Contrast Case

Patient Explanation and Procedure Introduction

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. All right.

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

Liver Scanning and Lesion Evaluation

All right. 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 plain as the patient is breathing.
Since the lesion can be evaluated for up to three minutes,
the breath hold would not be effective.
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.
I'm gonna have you taking a breath and hold 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 de cube 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 plain
as she is breathing.
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.
That would not be an ideal plane in which
to dose in this patient.
Now we're back longitudinal,
and this will be the plane in which we will do the,
in imaging after injection.

Contrast Agent Preparation

Hooking Up the Contrast Agent

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.
Right now the stop caulk 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.

Preparing Definity

Definity appears as a clear liquid as we can see
to activate definity.
The vial mix is used, the vial is placed into
the vial mix
and is agitated for 45 seconds.
This activates the agent upon completion
of mixing.
The agent is removed from the vial mix.
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 definitive
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 optisan.

Preparing Optison

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

Preparing Onc

Onic 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 life sized 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
re-inject 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 lumon.
As we can see here
the components to prepare.

Preparing Sonavue

OID come in a box
and it includes the saline,
the powdered agent,
and the spike to prepare Sona void.
The ampule of saline is opened
and two mls of saline are removed from the ampule.
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 prior to
We will localize the lesion.

Contrast Imaging Setup and Injection

Each manufacturer has push button technology for contrast.
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 microbubbles.
Initially, the image looks black as we see here.
We ensure that the lesion is visible
and we're ready for injection.
Before we inject, we want to make sure
that the agent is well suspended.
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.
We're gonna inject the contrast.
We want to inject about one cc a second.
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 tarting the timer on the machine.
And again, a just nice even pressure on the saline.
Beautiful.

How far out do you want me to film Dr. Byrne?
Okay.
What time do we have now?
A little bit over two.
If you want to just freeze and,
and then stay where you're at.
But then we'll take another,
turn it back on and again in a minute.
Okay. Just to get him images. Showing it. Spelling. 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 a still frame.
It just shows blood. Okay.

Routine Liver Examination Prior to Injection

We're going to do a routine examination of the liver
prior to the contrast injection,
and we will locate the lesion
and localize the lesion in both longitudinal
as well as in transverse.
In addition, once we have evaluated the entire liver,
we are going to determine which plane will be best
in order to do the injection.
Taking a breath and hold it please.
If there's more than one, go ahead and breathe.
There's more than one lesion to evaluate.
We will select the lesion that is closest to the transducer
and most easily kept in plain as the patient breathes.
As we can see in this patient, in a longitudinal plane,
as she breathes, the lesion stays in plain,
but in a transverse plane, as she breathes,
the lesion is seen in the image and then leaves the image.
In this patient, a longitudinal plane is a better plane.
In which two image
we want to evaluate blood flow with color doppler
and also with power Doppler.
Knowing that we are going to see
blood flow patterns
and evaluate for characteristic blood flow patterns
after the injection prior
to injection, we will localize the lesion ensuring that
the lesion stays in plain as the patient is breathing.
If needed, a mark can be made on the patient's skin
to ensure that the proper transducer position
can be easily found prior to injection.
If the patient needs to be placed into a decubitus position,
this can be done in this particular patient.
The Image without her being
deed is adequate, but the cubist position can be used.
Also, each vendor
has push button technology
to enter the contrast imaging package.
We prefer a side by side imaging
or dual screen imaging to allow us
to localize the lesion.
In the gray scale image, we can optimize the image
independently between the gray scale side
and the contrast side.
Notice in this image, we have a lot of signal in
the contrast side of the imaging.
We want to reduce the gain in that side,
so we don't have echoes
that represent anything other than the
actual harmonic signals.
From the contrast bubbles.
We may continue to continue to see some specular reflectors,
especially in the near field, which is acceptable.
However, now we can see that when we do the injection,
we will only recognize signal from the
actual contrast agent.

Post-Injection Evaluation and Techniques

Contrast injection started contrast injection stopped.
Saline flush started
saline flush end.
Okay, notice that we start to lose some
of the bubbles in the near field.
Potentially we're burning a few of those off.
Intermittent scanning can be used to watch
for filling of a hemangioma
or wash out of a metastasis or an HCC.
We may need to scan up to five minutes in length to ensure
that if an HCC is visualized that we see wash out
or we see fill in of a hemangioma.
In order to evaluate reperfusion, most vendors have
what is called a flash technique as well,
which uses a few frames of high MI
to temporarily burst bubbles and watch for reperfusion.
This can only be done while we
have some bubbles left.
However, because there are a limited number of bubbles,
if we decide we need a second injection,
we can turn up the power to burst bubbles.
And this is actually best done outside of the contrast mode.
We can go to a high MI
technique like color doppler.
Notice that our MI right now is at 1.3.
We can actually even make it a little higher than
that if we would like.
And we can also position the transducer over larger vessels
like the IBC or the aorta to destroy more bubbles.
This will allow for a clean wash in on
a subsequent injection.
Now if we go back to our contrast mode,
we can see fewer bubbles persisting within the liver.