Advanced Critical Care Echocardiography Research Articles

Evaluation of an advanced critical care echocardiography program: a mixed methods study.

Limited data exist on advanced critical care echocardiography (CCE) training programs for intensivists. We sought to describe a longitudinal echocardiography program and investigate the effect of distributed conditional supervision vs predefined en-bloc supervision, as well as the effect of an optional echocardiography laboratory rotation, on learners' engagement. In this mixed methods study, we enrolled critical care fellows and faculty from five University of Toronto-affiliated intensive care units (ICU) between July 2015 and July 2018 in an advanced training program, comprising theoretical lectures and practical sessions. After the first year, the program was modified with changes to supervision model and inclusion of a rotation in the echo laboratory. We conducted semistructured interviews and investigated the effects of curricular changes on progress toward portfolio completion (150 transthoracic echocardiograms) using a Bayesian framework. Sixty-five learners were enrolled and 18 were interviewed. Four (9%) learners completed the portfolio. Learners reported lack of time and supervision, and skill complexity as the main barriers to practicing independently. Conditional supervision was associated with a higher rate of submitting unsupervised echocardiograms than unconditional supervision (rate ratio, 1.11, 95% credible interval, 1.08 to 1.14). After rotation in the echocardiography laboratory, submission of unsupervised echocardiograms decreased. Trainees perceived lack of time and limited access to supervision as major barriers to course completion. Nevertheless, successful portfolio completion was related to factors other than protected time in the echocardiography laboratory or unconditional direct supervision in ICU. Further research is needed to better understand the factors promoting success of CCE training programs.

FEASABILTY, UTILITY, AND SAFETY OF CRITICAL CARE TRANSESOPHAGEAL ECHOCARDIOGRAM PERFORMED IN A COMMUNITY HOSPITAL ICU

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: The Intensivist faces the challenging hemodynamics and complex heart-lung interaction in ventilated patients on daily basis. Critical care transesophageal echocardiogram (TEE) serves as another valuable diagnostic tool for the critical care provider when the transthoracic echocardiogram (TTE) fails to solve the hemodynamic dilemma, most likely because of inadequate window. We want to share our experience at a community hospital intensive care unit (ICU). Most importantly we examined the safety and feasibility of the procedure as well. METHODS: We retrospectively reviewed the charts, TEE reports and images of 16 patients in our ICU. We looked at the rationale behind doing a TEE, weather or not there was any clinically relevant finding from the TEE image acquisition and if that changed clinical management. RESULTS: TEE was feasible and safe in all 16 exams. There were no complications. The most common reason for the TEE was complex hemodynamics in the setting of poor TTE views. 4 exams were done to assess resuscitation during cardiac arrest and to identify any reversible or irreversible causes of the arrest. 1 exam was done to guide ECMO cannula insertion under direct visualization. 1 exam was done to examine the effect of a recruitment maneuver on the right ventricle (RV). We observed a clinically relevant finding in 14 exams. Subsequently these results were conveyed to the medical team taking care of the patient. As a result of the TEE report, a medical decision that changed current management by the primary team was done in 13 exams out of all 16. The most common treatment implemented based of the TEE report was the adjustment of the ventilator settings to improve RV function. Other important decisions included shock differentiation in a complex hemodynamic state, starting an inotrope and even changing LUCAS device position during CPR since initially it was observed via the TEE that the compressions were obstructing the left ventricle outlet (LVOT). CONCLUSIONS: In line with previous data, we found that critical care TEE is feasible, clinically useful and most importantly safely done by intensivists who received adequate training in advanced echocardiography. Our study shows that TEE is another valuable tool that intensivists in north America should be familiar with as it is the case in Europe. CLINICAL IMPLICATIONS: Critical Care TEE is a valuble tool that the intensivist can use to solve hemodynamic dilemmas. It is safe and feasible and has an attractive learning curve.We encourage critical care training programs to consider training their fellows in advanced echocardiography. In the Era of visual medicine, advanced critical care echocardiography is knocking on the doors. DISCLOSURES: No relevant relationships by Mohammad Arabiat, source=Web Response No relevant relationships by Karan Singh, source=Web Response

