Critical Care Echocardiography Research Articles

Myths about critical care echocardiography: the ten false beliefs that intensivists should understand.

Myths about critical care echocardiography: the ten false beliefs that intensivists should understand.

Impact of a 2-Day Critical Care Ultrasound Course during Fellowship Training: A Pilot Study.

Objectives. Despite the increasing utilization of point-of-care critical care ultrasonography (CCUS), standards establishing competency for its use are lacking. The purpose of this study was to evaluate the effectiveness of a 2-day CCUS course implementation on ultrasound-naïve critical care medicine (CCM) fellows. Methods. Prospective evaluation of the impact of a two-day CCUS course on eight CCM fellows' attitudes, proficiency, and use of CCUS. Ultrasound competency on multiple organ systems was assessed including abdominal, pulmonary, vascular, and cardiac systems. Subjects served as self-controls and were assessed just prior to, within 1 week after, and 3 months after the course. Results. There was a significant improvement in CCM fellows' written test scores, image acquisition ability, and pathologic image interpretation 1 week after the course and it was retained 3 months after the course. Fellows also had self-reported increased confidence and usage of CCUS applications after the course. Conclusions. Implementation of a 2-day critical care ultrasound course covering general CCUS and basic critical care echocardiography using a combination of didactics, live models, and ultrasound simulators is effective in improving critical care fellows' proficiency and confidence with ultrasound use in both the short- and long-term settings.

Ten good reasons why everybody can and should perform cardiac ultrasound in the ICU.

Critical care ultrasonography (CCUS) has been defined as an ultrasound evaluation of the heart, abdomen, pleura and lungs at the bedside by the intensivist, 24/7. Within CCUS, critical care echocardiography (CCE) is used to assess cardiac function and more generally haemodynamics. Experts in haemodynamics have published a 'consensus of 16' regarding an update on haemodynamic monitoring. They reported the ten key properties of an 'ideal' haemodynamic monitoring system, which perfectly match the ten good reasons we describe here for performing CCE in critically ill patients. Even though unfortunately no evidence-based medicine study is available to support this review, especially regarding CCE-related improvement of outcome, many clinical studies have demonstrated that CCE provides measurements of relevant, accurate, reproducible and interpretable variables, is easy to use, readily available, has a rapid response time, causes no harm, and is cost-effective. Whether it is operator-independent is obviously more debatable and is discussed in this review. All these characteristics are arguments for the extensive use of CCE by intensivists. This is why experts in the field have recommended that a basic level of CCE should be included in the training of all intensivists.

Impact of hemodynamic monitoring on clinical outcomes.

In recent years, there has been a tremendous growth in available hemodynamic monitoring devices to support clinical decision-making in the operating room and intensive care unit. In addition to the "tried and true" heart rate and blood pressure monitors, there are several newer applications of existing technologies including arterial waveform analysis, intraoperative and bedside critical care echocardiography, esophageal Doppler, and tissue oximetry, among others. Several monitoring devices demonstrate positive effect on outcomes, especially when used in conjunction with specific goal-directed therapy protocols to achieve a desired clinical effect. Other devices remain in the validation stage, awaiting comprehensive comparison to established techniques. While these new technologies offer promising advances in intraoperative and critical care, they are often quite costly and many devices lack strong evidence for widespread adoption into clinical practice. In this review, we highlight the current data on clinical outcomes with the use of available hemodynamic monitoring devices.

Basic critical care echocardiography by pulmonary fellows: learning trajectory and prognostic impact using a minimally resourced training model*.

The spread of basic critical care echocardiography may be limited by training resources. Another barrier is the lack of information about the learning trajectory and prognostic impact of individual basic critical care echocardiography domains like acute cor pulmonale determination and left ventricular function estimation. We thus developed a minimally resourced training model and studied the latter outcomes. Prospective observational study. Twenty-bed medical ICU. Echocardiography-naive trainees enrolled in the first year of our Pulmonary Medicine Fellowship Program from September 2012 to September 2013. We described the learning trajectory in six basic critical care echocardiography domains (adequate views, pericardial effusion, acute cor pulmonale, left ventricular ejection fraction, mitral regurgitation, and inferior vena cava variability) and correlated abnormalities in selected basic critical care echocardiography domains with clinical outcomes (mortality and length of stay). Three-hundred forty-three basic critical care echocardiography scans were done for 318 patients by seven fellows (median of 40 scans per fellow; range, 34-105). Only one-third patients had normal basic critical care echocardiography studies. Accuracy in various basic critical care echocardiography domains was high (> 90%), especially beyond the first 30 examinations. Acute cor pulmonale was associated with ICU mortality when adjusted for Acute Physiology and Chronic Health Evaluation II score and presence of sepsis, whereas mitral regurgitation was associated with longer hospitalization only on univariate analysis. Basic critical care echocardiography training using minimal resources is feasible. New trainees can achieve reasonable competency in most basic critical care echocardiography domains after performing about 30 examinations within the first year. The relatively high prevalence of abnormalities and the significant association of acute cor pulmonale with ICU mortality support the need for basic critical care echocardiography training.

