Stress Echo's

STRESS BASELINE

·        Make sure correct data in CVIS as usual.

·        Select the type of stress in place of TTE (pull down box) on upper right, in CVIS.

·        Select the attending MD, in CVIS.

·        Select correct CPT codes for stress billing, in CVIS.

·        Select TTE in the bottom, right pull down box as usual.

·        Make sure stress "EKG" cable connected to system EKG port.

·        Quickly image pt to locate windows and hook patient up to EKG. Select PUH ECHO and complete a full TTE as usual. Enter all pertinent data on the CVIS TTE worksheet.

·        Notify RN that the TTE baseline is completed and check to see if a saline bubble study (as in all liver TX pts) or any other type or measurement is needed before ENDING the baseline TTE study.

·        Hit SONOGRAHPHER/DIAGNOSIS to return to previous encounter page. Select the type of stress at the bottom right pull down box to bring up the proper stress worksheet.

·        Ask pt if they have gone to the bathroom recently.  Dobutamine can exaggerate the pts urge to urinate. Also, it is unsafe for the pt to get up from the exam table until they are finished with the stress test.

·        If the stress portion is canceled after the baseline images (in the stress protocol) and contrast has been used for these images only (not the baseline TTE images), make sure there is documentation (storage) in kinetx of these stress images with contrast. It may be necessary to reacquire contrast images in the TTE protocol and merge with the first set of baseline TTE images.

PHILIPS DSE STRESS TIPS:

·        Hit PRESET. Select DSE stress or DSE CONTRAST.

·        BASE LAX will appear to right of imaging sector.

·        If using Definity contrast the BASE AP4 will appear first.

·        Adjust ROI, focus gains and depth (best for all views).
Acquire best image and continue to other views. Make sure image title (knob is below and to the far right of the touch screen display) matches the view acquiring.

·        Once optimal BASE LAX, SAX, AP4, AP2, AND APLNG IMAGES are acquired, hit ACCEPT BASE, unless an edit is necessary. The EDIT key appears next to the ACCEPT key on the touch screen and inform RN that baseline stress is completed.

·        The 5mcg stage and 10mcg stage are next. Repeat the acquisition process above.

·        Hit PAUSE PROTOCOL for the 20mcg, 30mcgand or 40mcg stages, unless one of these stages becomes the peak stage. Hit ANNOTATE and type the dosage/stage to right of image sector. These images will be acquired (and recorded) out of protocol until 85-100% unless otherwise prompted by RN. Hit PAUSE PROTOCOL again to return to present protocol and ACQUIRE the PEAK images.

·        Hit ACCEPT PEAK. Hit DISPLAY IMAGES. RECORD all stages
for 1-2 sec.

·        Hit ANNOTATE. Type RECOV (for recovery images). Hit PAUSE PROTOCOL and acquire these images at 5-6 min after peak or as
close to 100 bt/min. RN will prompt timing of this. Some pts take longer to recover if given atropine.

·        Hit END study. Place folder in stress bin or hand to MD.

Phases of Dobutamine stress echo:

Place 10 lead ecg

Do base echo

Determine us of contrast

Picture needed -  AP4, AP2, AND APLNG IMAGES BASE LAX, SAX

Start Dobutamine

Phases last 3 minutes.

Picture after 1/2 the time of each phase.

5 mics – on protocol

10 mics – on protocol

Pause protocol

20 mics

30 mics

40 mics

50 mics

At any stage Peak could be achieved un-pause protocol and take pictures

Recovery after 5-7 minutes of peak or at heart rate of 100

PHILIPS TREADMILL STRESS

 ·        Select TREAD (or TREAD CONTRAST) under PRESET on the touch screen.

·        Acquire REST LAX, REST SAX, REST AP4, REST AP2, and REST APLNG.

·        View images for optimal quality (depth, ROI, focus, gains) before ACCEPTING the stage.

·        To edit, hit the EDIT that appears next to the word ACCEPT, on the touch screen. Select the quadrant to edit loop and reacquire that Image.

·        View selected images once again before hitting ACCEPTS on the touch screen. IMPOST will appear to the right of sector for the post treadmill images.

·        RN will perform the necessary EKGs.

·        Instruct pt how to get to bed from treadmill immediately. After exercise, Make sure you have asked if they need to use the restroom.

·        Once treadmill is stopped, hit the ACQUIRE button. The tape button will automatically record. Make sure TAPE button is on as the images are quickly taken. Acquire the AP4 first if using contrast. Otherwise, record the best images first.

·        There is limited time to change the title of the view in the IMPOST. Make sure ROI; focus and gain are appropriate for all views. Focus on the imaging at IMPOST.

·        Hit END ACQUIRE on the touch screen display.

·        For additional pictures outside the protocol, hit PAUSE PROTOCOL on the upper left side of the touch screen. Hit PAUSE PROTOCOL again to return back to stress protocol. Make sure tape button is on as necessary.

