1. International Veterinary Ultrasound Society (IVUSS)
Suggested Imaging Protocol for Standard Abdominal Ultrasound Exam Consensus Statement, December 2019
A combination of still images (25-40) +/- video clips (3+) may be made to include the organs below. Measurements should be included as still images. The images/clips should have patient identification (name +/- patient number), date of the examination and facility name embedded. Each image/clip should be labeled to identify the organ being examined (eg. left kidney, left kid or LK). Where applicable, it should be labeled whether the organ is in sagittal (eg. sag) or transverse (eg. trv).
Images may be archived in jpeg ( with appropriate measurements included), DICOM, or manufacturer’s native format. Jpeg format with measurements is preferred for referring cases to another hospital.
The sonographer should scan each organ in its entirety in sagittal and transverse planes, even though only certain sections will be captured as still images or cine loops. In addition, the entire abdominal cavity should be scanned in a transverse “mowing the lawn” pattern to ensure no masses or pathology not associated with any particular organ are present. Abnormalities should be measured and imaged in at least two planes.
Deviations from the recommended images listed below are allowed due to anatomic variations or abnormalities.
Organs to be scanned with number of images captured:
Liver/gb—3+, including at least 1 intercostal image, sagittal and transverse images, and portal hilus
Common Bile duct (cystic, proximal and distal if seen) Duodenal Papilla (if seen)
Hepatic LN’s (if seen)
Measure: Gall Bladder Wall thickness if thickened
Common Bile Duct diameter if dilated Bile Duct Wall thickness if thickened Hepatic LN thickness
PV/CVC/Ao diameter if warranted
R Kidney—2 , including one transverse at the level of the renal pelvis Measure: Kidney sagittal length at level of the renal pelvis
Renal Pelvis if dilated in transverse, not to include proximal ureter Ureter diameter, if dilated
R Adrenal—1
Measure: Caudal pole thickness, +/- cranial pole thickness
Duodenum—1
Measure: Wall thickness serosa to luminal side of mucosa
Pancreas—1-3, left and right limb, body Measure: Thickness of left and right limb
Pancreatic duct if it appears dilated
Stomach—2-3, body/fundus, pylorus, pyloro-duodenal outflow (PDJ) if seen Measure: Wall thickness at inter-rugal fold
Spleen—2-4, at least one of which shows venous colorflow
Measure in cats: Thickness in sagittal at level of the splenic hilus
L Kidney—2, including one transverse at the level of the renal pelvis Measure: Kidney saggital length at level of the renal pelvis
Renal Pelvis if dilated in transverse, not to include proximal ureter Ureter diameter, if dilated
L Adrenal—1
Measure: Caudal pole thickness, +/- cranial pole thickness
Colon – 1-3, ascending/ICC junction, transverse, descending Measure: Wall thickness serosa to luminal side of mucosa
Right Colic Nodes—1 Measure if abnormal
Jejunum—3+
Measure: Wall thickness serosa to luminal side of mucosa
Jejunal nodes–1
Measure: Thickness/diameter capsule to capsule
Medial and internal ilac nodes/caudal vena cava/aorta at level of trifurcation—1+ Measure: LN thickness capsule to capsule
Urinary Bladder—2, including trigone, and including one transverse Measure: Wall thickness if thickened
Urethra—1, may be included with prostate
Prostate—2,
Measure: length, width, and height if abnormal
Uterus—1-3, including body and each horn Ovaries—2
Testicles—2
The ultrasonographer should be adaptive to the case in front of them, and the following should be imaged if warranted:
Penis—proximal and distal to the os penis Sternal lymph node
Pericardial sac
Right or left atrium and auricle
Lung—1-2 views to demonstrate if peripheral pulmonary nodules or pleural effusion are present
Heart—1 view to determine if pericardial effusion is present, subjectively assess left atrial size, LV contractility, and cardiac volume. Full cardiac assessment, including echocardiogram, should be recommended if cardiac abnormalities are suspected.
2. Useful Guidelines relevant to Medical Point of Care Clinicians for Consideration by Veterinary Clinicians and Ultrasound Practitioners
Ultrasound Clinical Governance – Prepared by The National Ultrasound Steering Group 2008
Introduction
Ultrasound (US) is used widely as a diagnostic test and for guidance of many interventional procedures. The wide application of US is reflected in the number of different professional groups who now undertake US examinations and the increasing number of environments in which ultrasound equipment is deployed.
US equipment is relatively cheap and the technique involves no ionising radiation nor significant patient or practitioner risk. Proper use of US has the potential to improve the quality of care in a safe and cost effective manner across a broad range of specialties.