Critical Care Echocardiography: A Primer for the Nephrologist

Critical care echocardiography (CCE) refers to the goal-directed use of transthoracic or transesophageal echocardiography and represents one of the most common applications of critical care ultrasound. CCE can be performed at the point of care, is easily repeated following changes in clinical status, and does not expose the patient to ionizing radiation. Nephrologists who participate in the care of patients in the intensive care unit will regularly encounter CCE as part of the decision-making and bedside management of ICU patients. The four primary indications for CCE are the characterization of shock, evaluation of preload tolerance, evaluation of volume responsiveness, and serial hemodynamic assessment to evaluate response to therapeutic interventions. This article provides an overview of the anatomical structures that are routinely assessed in basic CCE, describes how these findings are incorporated into the clinical assessment of critically ill patients, and introduces some common applications of advanced CCE.

Ultrasonography in the Critical Care Unit.

Purpose of ReviewThis article summarizes the utility and evidence supporting the use of ultrasound exams in the intensive care unit.Recent FindingsPoint-of-care ultrasonography (POCUS) is widely used by intensivists managing critically ill patients whereby they can accurately and rapidly assess for many pathologies such as pneumothorax, pulmonary edema, hydronephrosis, hemoperitoneum, and deep vein thrombosis among others. Basic and advanced critical care echocardiography, including transesophageal echocardiography, are routinely performed to determine the etiology of hemodynamic instability in undifferentiated shock and to guide subsequent therapy. The use of POCUS in the assessment of volume status is controversial with studies demonstrating that respiratory variation of the IVC is not reliable and with analysis of aortic blood flow velocity after passive leg raising maneuvers being the most promising.SummaryPoint-of-care ultrasonography allows frontline clinicians to make real-time diagnoses and treatment decisions. This article will provide the reader with a broad overview of this important topic.Electronic supplementary materialThe online version of this article (10.1007/s11886-020-01393-z) contains supplementary material, which is available to authorized users.

Effectiveness of an Advanced Critical Care Echocardiography Course.

Advanced critical care echocardiography (CCE) involves comprehensive assessment of cardiac structure and function for frontline critical care applications. This study reports the effectiveness of a 3-day course in advanced CCE. We studied the outcome of 5 consecutive advanced CCE courses delivered between 2013 and 2017. A total number of 239 learners were studied. The course included didactic lectures, image interpretation sessions, and hands-on training with normal individuals as models. Training domains included left ventricular structure and function, right ventricular structure and function, valve function using comprehensive 2-dimensional imaging, and Doppler-based measurements for cardiac pressures and flows. Measurements of course outcome included pre- and postcourse assessment of knowledge, image acquisition, and image interpretation skills. Learners rotated between hands-on training and interpretation sessions. The teacher-to-learner ratio was 1:3 during hands-on training. Interpretation sessions consisted of review of normal and abnormal echocardiographic videos with interactive small groups. Learners completed a video-based knowledge assessment examination before and after completion of the course. Hands-on image acquisition skills were tested at the completion of the course during all the years. For years 2016 and 2017, a precourse hands-on skill test was also performed. There was a statistically significant improvement in knowledge and image interpretation skills in the cohort of 239 learners over 5 years of study period. There was improvement in image acquisition skills over the 2-year period when it was measured pre- and postcourse. A 3-day course on advanced CCE resulted in improvement knowledge/image interpretation and hands-on image acquisition skills. Clinical Implications: Advanced CCE has assumed an important place in hemodynamic monitoring of critically ill patients. A course of similar design may facilitate training of frontline clinicians in advanced CCE.

