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  • Pitfalls of Echocardiography as a

    Haemodynamic Monitoring Tool

    A/Prof Ian Seppelt FANZCA FCICM

    Dept of Intensive Care Medicine, Nepean Hospital,

    University of Sydney

    George Institute for Global Health, University of NSW

    Faculty of Medicine and Heath Sciences, Macquarie University

  • Haemodynamic Monitoring by Echo– Presenter

    Disclosure

    • No conflicts to disclose

    • Thanks to Drs Sam Orde, Marek Nalos and Martin Stefan

  • Prehistoric

    Intensive Care

  • The value of bedside ultrasound

    • Echocardiography

    • Thoracic ultrasound

    • Vascular access

    • Neural blockade

    • Hepatic and renal

    ultrasound

    • FAST in trauma

    • Pretracheal ultrasound

  • Characteristics of „Point of Care

    Ultrasound‟

    • Exam is for a well-defined purpose

    linked to improving patient outcomes

    • Exam is focused and goal-directed

    • Exam findings are easily recognizable

    • The exam is easily learned

    • Exam is quickly performed

    • Exam is performed at the patient‟s

    bedside

  • From 2014 all trainees must demonstrate

    competency in basic echocardiography.

    In order for the Trainee to fulfil this requirement,

    satisfactory completion of the following is required:

    (a) Attend an accredited course in basic echocardiography

    (b) Perform, document and appropriately interpret 30 basic

    studies.

    (c) Perform at a satisfactory level in a „hot-case‟ (live) exam

    (d) Complete a short on-line MCQ exam (CICM website)

  • … the indications seem pretty clear

    Indications For Transthoracic Echocardiography in the

    Critically Ill Patient

    1. Haemodynamically unstable patient:

    - Assessment of ventricular contractility

    - Identification of major valvular abnormalities

    - Assessment of preload

    - Assessment of left ventricular diastolic function

    - Initial assessment for large intracardiac shunts

    2. Unexplained respiratory failure

    3. Left ventricular failure

    Committee on

    Echocardiography in Intensive

    Care, ANZICS 2007

  • … the indications seem pretty clear

    Indications For Transthoracic Echocardiography in the

    Critically Ill Patient

    4. Right heart failure/pulmonary hypertension

    5. Suspected valvular disease

    6. Sepsis of unknown origin - initial assessment for features of

    endocarditis

    7. Clinical features suggesting the presence of pericardial effusion

    and tamponade

    8. Suspected thoracic aortic pathology

    9. Onset of new heart murmur.

    Committee on

    Echocardiography in Intensive

    Care, ANZICS 2007

  • … the indications seem pretty clear

    Indications For Trans-oesophageal Echocardiography

    in the Critically Ill Patient

    1. Inadequate TTE

    2. Required detailed assessment of cardiac valves, interatrial and interventricular septum and great thoracic vessels (i.e. suspected aortic dissection).

    3. Suspected endocarditis

    4. Suspected cardioembolic events or screening for intracardiac thrombi prior to cardioversion.

    5. Suspected dysfunction of the prosthetic valve

    6. Assistance in interventional techniques and assessment of intracardiac devices.

    7. Resuscitation

    Committee on

    Echocardiography in Intensive

    Care, ANZICS 2007

  • Benefits of TTE

    • Immediately available, non invasive

    • Best modality for:

    – LV function

    – Right heart evaluation

    – Effusions and tamponade

    – Evaluation of aortic stenosis

  • Benefits of TOE

    • Modality of choice for

    – Endocarditis

    – Evaluation of septal defects and shunts

    – Ascending and descending aorta

    – Intracardiac masses and thrombi esp LAA

    • Also indicated if poor TTE windows due to

    surgery, dressings, body habitus etc.