Bedside Critical Care Echocardiography Revealing an Unsuspected Diagnosis

Bedside Critical Care Echocardiography Revealing an Unsuspected Diagnosis

International consensus statement on training standards for advanced critical care echocardiography

International consensus statement on training standards for advanced critical care echocardiography

The gray zone of the qualitative assessment of respiratory changes in inferior vena cava diameter in ICU patients

IntroductionTransthoracic echocardiography (TTE) is a useful tool for minimally invasive hemodynamic monitoring in the ICU. Dynamic indices (such as the inferior vena cava distensibility index (dIVC)) can be used to predict fluid responsiveness in mechanically ventilated patients. Although quantitative use of the dIVC has been validated, the routinely used qualitative (visual) approach had not been assessed before the present study.MethodsQualitative and quantitative assessments of the dIVC were compared in a prospective, observational study. After operators with differing levels in critical care echocardiography had derived a qualitative dIVC, the last (expert) operator performed a standard, numeric measurement of the dIVC (referred to as the quantitative dIVC). Two groups of patients were separated into two groups: group (dIVC < 18%) and group (dIVC ≥ 18%).ResultsIn total, 114 patients were assessed for inclusion, and 97 (63 men and 34 women) were included. The mean sensitivity and specificity values for qualitative assessment of the dIVC by an intensivist were 80.7% and 93.7%, respectively. A qualitative evaluation detected all quantitative dIVCs >40%. Most of the errors concerned quantitative dIVCs of between 15% and 30%. In the dIVC <18% group, two qualitative evaluation errors were noted for quantitative dIVCs of between 0 and 10%. The average of positive predictive values and negative predictive values for qualitative assessment of the dIVC by residents, intensivists and cardiologists were 83%, 83%, and 90%; and 92%, 94%, and 90%, respectively. The Fleiss kappa for all operators was estimated to be 0.68, corresponding to substantial agreement.ConclusionThe qualitative dIVC is a rather easy and reliable assessment for extreme numeric values. It has a gray zone between 15% and 30%. The highest and lowest limitations of the gray area are rather tedious to define.Despite reliability of the qualitative assessment when it comes to extreme to numerical values, the quantitative dIVC measurement must always be done within a hemodynamic assessment for intensive care patients. The qualitative approach can be easily integrated into a fast hemodynamic evaluation by using portable ultrasound scanner for out-of-hospital patients.

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.

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.

Focused critical care echocardiography.

Portable ultrasound is now used routinely in many ICUs for various clinical applications. Echocardiography performed by noncardiologists, both transesophageal and transthoracic, has evolved to broad applications in diagnosis, monitoring, and management of critically ill patients. This review provides a current update on focused critical care echocardiography for the management of critically ill patients. Source data were obtained from a PubMed search of the medical literature, including the PubMed "related articles" search methodology. Although studies demonstrating improved clinical outcomes for critically ill patients managed by focused critical care echocardiography are generally lacking, there is evidence to suggest that some intermediate outcomes are improved. Furthermore, noncardiologists can learn focused critical care echocardiography and adequately interpret the information obtained. Noncardiologists can also successfully incorporate focused critical care echocardiography into advanced cardiopulmonary life support. Formal training and proctoring are important for safe application of focused critical care echocardiography in clinical practice. Further outcomes-based research is urgently needed to evaluate the efficacy of focused critical care echocardiography.

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.

