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  • Haemodynamic assessment of the critically ill in the ICU using echo

    Kalliopi Keramida, MD, MSc, PhDHammersmith hospital, London, UK

    11-13 2016

  • Hemodynamic assessment in the ICU

    Invasively

    Pulmonary artery catheters

    Central venous catheters

    Central arterial catheters

    Non-Invasively

  • HISTORICAL ASPECTS

    Warner Forssman in 1929, when he threaded a catheter into his own heart, for which he shared the 1956 Nobel Prize along with Drs. Richards and Cournand.

    Bed-side use was facilitated by the addition of a flow directed balloon to the catheter by Dr. Swan, and a thermistor tip by Dr. Ganz which enabled measurement of cardiac output in 1967.

  • HISTORICAL ASPECTS

    Lack of benefit and potential harm associated with the routine use of RHC.1-6

    Superiority of bedside echocardiography over RHC.7-9

    Central venous catheters and pulmonary artery catheters (PAC) have not been found to improve survival or decrease the length of stay.10

    PAC can be inaccurate in estimating LV filling pressures 4,10 or diastolic dysfunction which is more predictive of mortality in hospitalized patients.11-15.

    1. Connors AF et al 1996 JAMA 276:889897. 10. Shah MR et al. JAMA 2005;294:1664-70.2. Richard C et al. 2003 JAMA 290:27132720. 11. Zile MR et al. Circulation 2002;105:1387-93 3. 3. 3. 3.Rhodes A et al. 2002 Intensive Care Med 28:256264. 12. Hammil BG et al. Anesthesiology 2008;108:559-67.4. Sandham JD et al. 2003 N Engl J Med 348:514 . 13. Redfield MM et al. JAMA 2003;289:194-202.5. Harvey S et al. 2005 Lancet 366:472477 . 14. Swaminathan M et al. Ann Thorac Surg 2011;91:1844-51.6. Binanay C et al. 2005 JAMA 294:16251633. 15. Groban L et al. Echocardiography 2010;27:131-8..7. Ozier Y et al. 1984 Crit Care Med 12:596599.8. Jardin F et al. 1985 Crit Care Med 13:952956.9. Jardin F et al. 1990 Crit Care Med18:10551060.

  • ADVANTAGES OF ECHO VS OTHER TECHNIQUES FOR HAEMODYNAMIC ASSESSMENT IN ICU

    Non-invasive Safety profile Portability Low cost Ease of use Speed Precise definition of diagnosis and clarification of

    pathophysiologic mechanisms Conduction of a direct anatomic evaluation of the heart in

    real time Adjunct to the physical examination

  • Focused cardiac ultrasound (FCU)

    - Point of care cardiac us

    - Bedside cardiac us

    - Quick look cardiac us

    - Hand held cardiac usSpencer KT et al. JASE 2013;26:567-81.

  • RACE (Rapid Assessment by Cardiac Echo)1

    FATE (Focused Assessed TTE)2

    BEAT (Beat - Effusion - Area - Tank)3

    FOCUS (Focus Cardiac UltraSound)4

    1 Khasawneh FA et al. Postgrad Med. 2010 May;122(3):230-7.2 Jensen M et al. Eur J Anaesthesiol 2004; 21 (9): 700-7.3 Gunst M et al. J Am Coll Surg 2008; 207 (3): e1-3.4 Labovitz A et al. J Am Soc Echocardiogr 2010;23:1225-30.

  • Echocardiography can be widely used

    14 ICU staff specialists with no previous TEE experience received 6 hour of training as mTEE operators. Echocardiographic examinations using mTEE after brief bed-side training were feasible and of sufficient quality in a majority of examined ICU patients with good inter-rater reliability between mTEE operators and an expert cardiologist.

    Cioccari et al. Critical Care 2013, 17:R121 In one study, ICU residents were given a short 8 hours course limited to

    interpretation of LV size and function, RV dilation, pericardial effusion, and pleural effusion. The residents were then able to evaluate 93% of 366 clinical questions with close agreement with the interpretation of expert operators.

    Vignon, P. et al. Intensive Care Medicine, 33, 1795- 1799. In a similar study, intensivists were given a 10 hour course in echo after which they

    performed hand-held bedside examinations. Their interpretations correlated well with those of experienced echocardiographers in 84% of the examinations and led to treatment adjustments in 37% of the subjects .

    Manasia, A.R. et al. Journal of Cardio-thoracic and Vascular Anesthesia, 19, 155-159.

    Several studies have demonstrated that after a brief educational intervention non-cardiologists are able to perform limited transthoracic examinations and correctly interpret studies most of the time.

    Vignon P et al. Intensive Care Med 2007; 33 (10): 1795-9.Melamed R et al. Chest 2009; (6): 1416-20.

