[CEUS-diagnosis of benign liver lesions]. / CEUS ­ Diagnostik benigner Leberläsionen.

CLINICAL/METHODICAL ISSUE: Focal liver lesions are commonly seen during routine ultrasound examinations. STANDARD RADIOLOGICAL METHODS: With native ultrasound there are lesions that cannot be sufficiently characterized. In these cases additional imaging might be necessary. METHODICAL INNOVATIONS: With contrast-enhanced ultrasound (CEUS), focal liver lesions can be characterized with high diagnostic accuracy. After the ultrasound contrast agent has been injected into a peripheral vein, the examiner saves video loops of the arterial, portal venous and late contrast phases. Combing the findings of native and contrast-enhanced ultrasound allows not only assessment of the etiology as benign or malignant but also detailed characterization of the focal liver lesion in most cases. PERFORMANCE: Using CEUS, focal liver lesions can be characterized with a sensitivity of over 95% and a specificity of about 83%. ACHIEVEMENTS: The advantages of CEUS include that there is no radiation exposure and that the ultrasound contrast agent has no effects on the function of the liver, kidneys or the thyroid gland. The main limiting factors for CEUS are bowel gas and obesity of the patient. PRACTICAL RECOMMENDATIONS: CEUS can visualize micro- and macrovascularization of benign focal liver lesions in real time. It is a useful imaging modality in unclear cases.

[CEUS-Diagnostic of malignant liver lesions]. / CEUS ­ Diagnostik maligner Leberläsionen.

CLINICAL/METHODICAL ISSUE: Cross-sectional modalities or conventional ultrasound are not always able to sufficiently identify and characterize malignant liver lesions. STANDARD RADIOLOGICAL METHODS: The evaluation of malignant liver lesions in conventional ultrasound relies on echostructure, shape and borders, but often warrants additional contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI) studies. METHODICAL INNOVATIONS: Contrast-enhanced ultrasound (CEUS) is a relatively safe imaging technique used for the detection and characterization of malignant liver lesions. The use of a second-generation contrast agent in dynamic real-time imaging allows the visualization of vascularization in any kind of liver lesion as well as liver perfusion during the arterial, portal venous and late phase. PERFORMANCE: Due to the different enhancement patterns, it is possible to differentiate a liver lesion with high diagnostic accuracy (over 90%). ACHIEVEMENTS: CEUS is a helpful complementary technique to cross-sectional imaging for the evaluation of unclear liver lesions and may frequently obviate additional contrast-enhanced MRI or CT studies. PRACTICAL RECOMMENDATIONS: CEUS enables the detection and characterization of liver lesions in real time.

[Reliable diagnosis of cystic renal lesions]. / Sichere Diagnostik zystischer Nierenläsionen.

CLINICAL/METHODICAL ISSUE: Cystic renal lesions are commonly seen during routine ultrasound examinations of the abdomen. STANDARD RADIOLOGICAL METHODS: Some cystic renal lesions cannot be sufficiently characterized using native ultrasound. In these cases additional imaging might be necessary. METHODICAL INNOVATIONS: Contrast-enhanced ultrasound (CEUS) is a reliable imaging modality to characterize cystic renal lesions. Contrast enhancement of septations and the cystic wall are visualized in high resolution. This information helps to categorize the cystic renal lesions applying the CEUS Bosniak classification. This classification helps to estimate the probability of a malignant etiology of cystic renal lesions. PERFORMANCE: Using CEUS, cystic renal lesions can be characterized with a high sensitivity and specificity. ACHIEVEMENTS: The advantages of CEUS include that there is no effect on the function of the kidneys or the thyroid gland and no radiation exposure. In some cases, additional cross-sectional imaging is necessary to optimize diagnostic accuracy. PRACTICAL RECOMMENDATIONS: CEUS is a helpful imaging modality to characterize cystic renal lesions, to avoid unnecessary follow-ups and to detect malignant cystic renal lesions.

[Contrast-enhanced ultrasound (CEUS) of the liver : Critical evaluation of use in clinical routine diagnostics]. / Kontrastverstärkter Ultraschall (CEUS) der Leber : Kritische Bewertung des Einsatzes in der Routinediagnostik.