Contemporary evaluation for medical ultrasound teachers

Modern critical care practice is increasingly making use of ultrasound to improve bedside diagnostics and enhance patient safety. Physician teachers and mentors therefore need access to mechanisms that maintain learning and professional development of ultrasound learners. We present an exploratory assessment of Distance Travelled Analysis, a novel form of continuous cyclical evaluation used in the context of a Fellowship in Critical Care Echocardiography and a practical guide to applying it to your practice. We adapted the qualitative process of ‘Distance Travelled Analysis’ from vocational education to construct the evaluation tool. We used the tool to collect primary data from the Echo Fellow over a five-month period. The quality and trustworthiness of the subjective primary data-set was triangulated using reflective conversations, spontaneous positive storytelling, face-to-face questionnaires and a summative assessment. Distance Travelled Analysis successfully translated onto the study curriculum, offering purposeful and active evaluation. The tool was able to identify a critical incident and alerted stakeholders to negative change allowing contemporaneous rather than post hoc action. An unexpected finding was that the evaluation tool significantly impacted both learner and mentor creating active learning exchange. The study findings expose the importance of reflective conversation as a balancing component of Distance Travelled Analysis. This qualitative work lends weight to the potential for continuous evaluation in high stakes curricula. The process of Distance Travelled Analysis could offer curriculum evaluators an agile alternative to traditional retrospective evaluation methods, preventing evaluation from being too little too late.

Establishing a critical care echocardiography laboratory

Echocardiography is increasingly utilized by intensive care physicians in everyday practice. Standardization of echocardiographic studies and reporting, quality assurance and medicolegal requirements necessitate establishment of a dedicated system within the critical care setting. We describe the process of setting up a critical care echocardiography (CCE) laboratory based on our experience from three separate ICUs.

Correlation of stroke Volume Measurement between sonosite portable Echocardiogram and Edwards Flotrac sensor-Vigileo Monitor in an Intensive care Unit

PurposeStroke volume (SV) is a parameter that is being recognized as an endpoint in fluid resuscitation algorithms. Its role is now being realized as an important variable in hemodynamic assessment in various clinical scenarios such as septic and cardiogenic shocks. Direct measurement of stroke volume (SV) and its novel corollary, stroke volume variation (SVV) derived by proprietary software, are preferred over mean cardiac output (CO) measurements because they render a more accurate reflection of hemodynamic status independent of heart rate. Flotrac-Vigileo monitor (FTV) (Edwards Lifesciences, Irvine, CA, USA) is a system that uses a complex algorithm analyzing arterial waveform to calculate SV, SVV, and CO. We assessed the feasibility of obtaining SV measurements with a portable echocardiogram and validated its accuracy with the FTV system in mechanically ventilated patients in our intensive care unit (ICU). Furthermore, we emphasized the importance of hemodynamic measurements and familiarity with critical care echocardiography for the intensivists.MethodsTen patients who were on mechanical ventilation were studied. A femoral arterial line was connected to the FTV system monitoring SV and CO. A portable echocardiogram (M-Turbo; Sonosite, Bothell, WA) was used to measure SV. CO was calculated by multiplying SV by heart rate. No patient had arrhythmia. We used biplane Simpson’s method of discs to calculate SV in which subtraction of end-systolic volume from end-diastolic volume yields the SV.ResultsThe comparison of simultaneous SV and CO measurements by echocardiography with FTV showed a strong correlation between the 2. (For SV, y = 0.9545x + 3.3, R2 = 0.98 and for CO, y = 0.9104x + 7.7074, R2 = 0.97).ConclusionsIn our small cohort, the SV and CO measured by a portable echocardiogram (Sonosite M-Turbo) appears to be closely correlated with their respective values measured by FTV. Portable echocardiography is a reliable noninvasive tool for the hemodynamic assessment of the critically ill. Its results need further validation with gold standard measures in a larger cohort of patients. However, our results suggest portable echocardiography could be an attractive tool in assessment of different hemodynamic scenarios in the critically ill.

Accreditation for Critical Care Echocardiography

We hope thatthese new accreditation processes run jointly by the IntensiveCare Society and the British Society of Echocardiography willnow take their place and establish ultrasound processes in theintensive care arena. Non-invasive imaging techniques are fast becoming a pillarof intensive care practice. Five decades of intensive careliterature and the development of ultrasound practice in ourneighbouring specialties of cardiology, general and emergencymedicine have driven intensive care practice to embracetransthoracic echocardiography as a standard of care in thecritically ill.The development of transthoracic echocardiographictechnology has conquered the traditional imaging boundariesin the critically ill and ventilated patient. Long the backbone ofcardiology practice, transthoracic echocardiography has nowfound a new and exciting niche in the intensive care unit.

The application of ultrasound in the critical care setting Part I. Critical Care Echocardiography.

The application of ultrasound in the critical care setting Part I. Critical Care Echocardiography.