The rapid proliferation of US equipment and the increasing numbers of individuals using US present a number of challenges to ensure that equipment purchase and deployment is sensibly managed, that the introduction of new services is evidence based and that training and assessment of individuals in the use of US conforms to national standards as defined by the relevant College where available and where not available in accordance with the RCR document ‘Ultrasound Training Recommendations for Medical and Surgical Specialties’ (2005).
The uncontrolled expansion of the use of US represents a significant clinical risk if
• examinations are undertaken by untrained or poorly trained individuals
• equipment is poorly specified or poorly maintained
• it is undertaken in the absence of clinical audit of performance.
Furthermore, if equipment purchase and deployment is not based on a thorough assessment of cost effectiveness and/or service improvement, the cost to the NHS can be significant without commensurate gain.
The National Ultrasound Steering Group (NUSG) a subgroup of the National Imaging Board recommends the establishment of a Clinical Governance Board for all providers of US imaging services. The responsibility for clinical governance should lie within each clinical directorate using US. Where this is already established, in some acute trusts, it has served as a template for the governance of procurement and training in other clinical disciplines.
The structure and remit of such a Board would necessarily be decided locally. The NUSG suggest the following terms of reference as guidance and recommend the self compliance tool, described below as a useful aide memoire to guide such a Board’s activities.
The Board would oversee the procurement, maintenance and replacement of equipment, the establishment and maintenance of service standards and the processes of training, supervision and audit, thus assuring the achievement and maintenance of high levels of competence, performance and patient safety
Outline Governance Board Membership
It is suggested that the board consists of:-
- Lead US Radiologist
- Superintendent Sonographer
- A clinical lead for each department using US for diagnosis that will represent their specialty on the Board. For example
- Obstetrics and Gynaecology
- Vascular imaging
- Cardiac imaging
- Anaesthetics
- Child health
- Emergency department
- Medical Physics Representative
- Clinical Risk Manager
- Service Improvement Manager
- Procurement Manager
- Director of Clinical Governance
- Finance Director or Senior Finance Manager
Recommendations
1. Recording of data
- There should be a permanent electronic record of all imaging studies.
- All imaging studies should be accompanied by an electronic report available with the images.
- The electronic images and the report should be available to all those with a bona fide requirement for image review.
- Where US is being used to guide a procedure (biopsy/injection/venous access etc) image storage may not be necessary. This should be determined by the Clinical Governance board of the Trust.
2. The Trust should develop criteria for evaluation of bids for US equipment based on
- clinical need
- estimated intensity of use
- need for equipment availability in an emergency
- the availability of skilled operators within the proposed clinical area
- availability of existing similar equipment which could be shared
- cost of maintenance
- an equipment replacement programme.
3. Where a bid proposal is to replace an existing service this should be identified and the clinical advantages made explicit. The Trust will need to consider whether the service improvement is justified and whether cost savings can be made by the transfer of the service.
4. The Trust should develop a robust policy to provide prompt and accurate US services for/within the whole health care economy.
5. The practice of US is a clinical skill that must be governed by professional standards equivalent to those issued by the GMC who recommend that doctors ‘recognise and work within the limits of your competence.’
6. All practitioners should ensure that their frequency of practice affords the maintenance of skill levels. This should reflect relevant College advice.
The NUSG recommends the adoption of the following self-compliance tool as a method of ensuring high quality standards for the procurement, use and maintenance of US equipment.
Self-Compliance Tool
Equipment
1. identify and list all US equipment in use in each department throughout the hospital
2. identify what each machine is used for.
3. identify how many sessions per week the equipment is used.
4. provide data on the numbers of examinations performed per machine per session.
5. provide the schedule of QA and electrical safety testing for each machine.
6. provide details of the maintenance contract for each machine.
7. provide details of the PACS connectivity of the equipment.
8. provide details of plans to achieve PACS connectivity where this is not already achieved. 9. provide details of measures for infection control
US users
1. each Trust should hold a register of US practitioners.
2. each department should identify all users of US equipment and their professional grade, their qualifications in relation to US and the conferring body.
3. where there are no formal qualifications, describe the nature of training and the processes of assessment of competence
4. describe the mechanisms whereby patients are given information about the examination. These should include, where available, patient information sheets.
5. where US is delegated to a non-medical member of staff, describe the governance arrangements of the process of delegation.
6. where the US is performed by a doctor (or sonographer) in training describe the arrangements for professional supervision.
7. describe the arrangements for obtaining informed consent from the patient
8. where the US examination is performed by a trainee describe the process of informing the patient and eliciting consent
9. what arrangements are in place for CPD in US.
10. what arrangements are in place for regular audit of US practice for each user.
11. what is the frequency of US practice and does it comply with national recommendations (at least one session per week).
12. describe the arrangements for ensuring that all staff are aware of US bio-effects and strategies to minimise these.