CLINICAL/METHODICAL ISSUE: Focal liver lesions are common incidental findings in abdominal ultrasound diagnostics. STANDARD RADIOLOGICAL METHODS: Characterization of focal liver lesions solely based on b­mode and color duplex is not feasible in all cases. METHODICAL INNOVATIONS: Using contrast-enhanced ultrasound (CEUS) it is possible to dynamically visualize the vascularization of focal liver lesions, which enables the characterization of benign and malignant liver tumors. The advantages of CEUS are that ultrasound contrast media do not show renal, hepatic or cardiac toxicity and do not influence the thyroid gland. The approach by fusion of CEUS and contrast-enhanced cross-sectional imaging combines the advantages of both imaging modalities. PERFORMANCE: Using CEUS focal liver lesions can be characterized with a diagnostic accuracy greater than 90%. ACHIEVEMENTS: The use of CEUS has become an important imaging modality to evaluate unclear liver lesions. PRACTICAL RECOMMENDATIONS: The use of CEUS provides vital information as a supplement to cross-sectional imaging and it has become an important tool in therapy planning, control and monitoring of malignant liver lesions.

[Sonoelastography in daily clinical routine]. / Ultraschallelastographie in der klinischen Routinediagnostik.

CLINICAL ISSUE: In the daily clinical routine characterization of focal lesions using native B­mode classical ultrasound and color Doppler can be difficult or insufficient; therefore, additional diagnostic information must be taken into consideration. STANDARD RADIOLOGICAL METHODS: Standard radiological methods in the daily clinical routine include native B­mode ultrasound and color Doppler ultrasound. METHODICAL INNOVATIONS: Using sonoelastography it is possible to evaluate and characterize tissue properties and focal lesions regarding their stiffness to acquire additional information on a noninvasive basis. PERFORMANCE: Sonoelastography enables the differentiation between benign and malignant lesions especially in organs that can be easily evaluated using ultrasound. This particularly includes the liver, the thyroid gland, the breasts and the testicles. Regarding the liver, sonoelastography techniques can also be used for evaluation of the tissue flexibility in the diagnostics of fibrosis and cirrhosis. ACHIEVEMENTS: Nowadays, elastography is implemented into every modern ultrasound system and has been established as a supplementary examination technique to the conventional ultrasound techniques. PRACTICAL RECOMMENDATIONS: Sonoelastography should be used in cases with unclear findings as an additional noninvasive tool for the differentiation between benign and malignant lesions.

[Pregnant women with COVID-19 ARDS on the intensive care unit]. / Die Schwangere mit COVID-19-ARDS auf der Intensivstation.

BACKGROUND: Pregnant women with coronavirus disease 2019 (COVID-19) are at increased risk of severe disease progression. Comorbidities, such as chronic arterial hypertension, diabetes mellitus, advanced maternal age and high body mass index, may predispose to severe disease. The management of pregnant COVID-19 patients on the intensive care unit (ICU) is challenging and requires careful consideration of maternal, fetal and ethical issues. OBJECTIVE: Description and discussion of intensive care treatment strategies and perinatal anesthesiological management in patients with COVID-19 acute respiratory distress syndrome (CARDS). MATERIAL AND METHODS: We analyzed the demographic data, maternal medical history, clinical intensive care management, complications, indications and management of extracorporeal membrane oxygenation (ECMO) and infant survival of all pregnant patients treated for severe CARDS in the anesthesiological ICU of a German university hospital between March and November 2021. RESULTS: The cohort included 9 patients with a mean age of 30.3 years (range 26-40 years). The gestational age ranged from 21 + 3 weeks to 37 + 2 weeks. None of the patients had been vaccinated against SARS-CoV­2. Of the nine patients seven were immigrants and communication was hampered by inadequate Central European language skills. Of the patients five had a PaO2/FiO2 index < 150 mm Hg despite escalated invasive ventilation (FiO2 > 0.9 and a positive end-expiratory pressure [PEEP] of 14 mbar) and were therefore treated with repeated prolonged prone positioning maneuvers (5-14 prone positions for 16 h each, a total of 47 prone positioning treatments) and 2 required treatment with inhaled nitric oxide and venovenous ECMO. The most common complications were bacterial superinfection of the lungs, urinary tract infection and delirium. All the women and five neonates survived. All newborns were delivered by cesarean section, two patients were discharged home with an intact pregnancy and two intrauterine fetal deaths were observed. None of the newborns tested positive for SARS-CoV­2 at birth. CONCLUSION: High survival rates are possible in pregnant patients with CARDS. The peripartum management of pregnant women with CARDS requires close interdisciplinary collaboration and should prioritize maternal survival in early pregnancy. In our experience, prolonged prone positioning, an essential evidence-based cornerstone in the treatment of ARDS, can also be safely used in advanced stages of pregnancy. Inhaled nitric oxide (iNO) and ECMO should be considered as life-saving treatment options for carefully selected patients. For cesarean section, neuraxial anesthesia can be safely performed in patients with mild CARDS if well planned but the therapeutic anticoagulation recommended for COVID-19 may increase the risk of bleeding complications, making general anesthesia a more viable alternative, especially in severe disease.