Assessment of left ventricular ejection fraction using an ultrasonic stethoscope in critically ill patients

IntroductionAssessment of cardiac function is key in the management of intensive care unit (ICU) patients and frequently relies on the use of standard transthoracic echocardiography (TTE). A commercially available new generation ultrasound system with two-dimensional imaging capability, which has roughly the size of a mobile phone, is adequately suited to extend the physical examination. The primary endpoint of this study was to evaluate the additional value of this new miniaturized device used as an ultrasonic stethoscope (US) for the determination of left ventricular (LV) systolic function, when compared to conventional clinical assessment by experienced intensivists. The secondary endpoint was to validate the US against TTE for the semi-quantitative assessment of left ventricular ejection fraction (LVEF) in ICU patients.MethodsIn this single-center prospective descriptive study, LVEF was independently assessed clinically by the attending physician and echocardiographically by two experienced intensivists trained in critical care echocardiography who used the US (size: 135 × 73 × 28 mm; weight: 390 g) and TTE. LVEF was visually estimated semi-quantitatively and classified in one of the following categories: increased (LVEF > 75%), normal (LVEF: 50 to 75%), moderately reduced (LVEF: 30 to 49%), or severely reduced (LVEF < 30%). Biplane LVEF measured using the Simpson's rule on TTE loops by an independent investigator was used as reference.ResultsA total of 94 consecutive patients were studied (age: 60 ± 17 years; simplified acute physiologic score 2: 41 ± 15), 63 being mechanically ventilated and 36 receiving vasopressors and/or inotropes. Diagnostic concordance between the clinically estimated LVEF and biplane LVEF was poor (Kappa: 0.33; 95% CI: 0.16 to 0.49) and only slightly improved by the knowledge of a previously determined LVEF value (Kappa: 0.44; 95% CI: 0.22 to 0.66). In contrast, the diagnostic agreement was good between visually assessed LVEF using the US and TTE (Kappa: 0.75; CI 95%: 0.63 to 0.87) and between LVEF assessed on-line and biplane LVEF, regardless of the system used (Kappa: 0.75; CI 95%: 0.64 to 0.87 and Kappa: 0.70; CI 95%: 0.59 to 0.82, respectively).ConclusionsIn ICU patients, the extension of physical examination using an US improves the ability of trained intensivists to determine LVEF at bedside. With trained operators, the semi-quantitative assessment of LVEF using the US is accurate when compared to standard TTE.

Training in critical care echocardiography

Echocardiography is useful for the diagnosis and management of hemodynamic failure in the intensive care unit so that competence in some elements of echocardiography is a core skill of the critical care specialist. An important issue is how to provide training to intensivists so that they are competent in the field. This article will review issues related to training in critical care echocardiography.

Editorial [Hot Topic : Current Practice and trends in echocardiography in Critical Care, Anesthesiology and Emergency Medicine (Guest Editor: Paulo Marcelino)

Echocardiography is a valuable diagnostic tool allowing visualization of heart chambers for a complete anatomical and functional evaluation. In the past years there was a clear trend toward its use in other than cardiology areas, like intensive care and anesthesiology. In the Intensive Care its use is now widely accepted, as the concepts on hemodynamic monitoring evolved. This evolution is related to the criticism on pulmonary artery catheter use and its relation with both morbidity and mortality. The use of invasive diagnostic tools is therefore to be avoided but alternatives should also be available. Echocardiography equipment´s evolution toward better downsizing and lower price made the technique even more assessible in the past decade. The use of echocardiography offers the intensive care phisician a tool for a quick and comprehensive diagnosis of the critically ill; also, the examination is fast, does not require the involvement of other health personnel or disposable materials. The information is assessed in real time and obtained based on direct visualization of the heart. Specific issues for the intensive care are also studied using echocardiography. Among them is the sepsis related cardiomyopathy. In anesthesiology the use of echocardiography is quite established, especially in cardiac surgery monitoring. However echocardiography is also a valuable tool in non-cardiac surgery. The evaluation of volume status, left ventricular performance or right heart chambers monitorng are all significant information, not provided by other monitoring tools. The expanded use of echocardiography in non-cardiac surgery should be the next step in this evolution, and many anesthesiologists are using it. Specific monitoring protocols for specific situations must be implemented. The assessment of the patients on the emergency room using echocardiography is an area of growing interest. Contrast echocardiography is a good example. Although patients with suspected heart disease are more often evaluated, the possibilities of echocardiography go far beyond this type of patients. Many features of the approach used in the intensive care can be applied, as well as other potential uses beyond strict heart imaging. Echocardiography is now an image technique used by several non cardiologists specialists. A specific knowledge in this different settings is expected, emerging from its use in distinct disciplines.