Documentation and communication of results
1. describe how records of imaging studies are currently stored and the availability of images for subsequent review for purposes of clinical management and audit.
2. describe security arrangements for access to images and other patient data.
3. describe how the results of imaging studies are recorded and communicated
- within the notes
- within a departmental computer database
- within the RIS
- within another data storage system available to all other bona fide practitioners.
4. describe how and when the results of imaging studies are communicated to the patient. 5. describe the mechanisms for booking patients and outline the minimum standards for booking and report turnaround times (RTT’s)
6. for any instances where it becomes known that a scan has taken place and not been documented a clinical risk form should be completed and acted upon by the clinical risk department.
3. Further Useful Reading
Royal College of Veterinary Surgeons, Practice Standards Scheme, May 2021
IMV Ben Sullivan Abdominal Ultrasound Training Videos
Diagnostic Ultrasound, Physics and Instrumentation, Peter Hoskins, Kevin Martin and Abigail Thrush, Cambridge University Press
Ultrasound Physics and Technology, How, Why and When, Gibbs, Cole and Sassano, Churchill Livingstone
Ultrasound and Instrumentation, Hedrick, Hykes and Starchman, Evolve. Elsevier. Com
Essentials of Ultrasound Physics, James Zagbebski, Mosby
Diagnostic Medical Ultrasound, Peter Fish, (Wiley and Sons publications)
J, Earnshaw, (2010) Ultrasound imaging in the National Health Service Abdominal Aortic Aneurysm Screening Programme, BMUS, London
RCEM July 2014 2014 Draft v5 PoCUS Governance Statement
Guidance on maintaining patient confidentiality when using radiology department information systems in November 2019.
Standards for interpretation and reporting of imaging investigations, BFCR (18)1, Second edition 2018
Lisciandro GR. Abdominal and thoracic focused assessment with sonography for trauma, triage, and monitoring in small animals. J Vet Emerg Crit Care 2011;21(2):104-122. doi:10.1111/j.1476-4431.2011.00626.x.
Boysen SR, Lisciandro GR. The use of ultrasound for dogs and cats in the emergency room. Vet Clin N Am Small Anim Pract 2013;43(4):773-797. doi:10.1016/j.cvsm.2013.03.011.
Boysen SR, Rozanski EA, Tidwell AS, et al. Evaluation of a focused assessment with sonography for trauma protocol to detect free abdominal fluid in dogs involved in motor vehicle accidents. JAVMA 2004;225(8):1198-1204. doi:10.2460/javma.2004.225.1198.
Lisciandro GR, Lagutchik MS, Mann KA, et al. Evaluation of a thoracic focused assessment with sonography for trauma (TFAST) protocol to detect pneumothorax and concurrent thoracic injury in 145 traumatized dogs. J Vet Emerg Crit Care 2008;18(3):258-269. doi:10.1111/j.1476-4431.2008.00312.x.
McMurray J, Boysen S, Chalhoub S. Focused assessment with sonography in nontraumatized dogs and cats in the emergency and critical care setting. J Vet Emerg Crit Care 2016;26(1):64-73. doi:10.1111/vec.12376.
Mattoon JS, Nyland TG. Ultrasound-guided aspiration and biopsy procedures. In: Small Animal Diagnostic Ultrasound. Elsevier Health Sciences; 2014; 50-77.
Ianniello S, Di Giacomo V, Sessa B, Miele V. First-line sonographic diagnosis of pneumothorax in major trauma: accuracy of e-FAST and comparison with multidetector computed tomography. Radiol Med 2014;119(9):674-680. doi:10.1007/s11547-014-0384-1.
Choi J, Kim A, Keh S, et al. Comparison between ultrasonographic and clinical findings in 43 dogs with gallbladder mucoceles. Vet Radiol Ultrasound 2013;55(2):202-207. doi:10.1111/vru.12120.
Rishniw M, Erb HN. Evaluation of four 2-dimensional echocardiographic methods of assessing left atrial size in dogs. J Vet Intern Med 2000;14(4):429-435. doi:10.1111/j.1939-1676.2000.tb02252.x.
Abbott JA, MacLean HA. Two-dimensional echocardiographic assessment of the feline left atrium. J Vet Intern Med 2006;20(1):111-119.
Boon JA. Veterinary Echocardiography. 2nd ed. Ames, IA: Wiley Blackwell; 2011.
Today’s Veterinary Practice. Sonography Assessment: Overview of AFAST and TFAST
Focussed Ultrasound Techniques for the Small Animal Practitioner, Lisciandro (Wiley Blackwell)
Ultrasound in Anaesthesia, Critical Care and Pain Management Arthurs and Nicholls (Cambridge)
If you have any questions after you go, please don’t hesitate to send an email to [hello@aspireucs.com]