·        Hit DIPLAY STAGES to view and select images. Make sure the title now matches the view. Use touch screen display to select images. A quad screen will display four images of the same view. Select the title (knob below and to the far right of touch-screen). Then, select the LOOP (on the touch screen) that corresponds to the quadrant of the best image on the monitor screen.

·        Once optimal images are selected, hit ACCEPT IMPOST on the touch screen. Again, editing is possible at this time. If more than one image is acquired for a particular view, hit EDIT, select the LOOP that corresponds to the quadrant on monitor and select sub loop using the touch screen. Dial to (sub-loop) to be deleted.

·        Once selection of images is completed, record selected images and hit END STUDY.

·        Folder is placed in stress bin.

PHILIPS BIKE STRESS TIPS:

 ·        Hit PRESET on touch screen. Select BIKE protocol. Use the TOOLS button on the upper left of the touch screen for contrast bike studies.

·        Acquire baseline images. The BASE LAX, etc. icon will be to the right of the imaging sector.

·        Make sure gains, depth; focus, and ROI are optimal.

·        Hit PAUSE PROTOCOL for images outside present protocol. This is usually done at the baseline TTE. NOTE: Ask attending MD to clarify or specify which extra images to acquire. At times this is listed on the pts script. Hit PAUSE PROTOCOL to return back to present protocol. These images may be repeated at peak.

·        Select baseline images by using the touch screen. A quad screen will display four images of the same view. Select the view title (knob below and to the far right of the touch screen). Then, select the LOOP that corresponds to the quadrant of the image on the monitor.

·        Once images are optimal, hit ACCEPT BASELINE to advance to next stage.

·        LOW LAX will appear to the right of the image sector. ANNOTATE the watts (25, 50, 75, 100, etc.) just under the LOW LAX icon (outside of the sector). Ask MD or RN for beginning watts. Watts to be changed/labeled every one and a half minutes (watch the clock) and images to be acquired until PEAK attained.

·        PEAK LAX will be obtained as indicated by MD/RN. Hit ENTER or DEFER SELECT to move along quickly to next stage. Remember that PAUSE PROTOCOL may be used here to measure additional images outside the present protocol. DO SO QUICKLY and AS DIRECTED by attending MD.

·        IMMED POST will appear once peak images obtained. ACQUIRE these immediately after peak images. Hit ENTER or DEFER SELECT.

·        Hit DISPLAY IMAGES. Carefully select the best image from what was acquired by hitting the LOOP that corresponds to the correct view title and correct stage.

·        RECORD all selected images for 1-2 sec before ending study. Folder is placed in stress bin or given to reading stress MD.

ACUSON STRESS TIPS

·        Baseline TTE must be titled by selecting stress baseline in the drop down box under STUDY/TYPE on the patient demographic page.

·        Once full TTE completed, hit BEGIN/END.

·        Retype patient demographics including the accession #.

·        Reset MI if using Definity contrast.

·        Select DSE in STUDY/TYPE drop down box.

·        Adjust ROI, focus, gains, and depth (best for all four views) to optimize image quality and display.

·        Set PROTOCOL to BASELINE by pressing the first key to the left and on the monitor box.

·        Once an image is selected, a quad screen will appear with four images of the same view. If there is an optimal image, hit REVIEW to move on to next view. If none of the images in the quad screen are optimal, hit REVIEW to return back to image screen reselect that view. All captured images will be displayed during image selection. Use the PAGE button to move through the images. One may select immediately after each view or after the stage. To select an image, highlight the best image using the track ball. A pull down box will appear in the middle of the screen. Highlight the correct title. A check mark will confirm your selection. To return back to imaging screen, hit the REVIEW button. Selecting a view once a stage is completed (i.e. Baseline stress, 5mcg. etc.) is helpful to conserve time when using Definity contrast. Review images by clicking the SELECTED/ALL image key, by clicking the far left monitor button to SELECTED.

·        It is imperative that the correct view title and stage are selected. The stages are advanced manually. BE CAREFUL not to prematurely advance to a stage until present images are optimal and assigned for the present stage. Once the images are selected for a particular stage,

·        THEN select the next stage (5mcg, etc.) title, clicking the knob on the monitor to the left. The system does not sense that an image view has been left un-captured as prompted in other systems (Philips), or prompt to accept/edit the stage. This must be done cautiously and manually with the Acuson.

·        The 20mcg, 30mcg, and 40mcg (unless the stage becomes peak) will be recorded only. Videotape all selected images for backup. Again, click the SELECTED/ALL knob to display only the selected images.

·        Images must be selected before ending the study. The system will not store any unselected images. Selected images should be recorded before ending the study. Recovery images are videotaped only, approximately 5+ min. after peak images. Stress RN can help with this timing.

·        End the study by hitting the BEGIN/END key. Images should be correctly titled on kinetx. Check info. in kinetx as usual. Place folder in stress bin or hand folder to attending.