  • How ICU studies differ from the

    cardiology outpatient lab … • Often supine, ventilated, unconscious patients • Other equipment can affect examination • Dynamic situation with concurrent resuscitation

    underway • Often a specific question “Is there a cardiac

    component to this patient‟s instability” • Repeated studies for monitoring • 24 hours a day requirement

  • How ICU studies differ from the

    cardiology outpatient lab … • Often supine, ventilated, unconscious patients • Other equipment can affect examination • Dynamic situation with concurrent resuscitation

    underway • Often a specific question “Is there a cardiac

    component to this patient‟s instability” • Repeated studies for monitoring • 24 hours a day requirement

  • How ICU studies differ from the

    cardiology outpatient lab … • Often supine, ventilated, unconscious patients • Other equipment can affect examination • Dynamic situation with concurrent resuscitation

    underway • Often a specific question “Is there a cardiac

    component to this patient‟s instability” • Repeated studies for monitoring • 24 hours a day requirement

  • All intensivists should be able to….

    do a basic echo to answer the following

    questions:

    1. Is the heart working?

    2. Is it really full or really empty?

    3. Is there an acute severe valve lesion?

    4. Is there a tamponade?

    These are

    not subtle

    findings!!

  • „Level two‟ examination

    • Let the experts worry about:

    – Degrees of diastolic dysfunction

    – Tissue doppler imaging

    – Quantifying subtler valve lesions and

    pressure gradients

    – Little ASDs and PFOs and other shunts

    – Congenital abnormalities

  • Focussed Assessment

    • Level 1 training for all intensivists

    • A FOCUSSED examination to answer

    specific questions

    – Not a comprehensive examination, and should

    not be thought of as such

    – Analagous to FAST in trauma

  • 2nd Singapore-ANZICS Intensive Care Forum 2013 12 – 14 July 2013 Max Atria, Singapore Expo

  • The RACE examination

    • Focussed 2D examination

    – Cardiac windows

    – Basic lung ultrasound

    – Vena cava assessment

    • Doppler examination de-emphasized

    • Course 1 – 2 days with extensive hands

    on experience

  • All registrars do RACE

    • Focussed RACE course during orientation

    period

    • All RACE studies must be documented

    – Standard pro-forma

    • Consultant review of images off-line

  • 1. Conservatism

    • “You can‟t teach an old dog new tricks”

    • “What I do now works for me”

    • Practicalities – teaching a whole department

    2. Turf wars with cardiology or radiology

    3. Where do we get training?

    4. Maintenance of skills

    5. Amateurs „dabbling‟ - making mistakes

    So why won‟t we all embrace

    ultrasound?

  • Pitfalls of Level 1 Exams

    • Over-interpreting findings

    – Statements about preload and filling based

    just on IVC collapse in ventilated (or non-

    ventilated) patients

    – RV function / ventricular interrelationships

    • Missing important things

    – Dyamic LVOT obstruction

    • Not understanding one‟s limitations

    A focused examination

  • Veillard-Baron et al, Bedside echocardiographic evaluation of hemodynamics in sepsis, Am J Resp Crit Care Med 2003 and Intensive Care Med 2006

    Echocardiography as a haemodynamic monitor?

  • Easy

    Often visual assessment of cardiac function

    sufficient to guide therapy

  • Difficult

    “It is better to be roughly right than precisely wrong.”

    Mervyn King, the former governor of Bank of England

    Does the patient have adequate cardiac output?

  • Outcome is improved with source control,

    prompt and adequate fluid resuscitation

    while striving to achieve early negative

    fluid balance

    CO monitors - PA catheter, PiCCO, LiDCO, Flowtrac,

    oesophageal Doppler, etc…

  • if trend of haemodynamics and fluid

    balance not according to expectation..

    perform clinical examination, review the

    chart and repeat echo

  • Does my patient need more fluid?

  • Static indices do not work

    R: Responders

    NR: Non-

    responders

  • IVC collapsibility in mechanically ventilated patients

    Collapsibility of 12%

    in ventilated septic

    shock patients,

    positive and negative

    predictive