The BLUE-Protocol, Venous Part: Deep Venous Thrombosis in the Critically Ill. Technique and Results for the Diagnosis of Acute Pulmonary Embolism
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A long chapter, but an easy, reasonable procedure, provided some clues are followed.
Vascular probes are not fully suitable for vascular assessment in the critically ill.
KeywordsDeep Venous Thrombosis Subclavian Vein Caval Vein Massive Pulmonary Embolism Popliteal Vein
The lower femoral vein. Detection, compression (V-point), and escape sign. Transversal scan at the right lower femoral vein. The femur is easily detected. Inside, tubular structures are isolated. One has marked coarse calcifi cations and should be the artery. The other is larger, ovoid more than round, and should be the femoral vein. Carmen maneuver (seconds 3–8) has correctly showed these were tubes – defi nitely the vascular pair, what else? The simple observation shows that the supposed vein has a marked echogenicity and is irregular and motionless: the thrombosis is quite certain. On compression (see at the bottom of the image the print of the Doppler hand through the posterior skin (seconds 25–34)), all soft tissues shrink. From skin to vein, they shrink from 4 to 2.5 cm. During this compression, the vein “escapes” a travel of 5 mm, while its cross-section remains 7–8 mm. Positive escape sign. This is, defi nitely, an occlusive deep venous lower femoral thrombosis (MOV 2736 kb)
Calf analysis. How it is done practically, what the operator can see on the screen, and how the vessels appear without and then under compression. 0”: the product is applied. 3”–6”: the probe is applied, then Carmen maneuver, and then stabilized. 7”: vision of the landmarks, two bones, one interosseous membrane, the tibial posterior muscle vessels. 12”: the eye of the operator does not leave the screen. 16”: the Doppler hand comes, and both thumbs join. 20”: the Doppler hand is at correct height. 28” and 35”: two compressions. 41”–46”: fi rst compression with full venous collapse. 52”–58”: second compression. For experts, the anterior tibial group is visible, much smaller, just anterior to the membrane and touching it. Note that the vessels are standstill spontaneously, but the compression, which collapses the veins, makes the artery systolic (roughly 110 bpm): functional artery (MOV 2736 kb)
- 5.Bernardi E, Camporese G, Bueller H, Siragusa S, Imberti D, Berchio A et al (2008) Serial two-point ultrasonography plus D-dimer vs whole-leg color-coded Doppler ultrasonography for diagnosing suspected symptomatic deep vein thrombosis. A randomized controlled trial. JAMA 300(14):1653–1659CrossRefPubMedGoogle Scholar
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