Editorial introductions

Current Opinion in Critical Care was launched in 1995. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of critical care is divided into 13 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Hans FribergHans FribergHans Friberg, MD, PhD, EDIC is a Professor of Anaesthesiology and Intensive Care Medicine at Lund University, Sweden and a senior consultant at Skåne University Hospital, Malmö, Sweden. Dr Friberg did his PhD-work at the Laboratory for Experimental Brain Research at Lund University, where he studied brain injury and mitochondrial dysfunction in rodent models of global and focal brain ischemia. Dr Friberg's present research area is post-resuscitation care and temperature management after cardiac arrest. He has published some 200 scientific papers. He is the senior author of the Targeted Temperature Management after cardiac arrest trial (TTM-trial) and also a senior author of the ongoing TTM2-trial. Dr Friberg is an initiator of the Hypothermia Network which has become the International Cardiac Arrest Registry (INTCAR), a transatlantic research collaboration with more than 6000 registered patients. He is the initiator of SWECRIT, a large regional biobank for critically ill patients in the ICU. Dr Friberg is a co-author of the ERC guidelines on post-resuscitation care and serves on the Board of the Swedish Resuscitation Council. Anthony S. McLeanAnthony S. McLeanAnthony S. McLean, BSc (Hons), MB.ChB (Otago), MD, FRACP, FCSANZ, FCICM, MRACMA is based at the Nepean Hospital, Sydney, Australia and is Head of Intensive Care Medicine and Professor with the University of Sydney, Australia. His research background ranges from critical care echocardiography and heart failure to genomics of sepsis in critically ill patients. He has been training basic and advanced echocardiographic techniques for many years, both nationally and internationally. He leads a dedicated research team into the use of echocardiography in the critically ill patient. Additionally, the Nepean Intensive Care Genomics team have been researching the utility of blood transcriptome analysis in septic patients for the past decade, developing international database networks with a particular interest in influenza and other respiratory viruses. He has over 130 publications in peer review journals, written books on both basic and advanced critical care echocardiography and has contributed multiple book chapters on aspects of Intensive Care Medicine. A strong believer in advancing Intensive Care medicine in the region he has participated in many scientific meetings and workshops in South East Asian countries. He is a past President of the Australian and New Zealand Society of Intensive Care and is also a past President of the Asia Pacific Association of Critical Care Medicine.

A decade of progress in critical care echocardiography: a narrative review.

This narrative review focusing on critical care echocardiography (CCE) has been written by a group of experts in the field, with the aim of outlining the state of the art in CCE in the 10 years after its official recognition and definition. In the last 10years, CCE has become an essential branch of critical care ultrasonography and has gained general acceptance. Its use, both as a diagnostic tool and for hemodynamic monitoring, has increased markedly, influencing contemporary cardiorespiratory management. Recent studies suggest that the use of CCE may have a positive impact on outcomes. CCE may be used in critically ill patients in many different clinical situations, both in their early evaluation of in the emergency department and during intensive care unit (ICU) admission and stay. CCE has also proven its utility in perioperative settings, as well as in the management of mechanical circulatory support. CCE may be performed with very simple diagnostic objectives. This application, referred to as basic CCE, does not require a high level of training. Advanced CCE, on the other hand, uses ultrasonography for full evaluation of cardiac function and hemodynamics, and requires extensive training, with formal certification now available. Indeed, recent years have seen the creation of worldwide certification in advanced CCE. While transthoracic CCE remains the most commonly used method, the transesophageal route has gained importance, particularly for intubated and ventilated patients. CCE is now widely accepted by the critical care community as a valuable tool in the ICU and emergency department, and in perioperative settings.

Levels of training in critical care echocardiography in adults. Recommendations from the College of Intensive Care Medicine Ultrasound Special Interest Group.

Critical care echocardiography (CCE) is commonly performed in many intensive care units across Australia and New Zealand (ANZ). The scope of practice ranges from Basic CCE through to Advanced CCE and includes the use of transthoracic echocardiography and transoesophageal echocardiography. Many training and qualification pathways exist with no standardisation of education goals. This document defines different levels of CCE expertise and recommends minimum training standards for each level of adult CCE in ANZ. Guidelines committee of College of Intensive Care Medicine's Ultrasound Special Interest Group held multiple face to face meetings, organised teleconferences, conducted a survey of the Fellows of the college and reviewed the international CCE training pathways prior to writing these guidelines.

