POINT-OF-CARE ECHOCARDIOGRAPHY IN PRONE PATIENTS ON MECHANICAL VENTILATION: A PROSPECTIVE CASE SERIES

Abstract

TOPIC: Imaging TYPE: Original Investigations PURPOSE: Point-of-care echocardiography plays an important role in evaluating critically ill patients admitted to the intensive care unit (ICU). Obtainable hemodynamic data has shown to be helpful in differentiating between different types of shocks and guiding management. However, this tool was frequently limited in the current COVID-19 pandemic due to the increasing number of critically ill patients requiring prone positioning for profound hypoxemia. Current literature has limited data regarding feasibility and utility of Point-of-Care Echocardiography in prone patients. METHODS: This a prospective case series involving a total of 21 patients with acute respiratory failure in the setting of COVID-19 pneumonia, requiring mechanical ventilation and prone-positioning, who were randomly enrolled over 4 months period. All patients underwent a bedside echocardiogram to visualize the apical four-chamber and five-chamber views, with the goal of assessing left ventricular function, right ventricular function and right ventricular size. The view was obtained with placing the phased array probe below the left nipple with the transducer indicator pointing toward patient left shoulder followed by moving the probe medially and laterally to obtain the best view. All images were reviewed by an independent board-certified cardiologist to assess quality and interpretability of images. RESULTS: Total of 21 patients were randomly included over a period of 4 months. Mean age was 56 years old with equal gender distribution (male 52%) and median BMI of 21 (IQR 24.8-37.8). Majority patients were ventilated with assist control/volume control mode with median PEEP of 12 (IQR 10-14) and tidal volume of 6 cc/Kg (IQR 6-7.5). LV function was normal in 14/21 (66%), decreased in 5/21 (23%), and unobtainable 2/21 (10%). Right ventricular function was normal on 14/21 (66%), decreased in 4/21 (19%), unobtainable 3/21 (14%). Median VTI was 18.9 (SD + 6.3), mean TAPSE was 17.6 (SD +6), median E/E’ 6.25 (IQR 5-8). 19/21 images were available for review by cardiology. Out of those, 12/19 (63%) scans considered of an adequate image quality and interpretability. While no difference in images quality noted between genders, a BMI of 35 and more significantly correlated with poor images [4/5 (80%) vs. 3/11 (21%);p=0.01]. In addition, left lateral prone positioning was more likely to be associated with adequate quality 5/6 (83%) as compared to other positions 6/11 (54%). CONCLUSIONS: Point-of-care echocardiography to obtain apical cardiac views is feasible in certain prone patients and can be optimized by left lateral positioning. Further studies are needed to explore and standardize the role of echocardiography in patients requiring prolonged proning. CLINICAL IMPLICATIONS: Point-of-care echocardiography can be adequate enough to provide valuable quantitative and qualitative hemodynamic data in critically ill proned patients. DISCLOSURES: No relevant relationships by Yaser Dawod, source=Web Response No relevant relationships by Benjamin Kenigsberg, source=Web Response No relevant relationships by Syed Nazeer Mahmood, source=Web Response No relevant relationships by Anantha Mallia, source=Web Response