  • ROLE OF ECHO IN THE ICU

    1. Diagnosis

    2. Guidance of interventions and therapy

    3. Haemodynamic assessment, monitoring

    and follow up

  • Indications of echo in the ICU Infective endocarditis Aortic dissection Unexplained hypoxemia Source of embolus Complications after cardiothoracic surgery Unresponsiveness to therapy LVAD Trauma Tamponade monitoring Pulmonary embolism Prosthetic valve thrombus Kidney/liver/lung tranplantation Major vascular surgery Orthopedic/spinal surgery Neurosurgey

    Beaulieu Y Crit Care Med 2007; 35[Suppl.]:S235S249).Porter TR. Et al. J Am Soc Echocardiogr 2015;28:40-56.

  • Indications of echo in the ICU

    1. The spectrum of haemodynamic instability Shock

    SHOCKSepticHypovolemicObstructiveCardiogenicK combinations or other kinds of shock

    Arrest Focused Echo Evaluation in Life support (FEEL)Pulseless electrical activity AsystolePseudo- pulseless electrical activity

    2. Acute respiratory failureRESP-F exacerbation of chronic Respiratory disease Pulmonary Embolism ST changes associated with acute cardiac or pericardial diseasePneumoniaheart Failure

    Walley PE et al. Critical Care 2014, 18:681.

  • HAEMODYNAMIC ASSESMENT WITH ECHO INCLUDES..

    LV and RV size and function

    Cardiac output

    Filling pressures

    Volume status fluid responsiveness

    Pulmonary artery pressure

    Valvular function and integrity

    Identification and quantification of pericardial effusion

  • Haemodynamic assessment means assessment of..

    1.Myocardial function

    2.Volume status fluid responsiveness

  • Assessment of LV systolic function

    1. Fractional shortening (M-mode)

    2. Ejection fraction (2D: Teichholz formula, FAC from SA views, volume estimations: area-length formula or Simpsons method, 3D, visual assessment)

    A low ejection fraction can reflect either an intrinsic LV systolic dysfunction or an excessive LV afterload, but in both conditions it reflects the fact that ventriculoarterialcoupling is inadequate.

  • Assessment of LV diastolic function

    Porter TR. Et al. J Am Soc Echocardiogr 2015;28:40-56.

  • Assessment of RV systolic function

    1. Qualitative: - RV free wall and IVS endomyocardialthickening and contraction.

    2. Quantitative: ejection fraction (RVEF), fractional area change (FAC), systolic tissue annular motion by two-dimensional, M-mode (TAPSE) or tissue Doppler (TV S wave), myocardial performance index (MPI) and measurement of dP/dt.

  • Continuous echo monitoring

    The ClariTEE probe uniquely may remain indwelling for up to 72 hours providing direct visualization of the heart over time, thereby enabling gold standard hemodynamic management.

  • Transgastric short axis viewLV filling and function

    Four Chamber viewBiventricular function

    Superior vena cava viewFluid responsiveness

  • Assessment of Cardiac Output

    Stroke volume is calculated using Doppler to measure the velocity time integral (VTI) of the flow signal at a given site, and 2D echo to measure the cross sectional area of the same site.

  • Assessment of Cardiac OutputTranscutaneous ultrasound

  • Echo Hemodynamic Monitoring of Cardiac Output

    Oesophageal Doppler Monitoring (CardioQ-ODM)

    measures blood flow velocity in the descending aorta by using a Doppler transducer at the tip of a probe, which is

    inserted into the oesophagus via the mouth or nose.

  • Volume status- fluid responsivenessA. Static parameters

    1. IVC size at end-expiration

    positive response to fluid infusion

    >20mm ->exclude any fluid responsiveness

  • 2. Restrictive pattern of MV inflow -> fluid unresponsiveness

    3. LV and RV diastolic diameters, areas and volumes

  • B. Dynamic parameters

  • I. In patients on mechanical ventillation1. Respiratory changes of the stroke volume Cut-off value 12% of AV Vmax and 20% of aortic VTI

    Feissel M et al. (2001) Chest 119:86773.

    2. IVC-SVC diameter changesDistensibility index of IVC Cut-off value of 12% (using maxmin/mean value) and 18% (using maxmin/min)

    The collapsibility index of the SVCCut-off value of 36%

    Feissel M et al. 2004 Intensive Care Med 30:18347.

    Vieillard-Baron A et al. 2004 Intensive Care Med 30:17349.Barbier C et al. 2004 Intensive Care Med 30:17406.

  • Limitations

    On mechanical ventilation and without spontaneous breathing effort during the measurement.1

    In sinus heart rhythm (except for IVC and SVC variations).1

    Low tidal volume ventilation false negative results.2

    RV dysfunction -> false positive results.3

    Pitfalls with IVC and SVC measurements.1

    1De Baker D et al. Hemodynamic Monitoring Using Echocardiography in the Critically Ill.Springer 2011.2Vallee F et al. 2009 Intensive Care Med 35:100410.3Mahjoub Y et al. 2009 Crit Care Med 37:25705.

  • II. In spontaneously breathing patients

    Maizel J et al. 2007 Intensive Care Med 33:11338.Lamia B et al. 2007 Intensive Care Med 33:112532.

  • Profound hypovolemia

    false negative

    Leg bandages

  • HEMODYNAMIC MONITORING IN SPECIAL SCENARIOS

  • Echo in hemodynamic monitoring of patients wit

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