POINT-OF-CARE ULTRASOUND HELPED DIAGNOSE PERSISTENT RIGHT UPPER LOBE INFILTRATE FROM ECENTRIC JET OF MITRAL INSUFFICIENCY

SESSION TITLE: Critical Care 3 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Approximately 0.2% of all cardiogenic pulmonary edema is unilateral and almost always associated with severe mitral regurgitation. It is often mistaken as focal lung disease like pneumonia, infarction or aspiration. It may lead to misdiagnosis and delay in management (1). Use of bedside echocardiography in diagnosis and management of critical illness is continuously evolving. Here we present a case of persistent right upper lobe infiltrate secondary to mitral valve insufficiency diagnosed with bedside focused echocardiography. CASE PRESENTATION: A 78-year-old woman with history of Heart failure (preserved ejection fraction), atrial fibrillation, severe chronic obstructive pulmonary disease and left upper lobe lung cancer status-post lobectomy presented with worsening dyspnea and respiratory failure. She was intubated in the emergency room for hypoxic and hypercapnic respiratory failure. She was treated for pneumonia of right upper lobe three weeks prior to this presentation. Her vital signs were BP156/78 mmHg, HR 120 bpm, Temp 99.0 F and saturation 96% of 60% FiO2. Respiratory exam was notable for rhonchi on right lung field and diffuse wheezes bilaterally. Chest x-ray showed persistent right upper lobe infiltrate. CT scan chest confirmed airspace opacity of the right upper lobe. Patient was started on intravenous antibiotics and IV steroids for presumed pneumonia and COPD exacerbation. Her infectious and cardiac work up remained negative. She remained on mechanical ventilation because of rapid shallow breathing. Bedside echocardiography was performed and showed eccentric jet of mitral regurgitation around posterior mitral leaflet occupying less than 40% of left atrial area consistent with mild to moderate mitral insufficiency. This finding was confirmed with transthoracic Echo. Patient had aggressive diuresis and after load reduction. Her rapid shallow breathing index improved and she came off mechanical ventilation and discharged later. DISCUSSION: Goal directed echocardiography helps integrate data and images to answer clinical question. It has been shown that bedside echocardiography performed by trained intensivist gives information promptly otherwise not accessible by physical exam alone(2). American college of chest physician competence in basic and advanced critical care echocardiography requires cognitive skills in recognition of clinical syndrome associated with acute massive valvular regurgitation and to answer whether valvulopathy is clinically relevant respectively(3).Our case is an excellent example demonstrating the advanced use of critical care echocardiography to diagnose a rare clinical presentation of mild to moderate mitral insufficiency causing right upper lobe infiltrate. CONCLUSIONS: Persistent right upper lobe infiltrate should prompt the use of bedside echocardiography looking for eccentric jet of posterior mitral leaflet. Reference #1: Attias, David, et al. "Prevalence, characteristics, and outcomes of patients presenting with cardiogenic unilateral pulmonary edema.” Circulation 122.11 (2010): 1109-111 Reference #2: Beaulieu, Yanick. "Specific skill set and goals of focused echocardiography for critical care clinicians.” Critical care medicine 35.5 (2007): S144-S149. Reference #3: Mayo, Paul H., et al. "American College of Chest Physicians/La Societe de Reanimation de Langue Francaise statement on competence in critical care ultrasonography.” Chest 135.4 (2009): 1050-1060 DISCLOSURES: No relevant relationships by Mohammedumer Nagori, source=Web Response No relevant relationships by Muhammad Shafi, source=Web Response No relevant relationships by Ziad Shaman, source=Web Response No relevant relationships by Edward Warren, source=Web Response

Feasibility, Safety, and Clinical Utility of Transesophageal Echocardiography Performed by Pulmonary/Critical Care Fellows in the Medical ICUs

