thorough evaluation of the liver and then localize the lesion.

It is important when we localize the lesion to be certain that the lesion stays in plane as the patient is breathing.

Since the lesion can be evaluated for up to three minutes, the breath hold would not be effective.

So here we can see the lesion and we will typically measure the lesion as well as evaluate the lesion in color Doppler and power Doppler.

We can see the lesion in transverse as well.

This is done as part of a routine abdominal examination.

Have you taken a breath and hold it, please. It please.

And even though this is showing limited evaluation of the liver, a complete evaluation of the liver is performed as part of a contrast study.

In this patient. We can see that the lesion is well visualized with her in a supine position.

If we needed to, we could decub her, but that is not necessary in this case.

It is perfectly acceptable to take a sharpie marker and make a mark where the lesion is to come back and find it later if need be.

Notice that in longitudinal the lesion is staying in plane as she is breathing.

So that will be beneficial throughout the injection.

If we look in a transverse plane, as the patient breathes, the lesion goes in and out of our image.

So that would not be an ideal plane in which to dose in this patient.

So now we're back longitudinal.

And this will be the plane in which we will do the imaging after injection.

Contrast Agent Hookup

So when you're hooking up the contrast agent, you want to put the saline perpendicular to the flow and you want to put the contrast agent in a straight line so that there's less pressure on the contrast agent when it goes in.

So right now the stopcock is on the off position here.

When we inject the contrast, we'll move it to this position so that the contrast goes in and we'll close off the contrast and use the flush to flush the agent in prior to activation.

Definity Preparation

Definity appears as a clear liquid as we can see to activate Definity.

The Vialmix is used, the vial is placed into the Vialmix and is agitated for 45 seconds.

This activates the agent upon completion of mixing.

The agent is removed from the Vialmix.

Notice now that the agent is a milky white color and that means the agent has been activated.

When we draw up the agent, we will use nothing smaller than a 20 gauge needle to avoid pressure.

We also will vent the Definity to avoid any pressure.

Upon withdrawing the agent, an appropriate amount of agent is then withdrawn.

Any additional air can be removed.

Notice that prior to activation, the vial contains a clear liquid to prepare Optison.

Optison Preparation

The vial is removed from the box and then rolled in the hands, and this will activate the agent.

At the completion of rolling, the agent will be milky white in color.

As we see here, the agent is then drawn into the syringe.

Optison does contain human albumin, so patients who have an objection to obtaining or receiving human blood products should be informed of this presence.

Lumason Preparation

Lumason comes in a self-contained kit and the necessary pieces for preparation of the agent are contained within the kit.

The actual agent is within this vial.

Notice it is a lyophilized powder.

There is also a spike and a vial of saline.

The plunger is unattached and can be screwed into the vial.

The lid is removed from the vial and the spike has a protective covering that is removed as well.

The spike is then placed into the vial.

The saline has a cap that is broken off and it does require a little force that can later be used to cap the agent.

If you desire, the syringe is screwed into the vial and the saline is placed into the vial as well.

At this point, to activate the agent, the agent is shaken for 20 to 30 seconds.

After shaking the vial, be sure there is no white powder left in the bottom.

If there is white powder, continue to shake and completely suspend the agent.

If the agent separates upon standing, the agent can then be resuspended by shaking again.

The contrast is drawn into the syringe that is already attached.

Taking care not to reinject the contrast into the vial because this will add pressure to the vial and could burst microbubbles.

This syringe now can be used for injection.

The labeling of the vial right now says saline.

This label, however, is removable and will then be properly labeled as Lumason.

Sonavue Preparation

As we can see here, the components to prepare Sonavue come in a box and it includes the saline, the powdered agent, and the spike to prepare Sonavue.

The ampule of saline is opened and two mls of saline are removed from the ampule.

Okay, The ampule is then opened and the spike is placed into the vial of contrast.

The spike has a portion on which the syringe can be attached.

The saline is then introduced into the vial and the vial is shaken for one minute.

With the syringe still attached, the contrast agent can now be withdrawn.

Notice it is a milky white in color indicating that the agent has been activated new injection.

Injection and Imaging

We will localize the lesion.

Each manufacturer has push button technology for contrast.

So when we activate the contrast package, the reconstructed B mode image will serve as a point of reference.

The detail in the B mode image is not as great as it is when we're not in the contrast package, but allows us to be certain that we're in the same area and in the proper area.

When we inject, we optimize the contrast side to listen only for the harmonic signals from the micro bubbles.

So initially the image looks black as we see here.

Okay. We ensure that the lesion is visible and we're ready for injection.

So before we inject, we want to make sure that the agent is well suspended.

So you may want to take it off and shake it a couple times just to resuspend the bubbles.

Then we're going to turn the syringe.

So we're gonna inject the contrast.

We want to inject about one cc a second.

So we're injecting the contrast.

And as we're done, we're gonna turn this, we're going to start the saline.

And at the start of the saline we're starting the timer on the machine.

And again, a just nice even pressure on the saline.

How far out do you want me to film Dr. Byrne?

Okay.

What time we have now? Little bit over two.

If you want, just freeze and then stay where you're at.

But then we'll take another, turn it back on again in a minute.

Okay. Just to get him images showing its phase. Okay.

And then I think what we can do is we can pull out stills at 30 seconds.

One minute, one and a half minutes, two minutes, two and a half minutes.

And have us still frame that just.