SESSION TITLE: Ultrasound in the ICU SESSION TYPE: Original Investigation Slide PRESENTED ON: Monday, October 24, 2016 at 04:30 PM - 05:30 PM PURPOSE: To evaluate the feasibility, safety, indications, and utility of transesophageal echocardiogram (TEE) in mechanically ventilated critically ill patients performed by pulmonary and critical care (PCCM) fellows in a medical intensive care unit (MICU). METHODS: This is a longitudinal descriptive study of TEE performed in mechanically ventilated patients in the MICU by PCCM fellows. 100 TEE studies were stored in a unit data base (QPath) that included a standard report with the indications for the study, description of hemodynamic parameters, and clinical application of the results. Examinations were performed by PCCM fellows under direct supervision of intensivists trained in advanced critical care echocardiography. TEE examinations included a standard image set. Therapeutic impact was described as the percentage of cases where TEE findings changed the therapy such as fluid resuscitation, inotropic/pressor use, antibiotic therapy, anticoagulation, and/or surgery. Complications and safety of TEE were documented. The therapeutic impact of the TEE was assessed based on review of medical chart and TEE final report. RESULTS: 100 TEE studies were performed in intubated patients with shock, respiratory failure, and inadequate transthoracic echocardiography views. In 36% of cases the TEE findings led to a change in therapy. Severe left and right ventricular dysfunction, endocarditis with surgical indication, severe valvulopathies, left atrial thrombus, and aortic dissection were identified in a timely manner. These findings led to a variety of therapeutic interventions which included inotropic support, right ventricular protective ventilator strategies, antibiotics for endocarditis, onset of anticoagulation, and valvular surgery. There were no complications related to the performance of TEE with fellows being the primary scanner. CONCLUSIONS: Assessment of shock for diagnosis or to guide therapy was the main reason for TEE evaluation followed by the evaluation of hypoxemic and/or hypercapnic respiratory failure in patients under mechanical ventilation. In 36% of cases the TEE findings led to a change in therapy, and there were no complications with the fellow assigned as the primary scanner. CLINICAL IMPLICATIONS: The use of TEE performed by PCCM fellows is feasible and safe in the MICU. TEE led to the identification of new clinically relevant information that resulted in a change of therapy in one third of the patients studied and led to confirmation of managment strategy in the balance of the patients. These results may encourage the incorporation of TEE training into PCCM fellowship training. DISCLOSURE: The following authors have nothing to disclose: Yunuen Aguilera Garcia, Karan Singh, Juan Mendez, Mangala Narasimhan, Seth Koenig, Paul H. Mayo No Product/Research Disclosure Information

Critical Care Transesophageal Echocardiography

Critical care transesophageal echocardiography (TEE) is useful in characterizing shock states encountered by intensivists when transthoracic echocardiography (TTE) gives insufficient information or when more detailed analysis of cardiac structures is needed. It is safe, feasible, and easy to learn and is a recommended component of advanced critical care echocardiography. This article reviews critical care TEE regarding training, equipment, comparison with TTE, indications, safety, and standard views of critical care TEE. It should be considered a companion article to a recent two-part series in CHEST that focused on advanced critical care TTE. Included with this article is an online supplement that has a representative series of critical care TEE images with clinical commentary.

Measuring and monitoring quality in satellite echo services within critical care: an exploration of best practice.

The subspecialty of critical care echocardiography is a rapidly developing area of cardiac imaging. The United Kingdom Committee for Critical Care Echocardiography was set up in 2009 to examine the remit of echocardiography in critical care, and a successful collaboration between the British Society of Echocardiography (BSE) and the Intensive Care Society has resulted in the establishment of two new critical care accreditation processes: Focused Intensive Care Echocardiography and Advanced Critical Care Echocardiography. These accreditation processes are currently driving the development of satellite echo services within critical care departments throughout the UK. Individual practitioner – and more recently, departmental – accreditation have become well-established processes advocated by the BSE. Practitioner accreditation promotes accountability, and departmental accreditation standardises the environment in which practitioners operate. The accreditation of individual echocardiographers has been embraced by the critical care fraternity; we propose that departmental accreditation for critical care echo services be viewed in the same way. Identifying quality indicators for satellite echocardiography services within critical care areas is therefore the focus of the present quality exploration: our aim is to propose a set of parameters against which satellite critical care echo services can be benchmarked. In publishing our suggestions, we hope to stimulate debate in light of the rapid evolution of critical care echocardiography as a subspecialty practice. We suggest that our proposed parameters could be used to maintain satellite critical care service standards and to help identify departments capable of delivering high-quality services and training in critical care echocardiography.

International consensus statement on training standards for advanced critical care echocardiography

International consensus statement on training standards for advanced critical care echocardiography

Advanced Echocardiography for the Critical Care Physician: Part 2

This article is the second part of a series that describes practical techniques in advanced critical care echocardiography and their use in the management of hemodynamic instability. Measurement of left ventricular function and segmental wall motion abnormalities, evaluation of left ventricular filling pressures, assessment of right-sided heart function, and determination of preload sensitivity, including passive leg raising, are discussed. Video examples help to demonstrate techniques described in the text.

Advanced Echocardiography for the Critical Care Physician: Part 1

This is the first of a two-part series that reviews advanced critical care echocardiography (CCE) techniques designed for critical care physicians. In this section, we review training in basic and advanced CCE. This is followed by a review of Doppler principles, including pulsed wave, continuous wave, and color flow Doppler. Included are Doppler measurement techniques that are useful for assessing the patient with cardiopulmonary failure and the common pitfalls of Doppler. This section ends with a review of the quantitative and semiquantitative measurements of stroke volume, as well as problems with measurement of stroke volume in the ICU and its useful clinical applications. Video-based examples will help demonstrate the techniques that are described in the text.

Doppler echocardiography in shocked patients

To reiterate the necessity of integrating echocardiography in the management of shocked patients and to propose a step-by-step functional evaluation of hemodynamics proven to optimize hemodynamic monitoring and to adapt the treatment. Echocardiography has become the cornerstone to hemodynamic monitoring. By providing real-time images, echocardiography has the advantage over 'blind' technologies of an excellent diagnostic performance and of quick provision of information about the pathophysiology of circulatory failure. Critical care echocardiography (CCE) has been defined as echocardiography performed and interpreted by intensivists themselves, 7/7 and 24/24, at the bedside. Basic CCE is mainly a diagnostic approach, allowing quick and focused examination of cardiac function. Advanced CCE is the core of functional hemodynamic monitoring. It is based not only on transthoracic echocardiography but also strongly on transesophageal echocardiography, a very useful approach in ventilated patients. However, this monitoring is discontinuous. A single-use 72-h indwelling transesophageal probe was recently tested, allowing functional hemodynamic monitoring more continuously. Echocardiography has become a hemodynamic monitoring technique used worldwide. It allows to make a quick and simple diagnosis of typical hemodynamic situations, by means of basic CCE, and also to achieve real functional hemodynamic monitoring, through advanced CCE.

Echocardiography in intensive care – where we are heading?

Echocardiography in intensive care – where we are heading?

International expert statement on training standards for critical care ultrasonography

Training in ultrasound techniques for intensive care medicine physicians should aim at achieving competencies in three main areas: (1) general critical care ultrasound (GCCUS), (2) "basic" critical care echocardiography (CCE), and (3) advanced CCE. A group of 29 experts representing the European Society of Intensive Care Medicine (ESICM) and 11 other critical care societies worldwide worked on a potential framework for organizing training adapted to each area of competence. This framework is mainly aimed at defining minimal requirements but is by no means rigid or restrictive: each training organization can be adapted according to resources available. There was 100% agreement among the participants that general critical care ultrasound and "basic" critical care echocardiography should be mandatory in the curriculum of intensive care unit (ICU) physicians. It is the role of each critical care society to support the implementation of training in GCCUS and basic CCE in its own country.